3.3 PPE Selection and Exposure Control

Standard precautions and body-substance isolation

Standard precautions (also called body-substance isolation, BSI) is the practice of treating every patient's blood, body fluids, secretions, non-intact skin, and mucous membranes as if they are infectious — regardless of the patient's known diagnosis. This is the fifth required component of scene size-up, and on the EMR exam it is a decision you make before contact, not a reflex you remember afterward.

Personal protective equipment (PPE) is the physical barrier that delivers standard precautions. The right PPE matches the expected exposure, so read the stem for the cue:

• Gloves — any anticipated contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated surfaces. This is the default for nearly every patient.
• Eye and face protection (goggles or a face shield) — when splashing or spray is possible: heavy bleeding, vomiting, suctioning support, childbirth, or a coughing patient at close range.
• Mask or respirator — a surgical mask for droplet risk; an N95 or higher respirator for suspected airborne disease (such as tuberculosis) per local protocol. A mask may be placed on the patient as well to limit droplet spread.
• Gown — when large-volume splashing of blood or fluids is likely.
• High-visibility garment — near traffic or machinery (a safety, not infection, control).

Choose PPE from the hazard, then control exposure

Do not wait until after contact to think about PPE. If the stem already says the patient is vomiting, bleeding heavily, coughing, or covered in unknown powder, the PPE decision happens before approach. A very common exam trap is the option that starts the assessment first and dons gloves later when the exposure cue was given up front — that is wrong.

A second trap is treating PPE as a substitute for hazard control. Gloves do not make a chemical spill safe. A surgical mask does not make an oxygen-deficient or smoke-filled space safe. A reflective vest does not stop traffic by itself. When the hazard exceeds basic PPE, the answer is to stage, isolate, and request the appropriate team — fire, rescue, or hazmat — exactly as in the previous section.

Exposure control continues after gloves are on. Keep clean and dirty areas separate. Do not touch your face, radio, phone, steering wheel, or clean equipment with contaminated gloves. Remove PPE carefully so you do not contaminate yourself, perform hand hygiene immediately after, and report any exposure (needlestick, splash to eyes/mouth, contaminated wound) through your local procedure for evaluation. Bag and dispose of contaminated materials per protocol.

The exam may place PPE in pediatric or family scenes — a sick child held by a parent, surrounded by toys and emotional bystanders. That does not remove exposure risk; the same PPE logic applies whether the patient is a child, older adult, pregnant patient, trauma patient, or medical patient. Identify the likely exposure, select PPE before contact, control the scene so contamination does not spread, provide only care that can be done safely, and tell incoming crews about any exposure concerns at handoff.

Doffing order and exposure follow-up

Most exposures actually happen during removal of contaminated PPE, not during care, so the order matters. A practical doffing sequence for gloves, eye protection, and mask is: remove gloves first (the most contaminated item), perform hand hygiene, then remove eye protection and the mask by the straps without touching the front, and perform hand hygiene again. Never reuse single-use gloves, and change gloves between patients at an MCI when feasible. Bag contaminated materials in a biohazard bag and dispose of sharps in a rigid sharps container — never recap a needle or hand a sharp loosely to another responder.

If you do sustain an exposure — a needlestick, a splash to the eyes, nose, or mouth, or contamination of an open wound — the steps are immediate first aid (flush the eyes/mucous membranes with water or saline, wash a wound with soap and water), then notify your supervisor and document the exposure, and finally follow your service's exposure-control plan for medical evaluation, which exists under federal bloodborne-pathogen rules. The exam expects you to know that an exposure is reported and evaluated, not ignored or self-managed.

Worked scenario

You arrive to find a young adult with a deep, spurting laceration to the forearm after breaking a window; blood is pooling and the patient is coughing. The exposure cues are immediate and obvious: arterial-type bleeding (splash risk) plus a cough (droplet risk). Before you touch the patient you don gloves and eye/face protection. You then control the bleeding with firm direct pressure, escalating to a tourniquet if pressure fails, while keeping your face and clean equipment out of the spray.

You avoid kneeling in the pooled blood, and you do not answer your radio with bloody gloves. This is the pattern the exam tests over and over: the exposure cue is in the stem, so PPE comes first, and the right answer never starts hands-on care barehanded when a splash or fluid cue was already given.

Specific takeaways:

• BSI/standard precautions assume every patient's fluids are infectious.
• Gloves are the baseline; add eye/face protection for splash and a mask/respirator for droplet or airborne risk.
• Don PPE before contact when the exposure cue is already in the stem.
• PPE never replaces specialized hazard control for chemical or oxygen-deficient scenes.
• After care: separate clean/dirty, doff carefully, hand hygiene, and report exposures.