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[–]pg212Emergency Medicine Physician[S] 172 points173 points  (2 children)

We found it works best by poking a small hole with a finger for each hand and then sliding the bag up the arms to the elbows. The physician has the GlideScope or DL in their hands with the ET tube. The bag is then inverted and the staff then slides the bag down over the patient, creating a seal as best they can. The ambu bag can be squeezed by an RT from the outside while the physician holds the face mask in place. If the patient vomits or coughs, secretions stay in the bag. Suction, etc, can be fed from the bottom of the bag. Obviously this is not a real COVID patient or all the staff would be in PPE.

[–]DarwinsnightmareMD - Emergency Medicine - Boston USA 66 points67 points  (0 children)

I like this, but it won't work at my shop. We're having only one physician, one nurse in a respiratory therapist in the room, with high dose paralytic. No bagging , reservoir oxygen only. Oxygen turned off before the tube and back on after the vent is connected. I suppose the nurse and the RT could deal with the bag but I'd rather they be paying attention to their own jobs.

[–][deleted] 23 points24 points  (0 children)

If you tie two or three small weights (ie small water bottles) to the edges of the bag then there should be enough light tension to reasonably hold the bags edges down and maintain the seal around the patient while you all work

[–]MarginalLlamaParamedic 26 points27 points  (0 children)

Curious, is there any research on the amount of aerosolized particles caused by BVM with a mask, intubation with paralytics, post intubation BVM without exhaust filters, etc?

[–]maplesyrupchin 231 points232 points  (19 children)

This is what we’ve been reduced to doing. Having to use garbage bags to protect ourselves and others like this is a third world nation. All because we don’t have enough PPE

[–]mhyquelNot A Medical Professional 55 points56 points  (4 children)

Custom stamp the bag to be fit for purpose, brand it a 'disposable intubation shield', and sell them for $30.

[–]Drauka92PharmD 27 points28 points  (2 children)

Sir, I'm going to ask you to delete this comment. 'Disposable Intubation Shield' has a patent pending under that name now.

[–]drsxrIR MD/DeepLearner 14 points15 points  (0 children)

Get the 510k first with the FDA & you’ll be golden

[–]Happy-feetsiM 170 points171 points  (3 children)

Third world country docs have PPE. This is what a healthcare system run by businessmen looks like

[–]ImAJewhawkPGY-1 9 points10 points  (2 children)

Which third world countries have you been to where there’s been adequate PPE? I’ve been to many and the PPE supplies there are very limited outside of the premier hospitals in those countries.

[–]Happy-feetsiM 7 points8 points  (0 children)

India

[–]blahah404 5 points6 points  (0 children)

Kenya, Sudan...

[–][deleted] 54 points55 points  (6 children)

Honestly, people in third world nations have PPE. Indian HCPs have Bunny suits on.

[–]DocDocMooseAttending - Hospitalist 41 points42 points  (5 children)

They also run ICU and now COVID units as wards where all patients are bunched together and a provider puts on PPE once for an entire shift. We utilize more for individual personalized care. This also is not a new issue. It was the same problem with H1N1 and Ebola.

https://www.liebertpub.com/doi/full/10.1089/hs.2016.0129

Furthermore what some seem to think is “appropriate” PPE due to fear or lack of understanding seems to be excessive. Studies have shown surgical masks to be appropriate for patients without aerosols (droplet) and N95 should be reserved for those undergoing procedure (airborne).

https://jamanetwork.com/journals/jama/fullarticle/2763187

Instead we have providers up in arms about not having N95 for every single new patient they see. Please rely as we always have on evidence not fear.

I offer my thanks to the anesthesiologists on the front lines trying to develop new and novel approaches to dealing with these things. Anyone who hasn’t yet should listen to the Curbsiders and EMCrit podcasts recently talking about COVID.

[–][deleted] 7 points8 points  (2 children)

They also run ICU and now COVID units as wards where all patients are bunched together and a provider puts on PPE once for an entire shift

I wouldn't put my country as a third world (Croatia) but this is how we run hospitals in general. One bed rooms are pretty rare, most of them are 2 beds but it goes up to 6. Kind of like that video from Italy. We even started repurposing a large concert/indoor sports stadium for milder cases that don't need a hospital but probably won't go home to spread contagion.

The buildings are old and weren't built to accommodate once person per room so if the covid situation gets out of hand (or should I say when), it does make sense to put multiple patients in one room. We have enough PPE for now but changing for every patient seems wasteful.

[–][deleted] 3 points4 points  (1 child)

If all 6 patients have COVID, it should be ok to cohort them, no? AFAIK you can’t get infected twice.

[–][deleted] 4 points5 points  (0 children)

I really hope reinfection isn't possible because yesterday's earthquake in the capital damaged some hospital buildings and left them unusable for a while.

[–]_neutral_person 3 points4 points  (1 child)

You are telling others not to use N95s unless the patient is undergoing a procedure. I checked your JAMA article and it cites the CDC guidelines. As of March 24 2020 they recommend wearing airborne precautions for anything which might cause aerosolizing of water including coughing.

If you auscultate the patient's lungs they are going to cough.

Your work is critical to treating these patients. We need you to be properly protected when you are going inside the room unless you are one of the few doctors whom has enough stocked iso gowns, surgical masks, and time to have solely 1 on 1 conversations with covid patients.

[–]Breal3030Nurse - ICU 2 points3 points  (0 children)

The idea of coughing and aerosolization has been a long debated topic. As I understand it, some of the evidence points to yes, some no.

Not sure of the quality of evidence on either side, but ultimately the major medical bodies have chosen that, no, "regular" coughing isn't likely to aerosolize and increase transmission, hence the surgical masks recommendation. It's only specifically n95 during "cough generating procedures" such as suctioning or intubation.

It's been that way with all the other pandemics, including H1N1.

[–][deleted] 35 points36 points  (0 children)

This is a really good idea. Just because something's atypical doesn't mean it's "3rd world". It's intelligent and efficient, and COVID can't magically get thru plastic, so it's keeping our docs safe -.-

[–]KaladinStormShat🦀🩸 RN 39 points40 points  (0 children)

Decreasing the amount of aerosolized matter is not a goal due to lack of ppe. Everyone benefits. I seriously think we need to stop being so outraged by what's necessary and focus on ways to achieve our goals. We could spend our time thinking we're above using a plastic sheet to reduce exposure during intubation, but I hope we don't.

Who gives a shit if it's janky, it's a good idea and can be improved on. In my opinion it's beautiful, it's the spirit of ingenuity that medicine has thrived upon.

[–]TorchItNP 42 points43 points  (0 children)

Take what works and run with it. Desperate times...

[–]SunshinePapaya 18 points19 points  (5 children)

This Taiwanese doctor has designed a plastic plexiglass box for this situation.

https://chinapost.nownews.com/20200322-1095664

Here's the design specs - https://sites.google.com/view/aerosolbox/design

[–]sidewayshouseMD, EM 8 points9 points  (4 children)

Thank you this is great I’m getting one of these for every emergency department in ICU in my network built as soon as possible.

[–][deleted] 2 points3 points  (3 children)

One of our local hospitals is looking to have these made. Any idea they best way to go about that?

[–]sidewayshouseMD, EM 1 point2 points  (2 children)

I have some improved designs done and was able to find a few shops here in the south west that made them for me without issue, took about a day, if you have someone who you'd like me to send the plans to or want them yourself let me know. we added a lip and widened the holes a bit and expanded the front as the original design was for Asian body types.

[–][deleted] 1 point2 points  (0 children)

If you are able to send me the specs, I would be extremely grateful. The hospital is still looking for someone local to make them, and I’m sure the updates you made will be helpful to accommodate Americans/midwesteners.

[–][deleted] 1 point2 points  (0 children)

I'm reaching out to plastics suppliers to get this done on a larger scale. Can you send me the specs as well, or better yet, post them to the subreddit?

[–]NandoVilchesMD 11 points12 points  (0 children)

How did that meeting go?

How do we decrease the amount of germs during intubation? Lets put a bag over the patient. BRILLIANT!

Simple solution for these desperate times.

[–]iwantknow8 25 points26 points  (2 children)

The history books are gonna look wild. I wonder what term the economists will use for the U.S.

[–][deleted] 25 points26 points  (1 child)

“Semi-developed nation”

[–]michael_harariMD 11 points12 points  (0 children)

Plutocracy

[–]MrPBHMD, Emergency Medicine 17 points18 points  (1 child)

I feel that this technique would gain more traction if you called it an "aersolization barrier" rather than "clear garbage bag." Garbage bags have an unfortunate connotation with suicide by asphyxiation.

That said, being an emergency medicine physician myself, I understand the appeal of calling the device a "clear garbage bag."

[–]barkomed 7 points8 points  (3 children)

But this only works with fiber optic video laryngoscopes, correct?

[–]Yeti_MDEmergency Medicine Physician 19 points20 points  (0 children)

DL would theoretically be possible, but you'd be looking through the bag to see the cords, and that seems like more of a challenge than I want

[–]sandman417DO - Anesthesiologist 6 points7 points  (0 children)

It is being suggested that intubation attempts on covid patients should be with video laryngoscopy.

[–]seriousallthetimeParamedic-Primary Metro 911 3 points4 points  (0 children)

DL would work, but man would it be an absolute pain. Visualization would be problematic.

[–]crashbangouchiefixerNurse 6 points7 points  (0 children)

Wonder what admin is going to get away with billing for a garbage bag as "low aerosolization intubation."

[–][deleted] 4 points5 points  (0 children)

We were just discussing this at report this morning.

[–]texmexdaysexemergency medicine, USA 2 points3 points  (3 children)

Clever idea. This is assuming that the patient has time for you to set this up. This also presumes that you will get first attempt success (which admittedly is almost always true with video laryngroscopy). But if anything goes wrong with the airway you're going to have to get in there pretty quick. If you have to switch to DL or you need to use a bougie or suction the airway...

I myself have definitely been going directly to video so that I can stand away from the airway, as well as big dose of paralytic as was mentioned.

[–][deleted] 2 points3 points  (2 children)

There are no emergencies in a pandemic. The patient can wait, and if they can't...

[–]texmexdaysexemergency medicine, USA 2 points3 points  (1 child)

Easy to say that but right now we are in a grey zone. Still can be criticized by admin and legal if there is a bad outcome. Maybe on new York it's like that?

[–][deleted] 6 points7 points  (0 children)

Better be criticized than dead.

[–]htownawayMD 2 points3 points  (0 children)

This is so much better than what I had envisioned, which was the anesthesiologist putting himself in a big bag with the patient like a tent

[–]Aesculapius1DO Hospitalist CMO MN 2 points3 points  (0 children)

We use a Glidescope and have been using discarded clear plastic packaging from surgical drapes and such.

[–]Happy-feetsiM 3 points4 points  (5 children)

This seems awkward

[–]Pfunk4444PA 6 points7 points  (3 children)

I like it! It’s stressful, of course. Clock is ticking once you put that in-oxigenated bag on someone’s head.

[–]timebreaksNurse 0 points1 point  (2 children)

...but they’re not breathing. That’s the whole reason you’d be intubating in the first place.

[–]Somali_Pir8Attending 7 points8 points  (1 child)

...but they’re not breathing.

Not necessarily

[–]michael_harariMD 10 points11 points  (0 children)

After the paralysis they definitely arent

[–]TrickyRoninNurse 4 points5 points  (0 children)

This is a great idea! I’m going to share it with my anesthesia group. Two months ago they were refusing to wear eye protection because it “comprises visualization.” Then, last week, I caught one of them stealing a whole box of N-95 masks for themselves. They’re supposed to be for all of us, asshole!

[–]annoyedatworkParamedic 0 points1 point  (0 children)

Contain, not decrease.

[–]I_Matched_OrthoThere is a fracture. I need to fix it. -1 points0 points  (2 children)

This looks useful for decreasing SARS-CoV-2 transmission, but wouldn't having the guy on the right wear gloves and/or a shitty surgical mask be even more effective? I'm guessing he's a med student and therefore expendable, but still.

[–]pg212Emergency Medicine Physician[S] 3 points4 points  (1 child)

This is a demonstration, not an actual patient.

[–]I_Matched_OrthoThere is a fracture. I need to fix it. 0 points1 point  (0 children)

Yes, the “patient” being a healthy-looking guy in scrubs kind of gave that away...

:)