Anaesthesia
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An editorial on pandemic information overload?
Yep. 😉
But setting aside the irony of adding 2,000 more words on COVID-19 information overload, Kearsley & Duffy neatly explore the challenge:
"Since the outbreak of this pandemic, our e-mail inboxes, social media feeds and even general news outlets have become saturated with new guidelines, revisions of guidelines, new protocols and updated protocols, all subject to constant amendments."
What's the thesis?
The authors' argument is that too much information in the era of COVID may be a bad thing: the marginal benefit of 'more' may be overwhelmed by the negative cost.
They acknowledge the tension between the pragmatic and perfect when it comes to information sources in the face of a rapidly advancing disease – and in particular the recurrent waves of shifting clinical guidelines.
Kearsley & Duffy mention the important role of rapid research, worryingly tempered by a surge in volume, but fall in quality, along with mainstream promotion of non-peer reviewed and pre-print investigations. They note how information technology in the pandemic climate exploits our biases: confirmation, anchoring, and novelty.
At an individual level they discuss the risk of pandemic 'alert fatigue', the growth of social media and excessive information sharing making quality assessment difficult, and the negative effect of both on well-being.
The take-home
We each have significant personal responsibility to consider the consequences when sharing information, especially if incomplete or risk of misunderstanding when stripped of context.
summary"As we learn to live with this virus it is important for us to be cognisant that we are all at risk of error; we need to work to reduce information overload and focus on unifying our approach to both information dissemination and presentation. We must go back to basics and apply the well-practiced human factors principles of good teamwork, communication and leadership.
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We need to avoid a situation where a crisis is overmanaged and underlead; “Ipsa scientia potestas est" or 'knowledge itself is power' – from what COVID-19 is teaching us however, can too much knowledge be a bad thing?"
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Why the interest?
The combination of a deadly contagion (COVID-19) and recognition that endotracheal intubation is a high risk procedure for the airway technician has lead to the development of novel medical equipment. One such innovation is the clear-perspex 'intubating box' designed to contain viral-aerosols released during intubation. There has been limited prior evaluation of the safety or efficacy of such devices, despite their promotion.
What did they do?
Begley et al. conducted 36 simulated intubations with twelve PPE-adorned1 anaesthetists, with and without intubating boxes. They primarily aimed to quantify the effect on time to intubation.
Investigators tested both a first-generation and newer generation device. Each of twelve senior anaesthesiologists performed three block-randomised intubations: no box, original, and latest-design box. The airway manikin tongue was inflated to simulate a grade 2A airway.
And they found...
Intubation time was significantly increased by both the older and newer box designs (x̄=48s and x̄=28s longer respectively, though with wide confidence intervals). More relevantly there were frequent prolonged-duration intubations with the box (58% >1 minute, 17% >2 min), but none without the box.
Most worrying, there were eight breaches of PPE caused by box use, seven occurring with the newer, more advanced design.
"PPE breaches often seemed to go unrecognised by participants, potentially increasing their risk further."
Reality check
Despite the superficial appeal of an intubation box, this simulation study warns that such devices fail both to support safe and timely intubation and to protect the clinician – the very arguments used to advocate for its use.
These failings occur before even considering the actual effectiveness in reducing viral exposure, the box's impact on emergent airway rescue, or the practicality of cleaning a reusable device now coated with viral particles.
The intubating aerosol box appears dead on arrival.
Bonus biases
Begley notes the appeal of such novel devices may be partly driven by 'gizmo idolatry' (Leff 2008) and 'MacGyver bias' (Duggan 2019), blinding clinicians to consider unknown consequences of box use and discounting resultant hazards.
summary
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Local COVID PPE guidelines were used: face-shield, goggles/glasses, mask, gown & gloves. ↩
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