COVID-19: Protected Intubation in the Sim Lab

This is the fifth COVID-19 case that we are publishing to provide simulation tools to healthcare providers during the 2020 COVID-19 pandemic. It involves the “protected intubation” of a known COVID-19 positive patient in the simulation lab.

This case was written by Chris Heyd for use as training for emergency medicine residents at McMaster University. It was created to train a large number of residents in the simulation lab to mitigate risk to participants and minimize disruption of clinical activities.

Dr. Chris Heyd (@cgheyd) is a emergency physician and trauma team leader at Hamilton Health Sciences. He is also Simulation Director for the Royal College Emergency Medicine Residency Program at McMaster University. He is interested in trauma and mass casualty medicine and how simulation can be used to prepare individuals and teams for rare and unusual events. He completed medical school in Victoria (UBC) and residency in Hamilton (McMaster). He holds a certificate in Disaster Management from Ryerson University.

Why It Matters

Outbreaks of novel respiratory illnesses occur with some regularity (e.g. Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS)). With world travel being a modern reality, disease spread can happen quickly requiring careful infection control practices. COVID-19 (aka 2019-nCoV & SARS-CoV-2) was first detected in Wuhan, China in December 2019 and has since been declared a pandemic by the WHO (see this link for further information).

The COVID-19 worldwide pandemic has overwhelmed healthcare systems in many countries and led to catastrophic loss of life. Many healthcare providers have been exposed and infected in the course of their work and protocols to protect providers have been rapidly evolving. Medical learners, including resident doctors, have been removed from some clinical duties and reassigned to others. We have seen a need for increased training to prepare residents and other learners for a time when they will be required to take on addition duties during the pandemic.

This simulation case takes place in the simulation lab in order to provide a safe space for the participants to get accustomed to unfamiliar protocols and procedures. The “protected intubation” has become standard of care during the COVID pandemic in order to maximize healthcare provider safety while treating the sickest patients. All team leaders must be comfortable with the principles of protected intubation and familiar with their local protocol.

We altered our sim lab to create a high degree of physical realism in the clinical environment. Some of the changes that we made:

  • Stripped out all equipment and made participants think about what they needed to take in
  • Narrowed the medications available for RSI and sedation
  • Kept the sim tech and charting nurse outside of the room and used a speakerphone or walkie-talkies to communicate between the inside and outside of the negative pressure room
  • Used a white noise machine to simulate a HEPA filter
  • Used expired or washable PPE (especially N95 masks) to simulate the communication barrier they create

Clinical Vignette

A 70-year old woman is being transported by EMS and they patch in to the emergency department. The patient is coming from home where she is isolating since testing positive to COVID-19. She has had a non-productive cough for six days but now she has been increasingly short of breath for two days. EMS found her tachypneic with an SpO2 in the 70s on room air.

Case Summary

This patient is in respiratory failure and requires intubation. Participants must prepare for her arrival, organize the care team, communicate effectively and secure the patient’s airway according to the principles of a protected intubation.

Download the case here: Protected Intubation in the Sim Lab

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