Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Since our last episode on Critical Matters,
Speaker: the COVID-19 pandemic has continued to grow exponentially around the world.
Speaker: Today, the United States is becoming the epicenter of the worldwide pandemic, and we are seeing a rapidly increasing number of cases throughout the country, with some areas such as New York, California, and Washington State taking the brunt of these cases.
Speaker: On today's episode,
Speaker: of the podcast, we will continue to talk about COVID-19, but we will focus on personal protective equipment and a lot of the anxieties around the potential lack of proper PPE for frontline clinicians.
Speaker: With a worldwide impact and supply chains affected as they are, it is possible and likely in some places that shortages on PPE will be encountered
Speaker: by clinicians caring for patients with COVID-19.
Speaker: This has created a tremendous amount of anxiety among clinicians, rightfully so.
Speaker: However, I do believe that there's always things that we have under our control that we can apply to mitigate and minimize the risk of ourselves and coworkers contracting the virus at the front lines.
Speaker: And I think it's very important for us to try to differentiate facts from fear
Speaker: and understand the available evidence and comprehend how we can best apply that at the bedside to keep us as safe as possible.
Speaker: In today's episode, I'll share a segment of a webinar that we held with my co-chief medical officers at Sound Physicians, Gregory Johnson for hospital medicine and Nate Ruck for emergency medicine to our providers.
Speaker: And specifically, we'll share a portion where I addressed
Speaker: the irrational use of personal protective equipment.
Speaker: Before we get into the recording, I think it would be appropriate to share a quote from Viktor Frankl, which I think speaks highly to the situation that today we're living that is unprecedented in our clinical careers.
Speaker: When we are no longer able to change a situation, we are challenged to change ourselves.
Speaker: Without further ado, this is our webinar on rational use of personal protective equipment.
Speaker: As John said and Greg said, I want to first start by thanking everybody for all the hard work.
Speaker: The stories that are coming from the field are amazing.
Speaker: I think not unexpected because I've met many of our teams and I know that this is an opportunity for them to really create value and serve the communities that we're in.
Speaker: Just as a general sound physicians update, like John mentioned, the number of cases continues to increase across all service lines.
Speaker: We will continue, the CMOs, John and Mark, working on the webinar series.
Speaker: A lot of the questions that you write, if they go unanswered, will help us guide future content.
Speaker: We also have a series of specialty-specific communications.
Speaker: that will continue.
Speaker: And I just want to assure you that the entire organization is focused on the front line and trying to really provide all our clinicians with the best tools possible to really try to make a difference with this pandemic and help our communities.
Speaker: So today's focus will be on clinical guidance on the rational use of personal protective equipment and keep our clinicians safe.
Speaker: And before I start, I think it's worth remembering
Speaker: that this is a very fluid situation.
Speaker: It's a novel virus.
Speaker: There is an enormous amount of information that is coming in.
Speaker: Not all the information is the same quality.
Speaker: There's a lot of information that also we have learned from previous pandemics of similar coronaviruses.
Speaker: And I think that ultimately what we need to understand is that these are unprecedented times for us as clinicians.
Speaker: And there are things that we will need to do probably that we never thought we would have to do.
Speaker: And I think that one of the tools that we can offer our clinicians is knowledge.
Speaker: And knowledge really is focusing on what are the things that we control, what are the things that we understand, eliminate noise and focus on moving things forward and really trying to make a difference.
Speaker: So as we said earlier,
Speaker: The goal here is to create the greatest amount of good for the greatest number of people.
Speaker: From a community perspective, I think the whole country has embraced, the whole world actually has embraced this concept of flattening the curve by implementing social distancing and other intervention at a community level.
Speaker: We are hoping that we can manage the surge of cases
Speaker: and that really we don't overwhelm every hospital system in America.
Speaker: As many of you might know, there are hospital systems such as New York that right now are at the brink and really, I mean, are taking an influx of patients that is something that we've never seen.
Speaker: And I think that we're hoping that with all these measures, we can really create the greatest good for the greatest number and get through together as a team.
Speaker: So why is this concept of rational use of personal protective equipment,
Speaker: being mentioned.
Speaker: And I think that it's very important to just face reality and acknowledge that there's what we want, there's what we need, and there's what we have.
Speaker: And we have to make sure that we can align those as best we can.
Speaker: Now, this whole idea of being rational about the way we use protective equipment, I think is something that has never really been an issue for us because we've never
Speaker: faced a situation like this.
Speaker: We would have one patient that needed isolation and you could get all the equipment you needed.
Speaker: But now we're really seeing a lot of patients in a scale that we never thought and that's overwhelming, not only hospitals in America, but across the world.
Speaker: There are three buckets that I think are very important in considering and constructing a framework for rational use of personal protective equipment or PPE.
Speaker: Number one,
Speaker: is understanding COVID-19 transmission, how the virus is transmitted.
Speaker: There's a lot we have learned.
Speaker: There are still things we don't know, but I think that understanding the available evidence helps us as clinicians anchor ourselves on reality and try to prioritize the best way we can with the context that we have to live at each one of our programs.
Speaker: Number two is the proper use of PPE based on what we understand of COVID-19 transmission, but also
Speaker: based on the reality of the place that we are in.
Speaker: And I think that the third bucket, which is disruption of supply chains, is something that we have never experienced in the scale that we're experiencing right now.
Speaker: And that disruption of supply chains is really due to many, many, many reasons.
Speaker: Number one, the epidemic started in China, which is where most of these factories reside.
Speaker: A lot of those factories are closed.
Speaker: And number two, it's a pandemic that's affecting the whole world.
Speaker: So never have we seen a surge of need at the same time at such a scale for these type of PPE.
Speaker: Number three is a massive hysteria in the community where people went and bought things that they can't use, don't need, and don't even know how to use and price gouging.
Speaker: And there's a lot of that going on, which ultimately has also obviously impacted the clinicians at the bedside.
Speaker: Having said that, I do think that there are things that we do, we can understand, there are things that we can do, and I would really emphasize that everything I present is based on the best available information and evidence that is out there.
Speaker: I rely heavily on WHO, on CDC, on peer-reviewed journals.
Speaker: I think that there's a lot of information on social media that is not actionable data sometimes, but I really think that if you think about this,
Speaker: as a clinician, as a scientist, there are some things that you can understand, some things that you can infer, and I think ultimately use a rational approach to guide how we deal with this, because I think that's ultimately the best chance we have to be safe and to protect ourselves and our teams.
Speaker: So what do we know about COVID in terms of transmission?
Speaker: Based on the best available evidence,
Speaker: The virus of COVID-19 is transmitted between people through close contact and droplets.
Speaker: And I think that that's a very important concept because everything that we know so far indicates that that is the way that this is transmitted.
Speaker: Now, there's other ways that we will talk in a second that are potential or plausible, but let's focus on what we do know.
Speaker: We do know that close contact and droplets are the key.
Speaker: And in terms of close contact, what does that really mean?
Speaker: It means being close to somebody in a length of less than six feet or one meter.
Speaker: And in terms of prolonged contact, some healthcare organizations such as the CDC at Singapore, they find it as 30 minutes of close contact without protection.
Speaker: And others such as Hong Kong, they find it as 15 minutes.
Speaker: But again, this is not, you just walk by somebody and you're gonna get COVID-19.
Speaker: It's related to droplets and close contact.
Speaker: Now, one of the likely ways that this happens is that you get droplets on your hand and then you rub them in your eye, your nose or your mouth.
Speaker: And that's an easy way of transmitting the virus.
Speaker: And that is why frequent hand washing is perhaps the most powerful tool we have both in the community and at the hospital level to prevent dissemination of this virus.
Speaker: Other community-based strategies or measures
Speaker: that are important are avoid touching your face, your eyes, your mouth and your nose in particular.
Speaker: Respiratory hygiene in the community, which means if somebody's gonna sneeze or cough to do it in their elbows and if they use a napkin or a tissue paper to dispose that tissue paper immediately and wash your hands.
Speaker: The use of medical masks, which are prevalent for the last several months around the world in communities and airports
Speaker: even in some hospitals, are only indicated for those who have symptoms.
Speaker: And they're indicated for those who have symptoms so that they will decrease the transmission of droplets to others.
Speaker: And finally, the whole idea of social distancing.
Speaker: More and more counties and states are going into quote-unquote lockdown, but the whole idea really of people staying home, people not gathering with other people, and especially, I think, for those who have symptoms or are COVID-19 positive,
Speaker: it's very, very important.
Speaker: So these measures are what I think as a society, public health officials are trying to push through and we're seeing different measures of this throughout the world, but in one way or the other, the world as we know it today is different.
Speaker: Today they announced a lockdown in India.
Speaker: It's the largest lockdown in the history of humanity, 1.2 billion people in lockdown.
Speaker: And I think it just illustrates
Speaker: to how people are concerned about this virus, but also that these measures actually can impact the number of transmissions.
Speaker: Now, there's been a lot of talk and a lot of concern about fomites and aerosol.
Speaker: And I think it's very important to understand that where this comes from.
Speaker: So all the clinical evidence available so far has indicated that the transmission of COVID-19 virus, the COVID-19 virus,
Speaker: producing virus is through close contact and droplets.
Speaker: There is one particular research published as a correspondence to the New England Journal of Medicine earlier this month where they, under experimental conditions, were able to show viable virus generated in aerosols and in different types of fomites such as copper, cardboard, stainless steel, and plastic.
Speaker: So nobody has been able to link this
Speaker: experimental finding to solid clinical evidence that this has caused a transmission of the virus.
Speaker: However, I think that it does bring up the point that that mode of transmission is plausible.
Speaker: In terms of aerosols, what that means is that what are situations that are most likely to generate circumstances similar to the ones that they had in the experiment?
Speaker: They're not a lot.
Speaker: but there are some aerosol generating procedures such as intubation, extubation, bronchoscopy, non-invasive positive pressure ventilation, nebulizers, CPR bagging that might fall in those categories.
Speaker: And you'll see throughout the discussion that that's why we're prioritizing certain types of airborne precautions for those situations.
Speaker: On the other hand, in terms of fomites, there is no clinical evidence that suggests that the fomites are an issue.
Speaker: but we do know that cleaning of our hands and cleaning of surfaces with soap appropriately, as we'll talk for hand washing and with alcohol-based products eliminates the virus.
Speaker: So again, even if fomites are a plausible source of contamination, I think that we do have tools that when applied in a consistent manner can mitigate that risk significantly.
Speaker: Now, in terms of experimental,
Speaker: Evidence based on this publication in this paper, you can see that both for aerosols and fomites, there's a possibility for the virus to remain alive.
Speaker: In terms of epidemiological evidence, it's been hard to prove, but from an airborne perspective, we do have some evidence to suggest that if we prevent droplets, we're in good shape as healthcare providers.
Speaker: But also the other evidence that I think is very important is with over 300,000 positive cases around the world and many more that are untested, over and over again when people have been quarantined, it has not been that they consistently infect everybody in their household.
Speaker: So if you take a good droplet precautions and you have a sick patient with COVID in your home or a positive COVID patient, it doesn't mean that everybody gets sick, which makes me think that if airborne were an important mode of transmission,
Speaker: on a regular day-to-day basis, that would be impossible.
Speaker: The spread of disease would be incontainable in households because those houses have no way of filtering the air.
Speaker: So as you can see, there is some epidemiological data that would suggest again that the main mode of transmission is droplets, that fomites and
Speaker: aerosols, other plausible are much less likely.
Speaker: And furthermore, in the clinical experiments that have looked at either exposure of a healthcare provider workers or in large randomized trials, not with this particular virus, but with influenza and other similar respiratory viruses, they have shown that the surgical face mask of droplet precautions have the same protection as those with N95 and other respirators.
Speaker: more evidence suggesting that perhaps the aerosol and the fomites are less relevant, but that we should still, because they're plausible, maybe focus on super high risk situations and what are the factors that we have to mitigate that.
Speaker: So we talked about community interventions and we talked about social distancing.
Speaker: I am making a very strong urge for everybody in our programs to really start thinking about how do we
Speaker: produce or how do we implement social distancing in the hospital, especially in the ICU, but I'm sure in the ED and also in our hospital teams.
Speaker: We work in groups.
Speaker: We do MDRs.
Speaker: I think we're going to have to start rethinking how we do that.
Speaker: We want to keep as much distance as we can because a lot of healthcare provider workers are getting sick around the world from other healthcare provider workers who have symptoms, and I think that that's going to be very important.
Speaker: So rethink how you do MDRs.
Speaker: Meetings should be virtual as much as possible.
Speaker: If it's a small number of people, maybe with enough distance, it's okay, but start rethinking how we do meetings.
Speaker: Rethink how we socialize at the hospital.
Speaker: I think that we need to support each other, but we have to be smart about things, and maybe after a tough shift, going out for happy hour in the big group is not the best idea.
Speaker: And then I think another issue that I think is very relevant is our work areas and call rooms.
Speaker: I have visited many of our programs, and I know a lot of our programs have call rooms where the clinicians and the rest of the team work together.
Speaker: Think about how do I implement not only social distancing there, but how do we clean things appropriately?
Speaker: How do we disinfect computers?
Speaker: How do we disinfect our phones?
Speaker: And really start thinking very deliberately about implementing social distancing, not only when we're out of the hospital, but when we're at work.
Speaker: what can we learn about healthcare providers from other experiences?
Speaker: There was a very interesting article that was shared by John earlier this week by Atul Gawande, and there's also other reports available through WHO and other sources that basically talk about what has happened in different places that have either been through the surge of their epidemic or are still in the midst of that, but have had more experience in terms of
Speaker: dealing with this for a longer time.
Speaker: And there's three, I think, that come to mind immediately that might give us some clues that might be useful for us to focus on what are the things that we can do that might help.
Speaker: So obviously, as you all know, the first epicenter of the pandemic was in Wuhan, China.
Speaker: In the initial wave at Wuhan, over 1,300 healthcare workers became COVID positive.
Speaker: Now, they really had a big problem with their healthcare workers force, and at one point, they were able to implement very draconian rules everywhere and were able to change the trajectory at other places in China, but they were able to bring in over 40,000 healthcare workers from other places in China to work in Wuhan.
Speaker: Now, these had bunny suits, N95s, droplet precautions,
Speaker: And they really, I mean, were very aggressive in having that for everybody.
Speaker: And it's very interesting that based on what's reported from that second wave of providers, zero got infected.
Speaker: So I think that that gives us hope that with the right implementation, we obviously can keep our workforce safe in the hospital.
Speaker: Now, the reality also is that we don't have all those suits, but they mostly did it based on
Speaker: use of N95s and droplet precautions as well.
Speaker: So let's look at other experiences and see what we can learn.
Speaker: The second epicenter of the pandemic has been in Italy.
Speaker: And as many of you know, Italy has been struggling for the last several weeks, especially in the northern area of the country, in Lombardy, with really a collapse of the healthcare system.
Speaker: There's been 8% of the infected COVID positive people are healthcare workers.
Speaker: they represent 1% or 2% of the population.
Speaker: So clearly that is an increased risk.
Speaker: And this has not been published, but in a webinar that was presented by WHO late last week, the head of the Italian Critical Care Societies was sharing their experience.
Speaker: And one of the things that he was very clear about was that when they have analyzed and looked at their healthcare worker that were positive, they do believe that a lot of people got exposed
Speaker: early on that they did not have droplet precautions and that a lot of the exposure also may have happened from socialization before and after work and that the healthcare providers themselves, the workers, were an enormous vector for transmission of the disease.
Speaker: So really, I mean, a lot of people have had the opportunity to hear these webinars from our Italian colleagues and to participate in some of these calls.
Speaker: Their plea is to be
Speaker: very diligent with PPE to prioritize, to make sure that people are utilizing it in the right way.
Speaker: And the third experience that I think is actually a shared one from Hong Kong and Singapore, where they had early rises in cases and took very decisive action, it might be more comforting for us in the United States because they did, at Singapore, they did utilize a very rational use of PPE.
Speaker: which they really prioritized the N95s for the situations where high aerosols might be produced or for the positive patients.
Speaker: They used droplet precautions in everybody and they also went further in terms of making sure that standard precautions such as washing your hands deliberately and using just regular gloves and even just a regular face mask for other patient interactions was done as early as possible and they have shown zero
Speaker: healthcare workers infected so far based on their reports.
Speaker: Very interesting also is that based on an exposure, one pneumonia patient in Singapore that exposed 41 healthcare workers, of which I think 85% of them had only dropped the precautions and only 15% had used at one point N95s.
Speaker: All those healthcare workers had, over a course of 14 days,
Speaker: double testing and none of them turn positive, suggesting that if we take the right droplet precautions and prioritize the N95s and airborne for the highest risk procedures, we can really keep our healthcare workers safe.
Speaker: So again, I think that this is information that I think is valuable.
Speaker: It doesn't give us all the answers, but I think that it would be foolish not to try to understand what has happened elsewhere
Speaker: as this pandemic continues to grow and affect the rest of the world.
Speaker: So let's move on now to talking about what we really consider rational use and how we should be thinking about this based on what we know, based on what we understand, and based on what the WHO and CDC have recommended.
Speaker: So in an ideal world, we would have all the PPE we want, understand exactly what we need, and not have to worry about it.
Speaker: In a pandemic world, that might not always be possible or that potentially could be a problem.
Speaker: So the way we optimize PPE availability is we use PPE appropriately, we minimize the need for PPE, and we do the best we can as a hospital, as a group, as a city, as a state, and as a country to coordinate PPE supply chains.
Speaker: And we'll talk about each one of these a little bit more.
Speaker: So in terms of
Speaker: Minimizing PPE need, I think that the first thing that we have implemented at Sound Physicians and we're trying to push forward, and there's different ways we can do this, is the use of telemedicine, especially for triaging and for patients who are not as sick.
Speaker: A lot of this can be done through telemedicine.
Speaker: There's been other seminars or webinars from Sound on the application and how to deploy this.
Speaker: The second is physical barriers.
Speaker: And that is very important for our ED colleagues, especially for triage, figuring out ways to triage people who might have COVID-19 so that we don't disseminate or infect all people.
Speaker: And I know that Nate and his team talked about that earlier today in terms of how to use TENS and outside triaging for a lot of patients who might not require hospitalization, but that who might still be positive and spread the disease.
Speaker: The restriction of healthcare workers, I think, is very important from entering the room.
Speaker: Think about how to minimize the number of times we need to do things.
Speaker: Labs should be drawn at once.
Speaker: People should be doing certain checks when they're giving medications.
Speaker: Consultants don't need to go into the room unless they really are going to examine the patient for something that's going to change management.
Speaker: Obviously, at this point, I think most hospitals with
Speaker: trainees and students have limited that number.
Speaker: Visitors is another big component of that.
Speaker: And I think that a lot of hospitals, depending where they are, are moving to more and more restrictive visitor policies.
Speaker: Obviously that has, may have positive impact and decreasing spread in the community and among healthcare workers, but I think it also has significant impacts on the community in terms of what it means in a time of crisis.
Speaker: And I think it's important for us to think about this because our kindness and compassion are probably not gonna be enough to help everybody that really is gonna need help.
Speaker: But it has happened in other places like in Italy when patients are dying by themselves and family members are not there.
Speaker: So just think about the toll that this takes not only on us as healthcare workers, but on everybody in the community.
Speaker: Other options to minimize PPE,
Speaker: In some places, depending on the structure of your hospital, what's available, what's possible, cohorting might help eventually to minimize the use of PPE.
Speaker: There's a lot about this in CDC recommendations.
Speaker: This is not necessarily, I mean, a given solution for everybody, but something to think as things progress.
Speaker: And finally, also, how do you deal with non-COVID patients
Speaker: And in a lot of instances where we would usually use PPE for some contact isolations, there's also a possibility of prioritizing and making sure that we're minimizing the use of PPE in other situations, which in this pandemic at this given crisis time might be less of a priority.
Speaker: So what about the use of PPE appropriately?
Speaker: And let's talk about this.
Speaker: And this is really, I think, what we really want to get to in terms of
Speaker: rational use of PPE.
Speaker: There are things that we need to do at triage.
Speaker: I think that our index of suspicion for COVID-19 as the pandemic progresses in our communities is going to be lower and lower.
Speaker: But anybody with acute respiratory illness of unknown origin who presents with fever or cough or shortness of breath, we definitely can have COVID.
Speaker: I think going further for our ED and hospitalist colleagues,
Speaker: Think about common diseases now like a COPD exacerbation, an asthma exacerbation, somebody who has a DKA.
Speaker: Why do these people usually get these?
Speaker: It's because they have something that exacerbated it.
Speaker: One of the most common causes is respiratory illness.
Speaker: So think about that as well.
Speaker: Is this DKA because I started having, I mean, a sore throat and had a fever, or is it just because I didn't take, I ran out of insulin?
Speaker: So all these things are going to be important and have a high index of suspicion.
Speaker: As soon as we suspect somebody being COVID positive, the first thing we can do is implement infection prevention control measures in all suspected patients.
Speaker: And that I think we should be very aggressive because it minimizes the risk of exposure for everybody else.
Speaker: So what are some of the infection control, prevention and control measures that we can implement immediately?
Speaker: So if possible, if you have anybody who you suspect or know has COVID, put a face mask on them, on the patient,
Speaker: that is source control.
Speaker: To all patients that we suspect having COVID or have COVID, apply droplet and contact precautions, and that usually means a single room with droplet and contact precautions.
Speaker: If possible, for those who are COVID positive or those who might undergo an aerosol-generating procedure suspected of COVID, we would use airborne precautions or negative pressure rooms.
Speaker: Most hospitals
Speaker: if they have a high influx of patients will run out of those or can run out of those.
Speaker: So again, the CDC recommends is to focus on droplets precautions and contact precautions, but to prioritize the use of airborne precautions for those patients at higher risk.
Speaker: And again, in terms of what we should use as providers in terms of N95s is again, preferred for those patients who are documented positive or those who are high aerosol generating situations and procedures
Speaker: such as intubation, BiPAP, bronchoscopy, and CPR.
Speaker: Now, so far, all the evidence or the preponderance of evidence clinically and epidemiologically would suggest that the main mode of transmission is droplets.
Speaker: Because of those experimental findings that can be aerosolized, I think, and because it's a novel pathogen, people have taken the extra precaution in those situations to prioritize for airborne.
Speaker: But I also think that we need to recognize that in many places the reality of running out of airborne rooms is true.
Speaker: So then you have to make decisions based on the best available evidence to try to keep everybody as safe as possible.
Speaker: What about, that's what we do for the patient.
Speaker: What about what we do ourselves as healthcare workers?
Speaker: I think the most important
Speaker: The thing I can reiterate both at home and at work is the frequent deliberate hand washing.
Speaker: I had opportunity to work clinically recently and it saddened me to see that there are many, many healthcare workers who don't know how to deliberately and effectively wash their hands for a situation like this.
Speaker: So I really think that you should really focus on this.
Speaker: If you're going to use water and soap, you must make sure that you cover all aspects of your hand
Speaker: Aspects that are often neglected are in between the fingers, the back of the index finger, the tip of the fingers, the thumbs, and you should be doing this for 20 or more seconds.
Speaker: So I think that if you really look at videos that we'll link in the email and you really start practicing very deliberately, you will see that in order to do a very efficient hand washing, it requires you to pay attention.
Speaker: And I think it's important for us to learn that, but more importantly, it's to teach it both at home and to our team, co-workers, so that everybody can stay safe.
Speaker: If you use alcohol, you still have to cover all those areas and you should be using alcohol-based products with 60% or more alcohol for 20 to 30 seconds and then allow it to dry spontaneously.
Speaker: The second aspect of this is to wear the appropriate personal protective equipment.
Speaker: And I think that this is where
Speaker: we have to be very careful.
Speaker: I think that every time that we utilize something that is not needed, it might be something that in the near future we wish we had.
Speaker: And I think that people take comfort in talismans and they believe that the more they have on, the safer they are.
Speaker: But the reality is the way you stay safe is by understanding what each situation requires
Speaker: understanding how to take every step very seriously and do it the right way, and also understanding that within the context that you might be living at your individual program, there might be times where you have to make some priority decisions, and that's best made as a group, as a team for the whole institution.
Speaker: So let's go over this, which I think is very important, the proper order of putting on and removing personal protective equipment.
Speaker: So what do you need for COVID positive patients?
Speaker: Suspected or positive COVID patients, you should have a gown that you put on.
Speaker: You wash your hands first deliberately, then you put on your gown.
Speaker: Then if you're not going to be in a high aerosolized situation, a face mask is recommended currently by CDC and by WHO as being appropriate.
Speaker: You then put a face mask or goggles, and finally you put on your gloves.
Speaker: You take care of what you need to take care.
Speaker: And when you come out, this is very important, you must wash your hands in between every step.
Speaker: I usually will even wash the gloves with alcohol.
Speaker: And the reason is that that decreases the likelihood that I'll self-contaminate.
Speaker: I usually remove my gown and gloves together without touching the external part.
Speaker: I wash my hands after that.
Speaker: I remove my face shield or goggles.
Speaker: trying to not touch my face, I wash my hands again, I then remove my mask or my respirator if it was a situation where required aerosol protection, and then I wash my hands again.
Speaker: And I think that doing that in a paused way takes time, but I think it's very important for us to take very seriously and to show to other people how to do it.
Speaker: And this is very important if you're in, again, if you are in a situation
Speaker: In most hospitals now they're limiting the N95s to COVID positive patients and eventually that might even be limited further to COVID positive or suspected patients in which there's a high risk of aerosol, which would be the intubation, extubation, bronchoscopy.
Speaker: But starting to think about this in a very rational way, I think is the only way that we can optimize the availability for everybody to be as safe as possible.
Speaker: Now, this is actually from the WHO.
Speaker: and it was updated a couple days ago as of late last week.
Speaker: And basically what you can see here is that for healthcare facilities or inpatient facilities, they talk about what you need to do in terms of PPE for healthcare workers who are providing direct care for COVID-19 patients.
Speaker: So if you're not in an aerosol situation,
Speaker: they're recommending medical mask, gown, gloves, and eye protection.
Speaker: If you are in an aerosol generating procedure performed on a COVID-19 patient, they're recommending respirators, which are the N95s in the United States, plus the standard or equivalent, plus the gown, the gloves, eye protection, and the apron.
Speaker: So I think that this is very important for people to understand that droplets is the main way to stay safe.
Speaker: And perhaps the most important intervention that we can control is the hand washing and making it as deliberate as possible.
Speaker: But as we move forward, we might have to select who gets the, when we use the N95s.
Speaker: And what's very clear from both the WHO and the CDC guidance is that when you're not working with patients, you don't need an N95.
Speaker: When you're not working with patients,
Speaker: you don't need to use a mask unless you're using that mask to protect others.
Speaker: And I think it's going to be something that's very important because that is only something that is used to protect others, not to protect yourself.
Speaker: So just remember that.
Speaker: And then you can see in triage, laboratory, and other areas, there is other recommendations by WHO, which are very much aligned with what CDC is saying right now.
Speaker: So we talked about how to minimize the use of PPE need.
Speaker: We talked about how to utilize the PPE we have in the best way.
Speaker: Let's talk a little bit about coordination of the PPE supply chain.
Speaker: And here I just have a couple of messages.
Speaker: I think that number one is we need to work with our hospital leadership.
Speaker: and understanding what's available, what's not available, what are they worried about, how can we optimize things?
Speaker: I think that sometimes there might be misalignment, but we have to be able to provide them the best information possible.
Speaker: And we, I think need to understand that divided house cannot succeed in this pandemic.
Speaker: They are doing the best they can, I'm sure, to help us.
Speaker: It goes beyond the hospital C-suite, it goes beyond the hospital system, it goes beyond the state, beyond the country.
Speaker: The impact of this pandemic is worldwide.
Speaker: and we're not prepared.
Speaker: And I think that's a reality that we need to understand.
Speaker: So what are the things that we can do to make sure that we utilize what we have in the best possible manner to keep all of us safe?
Speaker: Number two, sound physicians is working other avenues to try to secure and help with this.
Speaker: And we don't believe that we can solve all the problems, but I think that in as much as we can help the teams that are in most need,
Speaker: I think obviously that Rob, John and Jess believe that this is our obligation and we all agree.
Speaker: So we're working on that.
Speaker: And this is a reality that we must confront.
Speaker: I wish it were different, but it's a reality we must confront.
Speaker: And that's why I think knowledge is power in understanding with what I have, what are the things that would keep me safe?
Speaker: And as you see, based on the evidence,
Speaker: Most people want things that are not really justified by the evidence, are mostly driven by fear.
Speaker: But if you look at the evidence, we can apply these things the best we can and understand that no matter what, there's always something you can do to mitigate the risk of spread.
Speaker: The last thing I want to talk about is what happens if we do everything to optimize and we still have a crisis period where we really get into trouble.
Speaker: Our hope is that as we move forward and things are activated, this won't be a problem in every hospital in America.
Speaker: But I do believe that based on what we're hearing from New York and what has happened in other places, it could very well be a problem in hospitals that we have.
Speaker: So I think you need to understand how to think about this.
Speaker: There are conventional capacity strategies, which means that it's business as usual and you would just do whatever is recommended.
Speaker: And I think that that's where people were operating some months ago.
Speaker: There are contingent capacity strategies, which now means that we still have what we need, but we are worried that if we don't take care of it, we might run out.
Speaker: And I think a lot of hospitals are implementing procedures and protocols for that.
Speaker: And usually this means that we would do things that we normally wouldn't do.
Speaker: So for example, in many hospitals, they are restricting the number of N95s to prioritizing to COVID positive patients or to patients who have high aerosols.
Speaker: You might reutilize
Speaker: and then 95 the same day.
Speaker: In other places, you might use them for a little bit longer if you are in a place where people are cohorted.
Speaker: So these are things that are done in order to try to preserve N95s and are obviously less than the ideal situation, which is you use it and you throw it away, but they're done under the circumstances to provide the greatest amount of protection to our healthcare workers.
Speaker: And then there's also a crisis or alternate strategies
Speaker: which is when you're actually very close or running out.
Speaker: And there's also recommendations from the CDC in this respect.
Speaker: And the idea is that if you are rational about how you deal with a crisis, the hope is that you can go back to a conventional capacity strategy or contingent capacity strategy as soon as possible.
Speaker: And we're hoping with everything that's going on, that will be the case if it happens to anybody.
Speaker: So in terms of
Speaker: What do we do if we run out?
Speaker: Just some thoughts.
Speaker: Obviously, what we're trying to do is prioritize the use of PPE.
Speaker: So prioritize based on risk.
Speaker: Risk in terms of aerosolized-producing patient, not aerosolized-producing situation.
Speaker: That's a big differentiator.
Speaker: If they're not aerosolized and you don't have enough N95s, you use regular face masks and face shields, and based on the available evidence, that is going to offer you protection.
Speaker: Prioritize based on need.
Speaker: So in terms of where are the areas that you might have more of this and high risk procedures and make sure that that's where the N95s go.
Speaker: There's also alternatives to N95s.
Speaker: A lot of people have asked me about the PAPRs or the Powered Airway suits, reserves.
Speaker: These are actually, we're trying to get them in a lot of hospitals.
Speaker: They're hard to, you can't really use it all day long.
Speaker: I mean, it's kind of hard, but if you're in an area that's
Speaker: cohort that might work, but also try to use those in a judicious way for those high risk procedures and then clean them again and use them again, I think is very important.
Speaker: But they also offer difficulties in terms that we don't have them for everybody.
Speaker: They also can increase cross-contamination and they require training.
Speaker: So I think something to think about for the highest risk procedures and there's other alternatives that the local authorities, state authorities and governments are looking into.
Speaker: Another thing that I think is very important is in some situations, cohorting patients when you get to the situations and a lot of places, I mean, utilizing the same PPE for more than one patient, if they're all COVID positive, obviously, that is something that has happened in ICUs and in hospitals that have been really overrun with a number of patients.
Speaker: And the other thing I always think is important is to focus on steps that are available.
Speaker: So even if you didn't have N95s,
Speaker: but you could control your hand washing, do appropriate droplets, source control on the patient, minimize the time you spend with a patient and minimize the time others spend with a patient.
Speaker: These are all things that will mitigate your risk.
Speaker: So always focus on what you can do, which is always something that can be done that is effective in mitigating the risk.
Speaker: And lastly is that as soon as you restore your supply, obviously returning to the best practice when supplies are available.
Speaker: So these are things that I think are hard to sometimes listen, but I think that understanding how to best approach them are a much more powerful weapon than anxiety in terms of making sure that we all get through this as best possible.
Speaker: This is an example from the CDC statement on crisis alternate strategies.
Speaker: and just showing you that no matter what the situation is, there are things that you can do in terms of keeping the distance from the patients.
Speaker: If you have to be close and it's not a situation where a respirator is needed, if you can cover the patient and cover yourself with face masks, that itself, I mean, is very important and can reduce risk.
Speaker: Also considering the use of other alternatives other than N95s for those high-risk procedures.
Speaker: There's what's called elastomeric, PAPRs,
Speaker: based on availability.
Speaker: So a lot of hospitals are working to secure those as well, but those are not usually something that you can buy by the thousands.
Speaker: So I think it would be prioritized again for the highest risk interventions and procedures.
Speaker: Finally, I want to talk about some special situations for healthcare workers.
Speaker: I know that I have received and Greg and Nate a lot of questions about this.
Speaker: I wish I had definitive answers, but let me share with you
Speaker: what WHO and CDC have shared, what's posted.
Speaker: Number one is healthcare workers who are positive for COVID-19.
Speaker: Obviously those patients, those healthcare workers should be quarantined.
Speaker: There's different procedures that are gonna be driven by state and local authorities.
Speaker: I think that this is different from somebody who got an exposure.
Speaker: So with exposure, initially people are being quarantined, but now without symptoms and self monitoring,
Speaker: A lot of those are allowed to come back to work with masks.
Speaker: With positive tests or symptoms, the initial guidance is for them to stay home so they don't infect other coworkers.
Speaker: Depending on what's going on in the situation, like in Italy, obviously, they're in a very different situation.
Speaker: That might change, but just be aware of what is going on from CDC and speak with your local health authorities.
Speaker: Pregnant patients in general, there's a lot of questions about this.
Speaker: There is no data available as of now that suggests or that demonstrates that pregnant patients are at a higher risk of contracting the disease or at a higher risk if they contract the disease of having worse outcomes.
Speaker: As you might remember, some of you who were through the previous pandemic, which was the H1N1 pandemic, that virus had a particular preference or had a particular impact on pregnant patients, and there were a lot of reported
Speaker: very severe ARDS cases in pregnant patients.
Speaker: We have not seen that, but the truth is that we do not know.
Speaker: So if this is a concern for a pregnant healthcare worker, they should talk with their clinician, they should talk with their supervisor, and there's maybe things that can be done to mitigate this, but as of now, the CDC is recommending that this is evaluated individually.
Speaker: In terms of immunosuppressed patients,
Speaker: I think that there are obviously a wide range of definitions of immunosuppression.
Speaker: I do believe that if you talk with transplant surgeons and cancer and doctors, oncologists, categories of severe immunosuppression that would include recipients of transplants who are in active immunosuppression, physicians getting active chemotherapy,
Speaker: And maybe physicians or healthcare workers who are being treated with immunomodulation therapy for rheumatoid disease or for rheumatological disease would probably fall in a special category.
Speaker: And those patients, those healthcare workers should talk with their physicians, but also with their directors about their concerns.
Speaker: Without doubt, the situation that many clinicians are facing around the world
Speaker: and might be facing in the United States regarding the availability of personal protective equipment and the availability to care for COVID-19 patients in the best possible way is very challenging.
Speaker: It is something that we have not experienced at this level ever in my recollection as a clinician and is clearly uncharted territories for most of my colleagues.
Speaker: I think it's important to stay balanced
Speaker: and understand that the difficulties ahead of us are significant, but that with good data or utilizing the best available data and by supporting each other, we can get through it.
Speaker: I hope that the conversation in this episode was helpful and I hope that everybody is doing the best they can to stay safe and make a difference on this pandemic that has affected
Speaker: every country and every person in the world in one way or the other.
Speaker: Traditionally, we talk about books and ideas at the end.
Speaker: I think that that is still very fitting for times like this.
Speaker: I introduced the episode with a quote from Viktor Frankl, and I think that a very appropriate book to read in times like this would be Viktor Frankl's Man's Search for Meaning, which is really a phenomenal account of what he endured during the Holocaust
Speaker: but really focused on the creation of the logos therapy or purpose-based therapy in terms of identifying what our role is in life.
Speaker: I think it's obviously a very powerful read, not a light read, but I think one that would give us a lot of insight into what is going on in our world today.
Speaker: And without going further, I would like to end the episode with another
Speaker: quote from that book by Viktor Frankl that says, between stimulus and response, there is a space.
Speaker: In that space is our power to choose our response.
Speaker: In our response lies our growth and our freedom.
Speaker: I hope that every intensivist at the bedside does the best use of that space and chooses the best response in terms of making the greatest good for the greatest amount of people.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
