When Dal’s Faculty of Medicine made the move to shut down all in-person learning in the middle of March, the Human Body Donation Program was also suspended, a rare or perhaps even unique event in its roughly 150-year history.
It would not be long, however, before the program would be re-started to meet a new and urgent need: training in safe airway management and intubation procedures for front-line health-care staff.
“How to intubate rapidly and safely — for the patient and staff — became an immediate and pressing concern,” says Dr. George Kovacs, a professor in the departments of Emergency Medicine and Medical Neuroscience who is a national leader in airway management training. “We knew it would be crucial for everyone to be on the same page with our procedures, because whatever any one person does affects not only their own safety but that of everybody else in the room.”
Suddenly, routine procedures for keeping patients oxygenated and threading breathing tubes into their airways (intubation) were fraught with danger, as these bring clinicians very close to the patient’s face, increasing their risk of being contaminated by aerosolized viral particles generated during the procedure.
“Unless we are confident by screening, we have to approach every patient as if they are infected with the coronavirus,” notes Dr. Kovacs, “especially if they are presenting with a primary respiratory problem.”
To support clinicians caring for these sick patients, Dr. Kovacs, Dr. Adam Law (Anesthesiology) and Dr. Tobias Witter (Critical Care) quickly developed provincial airway management guidelines for patients with known or suspected COVID-19 infection.
Dalhousie’s Department of Emergency Medicine jumped into a leadership role early, using its internationally recognized airway management education resources to support frontline clinicians across Nova Scotia. The provincial Emergency Program of Care, led by Dr. David Petrie, also stepped in to help: zone leads with airway management expertise (Dr. Nick Sowers, Dr. Adam Harris, Dr. Sam Campbell and Dr. Lori Beatty) began supporting hospital emergency departments around the province as they adapted to an ever-changing clinical environment.
Emergency departments across Nova Scotia began running simulations of the new COVID-19 airway protocols, with team members including nurses, respiratory therapists and paramedics. Staff had to learn how to put on and take off protective equipment and work together as a team to safely intubate critically ill patients with known or suspected COVID-19 infection.
Responding to a need
“While we regularly performed these procedures in the pre-COVID-19 era, things were different, the stakes were now higher for the patient and the team,” Dr. Kovacs explains. “Every team member needed to know the exact steps for entering the room with all of the necessary equipment, setting up and performing the intubation, placing the patient on the ventilator, then leaving the room and safely removing protective equipment soiled with virus. There is nothing routine about this process, no matter how many times you have performed intubations in the past.”
As one of Dal Med’s emergency medicine leads on airway management training, Dr. Kovacs knew frontline staff needed simulation training to practice the physical skills required to safely perform the COVID-19 procedures. He also knew Dalhousie medical school’s Clinical Cadaver Program had the potential to support the rapid implementation of the new provincial airway management recommendations for COVID-19.
“Teams needed to test techniques for maximizing oxygen delivery that were safe for both the patient and provider, using both new and existing equipment,” Dr. Kovacs says, “and physicians needed to practice using new video laryngoscope equipment recommended in the guidelines and acquired to safely intubate COVID-19 patients.”
Procedural research "on the fly"
As medical director of Dalhousie’s Clinical Cadaver Program, Dr. Kovacs knew there is no higher-fidelity model than one that uses the human body. So, he reached out to Rob Sandeski, who oversees the medical school’s Human Body Donation Program.
“Cadavers for clinical training are different than cadavers used for traditional anatomy studies,” explains Sandeski. “We use different embalming processes that preserve the pliability of the tissues for training in clinical procedures, whereas the tissues become quite hardened in traditional processes.”
With appropriate approvals, the Human Body Donation Program began accepting donations again — with strict criteria and screening processes to ensure none of the donors had been infected with the coronavirus — and teams began working with the cadavers.
Within days, practice-changing training was underway. Nova Scotia’s EHS LifeFlight critical care transport team members were granted access to the reopened Clinical Cadaver Program to practice their intubation skills using a new video laryngoscope. Meanwhile, physicians in Halifax were able to use clinical cadavers to refine their skills in the Nova Scotia Health Authority’s “Sim Bay” simulation centre in the emergency department at the QEII Health Sciences Centre.
It was challenging to adopt new protocols in the absence of high-quality evidence, but in this circumstance, it was necessary to not only run with the best-available evidence but also be able to listen and learn from the experiences of others. “I was on the phone with my colleagues in New York on a regular basis,” Dr. Kovacs says. “We were learning from their successes and failures, all of which influenced our local recommendations, training and simulation.”
Dr. Kovacs and his colleagues had the unique opportunity to perform procedural research “on the fly.” Because they had access to clinical cadavers, they could open the chest and observe the lungs while testing various oxygenation techniques that needed to be modified to use safely on COVID-19 patients.
From hypothesis to peer-reviewed publication, practice-changing research can take years. In these times, Dr. Kovacs remarks, “guidelines were being generated and practice changed in a matter of weeks. We ramped this up FAST. It was amazing. The silos went down and people adopted a can-do collaborative attitude; we worked every waking hour.”
Even though it was fast, it was not simple or easy. “I cannot stress enough how complex this was to roll out,” Dr. Kovacs says. “At the same time we were learning new airway procedures, we were also learning new ambulance-offloading and patient transport procedures, how to adapt patient flow and turnover, how to clean rooms, and how to practice social distancing while training and caring for patients in the emergency department. And every day, things changed.
Honouring a commitment
Thankfully, Nova Scotia hospitals were not inundated with a high volume of COVID-19 patients in the first wave of infections. Whatever happens in potential subsequent waves, staff are now ready.
“We have adjusted to the new protocols, the new equipment, the new ‘normal,’” Dr. Kovacs notes. “It’s not so cumbersome or difficult anymore.”
Even so, the teams will continue to be diligent in practising their new skills, and the clinical cadaver program will continue to be a crucial element in ensuring their proficiency.
Due to COVID-19 prohibitions on gatherings, there will be no in-person memorial service this spring to honour the people who donated their bodies to medical education at Dalhousie. Instead, Sandeski is coordinating a video service for all of the families to attend.
“This is a difficult year for us all,” Sandeski says. “Typically, as many as 600 people attend our annual memorial service in honour of the people who donated their bodies to our learning programs. We will do our best to honour the donors and their families for their outstanding commitment to advancing health care.”
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