Embrace the Catastrophist Within: Protecting Ourselves From Respiratory Infection

My husband calls me his catastrophist. I’ll admit it. I relish disaster movies and read history about plagues and calamities. All my knick-knacks are glued down in anticipation of the next earthquake. I’m always pointing out the worst possible thing that could happen when we embark on any adventure —even if that adventure is barbecuing in the backyard.

But a good anesthesiologist, or any health care provider, has to embrace the catastrophist within because our goal is to protect our patients from the unexpected. We have to constantly imagine the worst-case scenario so that if, or when, it happens we not only recognize it early, we’re ready for it. What we’re often not good at is protecting ourselves at work. We tend to be so patient focused that we often don’t even think about personal hazards.

My first personal experience with this was as a first year anesthesia resident. I was ventilating an intubated teenager suffering from bleeding esophageal varices during a code. She had severe cirrhosis from non A-non B hepatitis. When the ambu bag fell apart, leaving me with no way to ventilate her, I didn’t wait for another ambu-bag to be brought. I plunged into mouth-to-endotracheal tube ventilation. We saved the patient. Somehow, either by sheer dumb luck or as a result of the series of gamma globulin shots I was then forced to endure, I did not get infected. But I could have been.

We are entering a period of time when it will be important for all of us, no matter what our role in health care, to be aware of emerging infectious diseases and preventing their spread. MRSA, VRE, MERS, H5N1, H7N9. There’s a veritable alphabet soup out there of resistant bacteria and viruses. Not only can we spread disease among our patients, we can catch it.

Over my career I have attended a lot of emergency intubations. If a patient has MRSA or VRE, Health Care Workers (HCWs) carefully put on cover gowns and gloves and take extreme precautions to prevent its spread. HCWs are often a lot less compulsive when dealing with respiratory illness.

Seeing a health care provider intubate a patient with pneumonia or ARDS without wearing a mask is unfortunately common. It is also common to see nurses and respiratory therapists, HCWs who would not think of suctioning an airway without wearing gloves or eye protection, to suction the airway of a patient with an unknown pneumonia without donning a mask. Well, how safe it that?

The SARS epidemic in 2003 gave us a lot of information on the epidemiology of spread of this corona virus, both in patients as well as HCWs. A recent article in the on-line publication of the University of Minnesota Center For Infectious Disease Research and Policy (CIDRAP) states (1):

“Twenty-two percent of SARS patients in Hong Kong were HCWs.
Nosocomial outbreaks of SARS resulted, overall, in 716 secondary and tertiary cases and 52% (410) of these were in HCWs. HCWs with the highest risk of SARS infection were those performing tracheal intubations, working in wards with artificial central ventilation, having face-to-face interactions with SARS patients, wearing single (vs double) gloves, and caring for a ‘super-spreader’ cases.”

Aerosol-generating procedures such as endotracheal intubation, manipulation of an oxygen mask, suction before intubation and non-invasive ventilation carried the highest risks of SARS transmission to HCWs (2).

Now this should be food for thought for all of us. Middle East Respiratory Syndrome Corona Virus (MERS CoV) is the same class of virus as SARS. Also starting to circulate are some of the potentially more lethal influenza strains such as H5N1 or H7N9. So far none is especially contagious, but that could change at any time. It’s a good time to start to question the safety of foregoing personal protective equipment in situations where respiratory contamination is possible.

According to the CIDRAP article (1),

“As of May 6, [2014] 96 (19%) of the 495 known Middle East respiratory syndrome coronavirus (MERS-CoV) cases, including a number of fatalities, were in healthcare workers (HCWs).

The vast majority of HCW cases—74%—have occurred in the Kingdom of Saudi Arabia, with 24% in the United Arab Emirates. Sixty-three HCW cases—or almost two thirds—were reported last month alone, and more than 60% of the 128 recent MERS patients in Jeddah were infected in a hospital, including 39 HCWs, 6 of whom required intensive care or died.”

Regular surgical masks are not very efficient at screening out particulates because they almost invariably leak around the edges. Testing shows 30-50 % of particles will leak into the face piece of a well fitting surgical mask, but this better than no mask at all. The N95 filter masks, when well fitted, allow less than 10% leakage (3).

A study looking at HCW infection rates from the 1918 Global Flu Pandemic showed that mortality in the United States for HCWs was 4.1/1000 compared with the general population of 3.9/1000 (4). Wait a minute! What 1918 Global Flu Pandemic?

When I was in school, I was never taught about the Great 1918 Flu Pandemic. I had to read about it in one of those history books.  Most people don’t know that this pandemic killed more people than World War I. It sickened 20-40% of the world’s population of 1.8 billion people (360-720 million people). Recent estimates put the global death toll between 40 and 60 million people and perhaps as many as 100 million. There is such disparity because of the loss of records in the war. In addition, many towns and villages in remote areas were simply wiped out, along with their demographic history. In comparison, only 10 million military personnel and 7 million civilians died in World War I.

The 1918 virus, a so-called swine flu, was so virulent it was known to kill some patients within 24 hours. As opposed to typical influenza, the majority of flu deaths were in patients between 20-40 years of age. The sickest patients simply developed a hemorrhagic pneumonia and drowned in their own fluids during an era when supplemental oxygen was in short supply and artificial ventilation and PEEP did not yet exist.

Now why it tended to attack younger rather than older individuals is still debated. However, the fact that it spread so far, and so fast, is likely due to the fact that a new, highly contagious and lethal virus, to which few people had immunity, arrived on the scene at the exactly the wrong time when the world was in utter chaos.

  • World War I was in progress. There was fighting in Europe, Africa and Asia. For the first time in the world’s history millions of people were on the move at the same time, from troop movements to refugees. And many of those people were living in close quarters. And the virus moved with them.
  • Because of the war, there was tacit press censorship in all of the major Allied countries prohibiting anything that might hurt morale from being published. People in government were picking their own facts to support their own messages. The start of the pandemic thus went unnoticed by many until too late to effectively intervene.
  • Shear numbers of cases overwhelmed the medical system. In addition, lack of adequate medical personnel in remote or war torn areas further disrupted care and hampered containment

For a really good and readable history about the 1918 Pandemic,  I highly recommend The Great Influenza, by John Barry (5).

Okay, so here comes the catastrophist. The world is starting to look pretty chaotic.

  • Our current world is filled with war torn areas. According to the UN Refugee Agency, there are now more than 50 million global refugees, more than at any time since World War II (6). Many of those people lack access to health care and live in refugee camps.
  • Millions of people are routinely on the move around the globe for business and pleasure. Any one of us can be anywhere in the world within 24 hours just by getting on an airplane. Twenty four hours is a lot shorter than just about any incubation period.
  • People are once again starting to choose the facts they like to guide policy decision and deciding to discard the facts that don’t fit into their belief systems. Science is sometimes being ignored for ideology.
  • Cross-over animal viruses are becoming more common as the population grows and moves into closer proximity to previously wild areas. MERS is thought to be a camel virus. H5N1 and H7N9 are bird flus. Ebola probably comes from bats. Humans often lack immunity to new cross-over viruses.

In the setting of growing global chaos MERS CoV is slowly spreading in a Middle East torn by conflict. The H7N9 and H5N1 Avian Influenzas are smoldering in Asia. Any of these viruses could mutate to become more contagious. And then there’s  Ebola currently spreading without control in West Africa.

I encourage you to check out the links below to the CIDRAP article (1) and to the CDC recommendations related to HCW personal protection from MERS (7). It has an easy to read  table showing appropriate airway protection strategies as well as patient isolation strategies. It’s certainly applicable to other contagions.

Also of interest are the Canadian Respiratory Protection Guidelines (8). This contains an algorithm, also shown in an easy to follow table, allowing the HCW to categorize risk and formulate protection strategies based on risk of contagion, facility resources, and location of care.  It’s thought provoking and well worth a look.

When you go to the ICU,  the emergency room, or even a patient home in an ambulance to assist ventilation or intubate a patient, you may not know the cause of his or her respiratory failure. As MERS and other respiratory infectious agents spread, we who manage the airway will be on the front lines and must be ever vigilant. Don’t rely on dumb luck to keep yourself and your family safe.

In addition, you must protect your patients. Hospital-acquired infections are estimated to cost $30 billion and to lead to nearly 100,000 patient deaths a year (9). You definitely don’t want to be one spreading the germs.

  • Wash your hands, or use an alcohol-based prep before and after every patient contact. Unless coaxed, less than 30% of us routinely wash our hands after patient contact – not a good statistic.
  • Wear gloves
  • Wear eye protection
  • Consider wearing a cover gown if the patient is infectious or the cause is unknown.
  • Be careful with contaminated equipment (you really don’t want to stick that used laryngoscope blade in your pocket to take back to the department, do you?).
  • If you see a colleague being incautious, point it out. You might save that patient or your friend.
  • And put on that mask if you’re managing the airway of a patient with respiratory illness.

May the force be with us

 

1. COMMENTARY: Protecting health workers from airborne MERS-CoV—learning from SARS, Lisa M Brosseau, ScD, and Rachael Jones, PhD ; May 19, 2014

2. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS One 2012;7(4):e35797.

3. Lee SA, Grinshpun SA, Reponen T. Respiratory performance offered by N95 respirators and surgical masks: human subject evaluation with NaCl aerosol representing bacterial and viral particle size range.

4. Low but Highly Variable Mortality Among Nurses and Physicians During the Influenza Pandemic of 1918–1919 G. Dennis Shanks, Alison MacKenzie, Michael Waller, John F. Brundage, Influenza Resp Viruses. 2011;5(3):213-219.

5. Great Influenza, The : The Epic Story of the Deadliest Plague In History Paperback – January 1, 2006 by John M. Barry  

6. UN Refugee Agency News Stories, 20 June 2014

7. CDC: Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

8. Canadian Respiratory Protection Guidelines

9. With Money At Risk, Hospitals Struggle To Get Staff To Wash Hands.  Anemona Hartacollis, New York times; May 28, 2013 

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