The March 2020 Trauma MedEd Newsletter: Coronavirus and Trauma Professionals

Welcome to the current newsletter. I am releasing this to nonsubscribers early due to the relevance of the information it contains.

Topics covered include:

  • Guidance from the American College of Surgeons
  • COVID-19 and the trauma surgeon
  • Coronavirus and your trauma service
  • Coronavirus and the trauma team
  • CT scan safety and the coronavirus
  • Changing trauma rounds for coronavirus safety
  • Coronavirus and your massive transfusion protocol (MTP)

The April issue will be released next month and will be a followup to this one. I’m sure we will learn quite a bit about the virus and our response to it in the ensuing month.

And please send me your comments, updates, or tips you have found helpful at your hospital! I’ll include them in the next newsletter.

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME202003.

 

Topic For The Next Trauma MedEd Newsletter: Coronavirus

Due to the high level of interest in all things Coronavirus that are related to trauma, I’ve changed the topic for the next Trauma MedEd Newsletter. The focus will now deal with this virus in detail.

As you know, I have already written a few posts on this topic over the last week. I’ve now retasked the next newsletter issue to share my thoughts on the virus and its impact on trauma professionals.

Topics will include:

  • Coronavirus and your trauma service
  • Coronavirus and the trauma team
  • CT scan safety and the coronavirus
  • Changing trauma rounds for coronavirus safety
  • Coronavirus and your massive transfusion protocol (MTP)
  • And more!

As always, this month’s issue will go to all of my subscribers first, in just a day or two. If you are not yet one of them, click this link right away to sign up now and/or download back issues.

Non-subscribers can pick up this issue when I release the issue on the blog this coming weekend. So sign up now!

How To MacGyver A Ventilator From Common Parts

A cardiac anesthesiology fellow, and several engineers from the University of Minnesota and a local device company got together over the past few weeks and cobbled together a ventilator from some spare parts. Here’s a picture to give you an idea of what it looks like:

It uses a metal toolbox tray, an Ambu bag, and some other spare parts lying around one of the medical device labs at the university. Essentially, a servo motor intermittently squeezes the Ambu bag, and there are adjustments for how often (rate) and how deeply (volume) the bag is compressed. There is a pressure limiting device included in the system as well.

This project illustrates how we will need to think outside the (tool)box in the coming weeks, especially as the number of severe Coronavirus cases begins to tax our supply of ventilators. And obviously, this thing will not get FDA approval in your lifetime. But if a choice needs to be made between using something like this in a pinch vs letting someone asphyxiate, the answer is pretty clear.

The group has produced a short YouTube video as well (see below), but it is rather short on details. You get to see some partial views of it as it is being tested on pigs. But so far, the concept is promising.

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Coronavirus: Using One Ventilator To Ventilate Up To Four Patients

It’s unusual for me to post on a Saturday, but we are currently living in unusual times. This tidbit caught my attention and I wanted to get this interesting idea out there for all to think about.

Hopefully, it will never come to this. But there are reports from both Italy and New York City that ventilators are in short supply. This video illustrates the technique used in some research that was actually published way back in 2006. It demonstrated the efficacy of using one ventilator on four patients at once.  It requires just a few connectors that are readily available.

But remember, this is off-label use and is not condoned by the FDA! And it probably violates every Department of Health and hospital policy written. But in a pinch, it is something to think about.

Obviously, there are lots of possible downsides. Four patients are essentially sharing one circuit. Even though the circuits are one-way, there is always an infectious cross-contamination risk. The paper shows that ventilation should be adequate on both pressure and volume control settings.

This type of thing is a very last resort, and hopefully no one will have to use it!

Reference: A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med 13(11):1246-9, 2006.

Coronavirus (COVID-19) And Your Trauma Service

In my last post, I made some suggestions on how to modify the trauma activation process to better protect your team members from exposure to the Coronavirus. Today, I’ll discuss some things you can do to reduce the exposure of your in-house team that provides care for patients.

First off, I’m not going to discuss the obvious things like personal protective equipment, or what to do when performing risky procedures such as intubation or extubation. Those have been covered elsewhere and each hospital has adopted its own standards.

I will be discussing more general concepts that help limit team member exposure to possible contamination or infected individuals. Here are some of my suggestions:

  • Make sure your hospital conserves the resources it needs to be a trauma center. A certain number of ICUs, operating rooms, and floor beds must be reserved for trauma patients. Your hospital should make contingency plans such that if COVID-19 patients are getting close to taking too many beds or other resources, there is an escape valve so they can be diverted or transferred to other non-trauma hospitals.
  • Save your trauma surgeons for things only they can do. Many hospitals have general surgeons on staff in addition to their trauma/critical care surgeons. Remove the trauma surgeons from emergency general surgery / acute care surgery services and concentrate them on the trauma and critical care services. Have the general surgeons cover the other services, and send all idle trauma surgeons home where it is safer. Rotate them through trauma and critical care on a regular basis. Imagine what would happen if you lose 2 or 3 of your trauma surgeons at the same time, and don’t let it happen to you!
  • Eliminate non-essential meetings and conferences. This includes morbidity and mortality conferences, journal clubs, and all educational conferences. These things have to go on the back burner for now and can be re-instituted once things return to normal.
  • Practice social distancing at essential meetings. Certain gatherings are unavoidable, such as care handoffs (“morning report,” and “afternoon check-out”). Reduce the attendees to only those whose input is critical. If needed, they can gather information from other small groups of providers to prepare for the essential meeting. But no more crowded rooms, please.
  • Don’t congregate with other providers unnecessarily. This means outside your office, in the lounge, and in the lunchroom. The usual social norms need to take a back burner to your own safety and health.
  • Use telephone conferencing as much as possible. You will be surprised at how many of these less-than-essential meetings can be handled virtually, or eliminated. One tip, though: print a copy of the agenda for reference. It seems to be more difficult to follow the flow of the meeting (and take/make notes) if you don’t have something you can visually refer to.
  • Redesign your care team. Do you really need your entire team (APPs, residents, nurses) hanging around all day like they usually do? The reality is that the bulk of the work on any trauma service generally takes place in the morning. The rest of the day is spent waiting for incoming trauma patients. Calculate the optimal number of providers based on your service census. Do the morning work, go on rounds (smaller groups, please), finish any post-rounds chores, then send the extras home. And rotate those providers so that some can spend time at home while the others are in-house.
  • Use residents wisely if you have them. They are part of your care team, too, so be sure to minimize their exposure. The previous tip on redesigning the care team applies to them, too. And frequently, they rotate through several hospitals, many of which are not doing elective surgery. So they may not have a lot to do. Work with the residency program director to see if you can temporarily add them to the trauma center coverage pool. This allows you to keep a larger number of residents at home while maintaining a reasonable number for your care team.

In my next post, I’ll cover changes you should consider in your Massive Transfusion Protocol.