Hospitals in Canada and around the world have taken huge steps in recent months to limit the exposure of medical personnel to patients with COVID-19. They have set up special services for COVID patients. They switched to medicine by phone and video. They have done everything in their power to stop the spread of the disease before it occurs – by limiting direct contact between patients and medical staff, and by providing doctors, nurses and technicians with protective equipment.
But some procedures simply cannot be done remotely. In medicine, some work must be done closely. One of the critically endangered COVID-19 patients is intubation.
Doing it properly and safely is literally a matter of life and death
Doctors say it’s probably the only riskiest COVID-19 procedure anyone is doing right now. It involves close contact with the main vectors of the disease: the mouth, nose and eyes. To intubate, doctors, nurses, and respiratory therapists must approach a very sick patient, insert a tube into their throat, and stuck in a potential blizzard of viral droplets until the procedure is complete.
For medical personnel right now, doing it right, doing it quickly, doing it cleanly and safely is literally a matter of life and death. This is why Trillium has set up a team dedicated to the airways. Their job during the pandemic was to carry out all COVID-19 intubations. Their aim is both to centralize expertise – more representatives lead to cleaner and faster executions – and to limit staff exposure. “I am so proud of everyone who volunteered to be part of this team,” said Dr. Ivan Cacic, anesthesiologist and medical director of medical affairs for Trillium.
On Friday, the hospital invited a National Post photographer to the hospital to attend a simulated intubation. Cacic and Dr. Tejinder Chhina, an anesthesiologist, then guided a reporter through the steps the team takes to intubate a patient.
The whole exercise went as a well-made effort to create calm out of chaos. Everything was planned. Everything was practiced. Everything has been checked and checked again. “This is all done so that we can lower the cognitive load during the situation,” said Cacic. “We don’t want to think about too many things. “
An airway team consists of four main members: an anesthesiologist, a registered nurse, a respiratory therapist and a safety officer. At the start of a typical day, the team huddles with staff who leave their positions, and then performs a simulation together as a group. “The key to this team is coordination,” said Chhina. They want to make sure, on each shift, that everyone knows everyone and that everyone works from the same script.
They try to contain, as best they can, what Chhina said is normally “an uncomfortable or unorganized environment”.
When the team receives a call, usually from the intensive care unit or the emergency room, they go through a procedure that, at this point, must be well drilled. They first go through a checklist to make sure they have the right equipment, which at that point should be split between two carts. To intubate, they will need medication, including induction agents and paralyzers, personal protective equipment (PPE), an endotracheal tube, and a video cart that can show them what they are doing in real time. .
Once the decision to intubate is made, they begin what Chhina calls donning PPE. Under the supervision of the safety officer, the three other members of the team each put on new gloves, a new gown, an N95 mask (the masks used for the simulation are of inferior quality) and a face shield. The security officer then checks each staff member for breaches or openings before allowing them to proceed. Once the doctor receives the “go” sign, the team breaks the ground in the secure room and intubation begins.
If someone else is in the room at that time, they will be asked to walk away from the patient. The team begins to administer oxygen. They check the patient’s vital signs and, when ordered by the doctor, when everything is ready and all the equipment is in place, they administer the induction and paralytic agents and insert the tube into the patient’s trachea. “We then detonated the cup, which is that balloon at the end of the windpipe,” said Chhnia. “We are blocking this. We confirm that we are in the right place. And after all these checks, we place the patient on the ventilator. “
If all goes well, it should only take a few minutes from the time they break the field until the patient is on the ventilator. It often takes them longer to “withdraw” or withdraw their PPE than to perform the procedure itself. At that point, the security guard takes over and makes sure everyone follows the plan.
The team has seen a steady increase in demand over the past few weeks. The patients they see are seriously ill or exhausted and in desperate need of oxygen. For the Airway team, cases tend to get muddled. It’s by design. “We want a repeatable process,” said Chhina.
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