Douglas Hartley, Creator offered

When the coronavirus pandemic first hit the UK, hundreds of surgical procedures have been placed on maintain. For a surgeon like me who performs operations on deaf youngsters to revive their listening to, this created a major ethical dilemma – I wished to get again into surgical procedure to offer this important care, however I didn’t wish to inadvertently catch or go on COVID-19 within the course of.

I frequently perform cochlear implant surgical procedure, a course of by which a surgeon embeds an digital machine which stimulates the listening to nerve within the ear. The scientific proof is obvious that this surgical procedure must be carried out on the earliest alternative in order that these youngsters can profit from with the ability to hear at a significant stage of their improvement.

However performing the surgical procedure as regular would have put each youngsters and surgical groups at risk. We wanted to give you one other method of doing issues. Our group in Nottingham needed to mix creativity and science to develop a novel and protected approach to restart cochlear implant surgical procedure in a matter of just some weeks.

This text is a part of Dialog Insights



The Insights group generates long-form journalism derived from interdisciplinary analysis. The group is working with teachers from totally different backgrounds who’ve been engaged in initiatives aimed toward tackling societal and scientific challenges.

A grave danger

Quickly after the pandemic started, among the earliest experiences, notably these from China and Italy, instructed that healthcare employees have been at considerably larger danger of contracting COVID-19 in comparison with most of the people, and that treating ear, nostril and throat (ENT) circumstances was significantly dangerous.

I used to be deeply saddened after I was informed that the one of many first healthcare employees within the UK to die of COVID-19 was Amged El-Hawrani, a 55-year-old ENT colleague from the college hospitals of Derby and Burton. El-Hawrani succumbed to this dreadful illness on March 28 in Leicester’s Glenfield hospital. Though I by no means had the pleasure of assembly him, his passing was an enormous shock to us all. And his publicity to the virus throughout his take care of his sufferers was a stark reminder of the brutality of this illness.

Amged El-Hawrani was one of many first well being employees within the UK to lose his life to coronavirus.

College Hospitals of Derby and Burton/NHS

Like different ENT departments internationally, our service at Nottingham College Hospitals NHS Belief initially halted all elective procedures in March when the pandemic hit the UK, so we may focus our group’s efforts on the administration of our sickest sufferers, together with these circumstances requiring emergency admission, and our most cancers companies.

Though this preliminary response proved efficient, we have been conscious that we weren’t assembly the wants of different sufferers with time-critical, albeit not life-threatening, circumstances. These sufferers included youngsters who’re born deaf and want cochlear implant surgical procedure to revive their listening to as rapidly as potential to maximise their probabilities of growing regular speech and language. Delaying cochlear implant surgical procedure can imply these younger individuals often by no means get better full speech and language expertise.

We all know this as a result of a number of the vital research that highlighted the significance of early cochlear implantation on speech and language improvement have been carried out regionally in Nottingham, which is residence to a lot of world-leading listening to researchers. The primary paediatric cochlear implant surgical procedure within the UK was carried out by the Nottingham Auditory Implant Programme (NAIP) which hosts one of many largest youngsters’s cochlear implant companies within the UK.

A novel danger to ear surgeons

As a cochlear implant surgeon for NAIP, and a analysis lead for the Nottingham Biomedical Analysis Centre, I used to be devastated that we weren’t in a position to present our deaf youngsters with the care they wanted. That mentioned, I’ll admit that the thought of performing cochlear implant surgical procedure initially of the COVID-19 outbreak was unnerving.

Cochlear implants could be life-changing for younger youngsters, however they want surgical procedure inside a particular window to have the most effective outcomes.

mady70/Shutterstock

ENT healthcare employees are significantly prone to catching coronavirus throughout surgical procedure due to the distinctive nature of the components of the physique we deal with. The nostril of an contaminated individual accommodates a major load of the SARS-CoV-2 virus that causes COVID-19. The nostril is straight related to the center ear by a small channel referred to as the eustachian tube, and different kinds of coronaviruses, together with the one which causes the widespread chilly, are generally discovered within the center ear. This implies it’s extremely probably that SARS-CoV-2 additionally exists within the center ear, although, nobody has confirmed this to this point.

The virus makes use of two proteins to enter human cells (ACE2 and TMPRSS2) which are discovered all through the liner of the nostril. The identical proteins are discovered within the eye, suggesting that eye transmission may be very probably. We additionally know that animals specific each these proteins of their ears, once more suggesting that SARS-CoV-2 is extremely more likely to be discovered there.

The virus is especially transmitted by way of massive droplets that require comparatively shut contact with an contaminated individual. It has additionally been instructed that it may be transmitted by way of aerosols, a lot smaller particles that may unfold over for much longer distances.

A number of medical procedures have been classed as “aerosol producing”, together with cochlear implant surgical procedure, which includes drilling into the bone behind the ear to entry the center ear. The high-speed drill we use throughout surgical procedure can unfold droplet and aerosol contamination all through a confined theatre house. These droplets and aerosols will include a combination of water, bone, blood, tissue and, probably, viable viruses.

Fixing the issue

At the start of the outbreak, whereas we knew we would have liked to restart cochlear implant surgical procedure urgently, we have been additionally extraordinarily conscious of the potential dangers related to performing this operation on the top of the pandemic. This drawback involved me significantly. Nonetheless, I discover that one of the simplest ways to handle concern is although motion, and it was at the moment that I used to be very grateful that I work in a metropolis which hosts one of many UK’s largest cochlear implant programmes.

Within the matter of just some days, following simply a few temporary emails, a number of telephone calls and the odd Zoom assembly, I managed to collect collectively a group of internationally recognised specialists who have been all excited about growing a mannequin of cochlear implant surgical procedure that we may observe through the pandemic.

My first port of name was Padraig Kitterick, head of listening to sciences at my college, who generously gave each his time and all of the funds we would have liked to assist this significant work. Subsequent, I contacted my esteemed surgical colleague, Gerry O’Donoghue, who pioneered cochlear implant surgical procedure within the UK. As at all times Gerry was enthused to be concerned. A lot in order that he additionally volunteered the experience of his son, Kevin, who works with us as an anaesthetist within the Queens Medical Centre in Nottingham.

Left to proper: Dr Kevin O’Donoghue, Professor Doug Hartley, Professor Gerry O’Donoghue, Dr Padraig Kitterick and Dr Rachael Lawrence.

Douglas Hartley, Creator offered

I then requested my colleagues from the anatomy facility if I may borrow sufficient skulls on which we carried out experiments that may assist us analyse the chance of spreading droplets whereas performing surgical procedure. With no second’s hesitation, Susan Anderson and her colleague Dominik Siwek replied, sure, after all they might be delighted to assist. Likewise, Richard Hague and his colleagues from the college of engineering offered us with important 3D printing companies to assist our work.

Early one Saturday morning, together with Rachael Lawrence, an instructional ENT surgeon in coaching, I collected the skulls from an in any other case abandoned anatomy dissection room on one of many higher ranges of the Queens Medical Centre. We carried them to one of many ENT theatres positioned on the different aspect of the hospital that had been generously offered by our theatre supervisor, Laura Mitchell.

Innovation gas: cupcakes offered by the writer’s daughter.

Douglas Hartley, Creator offered

As soon as our group was gathered, we set to work, fuelled by scrumptious truffles that had been baked by my youngest daughter Alice, adorned with rainbows in assist for the NHS.

Our first job was to correctly visualise the extent of droplet unfold throughout cochlear implant surgical procedure. To do that, we determined to exchange the fluid that we usually use to irrigate our high-speed drilling with a fluorescent dye.

By simulating a cochlear implant operation utilizing this setup, we may see the place the dye landed and perceive whether or not we may proceed finishing up surgical procedure sporting normal private protecting tools (PPE).

It quickly turned obvious from the distribution of luminous dye across the theatre that the contaminated droplets may unfold greater than two metres from the positioning of drilling in all instructions. This not solely contains the realm that the surgeon works in, but in addition the nurses, the anaesthetist, and different theatre workers.

How the fluorescent droplets unfold from simulated cochlear implant drilling.

Douglas Hartley, Creator offered

Even worse, we discovered that droplets simply migrated beneath our full-face visors, the usual beneficial PPE for aerosol-generating procedures within the UK. The droplets landed very near the eyes of the individual sporting it. This instructed {that a} visor provided insufficient safety.

However we weren’t discouraged. Now we knew the extent of the issue, we have been in a position to work across the clock for the subsequent few weeks till we managed to develop and refine some somewhat uncommon options.

Testing PPE

Throughout our research, we evaluated quite a lot of PPE choices, together with a number of different an infection management options. These included a full-face respirator and a mixture of a half-face respirator and security goggles, generally often called “spoggles”. We had additionally learn experiences of groups, together with one from Stanford College, who had modified a full-face snorkel masks for use as PPE, so we tried this too.

The complete-face respirator strategy.

Douglas Hartley, Creator offered

We used a scientific evidence-based strategy to judge the PPE for its usability and effectiveness. Throughout simulated cochlear implant surgical procedure, we evaluated every kind of PPE throughout a number of parameters, together with its impact on a surgeon’s capacity to speak, their visual view, and their consolation.

Most of the PPE choices we tried, not least the full-face respirator, have been discovered to considerably limit the surgeon’s imaginative and prescient throughout working. That rendered them unsafe for performing this type of surgical procedure. Slightly worryingly, we additionally discovered that the modified snorkel masks that had been described by numerous teams on the web was related to rebreathing of carbon dioxide, so this was not a viable long-term possibility for PPE.

The snorkel strategy concerned re-breathing carbon dioxide, which could be harmful.

Douglas Hartley, Creator offered

As an alternative, we discovered that the mixture of “spoggles” and a half-face respirator masks had persistently superior efficiency throughout all facets of medical usability in contrast with all different choices.

The spoggles offered the profitable resolution.

Douglas Hartley, Creator offered

Throughout our research, we additionally labored with a surgical product producer to develop a novel drape, principally a tent, that was designed to be suspended from a microscope protecting the affected person’s head and torso to offer a bodily barrier between the positioning of drilling and the remainder of the group.

We discovered that the working tent considerably contained the droplets and prevented them from spreading across the theatre atmosphere. We have been the primary – and are presently solely – group on the planet to develop an working tent design that’s marked for medical use. After finishing our research, we now had acceptable PPE and a protecting working tent to allow the protected re-starting of cochlear implant surgical procedure through the pandemic.

Prof Gerry O’Donoghue fashions the brand new surgical tent.

Douglas Hartley, Creator offered

The brand new surgical regular

Our suggestions have been quickly disseminated internationally by way of webinars and journal publications and rapidly adopted as normal affected person care by our hospital belief and, subsequently, embraced in different departments within the UK and internationally.

Regionally, it was with large aid that we recommenced cochlear implant surgical procedure for profoundly deaf youngsters after a number of days of finishing our research: simply a few months after this process was placed on maintain. Working occasions have been slightly longer initially, and for the primary few procedures we opted to have a backup surgeon accessible simply in case the first working surgeon wanted some assist utilizing this new setup.

In the present day, these new measures have develop into second nature to our theatre group, working occasions are akin to our pre-COVID surgical procedures, and lists are working as earlier than with only one surgeon working. Aside from slightly discomfort related to sporting the PPE for lengthy durations of time, and the continuing detrimental impression of the PPE on communication, we’ve all just about accepted the setup as our new regular. Actually, I might go as far as to say, it will really feel slightly bare to function with out these measures now.

We have now needed to discover new methods of speaking whereas sporting PPE.

Douglas Hartley, Creator offered

The protected recommencement of cochlear implant surgical procedure in Nottingham, and in different centres across the globe, has given many a whole bunch of deaf youngsters worldwide the prospect to listen to. These youngsters can develop up with the potential to develop comparable speech and language expertise to their friends. With out this well timed surgical intervention, life would have been very totally different for these youngsters and their households.

The worth of pace and collaboration

The coronavirus disaster has been an odd and scary time for everybody, and it has offered us all with many important challenges in how we reside and work. But it surely has additionally opened a lot of doorways for brand spanking new alternatives and potentialities.

Earlier than COVID-19, when you informed me that I’d must assemble a tent by which to function this yr, whereas sporting spoggles and a respirator masks, I might not have believed you. That mentioned, I’m positive that most individuals wouldn’t have predicted how a lot we’ve all needed to depend on Zoom and different new digital media to facilitate our work and social interactions with others over the previous few months.

The method concerned to translate a novel thought from the laboratory bench right through to implementation on the affected person’s bedside is generally a really sophisticated and prolonged one that may take years, and typically many years, to finish. So it has been heartening to witness the worth of a group working to unravel an issue at breakneck pace, with out a lot want for the phrase: “I don’t suppose we will try this.” Necessity is actually the mom of invention and, confidently, a few of this innovation spirit will reside on past the pandemic.

What subsequent?

Evidently COVID-19 is more likely to be with us for the foreseeable future. So we’ve no plans to desert our PPE and working tent for cochlear implant surgical procedure any time quickly. Actually, there’s a sturdy argument among the many surgical neighborhood that these measures ought to at all times be used to guard the theatre group from potential contaminants, and the affected person from publicity to infections in theatre, whatever the present pandemic.

Different surgical specialities have additionally been very within the working tent technique as an an infection prevention management measure, together with those who generally use an working microscope, corresponding to spinal surgical procedure, ophthalmology and neurosurgery. Sooner or later we might even see a wider use of working tents.

Definitely, our theatre groups face an ongoing drawback from the damaging impression of PPE on communication throughout surgical procedure. It goes with out saying that communication is vital for the protected functioning of an working theatre, and this drawback wants an pressing resolution. That’s why our group and different centres around the globe are persevering with to work on the design, not solely to help communication, but in addition to facilitate easy accessibility into the tent for the surgeon and theatre nurses, whereas retaining the contaminated droplets inside.

Though COVID-19 has offered important challenges to recommencing cochlear implant surgical procedure, via collaborative teamwork throughout a variety of disciplines, we discovered options. As a group we’ve actually learnt from this expertise; classes that I hope we’ll retain far past this pandemic.

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Douglas Hartley works for Nottingham College and Nottingham College Hospitals NHS Belief. He receives funding from the Nationwide Institute for Well being Analysis, the Medical Analysis Council, Motion on Listening to Loss, Cochlear UK, Superior Bionics and Rinri Therapeutics.