Experiences of a Paediatric Otolaryngologist: navigating the current challenges

26 March 2020

Rohit Verma, of Sheffield Children’s Hospital, notes the following practical observations, which may help surgeons navigate some of the challenges currently affecting them in operating theatres.

There is currently a lot of confusion from theatre and ward staff when they hear that surgeons are undertaking full PPE for a case involving a patient who is otherwise being nursed in a standard fashion. It is essential to engage with ward nurses, porters and staff who bring patients to theatre, as well as recovery staff, so that they can understand both why we in theatres are assuming full PPE protection, and what their own requirements are. This prevents staff feeling that they are being put in a dangerous position, while minimising unnecessary use of PPE supplies. At Sheffield Children’s Hospital we have addressed this by including the porter and recovery nurse in our theatre briefing. Our anaesthetists have devised a COVID-19 checklist, part of which involves each member stating exactly what type of protective equipment they’re expecting to wear, which is helping to prevent confusion.

While this remains a learning phase for all concerned, and timings should improve, there are innate inefficiencies when using full precautions. I would advise that you need to factor in at least an additional 90 minutes to 2 hours for your case. This includes time for the anaesthetist to prepare and time for the patient to be fully recovered in theatre, as well as turnaround time for cleaning.

As far as the practicalities of operating in these conditions are concerned, the following things have become obvious to me:

1. Communication in theatre is extremely challenging. While fit-testing for the masks involves reading a few sentences, in reality you have to raise your voice in order to be heard through the mask. With the additional noise of laminar flow, you almost need to shout to be heard by your anaesthetist at the end of the bed, or even your scrub nurse. The difficulty is that raising your voice involves extra movement of the jaw, which can potentially disrupt the fit of the mask. I have resorted to (politely) stamping my foot in order to catch the anaesthetist’s attention. This is also a signal to other members of the team that I need to communicate something, so that someone can come close enough to hear my message and relate it to the relevant member of the theatre team.
    
2. I would allow at least an additional 25% operating time for any procedure. This is mainly the result of the communication issues as detailed.
    
3. It is impossible to take a phone call whilst in full PPE – your voice is distorted and people cannot hear you. We have adopted a buddy system on call in ENT, so while you are operating, another consultant is able to take calls and offer advice as required. This will also apply to any middle grades who are assisting in the procedure. This is especially important out of hours.
    
4. At the end of a procedure, there is naturally a strong desire to leave the theatre as soon as possible. While understandable, it does jeopardise important events such as a post-procedure debriefs. During this learning phase, I would encourage the operating surgeon to seek feedback from the team members, perhaps later in the day, so that we are still able to gain useful insights. We are all in the learning phase and I don’t think any trust is going to have a perfect approach, but it is important that we don’t miss out on experiential learning at this critical time.
    
5. In terms of planning your surgery, if you think that something might possibly be needed, I would advise that you discuss it very clearly at the brief. Be pessimistic – your usually dry intracapsular adenotonsillectomy for severe OSA might bleed heavily. Could you need a bipolar diathermy available? Assume that the runners outside are not your regular ENT team and they may struggle to find something very specific. Additional equipment can be stored in plastic bags in the anaesthetic room, keeping them clean. That way, while they are readily available to be brought into theatre, if unused they are not risking contamination, necessitating disposal and wastage.
    
6. It is likely that, as a result of staff sickness and unfulfilled PPE training requirements, you may find yourself working with a team less experienced than your usual colleagues in the procedure you are undertaking. Take time to identify exactly what pieces of equipment you are likely to need, the order of the procedure steps, and perhaps help them set out their theatre trolley in such a way that the instruments are arranged in a logical order. I have been fortunate enough to work with scrub nurses whom I know well, but even then we struggled. In this unusual environment it pays dividends not to make assumptions that the scrub nurse knows what you are going to ask for next.
    

As an aside, many of us have middle grades who cover from different hospitals and perhaps have consultants coming from different hospitals on call. Each trust seems to have differing FFP3 masks, and the fit-testing for one device may not be applicable to another. I would advise that clinical leads ensure that anybody who might be involved in an emergency procedure has an up-to-date fit test with the masks that you have locally, or otherwise ensures that each on-call middle grade or consultant is provided with sufficient FFP3 masks by their host trust, so that they are able to bring them to another site if required on call.

I hope these insights are helpful. There is no substitute for practising the setup and preparing for each case in detail.