Fortunately most of the readers here will never be in this situation! But those of us in the front lines (emergency physicians, intensive care providers, and anesthesiologists) unfortunately land directly in the line of fire of SARS-CoV-2. The highest risk environment is when placing breathing tubes in infected individuals (necessary to connect a patient to a ventilator), particularly with our shortage of PPE.
We know that SARS-CoV-2 infects humans primarily through the mucosal membranes of the face, meaning eyes, nose, and mouth. How does the virus reach there? There are three possible routes to reach these membranes: through direct inoculation (such as us touching our face with our hands), through respiratory droplets (small water droplets ejected from an infected person’s cough or sneeze), or through even smaller particles ejected from an infected person’s nose or mouth, called aerosols (what we call airborne transmission).
The first two routes (direct inoculation and droplets) are widely accepted. Airborne transmission is highly controversial (note that this is the only reason to where an N95 mask/respirator, as opposed to a regular surgical mask). While early studies suggested this was a possible transmission route, it is now felt that aerosols are unlikely to represent a significant or common route of transmission. There is one significant exception: manipulating an infected individual’s airway (throat and trachea) carries the risk of aerosolizing virus (such as when placing or removing a breathing tube to connect to a ventilator).
Unfortunately, the shortage of PPE prevents frontline healthcare workers from being able to optimally protect their faces in these high-risk situations. This is particularly the case for N95 masks, because our high-risk procedures are the only time N95 masks are actually necessary (but these masks remain in incredibly low supply). Enter a creative solution: physicians from East Asia developed the “aerosol box”. This simple, yet effective, solution helps minimize the spread of droplets and aerosols during these incredibly high-risk procedures (placing and removing breathing tubes). In fact, researchers at Harvard recently studied just how far these droplets may be able to travel during these procedures, and the results were not good, with droplets extending multiple feet away from the patient in their simulations. Fortunately, the use of this simple box significantly reduced contamination on equipment and personnel.
I built one of these boxes to use in the operating room, and the most difficult part was to find Plexiglas! I knew our masks and face shields were on shortage, but I did not know that Plexiglas was also on shortage (from companies trying to build protective screens for their cash registers).
Take-home: do not place or remove breathing tubes at home! More importantly, always follow physical distancing guidelines, even if wearing a mask. Remember, wearing a mask is never a substitute for physical distancing and hand hygiene.
Please stay safe everybody!