 All right, I think it's time to go. And then, hello everybody, I'm Morgan Hutchinson and I'm an emergency doctor here in Philadelphia at Congress Jefferson University Hospital and I'm a member of the Health Design Lab. Yeah, I'm at Fields and I'm also a emergency physician and a faculty of the Health Design Lab and we're very excited to bring you designing on the front lines. We're very happy to have you all. Please mute your audio to make the best experience for everybody and use the chat box. We'd love to hear from you. Who are you? Where are you from? What do you do? And then also please add all your questions and comments to the chat box. We'll have time at the end to answer them. All right, and we're very excited to have a special guest with us today, Dr. Rich Levitan, an expert in airway management and a crusader has been leading the fight against COVID in New York City. Thanks, Rich. Absolutely. Hey, thank you. Thank you, Rich. First, we wanna give you a little background as to why we made this webinar and what we'd like to accomplish. Yeah, Maureen, tell us why are we here? So our healthcare system was not prepared for this COVID-19 pandemic. Doctors around the country were pleading for PPE while watching their patients and colleagues fight for their lives against the deadly virus. Because this unmet need, healthcare workers and designers have been working tirelessly to find solutions. That's right. Here at the Health Design Lab, we pride ourselves on bringing together healthcare experts and design experts together to solve problems. And as emergency physicians, we are working on the frontline where we experienced the pandemic firsthand, but we try to do so with the eye of a designer. We can't overstate enough how important we feel co-design is in the Health Design Lab. And this is kind of a typical day in the Design Lab where we're bringing together physicians, patients, industry, designers, all together to solve problems. Of course, these pictures are pre-COVID. So in the days of COVID, it's really important for us to really work together to come together in virtual settings to keep up this design momentum and this collaboration. This pandemic has been a perfect opportunity for us to all come together, doctors, nurses, designers to solve these problems. These are just a few of the examples of things we've been working on in our lab. You'll see everything here from the bunny suit or the papar adaptors to training programs for manual ventilation to 3D-printed COVID swabs. We bring designers into the healthcare space to solve problems that didn't even exist a few months ago. Our innovations keep doctors safe and help us protect patients and provide the best care to patients with COVID-19. We've also been working on rapid prototyping as we quickly realized that we needed to find a way to collaborate with each other as we're all experiencing the same challenges. Designing on the frontline brings together healthcare workers and designers to tackle some of the biggest challenges during COVID-19 pandemic. That's right. And so today we're gonna touch on a few design challenges involved in frontline emergency medicine, airway management. Morgan and I will introduce a popular topic, intubation boxes, and then we'll turn it over to the airway master, Rich Levitin, and followed by a Q&A period afterwards. So please feel free to use the comment box or the chat box to leave comments. Keep it clean. We are recording this, but throw in any questions or comments you may have, and we're gonna get to that at the end and go through those. So intubation is a super common emergency department procedure. It's extremely high risk during the COVID pandemic for transmission to the doctor. Normal breathing, coughing, sneezing, vomiting can all cause the doctor to get COVID from the patient. In this video on the right, we're demonstrating using fluorescent dye, the trajectory of a cough from a patient. That's right, and in the design lab, when we come across a design challenge, we like to use something called the how-might-we statement to kind of frame the challenge. So here the question is, how might we create a reusable protective barrier for healthcare providers during intubation? So, Morgan, how might we do this? Great question, Matt. So a great design tool that we often use is trying to see how other industries have solved similar problems. Slide. So think about the sneeze guard. The sneeze guard was invented back in the 1950s in the restaurant industry. This basically solves the same problem, how to keep respiratory particles off of food. And that's exactly what we started doing and what designers around the world started doing to solve this problem. I love that you looked up what year the sneeze guard came out. I did, I looked it up just 10 minutes ago. Great thoroughness and fact-checking, appreciate that. Absolutely, gotta have the fact. So providers around the world started creating simple barrier devices that were reusable and that were made from already available materials. The most common one was called the aerosol box. This one was described by Shen Yang, an anesthesiologist in Taiwan. This simple box has arm holes so the provider can put their arms through those holes. It's reusable, easily cleanable and it provides barrier protection during the intubation procedure. Yeah, totally. And we jumped on this real quick. We had our friends at NexFab, which is a makerspace here in Philadelphia, make us one and we started testing it right away. And while we did find this to be great enclosure that had face validity for containing droplets and it was pretty intuitive to use, it did have a few drawbacks. So if the intubation goes very smoothly as demonstrated by Morgan here, great job, Morgan, on doing this. And there's really, yeah, there's really no issue but the event of a difficult intubation or if the person intubating isn't very good, maybe like myself or like Bangku, then this thing can be a problem. You can't pick it up and move it out of the way to troubleshoot and it inhibits your maneuverability. It's almost kind of like also an extra cognitive stress sometimes when you need to troubleshoot. And so this kind of, we kind of identify some issues right away with it. Also, if you do after you get the intubation performed and you get the tube in, you need to bring in a bag to start bagging the patient. And sometimes that was issues with the lid of the box creating a height restriction. And finally, a lot of times we like to do something called ramping patients where you actually lift up the patient's head because they have a difficult airway and the height of the holes or the height of the lid sometimes provided a restriction in doing this. And so here, Morgan is actually trying a couple of different designs. So on the left, we have that original intubation box and in the middle, we have a design that our anesthesia colleagues created. It was kind of cool. They were working on this in parallel. I think a lot of people, this is what was really cool about intubation boxes is a lot of people are working on this in parallel. And so this intubation, it's intubation, what they call it the intubation shield tried to solve a few of these issues. So Morgan, do you wanna talk about this design? I do. I think your screen sharing stops. I did. Let me go back. Sorry, I don't know what happened. So this new design that anesthesia made for us was excellent. It was a lot lighter than the original airway box. It was easier to use for that reason. It only had the three sides. And so if there was an emergency, which is the most important thing, you could just push it forward on top of the patient's thorax and go forth with a normal intubation. Yeah, totally. And I really like this design. One of the other things about it too is if you notice the sides are, because it's a very thin material, the sides are flexible, and that lets you accommodate for a broader shoulder width, which was really cool. Just like our friend Carlos here. Our friend Carlos here. Okay, and cool. Sorry, did you mention the flipability of it? I did, yeah. If you have an emergency while you're doing airway, you slip it forward. Oh, great. Yeah, so. If you decide you don't need it anymore, you can just push it forward onto the patient and go do regular intubation. Right, so that's huge for us people who maybe not being as good at intubation as Morgan and we need to like troubleshoot or use a backup method, cool. So I love this design too, but one thing that really was a downer for me was the draping that was required to create barrier protection. I feel in the emergency department that I probably don't initially have time to put on a drape, or you might have to do it ahead of time and that requires a lot of preparation and we're pretty busy. So that led us to want to create a third design, which we show here where we actually added on a bit of a lip on the top. So just another iteration to try and create a little bit more barrier protection that might be a hybrid between the shield and this, but also kind of retains that thin plexiglass that's a super lightweight and can be flipped. So kind of fun design process and iterative design here. And so the next kind of question we had for these designs was how well do they work? So here is an image from, you may have seen from the New England Journal of Medicine where there was a publication in which somebody showed a methodology for testing these using a balloon filled with dye that was inserted into the airway of a mannequin and then filled with air and exploded and that was kind of to simulate a cough. And here obviously is a cough simulation without the barrier device. So we wanted to check this out for ourselves. So this is a picture of us doing a simulation ourselves just last week up in the operating room. What we did was we ran a tube through the patient's nose and then out through the mouth and put a balloon full of fluorescent dye on the end of that tube, hooked it up oxygen, just like Matt said, and until the lymph popped, simulated in the cough. Yeah. And what's not pictured here is the big streak of dye that Morgan got all over her expensive fixed scrubs when she did this. So I would recommend using your cheaper free hospital scrubs lesson learned. Better at intubating than doing a simulation. So in this one, we're testing the box versus the shield. We found that the box actually did a better job of protecting people that were standing on the sides of the bed and at the foot of the bed. They both did an equal good job of protecting the person who's doing the intubation. But with the shield, you actually got a lot more squatter on the sides of the bed and down at the foot. Yeah, so the second one here is the shield. So I've seen a lot of designs out there and that's what, again, what's so cool about these intubation shields are people are coming up with really creative solutions everywhere. This design was from a Frantoni Saks setter from the CoverAid PHL group here in Philadelphia. And it's a cool approach, different approach and inflatable design that creates an enclosure. So really good protection, lightweight. I might, one issue that we may have with this is again that needing to reach in, troubleshoot or have height issues. But I know that he's had, I haven't personally tested this but he's got some good feedback on this design. And there are a lot of other cool designs out there that are using kind of more rigid frameworks with draping over it. And then some people are using a drape only approach in a glidescope technique. So I think different people have come up with different solutions and I think solutions also may be kind of relevant to the setting. Shout out to our fellow Michelle for modeling in that picture. I know, she let me take the photo and put the intubation cover on it but she wouldn't let me intubate her. I was so disappointed. I think she saw what happened to the mannequin. Yeah, okay. I probably wouldn't let me intubate me also. So fair enough. All right, so in conclusion, some considerations for intubation barriers and some ongoing questions that I think are important as we as healthcare providers and designers try to work together on creating the best solution is thinking obviously about the weight of these boxes or shields, the height of them as height seems to be important. Also armhole size, this was a design that was sent to us which looked really good but they cut the armholes way too small. I could barely fit my arms into it. So that's important to think about. Also, another, a lot of designs have incorporated port holes on the sides so that people can reach in and perform like the respiratory therapist can adjust the tube and fix the tube. Also thinking about what kind of stretcher you're using is this in the ICU, the emergency department or the operating room. They have different stretcher sizes and your patient population, the patient population in Taiwan. It's a bit different than perhaps South Philadelphia whether you're using a drape and then the cleanability of it. The more sides you have to it, the harder it is to clean. So the shield design is really easy to clean three sides whereas the box has more crevices we have to get into versus being disposable. And then kind of finally the 800 pound grill on the room is what further research needs to be done to even show that this works. So we need to show that through research that we're decreasing COVID transmission that this is a worthwhile pursuit. Certainly, sneeze guards in restaurants help contain germs. So I would imagine that these barriers also help us contain germs for COVID but it's important to show that with the research. Any other thoughts, Morgan? I think we should move on and introduce our special guest. Awesome, I completely agree. If anybody has any questions or thoughts, please put them in the chat box and we're gonna touch on this and any questions from Rich's talk at the end. Awesome, thank you for everybody who's put your comments and questions in the chat box. We're gonna address all those at the end and we really are excited to hear from all of you in the audience today. But without further ado, I'd like to introduce our friend Rich Levitan. Rich is an emergency doctor and a renowned airway expert. He's dedicated his career to mastering, improving and teaching others the art of airway management. He's invented countless devices and techniques that are now commonly used to improve the way that we care for our patients. His most recent work has focused on airway management tools for patients with COVID-19. Rich, thank you so much for joining us. Hey, thank you for having me. So just thinking about your last segment, I do wanna point out there's another piece of this that is unique about COVID and that is that our patients with COVID, their brains are normal, most of them that we see that we intubate. Unlike most patients who we intubate who are in profound shock with hypoperfusion or acute hypoxia, so their brain isn't working right, or CO2 retention, which causes people to be narcotized, these people are crisp. And so thinking about all of these devices getting placed over people who are awake, alert and appropriate when we're starting airway procedures, it's just a whole nother piece of this that until I started watching your designs, it didn't occur to me. Like what is the impact of that from the patient perspective that we're putting this over them? So just another thing to mention. Absolutely. You know, there's a lot of things about COVID, obviously, that are rather interesting for me from a design perspective. And so I'm gonna just start sharing my screen and I live now, by the way, up in Northern New Hampshire. So you're looking at my post and being constructed house. I live up in the White Mountains at about 2,000 feet, you know, and I went to New York for 10 days. So the real experts are the folks on the front lines, particularly in the outer boroughs of Brooklyn Queens and the Bronx who took it hard during the pandemic surge. I was there for 10 days, right as it went down. And the amazing thing about it was chest how awful these people's chest x-rays looked, how terrible their oxygen saturations were, and yet they were on their cell phones. And that just was like nothing I'd ever seen. But from a design perspective, I'm gonna switch to sharing my screen and just show you here my keynote presentation here. And, oh, hang on, do you guys have it? No. I'm just trying to move around here. How about now? Yeah, it's that green button on the bottom, share screen. Yeah, I'm working on it. Okay, share screen, you know, okay, here we go. Perfect. Got it, cool. So let's talk design. You know, one of the most amazing things that I've seen in medicine is looking at pulmonary angiography and looking at the design of the way the lungs work. You know, that just always blows me away and that the design of pulmonary vessels and everything, it mirrors fractals and how trees look, you know. But it is interesting to think about the design of the lungs, how this virus affects these people. And so I have on my screen on the left, you know, a chest x-ray was somebody who had mild COVID, 92% sat. And on the right, somebody with much more severe. But COVID starts out in the lower lungs and it starts out also in the posterior lungs. And you know, in hindsight, people who do not inflate their lower lungs and posterior lungs well are at highest risk for bad outcomes. We thought early on that everybody with lung disease would be equally affected. But what we've discovered actually is that if you are hyperinflated with asthma or COPD, you actually are less likely to get this disease that in China, only 4% of deaths were in these people who were heavy smokers with COPD. And so it's weird that the disease basically attacks in the areas of lung where we see a lot of elderly without electricity and a lot of obese people without electricity. But this leads into this whole realization about pruning and positioning. So I have up here a picture just showing safe apnea in the morbidly obese. And this is all pre-COVID, but morbidly obese people do not have a long safe apnea time. What's interesting is when they're laying flat on their back, their safe apnea time after oxygenation is only two minutes. But if you tilt them, as shown on the left side, you actually go from two minutes to three minutes of safe apnea. Now, interestingly, when you bend them at their waist, you don't get the benefits of tilting them down. You get somewhere in the middle. And that's because the belly impedes the lower lung excursion. And I think that is actually why obese people don't do great in COVID is because they simply can't expand their lower lungs. But getting to this, it brings up the question of pruning. And pruning is essentially a design solution to how to aerate most of your lungs. And anything that runs fast, if you're a mammal, runs prone. So I've got a greyhound, I've got gazelles, I've got race horses up top. And human beings in the highest aerobic activities on the planet put themselves into prone positions. I have climbed that altitude. I have not gone over the Alps and the Tour de France, but I've climbed that altitude. In the past, I used to think that my bending over and breathing was just pausing and sort of balancing my load. Now I realize the benefit of pruning. And the reason why all these animals are designed this way, why they run prone, has to do with what happens with the heart and the bulk of our lungs and where it is relative to our thorax. So I have here CATSCANS, and this comes from a paper written by a guy who has pioneered the work in ARDS named Gattinoni. And Gattinoni actually has described the L and H type, the phenotypes that we're now commonly addressing or using in describing COVID. So this is the same Gattinoni who put out this paper recently on L and H types. Well, back in 2012, he, I'm sorry, in 2002, he put out a paper on the value of pruning in ARDS and I took these images and initially he just had them supine and then he had them prone, but he reversed the heart because he just kind of flipped it over. And I modified it just to show you with the heart in the same location how there is tremendous benefit. So if we go to the top left to the bottom left image, when the heart goes from being upright to now being on the sternum and the patient is on their stomach in that prone position on the left side, what you see is more area of the lung is now black. And the same thing happens on the right side. So pruning is a design solution, literally a design solution to working around how to best aerate the lungs. And it was amazing to me in New York City to have these people come in with pulse oxes of 50. And as I mentioned, because there are saturations, I believe have gotten slow, slowly to that very, very low level, but it's taken days, and I think somewhere between three and five days, but it's taking days for them to get there that they are awake, they're alert, they're on their cell phones with numbers that normally we don't ever see anybody talking. But so they get there slowly and yet they get this advanced illness because of what I have started calling silent hypoxia. And, but it was amazing to me to have these people come in at 50, put nasal cannula on them, add a non-rebreather, and suddenly their pulse oxes up in the 80s, but they are still tachycardic and they're still breathing fast. So patients come in generally with this disease, breathing at 30, 40 or more times per minute. When we add oxygen, their saturation goes up, but often their work of breathing doesn't. They are still breathing quickly. Now, many of them don't subjectively feel that, but when you look up at a respiratory rate of 35 or 40, that's not normal. And their tachycardic also generally 110, 120s when they're really low on their oxygen saturations. What we found was when we prone them, when we turned them onto their stomach with a combination of oxygen devices, what would happen is their respiratory rate would go down, their work of breathing would go down, their pulse would go down. And generally within, you know, minutes to hours, you have a very good sense if you've made enough forward progress to avoid intubating them. And so I learned this, by the way, from Nick Caputo and the Bronx, from Ruben Strayer and Brooklyn and from other ER docs. And Nick actually was kind enough and quite generous to throw me in as the last author on this paper that just published about 10 days ago in academic emergency medicine on the value of a weight pruning. And, you know, this is the first time in human history that a large number of patients are being treated with a weight pruning as part of their therapy. Now, on the ICU side, pruning has been commonly done in ARDS since that Gatenoni paper in 2002. So it's not a new concept there, but, you know, a few beds in a hospital are specifically designed to help prone people. They're called pruning beds or rota beds. But, you know, even big centers only have a couple of them. And so now, you know, at Bellevue, you walk in, there's 150 patients in the ER, 30-something are intubated, they are all getting flipped over using what they called the burrito, which was just this wrap of sheets. And twice a day, they're flipping them. But all of the non-intubated patients with COVID pneumonia were also having this pruning maneuvered as well as other positioning maneuvers. And, Susie Bentley, who is out of Elmhurst, created a set of sort of positions for these patients. And it was published in both English and Spanish. And it included pruning as well as right and left recumbency and sitting up in a chair. And sitting in a chair, I think, is much better than sitting in a stretcher because, particularly if you're larger, sitting in a stretcher causes the lower lungs to not be able to fully expand. But what I did notice, you know, in this whole effort to try to do pruning, is that large people did not do well with it. And I was chatting with my son after working a shift at Bellevue. And by the way, you know, I did about 10 in a row. And it's just hard to go through an entire shift in full PPE in the respiratory unit. It was just brutal. But I was coming home and I was telling my son about this. And I was saying how, but we had some large people who we couldn't prune. They just wouldn't tolerate it. And we were chatting and, you know, it occurred to me, what if we used a pregnancy massage mattress? Like they must make those, right? And so my son finds online a pregnancy massage mattress. And he sends me a picture of it and it's up there in the right corner. And this was made by a spa company called Earthlight. And you can tell it's very designed for females with gravid abdomens. And, but it was pretty cool because it gets you off of the bed. It allows your arms to go on your side and it is really comfortable. And if you're large, that center area, there's a cushion that you can take out and it allows your large belly to fall into that cavity. So, you know, my thought was if we can prune the fluffy, this is really valuable because there's a lot of people, and I started using that term fluffy, because there's a lot of people in America who fit that category. They're pretty round. And, but not in New York. New York actually has quite the skewed population. I bet Philly, well, Philly has a mix, right? You guys definitely have plenty of people who like Wawa and pretzels and other things that, you know, Pennsylvania has in spades. But yeah, being able to prune the fluffy though would be a useful thing. So I get this overnighted to me, speak to this woman who tells me her whole company is shut down. And I say, well, you know, if you can make pruning cushions, maybe you guys can get an exemption and you can start making these. And it would help people who have COVID pneumonia because we're trying to prune them. And so she overnighted this me the next day. And I bring it in. And the first patient I tried it on was a woman whose pulse ox was in the 40s when she hit the door. And she was tacky to 120 respiratory rate over 40. And she came in and I found out that her husband was next door to her and his pulse ox was in the 50s and also had terrible respiratory parameters. Well, they were both larger. We tried turning them over and they both complained that it wasn't very comfortable. And I pulled out this pruning mattress and she fell asleep on the pruning mattress for two hours. And she felt much better. And then when she got off it, I put her husband on it. And we put them into the same room because we ran out of rooms for all of these patients. We were trying to keep the people who were on high flow nasal cannulas in negative pressure rooms. So, but they ended up alternating. They got admitted to the hospital in the same room and they ended up alternating use of this pruning cushion. And I believe they both avoided intubation though I didn't follow them after the first day in the ER. But I called up my brothers and said, hey guys, I stumbled upon this thing. And if we could get more of these cushions we could help out a lot of docs in New York. Well, I am the black sheep in my family. My older brother has had a modicum of success in the investment banking and venture capital world. My twin is an internet entrepreneur and I'm just a New York doc. But I called him up and I said, hey guys, how about you get some of these and you ship them to all these hospitals in New York. Just send them. And I called up some friends of mine, Nick and the Bronx, Ruben and Brooklyn, Swami in North Jersey and others. And I said, hey guys, I got these pruning cushions. Why don't you try them? Well, my brothers ended up creating this charitable organization called Prone to Help. We started raising some money. And as of now we have shipped about 250 of these to over 125 hospitals around the country in about 35 states. And we've gotten some great feedback. There are some issues on the design side with this current design. It's relatively tall. So it's a little tricky for the patients to get on and off. The head space isn't quite as open. There is an opening there and patients do like text on their cell phones and stuff while they're pruning. So that actually is kind of cool. It works pretty well with nasal cannulas. I haven't tried it with CPAP masks and people in the unit were like, can we try this in the intubated? And I'm like, I don't really know if there's enough room there. And this device was kind of the off the shelf solution that I found, but it got me thinking how to better design it. And my son actually connected me with another company and I started getting inquiries from companies when we put up our website, Prone to Help. I started getting inquiries from other companies who potentially could make these. And so the next iteration of this, which I've worked out just this past week is actually a much more sophisticated product that the manufacturer was using for spinal surgery. And it was designed for the OR and for radiology. So when they're doing fluoro guided stuff on the cervical spine. And so this is the next iteration of the product. It has more space underneath the head. The cushion can be adjusted in a variety of ways. And I foresee in the future, specific cushions that are actually designed for CPAP masks and for intubated patients. And that this could be used not only in the awake, but also in the sedated intubated crowd. The fabric actually meets all this criteria that is supposed to be used in hospitals in terms of being antimicrobial, easily wipeable and other features like that. And so this company is called Oatworks. The first one's name was Earthlight and they're in California. This one's in Pennsylvania. But I foresee continued devices, the pruning cushions that are designed by companies all over the country and will allow, inexpensively, we're talking a few hundred dollars, the ability to prone patients, both awake patients as well as intubated patients. And it's pretty cool if we can keep people off of ventilators if we can improve care without having to go to intubation. And the other piece of this obviously is the sooner we get patients, the earlier we identify them before they present with severe lung injury, the better. So I've gotten very keen on pushing pulse oximetry monitoring, particularly in COVID positive patients, but also in the elderly, because my belief is that with simple maneuvers with earlier identification, patient positioning maneuvers, early treatment with oxygen, earlier input into the healthcare system, monitoring of inflammatory markers, earlier steroids, earlier IL-6 agents. And what will happen is we'll keep many more people off of ventilators. So in Nick Caputo's 50 patients out of the South Bronx, two out of three avoided a ventilator for their entire hospitalization. Imagine if that goes to one out of six or if that goes to one out of 12, what we are gonna see, and I'm hoping for, is a logarithmic collapse of the resources that stress our healthcare system, a dramatic improvement in mortality if we get people earlier and we can do these less invasive things. So I am so much more hopeful about where we are as a country, as a health system, and our ability to treat this if we push the detection window of COVID pneumonia to that silent hypoxic phase in the first few days of the illness, we get more people whose pulse ox is in the 80s instead of in the 50s, people who haven't been sick for days who don't have a huge amount of inflammation and are already significant end organ injury. So it's really exciting. And I do believe, honestly, that we're getting a lot better at this. I reject the sort of nihilistic approach that you get this virus and it runs its course. I think it's like any other disease in medicine. If you get it earlier, we're gonna do better. And so that's my hope. And I think that proning and high-flow nasal cannulas and other things, especially valuable. So, but anyway, that's my story and I'm sticking to it. I do wanna share with you a couple other images, one here just to tell you. And by the way, prone to help if you are a healthcare provider, we are sending out these cushions free. So it's a charitable thing. You just tell us what hospital you wanted at and we ship them. And then, so but here's a picture from New York City. I was kicked out of my brother's apartment. That first picture you showed was this New York time story. But when I was kicked out of my brother's apartment, I was put up in a hotel and free, by the way, from some hotel person who knew my brother and they were very kind. And that black dot in the upper right corner of the screen is a bald eagle that has 44 stories above Central Park. And that was just freaking cool. So this thing came right in front of the window, swooping, actually just thoroughly amazing. So anyway, that's what I wanted to share with you. The last thing I wanted to mention, we were talking about pandemic playlists. And so I have one on my pen, a song on my pandemic playlist and it's from Short Change Hero, a TV show called Strike Back. Anyway, the title of it is basically, this ain't no place for no heroes. So I don't know if you guys have a pandemic playlist yet. Hang on, wait for the chorus. Then I'll, So that's my take on this. Anyway, thank you guys for having me. And let's see here, how do I change back my screen? Just at the top, you can stop sharing or probably Rob can do it too for you. But thank you so much, that was really awesome. We really appreciate having you here today. We've got a lot of good questions from the audience, but first, thank you for the pruning pillows that you sent to us. We got a few pruning pillow imaginers that's here at Jefferson from prone to health and they have been awesome. We had a patient that was really hypoptic. We were about to intubate and we put on the pruning pillow and her oxygen sat went up and she fell asleep and she was super comfortable and she avoided intubation. So that was awesome. Every win is an exponential win. You know, it's a win for the patient. It's a win for the system. Absolutely. We've got some good questions here and everybody please keep adding your questions to the comment box. I'll start with a pics question. Do you believe in L and H or low and high phenotypes? And does COVID data from Boston and Seattle fit or deviate from that model? So, you know, there is a lot about this disease that is complicated. There are way smarter people than me to answer this question too. But I do believe unlike Gattinoni's assertion that in L type things are not recruitable. In my experience, the people who I would have thought are L type when you prone them their oxygenation improves dramatically. So I think that argues against this notion that Gattinoni had that these people in L phenotype you know, are not recruitable. I have seen when I've bagged them with a peep valve that their oxygenation goes up. I have seen a million times when I prone them their oxygenation goes up. So I think as a general concept the notion that you have a period of compliance followed by deterioration, stiff lungs and much more difficulty ventilating them. I think fits with what my clinical observations are but I'm not sure that the subsequent assertions about recruitability, the role of peep and other things is true as Gattinoni has described it. And you know, Josh Farkas, far brighter than me, Scott Weingart, the ICU docs out there who have been addressing this I think have rightly questioned some of that aspects of Gattinoni's classifications. Ask a dumb question. What is L type versus? So there is a L and H refers to low and high it basically has to do with compliance that early on in the disease the lungs are still flexible, they're not stiff. So it's low resistance, high resistance and correspondingly the reverse of compliance. So what you have are the early phase of this illness where the lungs are quite compliant patients are still breathing well enough they are blowing off carbon dioxide effectively and their lungs are not stiff and Gattinoni believes the second stage of the disease when you measure it out by CT scan that the lungs actually are filled with fluid the lungs have gotten stiff and they no longer have this compliance that we see early on. So some people feel that once you get to the H type, that second stage I think however you describe that the need for intubation goes up dramatically because in the nursing home players I think at the height of the surge a lot of patients who were brought in the elderly were brought in because they've been laying in a bed for a week or 10 days they were already with stiff lungs, heavy lungs and they had hypercarbia and elevated lactic acid and they couldn't oxygenate. And that's what we see at the end of COVID pneumonia whereas at the beginning you're losing alveoli but your lungs are still flexible you have a big right to left shunt but you're able to breathe fast enough to blow off the CO2 and your lungs are still working and the patients just gradually increase their respirations to accommodate and sort of handle this low oxygen but just to give you a sense of how crazy their blood gases are and how effective they are at blowing off CO2 I had one patient whose blood gas was 768, 1639 that's arterial 39 but I've never seen in my clinical practice other than in the high mountains I used to work on Denali I went to Peru and Bolivia with the military taking drugs and drawing blood gases at 22,000 feet I've never seen blood gases like that severe respiratory alkalosis blowing off CO2 effectively coupled with ridiculously low really low oxygen saturations. Absolutely, there's a so this question I think we talked about a lot I think probably a lot of other emergency doctors have asked a lot what about the role of proning patients that are discharged home? The patient that you discharge and you think there's a high risk they're gonna come back the next day or in a few days and be worse you tell that person to go home and sleep on their belly? Um, you know again it's a matter of what they're comfortable with I recently ordered a new bed and it's called The Plank and it's made by a company called Brooklyn Bedding but I did a lot of research on bedding and it turns out that you know when you have these soft cozy beds with the toppers that are like memory foam you know that's well and good if you're a back sleeper but if you're a stomach sleeper it's better to have a firmer bed but I think that the tolerance of proning is a function of body habitus and particularly during sleep and I think this is a huge unrecognized area of this illness is during sleep all of us naturally drop our oxygen levels and if you have OSA and males by the way have it much worse the level of hypoxia during sleep is much worse in males than it is in females that female hormones are protective it seems like from some of the worst aspects of OSA it's not that women don't get OSA but their oxygen saturation is not as severe and so I wonder how much of this contributes you know but getting back to this with proning I think the most important thing to appreciate is we don't have a whole lot of data but there is some and somewhere between eight and 15% of patients who are discharged with COVID will bounce back in some studies I've heard from companies that make remote monitoring pulse oximetry there's a company out of Ireland that's doing this and there's some others that we're finding yeah maybe one in 10 actually bounce back so in my ideal view of this you know how we face this disease I think everybody who goes home should have pulse oximetry monitoring and everybody we diagnose in the ER with COVID should get monitored for two weeks out of Italy a friend of mine a new friend of mine I met through the Twitterverse Roberto Cosenti Cosentini sorry he had 250 patients who they diagnosed with COVID in a merge half of whom had mild COVID pneumonia he sent them all out with pulse oximeters 5% came back nobody got intubated because they came in early nobody wound up on a ventilator and no one died so I think you know how we monitor patients as an outpatient is important could proning help as an outpatient yeah I think it could but pulse oximetry I think is really critical right so we've got a lot of non medical people in the audience and the last couple of questions I think a lot of people have been asking to us and to others so what other design challenges have you come across that are in need of innovation especially for medical students and then the second question how would you encourage non-healthcare professionals and companies to get involved and contributing to needs during this pandemic this could either be funding or providing materials to design such as innovation design innovative design do you want me to address that or you wanna have that to others I can give you my two cents and then I'd curious what other people say but you know I think a huge unmet unrecognized aspect of this is the need to expand negative pressure rooms you know we have historically 150 years ago we figured out that washing hands between patients was important in this respiratory pandemic there's been several studies that show that SARS and also COVID-19 can get into vent systems we know of infections that have happened that way and there's high rate or there's high amounts of viral particles around some of these vent systems so in my little hospital in Northern New Hampshire I reached out to my boss and the HVAC engineers in my hospital created these window-based negative pressure fans to suck air out and if we're gonna do non-invasive stuff where they're not on a tracheal tube but they're on high-flow nasal cannules and other things we want negative pressure and I think if we had an army of these people go out to all the nursing facilities around the country and help the hospitals make more negative pressure rooms I think that would be good for decreasing risk to healthcare workers as well as between patients but that's my two cents on that in addition to the emphasis on I think high-flow nasal cannula systems. That's an excellent answer I totally would agree with that a couple of questions about sort of like specific patient types how would you recommend different interventions or admission sort of threshold for pregnant patients especially late term, third trimester pregnant patients and I would add in there, how about children? You know, I don't have enough of an end to tell you about pregnant people but in general, I think if you think somebody has COVID if they have COVID pneumonia I wanna know what their biomarkers are I wanna know where they are in the course of illness thankfully most of the kids don't seem seriously ill but they are definitely spreading it they are definitely getting it and we're hearing of rare cases now that millions of Americans literally I believe five to 10 million Americans have been infected so you hear of occasional just awful things encephalitis, carditis, other stuff but for most patients this disease attacks the lungs and that's where it causes the biggest problems so discharge decisions anybody 92% or lower I am extremely worried about sending home but I think that when you have a high degree of suspicion hopefully we're moving to a point now where we can do point of care testing and you recognize they have COVID and then depending on what their oxygen saturation is they're monitored with pulse oximetry or they're brought in given early oxygen and some positioning maneuvers and other things but I don't have enough of an end in the pregnant or sick kids to tell you specifically about them. Thank you. I'm going to ask this question and open it to Matt also and to you. So Tony asks is an intubation enclosure just nice to have or is it a need in the emergency department and how do you go about adopting new devices like this in your own emergency department in your own institution? Yeah, I'd love to, Rich I'd love to get your take on the intubation shields and barrier devices. I didn't use them at Bellevue. My friend Nick Caputo took a patient belonging bag which in the HHC system is clear plastic and he split it down the sides and he just dropped it on him as a drape. There was one case I had where somebody deteriorated somebody we had given litics for a stroke and it turns out he also had COVID pneumonia and then he bled in his brain and we had to urgently intubate him and he was coughing and bucking. Once you give drugs to these people and there are a side I think the aerosol risk is low. It's what happens when you go into the room and all the peri-intubation stuff and for me the peri-intubation stuff is best done with a CPAP enclosure in a closed circuit with a viral filter and then I push drugs and I sit them upright and I use ketamine and rocker but I sit them upright and I hold that mask on them for 45 seconds and then we open the mask but they're not breathing at that point. Lay them down and quickly intubate them but I don't have any experience with it. I find even though I am an airway enthusiast I like to use that term instead of an airway expert that if I were to add a box around the patient it would probably freak me out. But really good PPE you know two layers gloves and gowns, respirator, full face shield like the PPE piece is huge. Yeah, no I mean it's interesting there's definitely been a mixed response from our group and there are definitely people who feel that yeah adding another step or complication to intubation is not a good idea. It's a very high risk procedure and then what's the benefit? Having done, I saw I've done about four intubations with the airway box and all four of them have gone well especially using VO-assisted laryngoscopy and I actually was supervising residents through these and we had one in particular that was a very obese short neck patient that was complicated actually EMS and tried to intubate and couldn't get it and did a supo-plotic and we did it and that was the one case where I did find a lot of value in the shield or we used a shield in that case because the patient did vomit and we had after it was over there was you know vomit on the shield. Yeah so and we were able to do it very well with the supo-plotic airway and a bougie using the shield without any problem. I think the one thing we found is that the important step is getting in position to intubate first and then dropping the shield in right before. A lot of people I noticed would walk up to the shield like put the shield on first and then try to adjust their bodies to the shield or to the barrier and not remember to adjust the bed height and do all the simple things you need to do to have a successful intubation so that was kind of a key learning point. So you know so I've kind of had mixed experience with it but definitely a lot of people you know don't see the value and I completely agree I think the original with the PPE argument is I think if you have a good PPE you know a good paper and all that stuff I'm not sure that it's going to change anything for you. I think originally the design was thought was that we're not we're running out of face shields or running out of simple barrier protection so you know I think in that case I would want to have it but otherwise if I you know I after having done it a while you know I kind of agree with you like if you have good PPE I'm not a hundred percent sure that and good RSI. Right and good RSI yeah and the paralytic argument completely agree with you get the patient down and there's not that risk yeah so. So we've got a lot of running out of a we've got a couple more minutes left and you know what one of our visions for having a session like this was really to connect the medical community who are on the front lines who we do have needs we're literally improvising as we go along and connecting us with folks outside in the design community and seeing if there are some connections that we can build so I put my email on the chat room there so we're hoping to do some more of these so if you have some ideas that you want to cover everything from how do we change the built environment to make hospitals safer so if you don't have COVID and you're coming in how do you how do we protect you from not getting COVID to personal protective equipment just let us know we love to cover them and and I learned so much from just bothering Rich on the phone I've been calling him and getting advice from him and talking to other other people that I'm seeing here so we want to just keep these short and sweet and and really use these to maybe inspire some ideas and people and to make some connections so thanks thanks for joining I'm going to hand it off to you Morgan absolutely thank you guys this is an excellent group I was just going to say it's as a last question so we've got a few of our design students here medical students who are interested in designing new products and services and new practices in medicine and what advice would you give these students as you've got so much experience with that to me yes yes you so I have learned increasingly how valuable it is to involve engineers earlier that it doesn't matter if you come up with the next best thing if it isn't able to be reduced cost effectively and efficiently so you know you want it not only to be better than a current product or to you know obviously address a need that the clinicians have but it has to be designed in a manner that allows production at an appropriate cost because if it comes in at you know multiples of a current product it's never going to assume a priority unless it you know is ten thousand percent better than the other products and what you're treating you know has incredible value so I've learned the hard way that involving engineers earlier is really critical it's not just about solving a problem it's how you solve the problem that then can be manufactured in a manner that is cost effective and easy to produce and automated because ultimately it's not about the component expense it's about the manufacturing expense so the more insight you have about how things are produced like the physical aspect whether it is injection molded or extruded or you know we can go into four million different terms but it really matters in a big way. That's great advice thank you so much we do have several engineers and designers on this call thank you guys so much for joining us it's been a really incredible talk and we're really happy to speak with you Rich thank you so much thank you for having me