I would first like to thank you for the thorough look at the literature regarding suction and instillation that was presented in the Oct.-Nov.-Dec. issue of the Bulletin . As you pointed out, the practice and techniques must be assessed each and every time we are at the bedside.

No two patients are exactly the same. Any rational practitioner at the bedside will admit that he or she seldom administers any intervention exactly the same to each patient, each time. As much as we try to standardize care, some interventions, especially invasive interventions (of which endotracheal tube suctioning is definitely one), do not lend themselves to standardization. Nor should they; the myriad variations in mucus, tubes, catheters and physiologic response to the procedure demand that we customize our practice for each and every intervention we perform.

Some may disagree with my apparently middle-of-the-road stance, which is that we shouldn't throw normal saline bullets away, but we shouldn't use them all the time either. Nevertheless, this may be the most appropriate stance when even the literature is so inconclusive.

On that point, I must say that I have never found any question that so many have looked at and yet no clear consensus can be reached. The Cochrane Group (that bastion of EBM) attempted a meta-analysis of available studies. They found that either no two studies used exactly the same method or that each studied different parameters or data points, making analysis virtually impossible.

A number of problems have led to that situation. First, each new study has many flaws: a sample size that is too small, inadequate staff training to assure consistent methods, and invalid measures (as you pointed out in the Bulletin ). Rather than copy the last study to see if the same results are reached, each new study design tries to correct all the flaws. Hence, no level of reliability is established for any study.

A second problem that is apparent in virtually all studies of bedside interventions is the variance in practice among practitioners. A couple of the studies of suctioning tried to reduce the variance through intensive in-servicing and exposing the sample patients to a closely defined group of practitioners who followed a strict protocol. The problems they had were that either the sample size became too small to be valid, or data sets had to be removed because of contamination of the technique by a practitioner altering the method. There is always variance among practitioners in how they score an assessment tool, provide an intervention, or score the response to the intervention.

All the literature on the topic and the polarity of viewpoints on the subject of saline instillation and suctioning point out that no one stance can possibly be right in all situations. We must be ready and able to adjust our practice at the bedside, as patients are all different each time we interact with them.

Do we need to instill every time we suction? No, definitely not. Should we never instill? No, definitely not. Do we need to assess before we suction? Yes, every time. Do we need to assess the patient's response after we suction? Yes, every time. THINK & BE AWARE.

Thanks again for a great Bulletin.

William S. Demaray, BS, RRT
University Hospital
Albuquerque, NM

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On March 23, 2003, being an RT at Mount Sinai Hospital in Toronto, Ontario, suddenly became more dangerous than it had been the day before. That was the day our SARS outbreak index patient arrived in the ICU. That 24-hour period turned both our professional practice and our lives upside down. Seven of our colleagues would eventually contract the disease from their close contact with this one patient. Through it all, we somehow managed to care for our patients, support our staff, and feed valuable information to the government policymakers during the crisis.

Team spirit and mutual support carried us through. This is our story of how we survived the outbreak.

Initial exposure

Our index patient was transferred to our facility with what looked like a community-acquired pneumonia (CAP). Initially, the patient was treated with bronchodilators and non-invasive ventilation (NIV). He coughed quite frequently and was intubated for deteriorating respiratory status.

SARS is a disease of exclusion. Because it mimics many other respiratory illnesses, we deal with on a daily basis, so there is a time lag in diagnosis. We treated this patient for four days before we had any idea that he had even been exposed to SARS.

By the time we discovered that our index patient was severely ill with SARS, he had exposed 69 ICU staff members, all of whom were sent home on quarantine.   This sudden and profound personnel shortage forced us to run an ICU on skeleton staff, changing most of our practice forever, in a heartbeat.

Our indexed patient was initially on multi-drug resistant staphylococcus aureus (MRSA) precautions, which is common practice when a patient is transferred from another facility.   We started him on antibiotics and humidified oxygen, but within 24 hours he deteriorated to the point of requiring NIV.   Later he would require fiber optic intubation to support his ventilation/oxygenation status. The intubation process seemed to be the key point at which our staff was exposed to the highest risk.

Meanwhile, at the referring institution, the outbreak had spread. As a precaution, since our negative pressure room was occupied, our index patient was transferred to another hospital ICU where one was available. At the time of transfer, his SARS diagnosis was confirmed, and eventually his family members became ill as well. Unfortunately, he would die from the disease a short time thereafter.

By the time the diagnosis was confirmed, all the patients and health care workers within our ICU had already been exposed. To prevent further spread, the ICU was closed to new patients and all the existing patients were put into extensive respiratory isolation, which meant putting the entire ICU under negative pressure isolation. Upon reentering the ICU, we had to don a gown, gloves, and N-95 mask or the duration of time spent in the unit.   We also had to change our gear between patients.

Go home!

Health care workers who were in the ICU for more than four hours during the index patient's stay were sent home on quarantine. Home quarantine involved total isolation from the outside world, including family, for ten days.   Those of us who were home quarantined slept in separate rooms, ate alone on separate plates/cutlery, could not prepare meals or have visitors, used a separate bathroom, and wore an N-95 mask in the presence of family. It was alienating, lonely, and terrifying. None of us questioned whether we would get sick. We felt it was just a matter of time until we did.

Our pregnant colleagues feared for the health of their unborn children. One of the drugs used in the early stages of the outbreak was Ribaviran, which is teratogenic and can harm the fetus. If they became ill, they would have to make a difficult decision about their therapy. Plus, no one knew what effects SARS itself would have on the unborn fetus.

At work, everyone   scrambled to ensure that we had adequate staff to cover the ICU. All our students had to leave their training rotations. With the staff quarantined and a number of maternity leaves, their help would have been   invaluable, since they were in the last month of clinical training.

Our Level III NICU, which cares for some of the smallest premature infants in the country, and our labor and delivery floor, which is responsible for 8,000 deliveries a year, became areas of concern. The RTs could not move freely between units for fear of exposing additional patients.

New equipment and processes

As a publicly funded institution, prior to SARS, we used a lot of reusable equipment for our adult population. Suddenly we had to place orders for disposable ventilator circuits, filters, gravity-fed humidifier pots, filtered non-rebreather masks, disposable saturation probes, and personal protective equipment.   The sudden demand for these items cleared the medical supply inventory shelves almost overnight, heightening the crisis and fears of exposure. Hospitals that got their orders in early got supplies, and those that did not were put on the backorder and waiting lists. At one point, personal protective equipment was backordered for three months. Staff feared the supply of N-95 masks would run out. Add to this the stress of having to care for sick colleagues, and it took a toll on all of us.

We did our best with our limited knowledge of the disease at the time. We attempted to stop all droplet spread by adding filters on all ventilator expiratory limbs, we stopped using NIV/HFOV altogether, we discontinued the use of web nebulizations, and we used MDIs exclusively. No more oxygen aerosols were allowed. We delivered only dry oxygen to our patients and we used only in-line suction catheters to avoid disconnection and splashes when suctioning. We put filters on all resuscitation bags. We used personal protective equipment for all high-risk procedures (intubation, extubation, endoscopies, chest tube insertions, open suctioning, and ventilator circuit/filter changes). We converted exclusively to disposable equipment. The RTs became the most valued reference resource in the building.

By converting an entire ward to a negative pressure unit, we created a SARS unit within the hospital. We had to decide how to transport infected patients from one area of the hospital to another and how to receive infected patients into our SARS unit. This involved a lot of coordination to limit the number of people exposed to an infected individual upon admission. We implemented a requirement that Security be called anytime we needed to use the elevator to go directly to the SARS floor.   After the transport of an infected patient, the elevator then had to be immediately decontaminated. In all, we treated 26 SARS patients at our hospital.

It became imperative to ensure that all the RTs were in-serviced and understood how to use the new equipment and the decontamination procedures. Most of the ICU RTs were at home on quarantine, so this added an even greater workload burden to the RTs left in the building. Disseminating information to the RT department came in the form of daily debriefings at report time for each shift. During the first week of the outbreak, the policies and procedures often changed hourly, making it difficult to keep the staff up-to-date on the latest procedures for handling equipment and patients.

Something from the movies

The CEO of the hospital sent out daily e-mail updates to all staff on the situation within the city and hospital to keep everyone informed. The hardest part was in-servicing 600-800 staff, both on how to use personal protective equipment and also on how to respond in the event of a cardiac arrest on a SARS patient. The days were difficult and exhausting, and16- to 18-hour days were not uncommon. I frequently heard from the director of respiratory therapy at 7:30 p.m., on her cell phone, in her car, on her way home. Thankfully, we had very supportive families and friends who understood how vital our role was to the outbreak and to the hospital.

Entering our hospital became a scene from the movie “Outbreak.” Since lining up to “run the gauntlet” took awhile, every morning, we arrived a half an hour earlier than normal.   Before we could even enter the hospital, we had to show identification badges to security personnel to be admitted into the building. Once inside, we immediately washed our hands with alcohol rinse and donned an N-95 mask. Then we fell into two lines of about a dozen gowned, gloved and masked screeners waiting to take our temperatures. Pulling our masks down just long enough for them to insert the thermometers into our mouths, we felt as though we were already contaminated. Some of the longest moments of the day were those tortured seconds spent waiting for the beep of the thermometer and praying for normal emperature readings.

Once a screener checked our health and travel forms to see if we had been in other outbreak hospitals within the city, we were free to enter the building with an N-95 mask on.   Weekdays became as quiet as weekends since only essential workers were allowed in the building. All doctors' offices were closed and all non-urgent/emergent surgeries were cancelled. No visitors were permitted in the building. The hospital was like a ghost town.

Once we were allowed to enter the hospital, we changed into our uniforms still wearing our N-95 masks. Upon entering the ICU floor, we washed our hands again, and then put on a gown and gloves to enter the ICU, get report, and start the day.   By this time, we were already tired, and the shift had barely begun. At mealtimes, we had to eat three feet apart, one at a time because only one person could remove their mask at a time. The cafeteria and coffee shops were closed, so we either “brown bagged it” or skipped meals. Most of the time, it was just too difficult to eat and drink.   Since we all lost weight and became dehydrated on most of our shifts, we began to refer to our new dietary habits as the “SARSdale” diet. By the end of 12 hours in an N-95 mask we were tired, hot and defeated. Walking back out into the outside world and taking that first breath of fresh, unmasked air was freeing.

For three months, the hospital operated under “Code Orange” (External Disaster) conditions. Extensive screening of staff and patients alike prior to hospital admittance continued. Our mobility within the building was strictly limited to the units we worked on. It was hot and uncomfortable, and we all experienced burnout to varying degrees.

Government takes charge

The hospital system in Ontario is divided into subspecialties. Each hospital has an area of expertise and serves a specific patient population. This severely limited our ability to serve the public at the height of the outbreak. Our emergency department was closed to ambulances, and the staff was deployed to other areas of the hospital. Fifteen percent of the provincial ICU beds were closed when our ICU closed its doors to admissions. Thirty-five percent of all ICU beds in the entire province were closed at the height of the outbreak. Later in the outbreak, the government designated SARS hospitals to offload the hospitals that had been affected and to allow for the critical re-opening of a trauma center that had to be closed during the initial outbreak.

The government dictated patient care and how the hospitals were to function during the outbreak period. We had to read directives received from the government and respond to them by communicating the information to the frontline workers so that we could change practice. It soon became apparent that the daily changes to practice were confusing to the staff. Trying to keep everyone up to date on the constantly changing policies and procedures was a challenge. In reacting to the rapid changes, we had to work on implementation strategies with a multidisciplinary team. We held daily teleconference calls with the government operation center for clarification. The hospital's multidisciplinary SARS team was one of the few still allowed to meet within the hospital, because large groups of people in close proximity to each other was strongly discouraged.

The hospital Intranet and departmental e-mail became key conduits for keeping staff informed. One of our physicians created an Intranet web site to allow access to educational material on personal protective equipment. This Intranet site soon became an international reference point. This teamwork spread among the hospitals citywide. The RT departments shared information and policy documents via our provincial professional society to decrease everyone's workload, allowing all the departments in the city to pool resources without reinventing the wheel.

Adverse media coverage during the SARS crisis only increased the public fear and stress. The fear within and outside the hospital created more work, since it required us to educate and reassure the public about the effectiveness of our measures to contain the spread of SARS.  

Psychological impact

It's difficult to describe what goes through one's mind at times like these. During my quarantine, my five-year-old son caught scarlet fever and my stepson missed his eighteenth birthday party. I cannot explain the guilt I felt as a parent and spouse for having inflicted this on my family. I chose my profession and the assumed risk involved, but my family did not. While my son was sick, I could not hug, kiss, bathe, or cuddle him. I felt stripped of the freedom I had taken for granted each day, which only added to my isolation.

Day three of the quarantine took the heaviest emotional toll on our staff. It was then that we learned that five of our colleagues had contracted SARS and were now in the hospital.   For me, that was the lowest point in the outbreak. Friends were sick, and now even more strictly isolated from their families, as SARS patients are not permitted any visitors under any circumstances. In the background I was constantly thinking of the high mortality rate associated with SARS. Our friends could die. Two more staff members became ill late in the quarantine period, which extended the quarantine for all staff for two more days. It seemed like an eternity.

Nothing short of amazing was the support we received from our managers and upper administration during the quarantine period.   The ICU director, nursing unit administrator, clinical nurse specialist, and director of respiratory therapy each took turns calling those us who were quarantined on a daily basis to offer moral support and to boost our spirits while we were at home. We came through the crisis with a stronger bond of teamwork and compassion for each other, despite the stress it added to our lives.

The greatest impact of the SARS outbreak was psychological. Some spouses threatened to divorce health care workers if they returned to work, and many chose to leave their professions. In many cases, those who got sick faced abandonment by friends and family, and sometimes extreme financial burden. Because the general public did not fully understand SARS, panic set in and society shunned hospital workers. People would move away from anyone who appeared to be a hospital worker on buses and commuter trains.   Neighbors ran away from us, our children were not invited to birthday parties, and our families and we were turned away from dentists, day cares, hairdressers and anyone else who worked in a “hands-on” profession. It all was pure anguish.   We all feared becoming sick and worried about our colleagues who were already sick.

“New normal” conditions

Luckily, our ill colleagues recovered.   After the initial illness period of two to five weeks, on average, they were all on the mend. All of them managed to return to work by the end of the third month. One of the first to return to work was the RT! (For more on her story, see your December issue of AARC Times .) Everyone's morale lifted significantly that day from the realization that you could have SARS, survive, and return to work.

As the crisis drew to a close, we had time to re-evaluate things. We lagged behind, and had to mask-fit all staff for N-95 masks. In the beginning, this was not possible due to the lack of time, availability of masks, and the number of staff requiring in servicing. Just trying to maintain a supply of any type of N-95 mask at the beginning of the outbreak was difficult. The general public even tried to hoard them. During my quarantine, my husband had to buy my supply of masks at Home Depot, as the medical supply stores had run out.

Currently, we live under “new normal” conditions. We put all patients with a fever +/- pneumonia under a higher level of contact and respiratory precautions. This will probably continue until the end of the influenza season, (especially with the outbreak of Avian Flu now in Asia) and then reassessed. All patients transferred from another hospital or nursing home require a transfer number that ensures that the patients have been screened at the referring institution prior to transfer so that we can put them under appropriate isolation precautions on arrival.

All staff must also monitor their own health more closely, and no one reports into work if they are sick. We wear body substance precautions gear for all codes and splash risk procedures – a standard we had become somewhat lax about enforcing prior to SARS. Infection control has a greater authority and presence within the hospital. SARS has also given us the opportunity to scrutinize our equipment cleaning procedures. But through it all, we continue to report to work. We are committed to our jobs, our professions and our patients.

Despite the fear for our own personal safety during the outbreak, we carried on. I have never been more proud of my profession and my colleagues. SARS taught us a lot of lessons about personal stamina, how well we work under pressure as a team, and how much we truly care. It was a time of personal and professional growth. Looking back, I am glad that I was part of the experience.

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