How Many Pairs Of Gloves Should Be Worn While Embalming

By: Jzyk S. Ennis, PhD

Embalmers in 2020 are faced with handling a highly infectious version of the Coronavirus, named COVID-19. As indicated by scientists and infectious control physicians, this is a highly infectious and transmittable disease. Susan Davidson and Dr. William Benjamin published a study that can be found in the current edition (5th Edition) of the Mayer embalming textbook.1 In this report, they state that: “The infectious nature of cadavers, regardless of their cause of death, has been documented. The routine transport and embalming of cadavers place the FSP [Funeral Service Personnel] in a position to be exposed to multiple infectious agents that are transmissible by mucocutaneous contamination, aerosolization, and direct inoculation.”2 What embalmers must remember is that they have been trained to treat every case as if it were infectious. Sadly, many funeral homes are now finding that those protocols are insufficient for even normal operating practice within the walls of their facility. Personal Protective Equipment (PPE), critically important to embalmer protection in COVID-19 and other infectious cases, is woefully lacking in type and supply at many funeral homes. Inexplicably, many funeral homes find themselves without normal supplies of PPE, much less what may be needed in a pandemic. To be sure, COVID-19 is a virus that requires the embalmer follow protocols established by the Centers for Disease Control (CDC), that include PPE. As you will see, PPE, along with proper disinfection, is absolutely critical to the protection of the embalmer and prevention of the spread of COVID-19.

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To gain some perspective on what the embalmer is facing, one only must look back at another version of the coronavirus that infected the population some years ago, Severe Acute Respiratory Syndrome (SARS). SARS is as close to COVID-19 as we can relate at this point. Another close reference is Mycobacterium tuberculosis (TB). In the study, Protecting health care workers from SARS and other respiratory pathogens: A review of the infection control literature,3 findings also support that PPE, reduction of procedures that can cause aerosolization of particles, and environmental disinfection are critically important to reduce the potential of infection of healthcare [for our purposes this would include funeral service] workers. Furthermore, this study found that certain medical procedures, like intubation, could actually cause smaller droplets of infectious material that could travel farther than normal coughing or sneezing.3

For embalmers, procedures that may cause aerosolization of particles includes: cleaning and packing of nasal/oral orifices, hydro or electric aspiration of the nasal/oral cavities, packing of the nasal/oral cavities, and thoracic aspiration following embalming that would include the lungs and trachea/larynx. Davis and Benjamin found that, “The routine aspiration of blood and other body fluids carries the risk of aerosolization of droplet nuclei.”4 Great care should be taken in each of these procedures, and only the licensed embalmer should be exposed during the embalming process. Limiting the number of people performing embalming procedures to reduce the potential for exposure and infection is highly recommended. As has already been reported by embalmers across the United States, covering of the face with a damp cloth during the removal and pre-embalming procedures is also highly recommended. While COVID-19 is not a bloodborne infection, a prudent step to further reduce your standard risk is to use a system of “closed drainage.” Closed drainage means to use a venous drain tube connected to a length of tubing sufficient to span the entire length of the embalming table and down the drain into the sink. Furthermore, some type of plastic wrap or plexiglass cover should be made to cover the drainage sink to prevent aerosolized particles from becoming airborne. Take great care when disposing or cleaning this surface after contamination. For those embalmers using the Embalming Water Control Unit (the water system that looks like kitchen faucets that supplies water to the embalming machine, the table, and aspiration) for hydro-aspiration, great care should also be used because aspirated materials could potentially become aerosolized from the control unit.

Does this mean that people who die from COVID-19 cannot be safely embalmed and should then all be cremated? No! Embalming COVID-19 cases is permissible when the following are followed:

• Follow protocols of the CDC and other reputable heath authorities.
• Properly don (put on) all required PPE (two pair of gloves if possible).
• Minimize infected material being aerosolized.
• Carefully disinfect nasal/oral cavities and pack them with a mortuary-grade disinfectant. Purging during embalming from the nasal/oral cavity could result in the aerosolization of infected material.
• Embalming using a higher than normal arterial fluid index and a higher than normal arterial solution concentration (see below).
• Use a slow rate of flow. A high rate of flow can cause distention of internal organs that may lead to purge and the aerosolization of infected material.
• Use approved hospital/mortuary-grade disinfectants that kill coronavirus and other infectious agents. Pay close attention to “contact time.” Contact time is the time the manufacturer suggest that the disinfectant remain moist on the surface before you wipe it off. Failure to follow manufacturer suggested contact times may result in improper and adequate disinfection.
• Properly doff (remove) all PPE (internet search the proper sequence!).
• Immediately wash your hands.
• Post embalming monitoring of the remains, especially if there is a delay in the final disposition.

As COVID-19 is a new infection, embalmers have questions as to the type of arterial fluid and the proper arterial solution concentration to be used for embalming these cases. There is no scientific research that addresses these specific questions; therefore, one must look to the standards of care for the funeral profession for guidance. Deaths related to COVID-19 may be similar to other diseases like TB and may also include organ and tissue damage. One must also consider that the disposition date may be many weeks from the date of embalming. Strong embalming solutions (approximately 5.75%) were required during and immediately after the influenza pandemics of 1918 and 1919.5 Unfortunately back then, chemicals were not as advanced as today and formaldehyde gray was expected as the outcome. Today, chemical companies have far advanced the science of embalming chemicals and outcomes do not have to be like those in 1918. Embalming standards of care have indicated that a minimum of a 2.0% diluted arterial solution is the minimum required dilution to properly begin to sanitize and preserve tissues from a dead body.6,7,8 Due to the infectious nature of COVID-19 and the possible delay in time between embalming and disposition, a stronger than normal index arterial fluid and concentration of arterial solution to be injected is recommended. The exact arterial fluid index and concentration of arterial solution to be injected is solely at the professional judgment of the embalmer; however, prudent practice would suggest a higher index and concentration than normal. U.S. Military protocols that expect delays to disposition generally require no less than a 3.0% diluted arterial solution for normal cases.9 Another reference to embalming concentration in the Mayer embalming textbook is a selected reading that, while dated (1989), offers insight into professional opinion on the minimum arterial solution concentration of at least a 3.0% for infectious disease cases.10 These guidelines may be a more realistic minimum and a starting place for the embalmer facing a COVID-19 embalming case.

As mentioned earlier, cavity aspiration and treatment should be performed with care. Aerosolization of infected material is highly possible during the hydro-aspiration process. Due to the infectious agent within the body, aspiration of the cavities should be performed as soon after arterial injection as possible. Following aspiration, the cavity should be treated with a minimum of two, sixteen-ounce bottles of a high index cavity fluid. Like with any case where there may be a delay in disposition, the deceased should be checked frequently and the cavity may need to be re-aspirated and re-treated with additional cavity chemical, as needed. As embalmers in the northern United States understand, a mold inhibitor may need to be topically applied, especially if there is a long delay in disposition and the deceased is placed in refrigeration or a damp storage area. Additionally, with any case where there is a delay in disposition, post-embalming monitoring of the deceased is very important. The embalmer should inspect the embalmed remains for signs of: softening of tissues that require re-embalming, purge, odors, leakage, insects/maggots, tissue gas, and dehydration.

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All of the previous information relates to a decedent that did not have an autopsy. In the case of an autopsy where the thoracic cavity was examined, the lungs should be removed. Great care should be taken to disinfect the entire body and especially the cavities with a hospital/mortuary grade disinfectant – the same method as the embalmer would for the nasal/oral cavities in the un-autopsied case. Additionally, great care should be taken when treating viscera that contains the lungs and other infected materials. In either an autopsied or un-autopsied case, follow CDC recommendations for disinfection and proper disposal of the body bags in which the deceased is transferred to the funeral home.

In conclusion, short of any directive from the CDC or other governmental agency that specifically prevents the embalming of a COVID-19 related death, embalming, when done according to CDC guidelines and approved professional standards of care, can be performed. Embalming and delayed disposition are an option for families to properly memorialize their dead at a future time when COVID-19 infection has safely passed. An added layer of preservation for funeral homes is also refrigeration after embalming. Refrigeration after embalming may provide an extra layer of security until the time of memorialization and final disposition. Like the military who are trained for their moment of war, embalmers have been trained for this moment of invisible war – the sanitary embalming of those who have died from COVID-19. Using CDC protocols, proper PPE, standards of care, previous training and experience, and good common-sense practices, safe embalming of COVID-19 deaths is possible so that families can have meaningful closure in the future.

References:

1. Mayer, R. (2012). Embalming history theory and practice. 5th edition. McGraw Hill Medical:

New York.

1. Davidson, S. and Benjamin, W. (n.d.). Risk of infection and tracking of work-related infectious

diseases in the funeral industry. Selected reading, p. 647. Embalming history theory and

practice. 5th edition. McGraw Hill Medical: New York.

1. Gammage B, Moore D, Copes R, Yassi A, Bryce E. (2005). Protecting health care workers

From SARS and other respiratory pathogens: A review of the infection control literature.

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American Journal of Infection Control; 2005; 33:114-121.

1. Davidson, S. and Benjamin, W. (n.d.). Risk of infection and tracking of work-related infectious

diseases in the funeral industry. Selected reading, p. 648. Embalming history theory and

practice. 5th edition. McGraw Hill Medical: New York.

1. Mayer, R. (2012). Embalming history theory and practice. 5th edition. P. 126. McGraw Hill

Medical: New York.

1. Mayer, R. (2012). Embalming history theory and practice. 5th edition. McGraw Hill Medical:

New York.

1. Ennis, J. (2016). Embalming standards of care. Author: KDP Publishing.
2. Ennis, J. (2018) Embalming and renal failure: A silent danger for embalmers. Author: KDP

Publishing.

1. Mayer, R. (2012). Embalming history theory and practice. 5th edition. Pp. 611-612. McGraw

Hill Medical: New York.

1. Mayer, R. (2012). Embalming history theory and practice. 5th edition. Pp. 610-611. McGraw

Hill Medical: New York.

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