Douglas Hartley, Creator supplied

When the coronavirus pandemic first hit the UK, 1000’s of surgical procedures had been placed on maintain. For a surgeon like me who performs operations on deaf youngsters to revive their listening to, this created a big ethical dilemma – I needed to get again into surgical procedure to offer this important care, however I didn’t need to inadvertently catch or go on COVID-19 within the course of.

I frequently perform cochlear implant surgical procedure, a course of during 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 having the ability to hear at an important stage of their improvement.

However performing the surgical procedure as regular would have put each youngsters and surgical groups in peril. We would have liked to give you one other approach of doing issues. Our group in Nottingham needed to mix creativity and science to develop a novel and protected strategy to restart cochlear implant surgical procedure in a matter of only a few 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 lecturers from completely different backgrounds who’ve been engaged in initiatives geared toward tackling societal and scientific challenges.

A grave threat

Quickly after the pandemic started, among the earliest reviews, notably these from China and Italy, steered that healthcare employees had been at considerably greater threat of contracting COVID-19 in comparison with most people, and that treating ear, nostril and throat (ENT) situations was notably dangerous.

I used to be deeply saddened once 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 look after 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 the world over, our service at Nottingham College Hospitals NHS Belief initially halted all elective procedures in March when the pandemic hit the UK, so we might focus our group’s efforts on the administration of our sickest sufferers, together with these situations requiring emergency admission, and our most cancers providers.

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

We all know this as a result of plenty of the important research that highlighted the significance of early cochlear implantation on speech and language improvement had been carried out domestically in Nottingham, which is residence to numerous 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 providers within the UK.

A singular threat 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 capable of present our deaf youngsters with the care they wanted. That mentioned, I’ll admit that the concept of performing cochlear implant surgical procedure initially of the COVID-19 outbreak was unnerving.

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

mady70/Shutterstock

ENT healthcare employees are notably prone to catching coronavirus throughout surgical procedure due to the distinctive nature of the elements of the physique we give attention to. The nostril of an contaminated particular person accommodates a big 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 frequent chilly, are generally discovered within the center ear. This implies it’s extremely doubtless that SARS-CoV-2 additionally exists within the center ear, although, nobody has confirmed this up to now.

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 doubtless. 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 through giant droplets that require comparatively shut contact with an contaminated particular person. It has additionally been steered that it may be transmitted through 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 entails 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 area. These droplets and aerosols will include a combination of water, bone, blood, tissue and, doubtlessly, viable viruses.

Fixing the issue

At first of the outbreak, whereas we knew we wanted to restart cochlear implant surgical procedure urgently, we had been additionally extraordinarily conscious of the potential dangers related to performing this operation on the peak of the pandemic. This drawback involved me enormously. Nonetheless, I discover that the easiest way to handle concern is although motion, and it was right now 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 only a few days, following simply a few temporary emails, just a few cellphone calls and the odd Zoom assembly, I managed to collect collectively a group of internationally recognised consultants who had been all considering growing a mannequin of cochlear implant surgical procedure that we might observe throughout 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 wanted 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 supplied

I then requested my colleagues from the anatomy facility if I might borrow sufficient skulls on which we performed experiments that may assist us analyse the chance of spreading droplets whereas performing surgical procedure. And not using a 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 school of engineering supplied us with important 3D printing providers 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 supplied by our theatre supervisor, Laura Mitchell.

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

Douglas Hartley, Creator supplied

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 activity 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 might see the place the dye landed and perceive whether or not we might proceed finishing up surgical procedure carrying normal private protecting gear (PPE).

It quickly turned obvious from the distribution of luminous dye across the theatre that the contaminated droplets might 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 additionally the nurses, the anaesthetist, and different theatre workers.

How the fluorescent droplets unfold from simulated cochlear implant drilling.

Douglas Hartley, Creator supplied

Even worse, we discovered that droplets simply migrated beneath our full-face visors, the usual really useful PPE for aerosol-generating procedures within the UK. The droplets landed very near the eyes of the particular person carrying it. This steered {that a} visor supplied insufficient safety.

However we weren’t discouraged. Now we knew the extent of the issue, we had been capable of work across the clock for the subsequent few weeks till we managed to develop and refine some fairly 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 mix of a half-face respirator and security goggles, generally often called “spoggles”. We had additionally learn reviews 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 total-face respirator method.

Douglas Hartley, Creator supplied

We used a scientific evidence-based method to guage 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 means to speak, their field of regard, and their consolation.

Lots of the PPE choices we tried, not least the full-face respirator, had been discovered to considerably prohibit the surgeon’s imaginative and prescient throughout working. That rendered them unsafe for performing this form of surgical procedure. Fairly 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 choice for PPE.

The snorkel method concerned re-breathing carbon dioxide, which may be harmful.

Douglas Hartley, Creator supplied

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

The spoggles supplied the successful answer.

Douglas Hartley, Creator supplied

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 overlaying 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 surroundings. We had been the primary – and are presently solely – group on this 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 throughout the pandemic.

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

Douglas Hartley, Creator supplied

The brand new surgical regular

Our suggestions had been quickly disseminated internationally through 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 the world over.

Regionally, it was with enormous aid that we recommenced cochlear implant surgical procedure for profoundly deaf youngsters after just a few days of finishing our research: simply a few months after this process was placed on maintain. Working instances had been a little bit 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.

At this time, these new measures have turn out to be second nature to our theatre group, working instances are akin to our pre-COVID surgical procedures, and lists are operating as earlier than with only one surgeon working. Other than a little bit discomfort related to carrying the PPE for lengthy intervals of time, and the continued detrimental affect of the PPE on communication, we’ve got all just about accepted the setup as our new regular. In actual fact, I’d go as far as to say, it might really feel a little bit bare to function with out these measures now.

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

Douglas Hartley, Creator supplied

The protected recommencement of cochlear implant surgical procedure in Nottingham, and in different centres across the globe, has given many tons of 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 completely different for these youngsters and their households.

The worth of pace and collaboration

The coronavirus disaster has been a wierd and scary time for everybody, and it has introduced us all with many vital challenges in how we stay and work. However it has additionally opened plenty of doorways for brand spanking new alternatives and prospects.

Earlier than COVID-19, for those who informed me that I’d must assemble a tent during which to function this 12 months, whereas carrying spoggles and a respirator masks, I’d not have believed you. That mentioned, I’m positive that most individuals wouldn’t have predicted how a lot we’ve got 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 throughout to implementation on the affected person’s bedside is often a really sophisticated and prolonged one that may take years, and generally many years, to finish. So it has been heartening to witness the worth of a group working to resolve an issue at breakneck pace, with out a lot want for the phrase: “I don’t suppose we are able to try this.” Necessity is really the mom of invention and, confidently, a few of this innovation spirit will stay on past the pandemic.

What subsequent?

Evidently COVID-19 is more likely to be with us for the foreseeable future. So we’ve got no plans to desert our PPE and working tent for cochlear implant surgical procedure any time quickly. In actual fact, 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 methodology as an an infection prevention management measure, together with people who generally use an working microscope, equivalent 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 destructive affect of PPE on communication throughout surgical procedure. It goes with out saying that communication is important for the protected functioning of an working theatre, and this drawback wants an pressing answer. That’s why our group and different centres all over the world are persevering with to work on the design, not solely to assist communication, but additionally to facilitate easy accessibility into the tent for the surgeon and theatre nurses, whereas maintaining the contaminated droplets inside.

Though COVID-19 has introduced vital challenges to recommencing cochlear implant surgical procedure, by means of collaborative teamwork throughout a variety of disciplines, we discovered options. As a group we’ve got definitely learnt from this expertise; classes that I hope we are going to 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.