Article Notes
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Local COVID PPE guidelines were used: face-shield, goggles/glasses, mask, gown & gloves. ↩
- Chloroquine/hydroxychloroquine
- Azithromycin
- Kaletra (Lopinavir/ritonavir)
- Colchicine
- Ivermectin
- Tocilizumab
- Thaildomide
- Remdesivir
Leff & Finucane's (JAMA 2008) 'gizmo idolatry' commentary is also related, and well worth a read. The human love of bells and whistles...
Daniel Jolley
Why the interest?
The combination of a deadly contagion (COVID-19) and recognition that endotracheal intubation is a high risk procedure for the airway technician has lead to the development of novel medical equipment. One such innovation is the clear-perspex 'intubating box' designed to contain viral-aerosols released during intubation. There has been limited prior evaluation of the safety or efficacy of such devices, despite their promotion.
What did they do?
Begley et al. conducted 36 simulated intubations with twelve PPE-adorned1 anaesthetists, with and without intubating boxes. They primarily aimed to quantify the effect on time to intubation.
Investigators tested both a first-generation and newer generation device. Each of twelve senior anaesthesiologists performed three block-randomised intubations: no box, original, and latest-design box. The airway manikin tongue was inflated to simulate a grade 2A airway.
And they found...
Intubation time was significantly increased by both the older and newer box designs (x̄=48s and x̄=28s longer respectively, though with wide confidence intervals). More relevantly there were frequent prolonged-duration intubations with the box (58% >1 minute, 17% >2 min), but none without the box.
Most worrying, there were eight breaches of PPE caused by box use, seven occurring with the newer, more advanced design.
"PPE breaches often seemed to go unrecognised by participants, potentially increasing their risk further."
Reality check
Despite the superficial appeal of an intubation box, this simulation study warns that such devices fail both to support safe and timely intubation and to protect the clinician – the very arguments used to advocate for its use.
These failings occur before even considering the actual effectiveness in reducing viral exposure, the box's impact on emergent airway rescue, or the practicality of cleaning a reusable device now coated with viral particles.
The intubating aerosol box appears dead on arrival.
Bonus biases
Begley notes the appeal of such novel devices may be partly driven by 'gizmo idolatry' (Leff 2008) and 'MacGyver bias' (Duggan 2019), blinding clinicians to consider unknown consequences of box use and discounting resultant hazards.
Daniel Jolley
The main premise of Duggan's argument is that our MacGyver bias is grounded in an overweighting of the perceived benefits of MacGyvered 'workarounds' to medical problems, with discounting or even ignoring of unknowns, risks and newly introduced hazards.
This bias is rooted in the satisfaction and enjoyment of solving a problem, the chance to "showcase one's creativity" and to be solutions oriented.
"The danger is that a workaround is so culturally appealing that it circumvents the level of scientific scrutiny that we would expect from any other equipment that we use. Novelty, immediacy, ownership, and ease of use can increase our propensity to bias and wilful blindness." – Duggan et al.
Daniel Jolley
Human Love of Bells and Whistles
"Increasing the technological complexity of treatment appears to increase the significance of an illness and the appeal of an intervention. Furthermore, if hospitalization is required, additional distinction may be conferred. For instance, good evidence demonstrates that oral rehydration during acute diarrheal illness is at least as good as intravenous therapy. For most patients, metered-dose inhalers are as effective as nebulized bronchodilators, but inhalers are generally regarded as lesser treatments. The gadgetry of gizmos somehow provides cachet, and electrified intravenous pumps and nebulizer machines seem more substantive."
– Leff & Finucane, 2008
Daniel Jolley
Wong briefly summarises COVID pharmaceutical therapies that are currently in trial, and importantly have received media attention.
Highlighting that off-label use of these drugs may be important causes of future toxicological presentations to emergency departments, especially for those widely used in the community for other indications (eg. Plaquenil, Kaletra, colchicine...).
Briefly discussed are:
Daniel Jolley