ST. LOUIS - The extremely contagious nature of COVID-19 during certain procedures led a Mercy team to create a new operating “bubble” that allows surgeons to perform an open tracheostomy on the sickest patients without moving them to the operating room.
Tracheostomy is high risk for the surgery team because of the aerosolization that occurs when a breathing tube is inserted into the windpipe. The procedure becomes necessary when very sick COVID-19 patients spend prolonged time on a ventilator. It protects their vocal cords and makes it safer to wean them from breathing support when their condition improves.
“We move the OR to the intensive care unit,” said Dr. Alison Gildehaus, medical director of trauma and acute care surgery at Mercy Hospital St. Louis. “Patients stay in their negative pressure, ICU rooms – removing the added risk of transport – and the surgery team comes to them. We limit the number of people in the room, thus conserving PPE, yet have added support right outside.”
A multidisciplinary team uses ordinary materials available in the hospital to create a bubble-like environment keeping both the patient and the surgical team safe during the tracheostomy.
“We took the idea of the aerosol box, designed by a Taiwanese doctor, and built upon it,” Dr. Gildehaus said.
The aerosol boxes, made of clear acrylic, lend a layer of protection to clinicians when they place a breathing tube through a patient’s mouth. With the surgical bubble, “By encasing the patient’s entire body in a tarped bubble, we protect the patient while reducing the risk of exposure to the care team.”
A team of five – an anesthesiologist, respiratory therapist, surgical technologist and two airway surgeons – are the only ones in the room during the tracheostomy. The team is supported by additional staff outside of the ICU room via in-room, two-way video capability.
The team practices and debriefs in a Mercy simulation lab to hone their skills and gain new insights.
“The simulation lab is invaluable,” Dr. Gildehaus said. “We practice together in a safe space before each procedure and in the beginning were able to try new materials to see what worked best to keep our patients safe. To date, we’ve successfully performed nearly five procedures on our COVID-19 patients and we expect to assist teams across Mercy in doing the same.”
Currently, the plastic used for the bubble is adapted from an OR biohazard bag, but the team hopes their innovation might lead others to come up with a more permanent solution.
Information for Medical Professionals
For medical professionals interested in learning more, Mercy’s team is sharing its step-by-step protocol for performing a trach in a bubble environment.