Ever since we got confined to our homes due to the lockdown, we also got confined to our laptops with the epidemic of Webinars. We had insightful and informative webinars on managing our practice and patients in the Covid Pandemic and guidelines for safety. Throughout the entire last month, I went to my clinic twice, I had some postops, some Clubfeets who were struggling with plasters and some emergency cases. Apart from this I did a plaster under GA considering the kid ‘’As Positive” with a PPE only to realize now retrospectively that it was a risky thing I did.
I don’t know if I should say it was fortunate or unfortunate, one evening I received a call from the Hospital ER that a Covid 19 Positive kid is being referred to our hospital (SRCC Children’s Hospital by Narayana Healthcare) for fracture fixation. The 5-year-old asymptomatic kid was screened preoperatively at the primary hospital and had a Grade 3 Supracondylar fracture without any neurovascular deficit. The Management of the hospital and the anesthesia department was also informed and we all together decided to schedule the surgery next morning. Luckily the hospital was fully equipped, and all OT SOPs were in place and prepared beforehand by the Head of Anesthesia: Dr Nandini Dave, who seemed confident and did sound very comfortable about the Positive kid and we all decided to meet for briefing and a mock drill an hour before the scheduled time.
The OT Incharge and OT Co-Cordinator were all geared up with the entire plan.
A PPE Suit worn in the year 2019 for reference.
Anaesthetist: 2( 1 in OT and 1 in standby area and for transfer), Ortho surgeons: 2, Nursing staff – 3 (Scrub Nurse, Circulating staff and one in buffer zone for providing if anything was needed) Technicians: 2 ( 1 in OT- for Anaesthetia and C-arm, while second one waiting in standby area) Housekeeping staff : 1
Out of the 10- 8 of us would enter the OT, 1 technician and 1 nursing staff would stay in the buffer zone.
OT setup and Buffer zone :
We isolated the area outside Negative pressure OT, this section had a separate entrance door, an elevator which was identified to shift this child, a scrubbing area, a shower and a connecting door to the main OT complex. A big trolley with PPE and Chlorhexidine solutions was arranged and was placed in the buffer zone- outside OT with 2 stools to sit while wearing the shoe covers. No one was allowed to carry any personal items such as bags, laptops, mobiles or keys in the Buffer zone and OT. We all went in the isolated area; the donning and doffing steps printouts were put on the walls and the OT Incharge and OT Co-cordinator watched us while this process through the door connecting the Main OT complex.
Donning Sequence :
We had 2 caps and 1 masks on already (N95). We all wore the lead apron, a plastic gown over it, gloves and then the hooded Coverall followed by the eye glass and a locally designed shield and 2nd pair of gloves. Once everyone had donned the patient arrived, the PAC and consent was done by 2 of us just outside the donning area. We used a Use and throw pen for this process. The child was premedicated with iv Midazolam, to avoid a crying, struggling child and to ensure a smooth induction. The child was shifted inside for induction. Its better that the surgeons wait outside during the airway handling process. The child wore a face mask throughout shifting until the anesthesia face mask was applied.
While myself and my fellow waited outside till we were called in we removed the top 2nd glove, wore a disposable gown and and over it 2nd glove.
The Anesthetists had done a great job, their workstation and monitor was covered with a clear plastic drape so they could touch the buttons and knobs, they used a plastic hood over the child’s face and an additional plastic drape around to prevent aerosol settling on surrounding surfaces. All extra trolleys, drawers were removed from the OT, all drapes/gowns were disposable ones, 2 viral filters are recommended. One at the patient end, and the other at the machine end of the closed circuit to reduce OT contamination. Open circuits (JR circuit, Bain’s circuit are best avoided). Circuit disconnections have to be avoided. Medications to prevent postoperative vomiting were administered.
We finished the entire procedure within less than an hour and then again all of us waited in the buffer zone till the LMA was removed and the recovery process was done in the OT itself rather than being shifted to any other area. We all waited till the child was fully awake and then brought outside and the standby anesthetist in a PPE and Covid ward nurse went along with child (who was shifted with the face mask on).
Doffing procedure was performed – with a buddy supervising. The top layers- Gown, top gloves were removed in the OT and then we walked out in the donning/buffer area and removed the following – coverall followed by plastic sheet and lead apron, applied Chlorhexidine to the gloves, then shield was removed from behind without touching the front part, and the 2nd cap was removed from head.
With a last pair of gloves , the inner most mask ,eye glasses and 1st cap on, we walked towards the shower, 1st the anesthetist as she had handled the airway and later the surgeon; the gloves were removed, chlorehex applied, new gloves worn before touching the eyeglasses and last mask. Following the Hot water shower we changed in new scrubs, new mask, head cover and fresh footwear, we went to the changing area and could leave the OT. Meanwhile deep cleaning of the OT and the buffer zone was done by housekeeping staff in appropriate PPE.
What I felt that- we read the guidelines or attend the webinars as an individual but in reality, it’s a teamwork, someone of us has to keep a constant watch on everyone and see to it that everyone is being responsible and following all steps.
An entire procedure consumes twice the surgical time and entry to exit from the OT can be exhausting, it needs a lot of patience, patience and patience, till everyone is done and the OT sterilization process starts.
Thinking about the entire team is important.
The communication with the parents of the child is very minimum and preferably on the phone.
I have been on both sides: Treating a patient “As positive“ and an “Actual Positive” there is a lot of difference in both the scenarios. The Positive report plays on everyone’s mind, people are scared and more vigilant as compared to treating “As positive” in presence of False negative report / No testing.
I would sincerely request everyone if you cannot follow the above steps and don’t have a setup to treat as above then don’t say- we shall treat everyone considering “As Positive” Because any breach in the process can put the entire team and hospital at risk. Our Lives and safety of people around us matter the most.