Can we drop the spacesuits yet & slip into something more comfortable?
This week I did some reasonably “normal” operating: caesarean sections, a couple of urgent general surgery cases, and some urgent gynaecology. Because the caesareans were done under regional anaesthesia they didn’t count as being “aerosol generating procedures” and so we proceded as normal, just with a facemask, apron and gloves, and of course the usual hand hygiene precautions.
Our guidelines currently require us to treat anyone having an “aerosol generating procedure” such as endotracheal intubation as being covid positive. Which is why some other cases are being treated with everyone in full PPE, a 20 minute break after the anaesthetist secures the airway, and another 20 minute pause at the end when the airway is removed, before the patient is recovered in the operating theatre.
This means that even the shortest procedure takes two to three hours out of the operating theatre, and we can get through only a fraction of the work we managed before. This is mirrored in operating theatres up and down the country, and the vast majority of the patients we are treating in this way have no symptoms of coronavirus, and often have a negative swab test already.
Unless we triple the size of our workforce we cannot continue like this if we want to have any chance of keeping up with our non-urgent work of hip replacements, hernia and haemorrhoid repairs. It’s also important that the longer we leave them the more disability these conditions cause, and many of them turn into surgical emergencies. We are causing active harm by not operating on non-urgent patients.
How do we keep our staff safe though? We have looked after healthcare workers on our makeshift intensive care units nationwide, and everyone is understandably nervous, and the PPE precautions provide us with reassurance and a feeling of safety. It’s going to take a brave person to announce that we don’t need them anymore.
The classifications of what is and what isn’t an “aerosol generating procedure” is something I find interesting, and much of it isn’t based on much evidence, just opinion. It’s important to remember that one of the biggest aerosol generating procedures is a cough – these can happen anywhere, and coughing is not in the PHE guidelines.
Although tracheal intubation is in the guidelines, I think there needs to be a distinction here between intubating someone with florid covid pneumonia vs intubating someone for planned surgery who is essentially asymptomatic and often has a negative swab. In the latter case, the patient does not have a cough, and even if they have asymptomatic disease, they’re unlikely to be shedding much virus. Many of these patients will already have had a negative test, and with our clinical assessment as being low risk it is obvious (at least to me) that treating all these as positive is entirely illogical.
Nothing is ever completely safe, and during my career I must have put myself in danger multiple times from intubating patients with TB and other communicable diseases, yet we didn’t wear FFP3 masks for everyone then. As cases continue to fall there comes a time we must decide that the risk to us and our patients of wearing the full spacesuit is greater than the benefit from it. This may be different in different regions – for instance London, the peak of the pandemic in April, now has the greatest reduction in cases. The reason for this is unknown, but I wouldn’t be surprised if we have wildly underestimated *quite* how many of us had the virus in February and March, when you couldn’t get a test for love nor money.
It is also important to keep in mind that the full spacesuit is not only uncomfortable, but leads to dehydration, pressure sores and overheating in the wearer. It also makes all the behaviours that are essential to surgical safety really difficult. Effective communication is hard, teamwork becomes very tricky, and diagnosing and managing unexpected emergencies becomes much much more difficult.
I know we’ve been inundated with guidelines during this crisis, but here I think we need some. But not risk-averse blanket guidelines that treat every region, every hospital the same. We need flexible, pragmatic guidelines that take account of the real harm we are causing our patients. We need to take account of how much virus there is in the local community and adjust our response to that, particularly now we are seeing so much regional variation. We also need to be mindful that some of our high risk members of staff may be more reassured by continuing to wear a higher level of PPE, but also allow others to perform their own risk assessment and reduce their own PPE level, while keeping their colleagues safe.
In medicine there is always risk, nothing is ever completely safe, and the “safe approach” may not be the safest way forward. We need to be flexible, responsive and respectful to our colleagues and our patients.