Refusing to intubate/extubate without PPE?

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Status Sciaticus

Status Sciaticus

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Hey everyone,

Just wanted to get some clarification regarding the COVID issue. As a resident, is it defensible to refuse intubating/extubating without N95s if you are concerned for COVID exposure? This is referring to elective cases, not urgent/emergent ones. I'm all for doing my job, but not at the cost of risking my life or the morbidity that comes with contracting COVID, especially for cases that should be cancelled. My concern is that if I refuse to do it, I will face retaliation from either the department or the administration with a non-renewal of my contract. The N95s are in short supply and not guaranteed to us; not able to get our hands on PAPRs/CAPRs either.
 
To be clear, you are talking about patients without known or suspected COVID infection, correct?

And you want to use the limited N95 masks that are needed for caring for patients with known COVID because you are worried it would be possible you are caring for an asymptomatic patient with COVID.

Feel free to voice your opinions about elective surgery, but in non-elective cases, we still need to provide care. I don’t think it is reasonable to wear an N95 (or two) for every single case. Wasting N95 masks on unlikely encounters is probably not the best use of what may become a very precious resource. Every mask used now is one you don’t have later if you are caring for one with known COVID infection.

I personally am not that selfish, but hey, gotta protect yourself.
 
let’s cut some slack here.
everyone’s a bit scared, if you’re not you’re a fool. we are in a high risk field at the front line, and we could get infected in the line of our work and go on to infect our families, friends and colleagues.

i think

for elective surgery (which will stop soon anyway)
1. suggest regional, and put a surgical mask on the patient
2. wear a surgical mask, and a splash guard if GA
3. paralyse well so they don’t cough / buck on intubation .. consider modified RSI too
4. consider having the filter put into the ETT prior to intubating.

for patients needing a tube for covid
full ppe with N95

but the question i posed in the clinical thread is what will people do when the n95’s run out
 
Manipulating the airway is high risk aerosolization. Every guideline is saying you need PPE to do it. Your hospital isn’t providing you with it? Don’t risk your life. Stay safe.

www.apsf.org

An Update on the Perioperative Considerations for COVID-19 Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continues to have a profound impact on life across the globe and has placed an enormous strain on health care systems...
www.apsf.org www.apsf.org

These are the recs. N95 at a minimum! Also, as a resident, maybe you shouldn’t even be doing these airways. The rec is for the most experienced person to intubate.
 
I can't imagine under any circumstances that a resident would face discipline for not willingly endangering themselves in the name of patient care. Nobody is going to expect you to rush into a negative pressure isolation room to intubate someone in nothing more than your scrubs in a scene more fitting for a movie.

It is possible your institution is moving towards a policy where trainees will not be involved in the care of COVID positive patients. You might want to check and help make sure the policy is clear to everyone in your department. But no matter what, as anesthesiologists, we have expertise in several domains that are going to be critical in the coming weeks and months. If not these patients, then the trainees will need to step up to help take care of the other patients.

No one is going to your house to come find you if you chose to stay home outside of assigned duty. And you won't suffer direct professional harm if you chose to do your job and nothing more. But most personal statements talk about serving their fellow man in times of need. Well here we go. Will be interesting to see who really meant it.
 
pjl said:
To be clear, you are talking about patients without known or suspected COVID infection, correct?

And you want to use the limited N95 masks that are needed for caring for patients with known COVID because you are worried it would be possible you are caring for an asymptomatic patient with COVID.

Feel free to voice your opinions about elective surgery, but in non-elective cases, we still need to provide care. I don’t think it is reasonable to wear an N95 (or two) for every single case. Wasting N95 masks on unlikely encounters is probably not the best use of what may become a very precious resource. Every mask used now is one you don’t have later if you are caring for one with known COVID infection.

I personally am not that selfish, but hey, gotta protect yourself.
Click to expand...

Like I mentioned, this would be for elective cases which we still have scheduled for the week. Considering that most of these patients are in a high risk area and the incubation period during which they can remain asymptomatic can be upto 3-4 days, any case has a potential risk for being a COVID carrier. Not wearing proper PPE risks me contaminating everyone I see subsequent to the initial encounter. As much as I care about my patients, I put my health first. If I get sick, I cant care for all the patients down the line where I would be quarantined for two weeks.

To your claim about me using up valuable resources, we can always move to PAPRs can we not? Would it be my fault that I'm 'wasting' N95s, or would it be on the hospital that is still doing gastric sleeves and tonsillectomies?

I just want to do right by me, my patients, and not get fired in the process.
 
GandalfTheWhite said:
Like I mentioned, this would be for elective cases which we still have scheduled for the week. Considering that most of these patients are in a high risk area and the incubation period during which they can remain asymptomatic can be upto 3-4 days, any case has a potential risk for being a COVID carrier. Not wearing proper PPE risks me contaminating everyone I see subsequent to the initial encounter. As much as I care about my patients, I put my health first. If I get sick, I cant care for all the patients down the line where I would be quarantined for two weeks.

To your claim about me using up valuable resources, we can always move to PAPRs can we not? Would it be my fault that I'm 'wasting' N95s, or would it be on the hospital that is still doing gastric sleeves and tonsillectomies?

I just want to do right by me, my patients, and not get fired in the process.
Click to expand...


How dare you not put your life in danger for the very generous average resident wage of $15 / hr
 
Where I am all covid related airway stuff is designated as attending only.

Having appropriate PPE is an OSHA requirement (and more). Speaking up about it makes you protected by multiple whistleblower laws. If they retaliate against you they’re in deep poop.
It’s probably not the hill you want to die on practically speaking... But if I were in your shoes there’s no way I’m doing anything with a covid patient without appropriate PPE - especially as a trainee .
 
GandalfTheWhite said:
Like I mentioned, this would be for elective cases which we still have scheduled for the week. Considering that most of these patients are in a high risk area and the incubation period during which they can remain asymptomatic can be upto 3-4 days, any case has a potential risk for being a COVID carrier. Not wearing proper PPE risks me contaminating everyone I see subsequent to the initial encounter. As much as I care about my patients, I put my health first. If I get sick, I cant care for all the patients down the line where I would be quarantined for two weeks.

To your claim about me using up valuable resources, we can always move to PAPRs can we not? Would it be my fault that I'm 'wasting' N95s, or would it be on the hospital that is still doing gastric sleeves and tonsillectomies?

I just want to do right by me, my patients, and not get fired in the process.
Click to expand...

Just talk to your PD and tell them what you're rightfully concerned about. Anything that could possibly happen to you is going to go through them. None of us is going to be able to give you a definitive answer here since none of us knows what your situation is and what the resources available to you are.

Nobody is going to take action against you for refusing to put yourself into an unsafe position. The effort it takes to initiate a corrective action against someone is enormous, and unless you do something that is so out of bounds that 50/50 people would agree you are being unreasonable you are likely to be fine.
 
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vector2 said:
How dare you not put your life in danger for the very generous average resident wage of $15 / hr
Click to expand...
GandalfTheWhite said:
Like I mentioned, this would be for elective cases which we still have scheduled for the week. Considering that most of these patients are in a high risk area and the incubation period during which they can remain asymptomatic can be upto 3-4 days, any case has a potential risk for being a COVID carrier. Not wearing proper PPE risks me contaminating everyone I see subsequent to the initial encounter. As much as I care about my patients, I put my health first. If I get sick, I cant care for all the patients down the line where I would be quarantined for two weeks.

To your claim about me using up valuable resources, we can always move to PAPRs can we not? Would it be my fault that I'm 'wasting' N95s, or would it be on the hospital that is still doing gastric sleeves and tonsillectomies?

I just want to do right by me, my patients, and not get fired in the process.
Click to expand...

Nobody is going to fire you for what you are proposing. Imagine the backlash against that, even if some misguided individual thought it was necessary.
My personal beliefs are as above...use N95/PAPR for known cases, regular mask/other protective plans as above in patients unlikely to have COVID. If I had unlimited supplies for myself and my hospital for the next 2 months, my plan would be different.

Our PAPRs are in shorter supply than N95 masks. Your hospital situation may be different.

Your hospital should consider these shortages if they are truly in a high risk area and doing elective cases. Most places are probably weaning down off elective cases even outside of high risk areas. They are around here, and we have no proven cases within 30 miles.

I would discuss any concerns with your program director rather than random attendings on a given day.
 
GandalfTheWhite said:
Hey everyone,

Just wanted to get some clarification regarding the COVID issue. As a resident, is it defensible to refuse intubating/extubating without N95s if you are concerned for COVID exposure? This is referring to elective cases, not urgent/emergent ones. I'm all for doing my job, but not at the cost of risking my life or the morbidity that comes with contracting COVID, especially for cases that should be cancelled. My concern is that if I refuse to do it, I will face retaliation from either the department or the administration with a non-renewal of my contract. The N95s are in short supply and not guaranteed to us; not able to get our hands on PAPRs/CAPRs either.
Click to expand...

I guess I would challenge the term "refuse" here...not sure it belongs in professional discourse regarding patient care. It's kind of confrontational too, where I'm not sure that it is really necessary. Grown ups can talk about issues surrounding the conduct of an anesthetic without becoming confrontational and the vibe doesn't have to go there. If the knives have to come out over stuff like this, you might have bigger problems than COVID-19.
 
drmwvr said:
If someone is intubating with their face closer to the patient's airway with DL than the glidescope...they're DL'ing wrong or they need glasses...
Click to expand...

When I DL, I bring the table up to about the level of my xiphoid. When I glidescope, I keep the table about waist height. For me, the difference in proximity to my face is significant. Maybe you’re short?
 
GravelRider said:
When I DL, I bring the table up to about the level of my xiphoid. When I glidescope, I keep the table about waist height. For me, the difference in proximity to my face is significant. Maybe you’re short?
Click to expand...

ha!....bingo.....didn't consider that....Either technique, my elbows are barely flexed and I lean back...good insight...and I wear glasses....
 
GandalfTheWhite said:
The N95s are in short supply and not guaranteed to us; not able to get our hands on PAPRs/CAPRs either.
Click to expand...

pretty sure that's a lawsuit waiting to happen.

If you don't have N95 with someone with SARS-COV-2 (or TB or anything that requires it), don't intubate. It was stressed at our morning meetings as a department.

GravelRider said:
I see myself using the glidescope more simply because I don’t have to put my face as close to visualize things with the glidescope.
Click to expand...

Damn everyone's airway looks so difficult all of a sudden.

Being serious for a second. Knowing what I know about OP, there is no way I wouldn't be concerned either if I was in OP's shoes. This is a great time to see where the priorities lie in the leadership as well.
 
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dchz said:
pretty sure that's a lawsuit waiting to happen.

If you don't have N95 with someone with SARS-COV-2 (or TB or anything that requires it), don't intubate. It was stressed at our morning meetings as a department.



Damn everyone's airway looks so difficult all of a sudden.

Being serious for a second. Knowing what I know about OP, there is no way I wouldn't be concerned either if I was in OP's shoes. This is a great time to see where the priorities lie in the leadership as well.
Click to expand...
An update:
elective surgeries are still being done this week, but will be canceled next week onwards. We can choose not to intubate, and the attendings will step in to do so. No LMAs, only ETTs. Were planning on keeping a sizable number of residents home to avoid exposing people unnecessarily. All positives, except the fact that elective cases are still being done this week.
 
GandalfTheWhite said:
An update:
elective surgeries are still being done this week, but will be canceled next week onwards. We can choose not to intubate, and the attendings will step in to do so. No LMAs, only ETTs. Were planning on keeping a sizable number of residents home to avoid exposing people unnecessarily. All positives, except the fact that elective cases are still being done this week.
Click to expand...

The range for elective can be pretty wide and gray. Somethings are technically elective but it is time sensitive.

But yeah breast implants should be cancelled. But would you really cancel papillary thyroid cancer?
 
dchz said:
The range for elective can be pretty wide and gray. Somethings are technically elective but it is time sensitive.

But yeah breast implants should be cancelled. But would you really cancel papillary thyroid cancer?
Click to expand...
That’s the guidance that our hospital has issued. Basically not all electives are elective. Sadly, we are alone among local hospitals in severely cutting back and so the crnas were are furloughing are pushing back a little. Hope that the other places follow suit soon.
 
At our shop we have a pretty good process in place. We are instructed to put on a surgical hat/bonnet, surgical gown (impermeable), 2 sets of gloves, shoe covers, and eye protection. Every intubation should be an RSI with glide scope if possible to both reduce bag masking/blowing COVID around the room and glide scope to put a little distance between you and the patient. We apparently have "run out" of PAPRs so everyone had to be tested for n95s. Of course that means mandatory shaving for all the dudes. Some attending have had a beard for 30+ years and it is hilarious to see them without facial hair. On a positive note it appears the average age in our department has gotten about 10 years younger!
 
Last edited:
JobsFan said:
...

i think

for elective surgery (which will stop soon anyway)
1. suggest regional, and put a surgical mask on the patient
2. wear a surgical mask, and a splash guard if GA
3. paralyse well so they don’t cough / buck on intubation .. consider modified RSI too
4. consider having the filter put into the ETT prior to intubating.
Click to expand...

I’m using a lot more remifentanil to get cough free extubations too
 
Painted said:
Don’t worry...CDC is saying you can use a bandana if you run out of PPE.
www.cdc.gov

Healthcare Workers

COVID-19 guidance, tools, and resources for healthcare workers.
www.cdc.gov www.cdc.gov
Click to expand...

I thought you were joking... then I read the article and found the words "bandanas and scarves" under HPC Use of Homemade Masks.

I had to check the website again to make sure I wasn't reading The Onion. Unbelievable.
 
MoMoGesiologist said:
Manipulating the airway is high risk aerosolization. Every guideline is saying you need PPE to do it. Your hospital isn’t providing you with it? Don’t risk your life. Stay safe.

www.apsf.org

An Update on the Perioperative Considerations for COVID-19 Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)

The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continues to have a profound impact on life across the globe and has placed an enormous strain on health care systems...
www.apsf.org www.apsf.org

The rec is for the most experienced person to intubate.
Click to expand...

Our ER docs who normally intubate their own have used this rationale to request that we do all their intubations from here on out. It was a hard pass by me and my colleagues.
 
Mofeen said:
Our ER docs who normally intubate their own have used this rationale to request that we do all their intubations from here on out. It was a hard pass by me and my colleagues.
Click to expand...

They tried to pull the same thing at our place. Got shut down real quick. Something tells me we’re gonna start getting a lot more stat calls for “difficult airways” now.
 
Would it be reasonable/safe to just always wear and reuse one n95 (maybe put a surgical mask over it) and treat it as dirty on the outside. Wash hands before and after putting it on? Then if you have a known covid case dispose of the n95 and get a new one?
 
fittipaldi1of1 said:
Would it be reasonable/safe to just always wear and reuse one n95 (maybe put a surgical mask over it) and treat it as dirty on the outside. Wash hands before and after putting it on? Then if you have a known covid case dispose of the n95 and get a new one?
Click to expand...
No
 
Why not? I’d hate to do a case without proper ppe then find out in a few days the patient had coronavirus.. I feel like wearing a n95 while in the hospital couldn’t hurt
 
fittipaldi1of1 said:
Why not? I’d hate to do a case without proper ppe then find out in a few days the patient had coronavirus.. I feel like wearing a n95 while in the hospital couldn’t hurt
Click to expand...

The argument for why not is we have a limited quantity of PPE and many places will likely run low/out at some point during this pandemic.

We’re only allowed to wear an N95 if your going in the same room as a patient who has tested positive or is awaiting test results/high suspicion for covid (though by the time they call us for anything if there was any remote suspicion the test is already cooking).

Even then, we’re re-using N95s as long as it wasn’t being used for a procedure at high risk for exposure (really just intubation, I don’t think anyone is dumb enough to bronch these folks)
 
fittipaldi1of1 said:
Why not? I’d hate to do a case without proper ppe then find out in a few days the patient had coronavirus.. I feel like wearing a n95 while in the hospital couldn’t hurt
Click to expand...

I've starting wearing N95 for every single case, plus a surgical mask outside to keep N95 clean. The hospital doesn't have any N95; I have to bring my own.
When the government is monkeying around telling you it's ok to wear bandana and scarf as PPE, you've got to take things into your own hands.
If you get sick/die or your family gets sick from you, neither your hospital nor your government would care at all.
 

3M™ Full Facepiece Reusable Respirator 6800 Medium 4 EA/Case | 3M United States

www.3m.com www.3m.com

1584725218451.png
 
Gasper said:
I've starting wearing N95 for every single case, plus a surgical mask outside to keep N95 clean. The hospital doesn't have any N95; I have to bring my own.
When the government is monkeying around telling you it's ok to wear bandana and scarf as PPE, you've got to take things into your own hands.
If you get sick/die or your family gets sick from you, neither your hospital nor your government would care at all.
Click to expand...

this is exactly what I’m thinking. I dont see any negatives to this..
 
Mofeen said:
Our ER docs who normally intubate their own have used this rationale to request that we do all their intubations from here on out. It was a hard pass by me and my colleagues.
Click to expand...


Our senior trauma surgeon said trauma service would run the COVID19 vents if the pulm/icu team gets overwhelmed since we anesthesiologists are not used to APRV ventilation. We said all yours baby!!
 
nimbus said:
Our senior trauma surgeon said trauma service would run the COVID19 vents if the pulm/icu team gets overwhelmed since we anesthesiologists are not used to APRV ventilation. We said all yours baby!!
Click to expand...
Forget APRV. Do what you know, low volume, high PEEP, ARDSnet protocol. APRV is nice in theory, NEVER PROVEN to do sh-t. It's as experimental as medications; it may help or not. For every patient, do what works for that particular patient.

The value of APRV may be in the early stages, because it prevents atelectasis. It also may be better tolerated with less sedation. One can do the same with PEEP (you keep raising PEEP until the PIP starts rising in equal amounts - i.e. no more recruiting of atelectasis, just distension), but PEEP is unpleasant to the awake patient, so one has to go ~2 cmH2O at a time.

Still, if you do need APRV, here's a refresher:
www.emcrit.org

APRV Guideline

general philosophy Let's admit it, nobody knows exactly how to set APRV. Numerous protocols and articles recommend different approaches. There has never been a human trial comparing two different APRV protocols, so it's impossible to dogmatically say whether any protocol is better than any...
www.emcrit.org www.emcrit.org
 
Last edited by a moderator:
I can get elastic straps from a regular non rebreather O2 mask in the O.R.? I can build one of these respirators but need elastic straps. All I can think of is the straps we have on our O2 masks.

Can you re-use a typical N100 respirator? What about a N95 mask? This stuff has very limited availability.
 
BLADEMDA said:
I can get elastic straps from a regular non rebreather O2 mask in the O.R.? I can build one of these respirators but need elastic straps. All I can think of is the straps we have on our O2 masks.

Can you re-use a typical N100 respirator? What about a N95 mask? This stuff has very limited availability.
Click to expand...
I too have only seen them on our masks. We could use head straps instead, but those would be unreliable :nono: .

Still, ANY good elastic should work.
 
Why is it that when I see pictures of Italy, China, and South Korea during this pandemic, I see healthcare workers in full hazmat suits and PPE from head to toe with N95 masks at bare minimum? Yet here we are told that we don’t have enough masks and are cobbling together PPE from random things? We are getting emails saying that surgical masks are all we need.

Something doesn’t add up. If there is not massive firings of hospital CEOs and administrators after this is over, I may actually start a riot. These idiots are nothing but a failure.
 
GravelRider said:
Why is it that when I see pictures of Italy, China, and South Korea during this pandemic, I see healthcare workers in full hazmat suits and PPE from head to toe with N95 masks at bare minimum? Yet here we are told that we don’t have enough masks and are cobbling together PPE from random things? We are getting emails saying that surgical masks are all we need.

Something doesn’t add up. If there is not massive firings of hospital CEOs and administrators after this is over, I may actually start a riot. These idiots are nothing but a failure.
Click to expand...
Because this is how America looks when she's "great".

Physicians will die before they riot. Bunch of losers with MD/DO after our names. Plus they will outlaw rioting, strikes etc. soon.
 
pgg said:
Clever.
Click to expand...

I'm going to be trying this as I failed my N95 fit test and our PAPR supply is limited to be using for patients who are not COVID+, but may be carriers of the virus.

What would your surgical and nursing colleagues in the OR say to you wearing this for the duration of cases for emergent, non-COVID+ patients? I can imagine some of our circulators would be writing me up for wearing this device. It would take a lot of effort to convince them that these actually filter much better than our regular surgical masks.
 
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