COMMENTARY

Ponchos and Plexiglas? COVID-19 'MacGyver' Clinical Tips

Robert D. Glatter, MD; Amy Faith Ho, MD

Disclosures

April 24, 2020

This transcript has been edited for clarity.

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, an emergency medicine physician at Lenox Hill Hospital in New York City and an advisor to Medscape Emergency Medicine.

The challenge of providing optimal patient care during COVID-19 has brought out the spirit of MacGyver in healthcare providers. This is the result of shortages of PPE and ventilators, which ultimately compromise personal protection against a virus that is droplet spread, likely aerosolized for short periods, and highly transmissible. In the end, we embrace creativity and practicality to make sure our clinical environment is safe and more adaptable to care for our patients.

Here to explain some of these MacGyver approaches for dilemmas we currently face during COVID-19 is Dr Amy Ho, associate medical director at John Peter Smith Hospital in Fort Worth, Texas, and my fellow emergency medicine advisor. Welcome back, Dr Ho.

Amy Faith Ho, MD: Hey, thanks so much for having me in this kind of crazy time, Rob.

Glatter: This has been so difficult. I'm sure we're all sharing in this quite challenging time and we're trying to make the best of it.

Ho: Because things are changing so dynamically, you've never seen such a grassroots effort in sharing data, coming up with different protocols, and MacGyver tricks. It's an incredible effort from all of medicine.

Glatter: Let's just dive in here. Our last MacGyver segment was an interesting one. We've talked about basic approaches to treating cyclical vomiting, dental bleeding, nausea, and other things pre-COVID.

Let's talk about what's most important to us right now: PPE. If we have to reuse N95s, is there a safe way to do this?

Decontamination of N95 Masks -- Bag Them!

Ho: Almost everyone is reusing N95s right now because of the shortages we have. One of the ways that we are reusing them is by trying to put them on for an entire shift and then store them somewhere so that the virus droplets, if they did get on the N95, can die before you reuse it again.

One of the ways that they've recommended is something I think everyone can do, which is to take a paper lunch bag, which can easily hold an N95, and after removing your N95—hopefully not touching the mask itself—put it in the paper bag, leave it there for up to 7 days to try to make sure there's no more live virus or droplets on it, and then reuse it appropriately. Hopefully, three to four N95s should be enough to get you through all of your shifts.

Glatter: You're leaving it for about a week. How long does the virus survive on surfaces? I've heard for cardboard, about a day; and then plastic and stainless steel, for 2 days. You're giving it a little bit of extra time, which I think is really reasonable without having that definitive answer.

Ho: Yes. Lancet has actually had a couple studies. In the most recent one, they looked at the length of droplets on certain materials, and they found 3 hours to 7 days. The scary part is that the 7-day one was a surgical mask. This is obviously temperature- and humidity dependent, but that's how most people came up with a 7-day protocol for the mask.

Glatter: Duke University School of Medicine has been looking at aerosolized hydrogen peroxide to decontaminate masks. Any thoughts on that? From what their data showed, it looked reasonable.

Ho: There are many ways to sterilize masks. Most of them are commercial and I found them personally difficult as a single MacGyver doctor. They are looking at UV light, a baking method where you put it in an oven at a fairly low temperature (that's supposed to be a commercial oven), and then the Duke trial that you're talking about. I think those are more system-level ways of sterilizing massively than for an individual doctor necessarily.

Glatter: Are you doing some of this at your shop right now?

Ho: My shop is very luckily—knock on wood—still able to supply N95s to the providers. We have had a look at that, but we're obviously trying to be judicious in our use.

Eye Protection When Face Shields Are Unavailable

Glatter: The next step is your eyes, which are so key in terms of a possible route of transmission. What are your thoughts on this? What are you doing?

Ho: The CDC is recommending that you have full eye protection. What that means is this absolutely could be like a full-powered air-purifying respirator (PAPR), but more realistically it's a face shield. There are face shields that can go from your forehead and drop down, or you can use any kind of eye protection that has a full seal.

Many ER doctors have looked into normal products they have, especially recreational ones. They can be sports goggles (eg, for racquetball) that have a seal all the way around your eyes. There's no droplet contact into your eyes. You can also use swim goggles, scuba goggles, or anything that provides protection all the way around.

Glatter: In terms of a full face shield—I've seen them being used and we're using them—do you have any tricks about cleaning those, or is that single-use-only in your view?

Ho: Most of the time, I think those are being reused as well. Traditionally, they can be completely wiped down with bleach wipes and then let them dry before either reusing or giving to another user.

Simple Modification to a Scrub Cap to Protect Ears

Glatter: Moving on to an additional trick you mentioned, which is a button on your headband or scrub cap. I came across this the other day on the Internet and thought it was really such a great way to save your ears. After every shift, my ears are killing me. This is something that I think would be very helpful to all providers.

Ho: Many of us started wearing scrub caps because we didn't have any covering for our hair, especially women or people with long hair who didn't want to wash it all the time. Almost everyone started wearing cloth scrub caps that you just throw in the laundry when you get home. Here is an example of one my mother-in-law made for me.


 

We sewed a button on both sides, and you can hook the mask around the button instead of your ears. You can have so much breakdown on your ears. I know people who have actually gotten skin infections just from the breakdown and then bacteria gets in there.

Glatter: That's definitely a way to save your ears. Obviously, infection is something that's so important, especially in our working environment. Anything to reduce the risk of that is important.

Ho: Less skin breakdown and also less readjustment and touching. The less you can touch your face, the better.

Removing Masks Without Touching Them

Glatter: Another trick you mentioned was a Tupperware for donning and doffing of the mask, which I'm really interested in.

Ho: I love this trick. When we started reusing N95 masks, they told us to try to take it off the face without touching it, which is extremely difficult to do. What some people came up with is that they started just using household Tupperware. Here's one. It's a little large, but I don't think the size is particularly important, except it obviously needs to encompass the N95.


 

If you have an N95 on your face, you bring the Tupperware to your face and then loop the straps over it one by one. Now your N95 is completely encompassed in your Tupperware for you to put into your paper bag. You can also seal the Tupperware if you want, but just make sure that there are a couple of air holes so that the mask can dry out.

This is another great way of storing it. When you need to put your N95 back on, it should be clean so you can touch it. If you're trying not to touch it, do the same thing. Put it over your face and then just bring the straps back over your head.

Glatter: That's a really nifty trick. I've seen people notch the sides, too, so it's not exactly flush.

Using FaceTime on an iPhone or iPad to TeleScribe

Glatter: Next, we are going to talk about operations. You mentioned about TeleScribing using FaceTime or an iPad. How is that figuring into our paradigm now?

Ho: There's work that requires us going into the hospital room and touching the patient, but there's a lot of work that actually doesn't. We didn't want to expose our scribes to coronavirus if we didn't absolutely have to. Given that their role is listening, taking notes, and sometimes talking to you, we can use an iPad or a cell phone with FaceTime to communicate with scribes.

The scribes will sit in a separate room completely out of clinical care and the emergency department, and we'll call them with our phone or FaceTime. When we go in the room, we just lay the phone or iPad on a desk so that they can hear the entire encounter and still scribe. It's an amazing way to still have them as an essential service but not have them actually exposed.

The same thing goes with patients, too. You can call them in their room and talk to them on their cell phone if you're just giving an update.

Minimizing Aerosolization When Delivering Oxygen Therapy

Glatter: The next part is surgical masks and how we can use them when we're using nasal cannulas, oxygen, and non-rebreathers. Would you discuss how you're using the facemask in that capacity and maybe any literature about whether that's protective from aerosolization?

Ho: There's so much concern about aerosolization and it's honestly extremely controversial. In general, people seem to accept that a nasal cannula is fine. Even then, they're still recommending a surgical mask to be placed over the patient's face with the nasal prongs.

There have been some techniques talking about putting a nasal cannula in addition to a non-rebreather and then putting a surgical mask over it to try to create a somewhat closed system, but there are still risks.

They've looked at high-flow nasal cannulas, which are considered most likely to have some aerosolization, and discussed whether putting a mask on over that could actually be helpful.

The summary, though, is that we don't 100% know. If you're able to put a mask over a patient who is temporarily receiving extra oxygen, that certainly can't hurt. Same thing for some commercial products now that are coming out, where it is a closed system non-rebreather.

Glatter: I think the reality is that some virus may escape and we don't really have the answer on this, as you were saying. Scott Weingart had a video talking about how there may be some escape 3 or 4 cm beyond the actual mask itself.

Again, this is all at your discretion with your department. There's no set policy, internationally or nationally, about how much aerosolization there is. This makes it problematic for our patients and patient care. This is certainly something on everyone's mind.

Ho: Run it by your hospital because there's a lot of stuff on the Internet about how to adjust CPAP, to try to add viral filters and make it a closed system. But again, you have to make sure this works with your equipment. Many hospitals have tried different tests where they'll spray something and see how widely it spreads out of the room. This is something to test before you necessarily go rogue on it.

Glatter: I think we can all agree that using a HEPA filter or something as simple as that when you're using a bag-valve mask makes sense. And that's a basic part of any airway equipment box in the COVID era.

Ho: Again, most people seem to have some kind of viral filter. Just check with your department on whether that's something that is expected to help in coronavirus specifically.

Personal Protection -- Using a Rain Poncho

Glatter: This brings me to really the most important part, which is intubation and how we can protect providers during this critical step. There are a couple of options that I would love for you to go over. One is the rain poncho. The other is the Plexiglas box described in the New England Journal of Medicine article.

Ho: When coronavirus first started hitting our shops, we started more aggressively integrating these items because of the aerosolization risks. I think everyone wanted to add some adjuncts to offer a little bit of extra protection. Even if you're in the correct PPE, it can still help with minimizing some of the spray.

My all-time favorite method for any doctor is the rain poncho because it's so easy to do and so cheap. You can buy clear rain ponchos on Amazon or anywhere, as long as they're clear. It's what you would wear at a stadium or a concert.

We'll take a rain poncho and put it over the patient, but we'll put it on backwards, meaning the hood is in the front of the patient. Once we sedate them, we lay them back, we pull the rain poncho so the head hole goes over their head, and then we can intubate through that. I have a picture here.


 

If you have an operator, you can have the person intubating use the head holes for both their hands. Alternatively, if they are a larger person with bigger arms, they can use one head hole and one sleeve hole for either hand.

Using the open sleeve hole, you can have the respiratory therapist (RT) help you if you need. If you're bagging or if you just need a little assistance with passing you a bougie or something else, it gives them extra access. This method is extremely cheap. You can buy these for less than a dollar or a couple dollars each on Amazon, and it's also readily available commercially.

Glatter: This is a single-use option, obviously, at a very inexpensive cost. You don't have to worry about sterilizing the intubation box or Plexiglas box. This brings me to the next option, if you want to go over that for us.

Personal Protection -- Plexiglas Box

Ho: The Plexiglas box has been extremely popular. I believe this actually came out of Taiwan initially; they published what they were doing. Then, in the New England Journal of Medicine, authors in Boston described their Plexiglas box and provided dimensions for it, and then did a simulation with a balloon and some dye so they could simulate what the spread would be if the patient were coughing during intubation.


 

This Plexiglas box is fairly simple. It's a box that you put over the patient's head when you're intubating. There are a couple of holes at the head of the bed for the proceduralist to use for their C-MAC and also for holding their tube. Frequently, there are a couple of holes on the side of the box as well for the RT to help assist.

We've found that this requires a little bit more discussion, because you need to go through some prototypes and make sure it works with whatever equipment you're using at your hospital. We have noticed that it's a little more difficult to sit the patient up if that's what you're trying to do with intubating. The patient tends to have to be fairly flat for this. That being said, this is a great, widely used box that you can create for less than $100.

Glatter: In terms of sterilizing this box, do you have a protocol in place? In other words, my concern is that you could get some spray and would need to meticulously clean this.

Ho: Absolutely. I think it's the same thing we've been seeing for everything else in coronavirus with reusing equipment: full bleach wipes, let it dry the entire time. Because of the reuse, we've recommended having several available, especially if you're intubating several patients at once.

Glatter: I tried this box and I noted that it was a little tight. That's one of the downsides of this. If you have a patient who's bigger, it's not necessarily a one-size-fits all. In principle it's doable, and that was my takeaway.

Ho: I'm totally with you. The box has been the less favored method for me, at least, because there's variation in the size of the proceduralist, the size of the patient, and positioning them.

I think the most important takeaway, though, is that before you use any of these adjuncts—poncho or Plexiglas box—you must try it to make sure that you're comfortable with your angling before you do it on a live patient.

Glatter: I think that's really important. Practice is key. The other thing is that you should have the most senior person intubating the patient. Unfortunately, this is not the time to have a resident, who hasn't really had a whole lot of experience or practice with intubating. In my institution, at least, they are having attendings intubate all patients for that fact alone.

Ho: That's been popular, as have anesthesia teams. Some hospitals are using core anesthesiologists and CRNAs to help intubate these patients to try to limit exposure, and to protocolize.

Final Takeaways

Glatter: Do you have a few key takeaways from this talk for our audience?

Ho: One, share what you're doing. Share it widely because the feedback is helpful. People will implement it and people will study it in different ways.

To keep yourself safe, more than anything, remember that you have to come first because every physician, every frontliner is valuable—their value can replicate over many, many patients.

And three, simulate everything. You never want to be with a crashing patient and trying something for the first time.

Glatter: Protecting yourself first is so important. It is really the key here. You can always pause for those extra few seconds to make sure you're protected because this is a very dangerous time, as we know, and we have to think of ourselves and our families and really play it safe.

Ho: I want everyone watching this video to absolutely stay safe and know that's probably the number-one thing in getting through this coronavirus.

Glatter: Thank you again, Amy. This has really been very valuable. I hope you stay safe and we'll catch up with you soon.

Robert D. Glatter, MD, is an attending physician at Lenox Hill Hospital in New York City and assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Glatter is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Amy Faith Ho, MD, is an emergency physician, published writer, and national speaker on issues pertaining to healthcare and health policy, with work featured in Forbes, Chicago Tribune, NPR, KevinMD, and TEDx. Amy is also a medical advisor for Medscape.

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