Examining patients - to glove or not to glove...

[CuriousGeorge2]

So, a few patient encounters had me grossed out recently (ex. examining a patient's foot when they had a pretty bad fungal infection + toe jam + a bunch of dead skin, palpating axillary lymph nodes in a patient who probably hadn't bathed in weeks, LE neuro exam on a patient who had episodes of explosive diarrhea with residual fecal matter all over their legs) and I was wondering if you guys use gloves for these types of situations. I didn't use gloves for any of the above mentioned encounters - I performed these exams in front of attendings and was honestly "afraid" to put on any gloves or even suggest it, b/c I haven't seen attendings use gloves except for rectals/ pelvics. I know that not every patient encounter is going to be pristine, but some things gross me out more than others and I'd prefer to use gloves in some situations if it's acceptable. Is it okay to use gloves when examining these patients? Will it offend the patients? Will it look unprofessional to the residents and attendings?

Am I just being a germophobe? What are your guys experiences?

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[Dwindlin]

I would have definitely gloved for all of those scenarios. I really can't imagine attendings/residents caring if you glove up for an exam, I know none if mine would ever care.

 

[username456789]

So, a few patient encounters had me grossed out recently (ex. examining a patient's foot when they had a pretty bad fungal infection + toe jam + a bunch of dead skin, palpating axillary lymph nodes in a patient who probably hadn't bathed in weeks, LE neuro exam on a patient who had episodes of explosive diarrhea with residual fecal matter all over their legs) and I was wondering if you guys use gloves for these types of situations. I didn't use gloves for any of the above mentioned encounters - I performed these exams in front of attendings and was honestly "afraid" to put on any gloves or even suggest it, b/c I haven't seen attendings use gloves except for rectals/ pelvics. I know that not every patient encounter is going to be pristine, but some things gross me out more than others and I'd prefer to use gloves in some situations if it's acceptable. Is it okay to use gloves when examining these patients? Will it offend the patients? Will it look unprofessional to the residents and attendings?

Am I just being a germophobe? What are your guys experiences?

All three of those scenarios would dictate the use of gloves, I would say. Perhaps I'm biased as a derm guy, but if there's any question about something communicable/infectious or just plain "gross" to you, it's a good idea to wear gloves. No attending should look down on you or make fun of you, and it should definitely not offend the patients. If any patient ever says anything to you about it, simply explain that the gloves are there to protect them from you and you from them. But seriously, I can't think of any incident in the past where a patient seemed offended that I gloved up.

That said, I don't generally glove up for routine physical exams (even routine skin exams, which involve a lot of touching). Obviously exercise discretion, and if a patient has been lying in a bath of their own feces, is otherwise visibly soiled, or has gaping prurulent wounds or the like, don a pair of gloves.

 

[Law2Doc]

...
That said, I don't generally glove up for routine physical exams (even routine skin exams, which involve a lot of touching). Obviously exercise discretion, and if a patient has been lying in a bath of their own feces, is otherwise visibly soiled, or has gaping prurulent wounds or the like, don a pair of gloves.

Always glove. Always. Patients don't care, and attendings understand. It usually takes someone you know getting scabies from pretty benign looking patient before you appreciate the importance of this.

 

[San Marzano]

Always glove. Always. Patients don't care, and attendings understand. It usually takes someone you know getting scabies from pretty benign looking patient before you appreciate the importance of this.

This. It is called "personal protective equipment" because it protects you.

As an added benefit, it helps patients. You won't be much help to your patients if you come down with MRSA/influenza/c. diff/etc. These bugs aren't always obvious on physical exam. Protect yourself= protect your patients.

 

[45408]

If in doubt, put gloves on. Plenty of my attendings have done disgusting things without gloves (picking at wounds, touching a dirty patient's feet, checking a femoral pulse in a really obese patient with poor hygiene).

If it's moist, wear gloves. If it's infected, wear gloves. If you can't see your hand while you're palpating something, wear gloves.

 

[Law2Doc]

This. It is called "personal protective equipment" because it protects you.

As an added benefit, it helps patients. You won't be much help to your patients if you come down with MRSA/influenza/c. diff/etc. These bugs aren't always obvious on physical exam. Protect yourself= protect your patients.

Pretty much everyone working in a hospital carries MRSA and an assortment of microbes as his personal arsenal of flora that he can pollinate from patient to patient, so remember that gloving protects the patient from you as much as the other way round too. Glove.

 

[joeDO2]

Agree with what everyone has said so far. Gloves are a must in the hospital.... remember to gel/wash before and after every time also.

 

[ztaw15]

One thing you pick up on quickly after starting clinical rotations is that no one is going to look out for you regarding this issue. Attendings/Residents generally see you as an adult, and let you make your own decisions. They will, however take steps to protect the patient - but usually not you. Plus as mentioned, many attendings/residents will do some incredibly disgusting things without gloves - I have seen them touch open wounds, do pelvics/speculum exams with only one glove (poor idea), clean wounds and do abscess debridement without faceshield (only takes one bad episode to change your mind here), and do deliveries without maks/faceshield (again, only one bad time needed to change your mind here).

And ancillary staff, who are generally much more concerned with "following the rules" then we are, will see you as "the doctor" and thus will not correct you as they normally would their nursing students etc.

If you are going to walk into an isolation room/Tb room without PPE when pre-rounding, odds are no one will stop you or even take notice.

You have got to look out for yourself. Even if your attending touches an open wound without gloves, don't copy them. Yes, it is likely that nothing will come of it, and your skin is a good barrier - if it is intact - but why take the risk?

You are going to do lots of things that inadvertantly offend someone during third year. Wearing gloves is probably not the thing to worry about in this regard.

 

[Rendar5]

If in doubt, put gloves on. Plenty of my attendings have done disgusting things without gloves (picking at wounds, touching a dirty patient's feet, checking a femoral pulse in a really obese patient with poor hygiene).

If it's moist, wear gloves. If it's infected, wear gloves. If you can't see your hand while you're palpating something, wear gloves.

Also may pay to have a pair in your back pocket for emergencies when youre a resident. One of my chiefs ended up delivering a baby barehanded while transporting the pt to L&D

 

[45408]

Pretty much everyone working in a hospital carries MRSA and an assortment of microbes as his personal arsenal of flora that he can pollinate from patient to patient, so remember that gloving protects the patient from you as much as the other way round too. Glove.

The MRSA carrier rate is much lower than you might expect.

Lancet Infect Dis. 2008 May;8(5):289-301.
Health-care workers: source, vector, or victim of MRSA?
Albrich WC, Harbarth S.

There is ongoing controversy about the role of health-care workers in transmission of meticillin-resistant Staphylococcus aureus (MRSA). We did a search of the literature from January, 1980, to March, 2006, to determine the likelihood of MRSA colonisation and infection in health-care workers and to assess their role in MRSA transmission. In 127 investigations, the average MRSA carriage rate among 33 318 screened health-care workers was 4.6%; 5.1% had clinical infections. Risk factors included chronic skin diseases, poor hygiene practices, and having worked in countries with endemic MRSA. Both transiently and persistently colonised health-care workers were responsible for several MRSA clusters. Transmission from personnel to patients was likely in 63 (93%) of 68 studies that undertook genotyping. MRSA eradication was achieved in 449 (88%) of 510 health-care workers. Subclinical infections and colonisation of extranasal sites were associated with persistent carriage. We discuss advantages and disadvantages of screening and eradication policies for MRSA control and give recommendations for the management of colonised health-care workers in different settings.

 

[Siggy]

When in doubt, follow the following tried and true cliche.

No glove, no love.

 

[Law2Doc]

The MRSA carrier rate is much lower than you might expect.

MRSA is a lot heartier and more prevalent now than when they started gathering data (1980!) in that study, and youd also need to account for geographic prevalence -- big hospitals in big cities will have higher MRSA rates due to population density, and more antibiotic abuse, I would think. Given those limitations, the percentage they cited is still not negligible -- 5% not such a small number when you have more than a dozen healthcare workers coming into your room daily. FWIW, the several residents I've known who have been swabbed were colonized so I have to think prevalence is simply higher these days.

 

[Whiskeypunch]

Wow, I didn't even know it was a thing that people didn't wear gloves. When I was shadowing the doc's would use the antibiotic stuff on their hands and then put on a new pair of gloves for every single room.

 

[VenusinFurs]

I don't always glove when touching feet that don't look too gross, but I probably should. I just really have trouble palpating things like pulses, lymph nodes, etc with gloves on.

I always glove if there's blood or poopy or if I have to touch the pubic region at all.

 

[Oxer45]

I don't always glove when touching feet that don't look too gross, but I probably should. I just really have trouble palpating things like pulses, lymph nodes, etc with gloves on.

I always glove if there's blood or poopy or if I have to touch the pubic region at all.

Better to develop your palpating skills with your glove on. I started doing it after I saw my first MRSA neck abscess on a healthy skinny 30y/o man (non HIV pt). I realized if he could get it, I could get it too. (before I was more cavalier. I used to think only old people w/ comorbidities get crazy infections)

 

[Law2Doc]

Better to develop your palpating skills with your glove on. I started doing it after I saw my first MRSA neck abscess on a healthy skinny 30y/o man (non HIV pt). I realized if he could get it, I could get it too. (before I was more cavalier. I used to think only old people w/ comorbidities get crazy infections)

You actually see neck stuff now and then on healthy healthcare workers just from contact with the infected tubing of stethoscopes, so not a bad idea to wipe that down periodically. Yes, you can catch stuff, so do wear gloves.

 

[FutureInternist]

You actually see neck stuff now and then on healthy healthcare workers just from contact with the infected tubing of stethoscopes, so not a bad idea to wipe that down periodically. Yes, you can catch stuff, so do wear gloves.

I always glove the end of the stethoscope as well !

 

[ucsfstudents]

Just use gloves. Make it a habit.

 

[Top Gun]

When in doubt, glove. No one will ever fault you for doing it. You know the old adage, better safe than sorry.

 

[OveractiveBrain]

So, a few patient encounters had me grossed out recently (ex. examining a patient's foot when they had a pretty bad fungal infection + toe jam + a bunch of dead skin, palpating axillary lymph nodes in a patient who probably hadn't bathed in weeks, LE neuro exam on a patient who had episodes of explosive diarrhea with residual fecal matter all over their legs) and I was wondering if you guys use gloves for these types of situations. I didn't use gloves for any of the above mentioned encounters - I performed these exams in front of attendings and was honestly "afraid" to put on any gloves or even suggest it, b/c I haven't seen attendings use gloves except for rectals/ pelvics. I know that not every patient encounter is going to be pristine, but some things gross me out more than others and I'd prefer to use gloves in some situations if it's acceptable. Is it okay to use gloves when examining these patients? Will it offend the patients? Will it look unprofessional to the residents and attendings?

Am I just being a germophobe? What are your guys experiences?

If its gross looking, glove

If its not, don't glove.

I've found it amusing to watch students glove up, then try to feel the temperature gradient in a person with an acutely thromboses artery (FAIL). Even more amused when they have tried to percuss an abdomen or, worse, a back. "I dont hear anything" Well I do, the sound of your gloves banging together. If you want to do an ACTUAL physical exam, that is, you want to gleam knowledge that adjusts your differential from your physical exam, do not wear gloves. That tactile, temperature, and general sensation is EXTREMELY limited when wearing gloves.

If you are doing a cursory exam (doing it becasue the patient expects it or because you are just going through the motions), or the exam is with your EYES and is GROSS then do glove. Im not touching nasty candidal fungus or getting near a wound with my bare skin. What if that laceration is
actually herpes? I mean seriously. Rashes, fungus, or grossness, gets a glove.

When in doubt, glove. No one will ever fault you for doing it. You know the old adage, better safe than sorry.

I wont fault you for wearing a glove, but I sure will make fun of you for trying to look like you know what you're doing while wearing gloves.

 

[Top Gun]

I wont fault you for wearing a glove, but I sure will make fun of you for trying to look like you know what you're doing while wearing gloves.

I wasn't saying to glove in EVERY situation. I would hope that everyone (attendings, residents, med students) is capable of using common sense when deciding whether to glove or not. Obviously if you have to check temperature gradient, or percuss, or whatever, and the area looks relatively clean, then you might be better off not gloving. If however, you are touching some orifice or some nasty looking lesion like a rash or fungal infection, then you'd damn well better glove. All I meant was that if you see a situation where you think it might be a good idea to glove (such as the scenarios I mentioned above), then do it. Exercise discretion.

 

[LabMonster]

If in doubt, put gloves on. Plenty of my attendings have done disgusting things without gloves (picking at wounds, touching a dirty patient's feet, checking a femoral pulse in a really obese patient with poor hygiene).

If it's moist, wear gloves. If it's infected, wear gloves. If you can't see your hand while you're palpating something, wear gloves.

Universal precautions. Wash hands, shake hands, glove, examine, deglove, wash out and you're good.

There is a cadre of "old-school" folks who will touch body fluids, soiled materials etc... You know about HepC right? Keep it clean - no patient will think it's funky. They'll think you were protecting their safety - and you are, while primarily managing your own health.

 

[Lactobacillus]

Definitely gloves, more-so for infection control. No one wants to carry around C. diff after fecal proximity. Not saying the pt had C. diff but take extra precaution when dealing with those potential situations. I've been following up with a pt, potentially TB+, and I wore gloves every time (confirmed negative as of today).

 

[Lactobacillus]

I meant to add that routine exams aren't necessary with proper hand washing (a given).

 

[OveractiveBrain]

I meant to add that routine exams aren't necessary with proper hand washing (a given).

Use the edit function. Replying a second time implies you really wanted a different message the second time. Seriously. Forum edicate! (see. I edited. I meant edicate)

 

[greatnt249]

Definitely gloves, more-so for infection control. No one wants to carry around C. diff after fecal proximity. Not saying the pt had C. diff but take extra precaution when dealing with those potential situations. I've been following up with a pt, potentially TB+, and I wore gloves every time (confirmed negative as of today).

Ideally, if a patient is suspected to have C. diff, there should be contact precautions already in place per hospital policy (gown & glove).

 

[Law2Doc]

Ideally, if a patient is suspected to have C. diff, there should be contact precautions already in place per hospital policy (gown & glove).

I can't tell you how many times the cultures and swab results have come back AFTER a team has already seen the patient. I've seen them put up contact precaution signs tons of times as I am walking out of the room having already examined the patient. It's stupid to rely on signs -- the patient is always non contact until the lab results come back, and by then he could have been examined several times. Glove up for everyone. Saying use your hands if an area on a patient "looks clean" is silly. How good are your eyes that you can see microscopic organisms? Please.

 

[cpants]

I can't tell you how many times the cultures and swab results have come back AFTER a team has already seen the patient. I've seen them put up contact precaution signs tons of times as I am walking out of the room having already examined the patient. It's stupid to rely on signs -- the patient is always non contact until the lab results come back, and by then he could have been examined several times. Glove up for everyone. Saying use your hands if an area on a patient "looks clean" is silly. How good are your eyes that you can see microscopic organisms? Please.

A lot of places put contact precautions in place as soon as a cdiff assay is sent, and they can't come off until it comes back negative.

Whoever said you can't percuss with gloves on, that's nonsense. With the exception of trying to figure out minor temperature gradients (how often do you need to do that?), pretty much the whole physical exam can be done competently while gloved. Yes you lose something in tactile sensation, but you don't lose anything important. Medicine is a game of risks and benefits. In this case the benefits do not approach the risks to patient or provider. You lose something in tactile sensation with a condom too...

 

[calvnandhobbs68]

A lot of places put contact precautions in place as soon as a cdiff assay is sent, and they can't come off until it comes back negative.

Whoever said you can't percuss with gloves on, that's nonsense. With the exception of trying to figure out minor temperature gradients (how often do you need to do that?), pretty much the whole physical exam can be done competently while gloved. Yes you lose something in tactile sensation, but you don't lose anything important. Medicine is a game of risks and benefits. In this case the benefits do not approach the risks to patient or provider. You lose something in tactile sensation with a condom too...

That's why I never use em.