The Art of Taking It Off...


I would have never imagined that I would be writing about taking off personal protective equipment (PPE) and certinely didn't think I would be learning about a fella referred to as the 'tiger king',  but here we are in 2020 and I am writing about taking off PPE. I was going to do this as a vlog but really didn’t want to waste the PPE.

This is going to be a quick overview of doffing PPE with the use of illustrations, because I am a visual leaner and I wanted to get this out quickly (I draw faster than I write). Hopefully we are pretty good with putting on the PPE, but honestly how much time was spent on taking it off, PPE that is.

As the PPE requirements change at a rapid rate, this is not going to be an all-inclusive review, just the basics of doffing gloves, goggles, mask and gowns. 

Special thanks to Courtney Graham for allowing me to use the amazing drawing of Sam. 


The sequence for putting on donning PPE should be: 

 Gloves > Gown > Mask > Eye Protection or Face Shield > Gloves 

1️⃣: 🚿👏🏼 or 🥃 👏🏼 

2️⃣: 🧤

3️⃣: 👕




Notice that you will be double gloving. Your second pair of gloves should be pulled over the wrist area of your gown. 


Now we will move on to taking it off…… 

Doffing PPE is much more difficult than it seems, as the risk of inadvertent personnel contamination is high. While doffing PPE it is important to be slow and methodical. Many instituations have facilitated the use of check lists as well as observers to ensure inadevertent contamination does not occur.  

For taking off or doffing PPE the sequence will be: 

Gloves > Gown > Gloves > Eye Protection or Face Shield > Mask  

1️⃣: 🧤

2️⃣: 👕

3️⃣: 🧤

4️⃣: 🥽

5️⃣: 😷


This is Sam. Sam will show you the propper way of doffing your PPE. 


As you remove your first pair of gloves, remember they are contaminated. 

Remove your first glove by grabbing your palm area and begin to pull them off. After they are removed, remove the opposite side by sliding your fingers under the glove and between the gown and peel them off. 


Remove your gown by grabbing the front of the gown and pull it away from your body. As you are pulling the gown forward, turning it inside out into a bundle. 

Remove your second pair of gloves as described above. 

Eye Protection or Face Shield: 

Remove goggles or face shield by grabbing the back of the strap. If you are using eye protection, do not grab the front of the glasses, grab the sides. 


When removing your mask, do not touch the front of the mask, untie the ties or pull the rear band to remove your mask. 

When this is completed, wash your hands! 

Be safe out there and remember there are no emergenices in a pandemic! 



Going Nuclear: Crisis Standards of Care

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Splitting vents, DIYing facemask, and having a blanket DNR are nuclear options that agencies and providers cannot immediatly jump to because there is a shortage or pandemic. Organizations and providers that carte blanche change the standards of care without strong planning and consideration can face serious legal ramifications. The process to develop crisis standards of care takes considerable planning to ensure that the healthcare system can provide reasonable care to limit the morbidity and mortality for the public at large.

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It’s important to be mindful that the experience and resources may vary widely among geographical areas and systems. Noticing that some hospitals within NYC are splitting ventilators doesn’t mean that your agency can do that at this time. Utilize their experience as an indicator to begin discussions and planning on developing and implementing crisis standards of care (CSC). 

Standard of Care Spectrum

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Conventional: capacity states that the space, supplies, and staff are consistent with daily practices operations, business as usual. The goal is to provide individuals with the best care possible.

Contingency capacity is not consistent with daily practices, but is functionally equivalent. Contingency capacity is our disaster triage plans that are implemented when demand exceeds community resources. Currently this contingency capacity would include not transporting low risk COVID-19 patients or reusing PPE.

Crisis capacity states that even the adaptive space, staff, and supplies are not consistent with daily operations, but sufficient to provide care to the population and requires a significant adjustment to the standards of care. Some examples would be utilizing DIY mask, splitting ventilators, or reallocating life-sustaining resources. CSC is an extreme option that cannot be utilized because of fear and is only utilized when the healthcare system is forced to. The goal is to provide the population with the best care possible.

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The spectrum may be in contingency mode while others are in conventional. An example is that your ambulances are staffed but providers are reusing PPE for the cycle.

States, and agencies even within the state, may vary on what stage of the spectrum they are at. The healthcare system should work toward recovery and getting back to conventional standards of care as soon as possible.

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Other Terms

When planning it is important to utilize specific indicators and triggers to enter into CSC. The indicators would could be predictors of change or availability of resources. Triggers are decision points about making adaptations. Developing the appropriate indicators and triggers allows agencies and systems to move between standards of care with the appropriate communication, resources, and legal defense.

5 elements of Crisis Standards of Care

These 5 elements have several associate components to them which are explained in further detail in the Crisis Standards of Care Guidance. Meeting these elements ensures that the CSC are ethical, legal, and consistent across localities and states. To meet these elements the healthcare system needs to develop a consensus among public health, hospitals, EMS, primary care, and healthcare coalitions. Some states may have very clear guidance such as Minnesota.

  1. A strong ethical grounding that enables a process deemed equitable and just based on its transparency, consistency, proportionality, and accountability;
  2. Integrated and ongoing community and provider engagement, education, and communication;
  3. The necessary legal authority and legal environment in which CSC can be ethically and optimally implemented;
  4. Clear indicators, triggers, and lines of responsibility; and
  5. Evidence-based clinical processes and operations.

There are many more resources available at ASPR Tracie and through your state’s public health department. Be tempered in your response. 

Moving to Crisis Standards of Care is by force not by will or fear.

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