It’s 2 PM, and your next appointment is a newly adopted 3-month-old mixed breed puppy presenting with lethargy. Upon examination and further history, you discover that the puppy has also been having bloody diarrhea and vomiting for the past two days. Due to unknown vaccination status and clinical signs, you run a parvo test… and it’s positive. Unfortunately, you and your assistant are contaminated by now, and so is your lobby. To limit further contamination, you ask for a gown and gloves. Unfortunately, the hospital doesn’t have gowns, so you need to make do with what you have.
What would you do? What could you have done differently? What do we do when we don’t have the necessary Personal Protective Equipment (PPE) available? Let’s talk PPE! And what to do if you don’t have it!
Types of PPE
If you want to get official, there are several levels of PPE – Levels A – D. Since Self Contained Breathing Apparatus is a tad overkill for everyday practice, we’ll be focusing primarily on Level D. If you are interested in learning all the different levels, they can be found at the American Veterinary Medical Association’s Personal Protective Equipment page. 1
In practice, commonly used (Level D) PPE ranges from our radiology protective gear to safety glasses, gloves, and lab coats. Frequently used PPE includes scrubs, gowns, gloves, masks, bouffant, and booties. As a relief veterinarian, you may not have the same PPE available every day. When arriving at a new hospital, asking what PPE is available and what protocols the hospital follows for infectious diseases will make things easier if a case arises.
Who are You Protecting?
Another crucial part of PPE is knowing who you are protecting. Are you protecting other patients? Are you protecting this patient? Are you protecting yourself? All the above? The answers will help you determine what PPE to wear and when it’s needed.
Situations for protecting “other” patients include a plethora of infectious diseases such as canine parvovirus, Canine Infectious Respiratory Disease Complex (CIRDc), or dermatophytosis. Situations to protect “this” patient include patients with suppressed immune systems, like those going through chemotherapy, puppies and kittens that haven’t received any vaccinations, or pregnant queens and bitches. Don’t forget to protect yourself and your team from zoonotic risks as well, such as leptospirosis, ringworm, giardia, etc.
Another thing to consider – what are you doing with the animal – walking a dog with CIRDc vs. looking at a dog with CIRDc on the table are two very different things. A gown may be perfectly appropriate with a dog on the table. If you are walking next to the dog on the ground, the gown may only cover above your knees, leaving the rest of your leg open to exposure of becoming a fomite. Keep this in mind when handling other patients throughout the day. If you had your legs exposed to a CIRDc patient, conducting the next puppy appointment on the table is safer, even though we all love a pile of puppies on our lap.
What to Wear
No day in vet medicine is ideal, but if you had your choice of PPE, the following chart might help guide you as you decide what to wear.
What If You Don’t Have It?
Not every hospital has full PPE readily available. What do you do if you don’t have PPE readily available? Do you have to risk it? NO! Get creative. Think through each disease and situation to determine how best to prevent further disease transmission.
- Prevent contamination before it happens – When you go through your schedule at the beginning of each shift, see if any red flags stand out – a puppy with bloody diarrhea, a coughing dog, etc. Check in with the team beforehand to see if they have a plan in place already. If not, most teams are happy to accommodate some adjustments to decrease the risk of contamination. Run that parvo test car-side instead of inside. Conduct exams out of the back of a car for suspected upper respiratory infections. Most of the time, the teams love it because it prevents bringing in an infectious disease that increases their time disinfecting the hospital.
- Get curious about screening questions – Ask teams what their screening questions are. Maybe ask them to add one or two more comprehensive questions while you are there or simply query the owner yourself before handling the patient. Remember to meet teams where they are and adjust yourself as needed. You’re there to help, not take over the practice.
- Be prepared – You can do many things to prepare for these situations.
- Always have a change of scrubs +/- lab coat in your car. Ideally, have a change of street clothes to change into after your shift, too, to prevent bringing diseases home to your family.
- Keep a trash bag in your car to stash exposed or contaminated gear and clothing to prevent your vehicle from becoming a fomite.
- Consider having a stash of disinfecting supplies or even PPE if you have a high-risk family member (fluffy or human) at home. As a veterinarian, you may be able to get your own account with a distributor depending on where you live. (Personally, I keep a change of scrubs, mask, hand sanitizer, some Rescue wipes, and a change of street clothes, including shoes, in my car so I don’t bring any infectious disease home to my own dogs.)
Ok, it’s happened. You have a possible infectious disease appointment and little to no PPE available. Here are a couple of options to consider when in this situation.
- Gloves – Hopefully, you will have gloves available, but if not, pay very close attention to proper hand hygiene and increase frequency!
- REMINDER: Even if you do have gloves – Gloves are not a substitute for proper hand hygiene!!!!! Check the video here for a refresher.
- Gowns/Coveralls – Lab coats, cloth surgical gowns, change of scrubs, and even trash bags work in a pinch. For trash/cadaver bags, cut out holes for your arms and head, and you are good to go!
- Masks – Cloth is great if you don’t have surgical masks available. Most of us have masks for COVID-19 readily available; stash a couple extra in your bag.
- Booties – Heavy-duty trash or cadaver bags can be secured with tape around your ankles (Caution: These can be slippery!) Consider bringing a change of shoes if that is an option.
Don’t forget how to Don/Doff properly!
- A final note on donning/doffing PPE; order matters! Take a minute to remind yourself how to don and doff properly. No matter what PPE you have available, if donned/doffed improperly, it can be just as bad as not wearing any at all. The table below is based on the American Animal Hospital Association Sequence for Donning and Doffing Personal Protective Equipment (PPE). 4
- Ask what PPE is available and what protocols the hospital follows – before you need it.
- Be curious about the hospital’s screening questions and add your own if needed.
- Be flexible and creative! If you don’t have the ideal PPE, get creative and do the best you can to protect your patients, yourself, and the team.
- Be prepared! Always have an extra pair of scrubs in your car.
- Order matters! Don and doff properly!
- Share your #ppefitcheck!
Colleen Shockling, DVM, MPH, DACVPM is a lecturer, researcher, free-lance writer, preventive medicine specialist, public health professional, Associate IndeVet, and dog mom of two.
More from IndeVets:
- American Veterinary Medical Association. “Personal Protective Equipment (PPE)”. American Veterinary Medical Association, 11 2022, https://www.avma.org/personal-protective-equipment-ppe.
- “Anderson et al. – Infection Prevention and Control Best Practices.Pdf.” Accessed November 11, 2022. https://www.wormsandgermsblog.com/files/2008/04/CCAR-Guidelines-Final2.pdf.
- Hand-Washing Steps Using the WHO Technique, 2019. https://www.youtube.com/watch?v=IisgnbMfKvI.
- “Sequence for Donning and Doffing Personal Protective Equipment (PPE).” Accessed November 11, 2022. https://www.aaha.org/aaha-guidelines/infection-control-configuration/protocols/personal-protective-equipment/.