Welcome to The Plague Pit – issue number 7.

There may be a chink of light this week for doctors near me. The South London Adult Critical Care Network (SLACCN) publish a daily update on COVID-19 cases in critical care units in subscribing hospitals. One of my colleagues has recently been posting the graphs to Whatsapp:

15/4/20 19:52   A1: [forwards graph of daily data from 16/3/20 til 15/4/20]

15/4/20 19:53   A2: Is that a plateau I see! [smiley emoji]

16/4/20 20:11   A1: [forwards graph of daily data til 16/3/20 til 16/4/20]

16/4/20 20:23   A3: That’s a plateau. That’s a bloody plateau. [smiley emoji with hearts]

16/4/20 20:23   A2: That’s what I thought!

16/4/20 20:24   A4: Come on you misery, it’s the start of a downward trend!

16/4/20 20:24   A4 2: [large throbbing heart emoji]

16/4/20 20:25   A5: Concur.

16/4/20 20:26   A6: Plateau was last week.

16/4/20 20:52   A3: I never said there wasn’t a downward trend too.

Yesterday’s SLACCN graph shows data until Saturday 18/4/20. The total number of cases has been falling a tiny bit every day for a week.

PPE (again) and other stories

There’s been a good deal of angry talk over the weekend about personal protective equipment (PPE). For now, I’m going to focus on practical aspects of the kit and not the logistics of supply.

For ICU and anaesthetic staff, basic PPE comprises gown, gloves, respirator mask and visor. A standard ICU shift is twelve hours and the PPE stays on throughout. PPE materials are not made of the finest breathable sports fabrics. They are really hot and uncomfortable. The masks are tight – ‘fit tested’ as I have said before,  to provide effective protection against viral contamination from COVID-19 patients. As a result, ICU staff coming off duty all bear temporary, characteristic facial stigmata. Several hospitals with COVID-19 patients are producing staff guidelines on how to minimise longer term skin damage (1)

ICU is stressful at the best of times. This additional burden is one of many linked to the care of COVID-19 patients. My Trust has recently enhanced its psychological support for staff involved

In theatres, where I have been working, we can at least remove the stuff between cases. The physical nature of PPE, though, may disadvantage the patient more directly during surgery than in ICU.

Things often move fast during an operation – the patient’s physiological state changes from second to second. Unimpeded communication between staff in theatre is important. PPE visors make this really tricky – powered air purifying respirators, even more so (see ‘All kitted out’, 31/3/20). I’ve cited Dr Jan Schumacher’s study on this before. (2)

My favourite bit of ‘surgical communication’ research, though, comes from Professor Roger Kneebone of Imperial College. It concerns the negative effects of recorded music, played in theatres for the ‘enjoyment’ of staff during more than half of surgical procedures (3)

The sound of music

The choice of music in an operating theatre is a difficult political issue. There are usually between three and eight staff present. For the purposes of this article, we’ll assume the patient – under general anaesthesia –  can’t hear anything. More on this in a future issue. As the alpha male or female, and the one ultimately responsible for the patient, the surgeon might reasonably be expected to call the shots.

Some surgeons – the minority, and usually the older ones – want silence. Others simply request ‘Music. Anything’. They almost never mean classical music. The choice of entertainment in this case falls to the most confident staff member who is not ‘scrubbed’, i.e. not in a sterile gown. That means the anaesthetist. If he/she is busy – we can’t avoid it sometimes –  another staff member may venture to turn on the radio. This uncontroversial option essentially delegates the playlist to someone (the radio presenter) who is not available for subsequent ridicule.

For some reason, radios in theatre are always tuned to Heart FM, champions of soft rock. This is the musical genre which effectively constitutes the lowest common denominator among health care staff. Inertia then ensues. I’ve lost count of the number of hip replacements I’ve sat through to the strains of Chris de Burgh’s ‘The Lady in Red’. Nobody actually wants it – but no-one can be bothered to change the status quo (or Status Quo, perhaps).

Even worse, though, is when the surgeon has views. Orthopaedic surgeons are particularly notorious –  and a few of them like their music very, very loud indeed. I’ve worked with both opera and Gangsta Rap enthusiasts in this category, the latter middle-aged and apparently from the Home Counties. Few anaesthetists signed up as regulars on his list. I can therefore confirm the negative impact of some music on intraoperative communication, on staff relations and – indeed – on sanity.

The best approach is a democratic one. With the arrival of Spotify, there is no reason why the theatre porter’s playlist should not be deemed equal to the cardiac surgeon’s. For many happy years, I shared my regular Thursday operating list with a lovely theatre nurse whose I-Pod famously had the finest and most diverse collection of music in the hospital. This was just as well, given the disparate requirements of the regular team: soul and reggae (plastic surgeon), disco (staff nurse), heavy metal (theatre assistant), punk/new wave (anaesthetist).

Other theatres tried to poach her unsuccessfully, but we managed to hold out. On a minor point, she was a really good nurse, too.

Private army

So, back to COVID-19, PPE and communication. The Trust where I usually work has done a deal with  a chain of private hospitals in London to keep urgent NHS cancer surgery services going. COVID-19 patients are treated at the original NHS hospital – the ‘mother ship’, as my colleagues now call it. The private hospitals take COVID-negative cancer patients requiring hysterectomies, nephrectomies, gastrectomies etc (removal of womb, kidney and stomach respectively).

The Trust’s anaesthetic ‘Home Guard’, like myself, have been allocated to the latter. Mostly we are a bit older so our ICU skills – needed for the care of pandemic victims – are a bit more rusty. Looking at the median age of COVID-19 patients on UK ICUs [61yrs, IQR 52,69. n = 3383. ICNARC data 10/04/20], we also appear to be more at risk of severe consequences if we get infected. The numbers don’t look great for men especially [male:female ratio for COVID-positive patients on UK ICUs = 73:27 Same source].

This split in duties has led to some honest and rather affecting exchanges between team members. Here is an excerpt from a message sent to the whole team by one of my colleagues now based at the private hospitals:

‘Today I went to the mother ship and it was really emotional

I haven’t been there for a few weeks and I really felt like getting back home. But things didn’t look the same way as they used to BC [before COVID]

I went to ICU to pick up a patient for transfer and I was shocked. The air was stuffed and muggy, beds less than a metre apart and many young people on them struggling for their life. And then the priority theatres booked with very sick patients from ICU [ICU patients often develop complications requiring transfer to the operating theatres for surgery]

But surprisingly, things didn’t look bleak or depressed at all. I was amazed by our wonderful staff everywhere in ICU, theatres and the TUBE team. They were all so kind, supportive, friendly accommodating, smiley – the list goes on.

I felt a little guilty because I’ve been redeployed to the cancer work, doing semi-elective cases in luxurious hospitals with state of the art theatres, delicious catering, breathtaking views. Of course, we also have our challenges and I know everything is important and useful in their own way,  what you guys are doing back at base is something more – the extra mile. Well done to everyone for everything you are doing and please stay safe!‘

For the record – I reckon the sandwiches are pretty average. The views from the operating theatre suite, less so:

Blood everywhere, almost….

Even on the cancer lists, treating patients who are COVID-negative, the protocol is full PPE for the tracheal intubation and effectively for the surgery that follows it. There are plenty of reports of false-negative tests. So the physical discomfort and poor communication that come with PPE are one real downside to my situation, however good the scenery.  Giving anaesthetics, or conducting surgery, in unfamiliar theatres is another, however good the staff are. Both factors really matter when things don’t go to plan.

I recently gave an anaesthetic for a laparascopically-assisted hysterectomy (removal of the womb, or ‘uterus’) in a theatre I had rarely worked in before. You can see an edited version of a similar operation here (https://www.youtube.com/watch?v=YlLy9V4M2f8).

Laparoscopic (‘keyhole’) operations can be performed to treat many conditions in many abdominal organs. For details, see https://en.wikipedia.org/wiki/Laparoscopy. With the patient under general anaesthesia, the cavity that surrounds the organs (the peritoneal cavity) is inflated using pressurized carbon dioxide. Several ports with valves are then inserted into the abdominal wall, allowing the surgeon to introduce cameras and long thin instruments into the inflated cavity for viewing, holding, cutting, burning, stitching and suction as required.

As in all operations, even the most competent laparoscopic surgeon may cause unintentional damage to other structures near the one of interest. The risks are very low, though higher in cancer surgery as the anatomy may be distorted and the organs and blood vessels more fragile or stuck to one another because of tumour or inflammation. During surgery, the continuous video images from the camera inside the abdomen are projected live onto a large screen next to the operating table. It’s the only way the surgeon sees what’s going on. Everyone else can it too. 

About ten minutes after the first incision, a large gush of blood flooded the view on the screen – and kept coming. One of the instruments had perforated the external iliac artery, the main blood supply to the leg. In the laparoscopic picture of the womb below, the left iliac artery can’t be seen but sits posterior to the white structure, bottom left (the left ovary).

The surgeon was able to grasp the damaged artery and clamp it with one of the other instruments to control the bleeding temporarily – a very skilful trick. Then he decided to convert the laparoscopic operation to an open one – a laparotomy – immediately. This would enable him to tie a ligature round the perforated artery and remove the uterus as originally planned.

A laparotomy entails a different set of surgical instruments and, in this case, an incision from the umbilicus down to the pubic bone. The nurses were getting things ready as quickly as possible. I increased the amount of intravenous fluid I was giving to the patient to make up for the rapid blood loss of about 500ml, 10% of her blood volume, in a few minutes.  I also requested two bags of blood urgently, matched to the patient’s blood group (tested before surgery). As things turned out, they were not needed but it was a tense half hour, involving the communication of many rapid instructions between all parties. The patient made an uneventful recovery

In 2009, the World Health Organisation pilot tested a surgical safety checklist intended to reduce risk of errors in the operating theatre

(https://www.who.int/patientsafety/safesurgery/checklist/en/).

Soon after this, the practice of a team debrief after an operation or theatre list was widely adopted around the globe. “What went well? What went badly?”  In our debrief, we agreed that the PPE had made urgent communication very difficult, especially as one of the team had failed a mask fit test and was wearing a powered air purifying respirator. I had also felt very uncomfortable that the first time I needed to request blood – an unfamiliar process in an unfamiliar institution – was in an emergency.

When COVID-19 has moved on, it will be interesting to see whether these and similar indirect consequences of the pandemic have had an impact on national death and complication rates from unrelated surgery.

Can’t see a thing down here

A few weeks ago, I was talking about PPE to one of our TUBE team, who perform the urgent tracheal intubations in COVID-19 patients needing mechanical ventilation. It turns out that the visor, necessary to protect the intubator’s face from contamination, actually makes seeing and moving more difficult during the procedure. An intubator should see something like this:

Next issue, I’ll explain why it’s sometimes not as straightforward as this for the TUBE team.

The Good Soldier

(1) https://www.ouh.nhs.uk/working-for-us/staff/documents/at-a-glance-facial-skin-care-under-ppe.pdf

(2) Schumacher J et al. A randomised crossover simulation study comparing the impact of chemical, biological, radiological or nuclear substance personal protection equipment on the performance of advanced life support interventions. Anaesthesia. 2017 May;72(5):592-597.

(3) Weldon S-M et al. Music and communication in the operating theatre. Journal of Advanced Nursing 2015;71(12): 2763-2774.