NTSP Special Interviews (Season 2): Sam Rigby, Atos-Medical

This Special Interview is a conversation with Mr Sam Rigby, Global Tracheostomy Lead for the Medical Device company Atos-Medical. Sam has a healthcare background and talks about his passion for his role supporting education and high quality tracheostomy care from the perspective of a global device manufacturer.

The UK National Tracheostomy Safety Project (NTSP) is committed to providing education, information and resources to improve patient safety and the patient experience for those with tracheostomies and laryngectomies. All of our resources are housed on our website www.tracheostomy.org.uk, accessed by over 30,000 visitors each month from around the world.

This is the only podcast to bring you literature reviews, hot topic discussions and interviews with healthcare staff, patients and families.

Our goal is to improve the safety and quality of care for patients with tracheostomies and laryngectomies through education. We work closely with patients, families and healthcare professionals to develop new resources to improve care. We’ve collaborated with key stakeholders in tracheostomy care since 2009, and developed freely accessible resources, supported by online learning developed with the UK Department of Health. We’ve worked with the Global Tracheostomy Collaborative since 2012 to improve care for patients and their families everywhere.

We are funded by grants, donations and in partnership with medical device companies through unrestricted awards. This podcast series is supported by unrestricted education funding from the Atos Learning Institute. The funding supports the professional production of the podcasts and videos, and the medical device companies that support us do not have any creative influence over the content that we record. All of our work is undertaken by volunteer healthcare staff, patients and their families. 

Most of our content is supported by videos. You can access our training videos and resources for Basic Care, Emergency Care and Vocalisation & Swallowing. Download and print bedhead signs and emergency algorithms from our resources. 

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Transcript

SPEAKER_01 0:18

Tracheostomy care during the pandemic. I'm going to hand over to my colleague, Dr. Kath Doherty, who's a consultant and atheist working at the Royal Manchester Children's Hospital. She's going to introduce a talk by her colleague, Mr. Neil Bateman, who's an ENT surgeon working at the same hospital. Over to you, Kathy.

SPEAKER_00 0:36

So now it gives me great pleasure to introduce my good friend and colleague, Mr. Neil Bateman. He is a consultant ENT surgeon in Manchester. He's also one of the founding members of the GTC. Neil's interests are pretty diverse, I would say. Clinically, they include LA surgery, a safe tracky camer. He's part of our MDT tracky team in Manchester. He's also part of the NTSP Pediatric Working Group. But his interests reach further than that, really. They also include health care for children within Greater Manchester. He's the clinical lead for the Children's Recovery Group. So he has an interest in equity of healthcare for children throughout the region. So it gives me great pleasure to hand over to Neil. Thanks, Neil.

SPEAKER_02 1:26

The first thing to say about children and tracheostomies is that children are not small adults. They have a different physiology and they have a different spectrum of disease. And in terms of tracheostomy care, the reasons for them having a tracheostomy are different for the large majority of them to adults. We are familiar with the majority of adults who are in hospital and end up with a tracheostomy have weaning tracheostomies. I realize that they they have tracheostomies for other reasons as well, but the majority are on the ICU and get a weaning trachea and are discharged home without a tracheostomy. Most children who have who have a tracheostomy are discharged home with it. It's really unusual that we do a weaning tracheostomy and send the child home without a trach. So the spectrum of issues is while it's similar to adults, the emphasis is very different. So this is an extreme example of this. This is an exit procedure, which stands for extrauterine intrapartum procedure. This is a child who was diagnosed antenatally with a large obstructing tumour, which was actually benign in the neck. And we knew that we weren't going to be able to get an airway easily. So we deliver the baby's head and shoulders with the still on placental support. And this is one of my colleagues trying to see the larynx and get an airway. When they were unable to do that, we aspirated uh one or two of these cysts, and I was able to do a tracheostomy with the child still half in and half out of the uterus. So, you know, that's a rather extreme example of how children with children's tracheostomies are different to adults. And of course, this child went home with their tracheostomy. Even though we excised the tumour, it was not felt that it was safe to try and decanulate decannulate the child because of the long-term effects of the tumour. So, why do children get tracheostomies? Well, as we've said, uh airway obstruction is a common reason, and more and more children uh are getting tracheostomies in our practice because of the need for respiratory support, either tracheomalacia or neurological problems. So the the tracheostomy is used as a portal for for long-term ventilation at home. So here are a couple of examples of airway obstruction. Uh on the left, we have uh uh acquired sublotic stenosis. Uh as you can see, there's no airway there. Both of these children have got tracheostomies, which is why I'm being so calm when I'm scoping them. Uh and on the right, we have a case of uh grade three congenital suglottic stenosis. So this was a child born with a pinhole airway, and on the left, the child was uh intubated for a period of weeks after birth and just scarred and stenosed up. So that's a very common cause of airway obstruction in our practice, and probably more commonly, our tracheostomies are done because of the need for respiratory support. So this is a child with really very severe tracheomalasia, secondary to a now repaired tracheoch tracheoesophageal fistula, and this child is going to at least need a tracheostomy to stent open that airway, and in a lot of cases will also need some long-term ventilation. So, what does this mean from a practical point of view? What it means from a practical point of view is that most children need a period of time before their tracheostomy can be removed. This is mostly measured in years, but most of them actually go home with a tube, and that means that we have to put in place for all of these children home care, care in nursery, and care in education, and that is a big part of pediatric tracheostomy care. So thinking about COVID-19, I think when I when I look back on it, and it's been a really fascinating, interesting, and of course, distressing and difficult time, initially I I think you can break it down into three phases. There was a a phase of high anxiety and frankly panic in some quarters, uh, and uh the the need to protect ourselves as healthcare workers, and the need to protect um our families and our patients. Um, and after a little while, there was a really concerted effort to return to some kind of normality, which people have termed the new normal. And then after that, there was and what we're facing in the UK now, and I realize that other countries may be at different points in this, is we're really facing a time where we're having to plan for the future and trying to get over some of the effects that the COVID pandemic has caused on our society and our healthcare services. So March 2020 was a fairly dark time for the country. Uh, we had our esteemed Prime Minister uh uh Boris Johnson uh announcing a lockdown where we were told that the most important thing was that we protect the NHS and everybody stays at home. Um it was a time that I don't think anybody who went through it will ever forget. Uh a significant uh uh proportion of the country seemed to think that what they needed at that stage was a year's supply of toilet rolls. So there was panic buying, and uh the shelves of most supermarkets were empty of toilet rolls. Um, and the country really was facing a very uh unprecedented um disruption, uh, and uh and there was genuine um fear and concern all around. And I would say none none more so than amongst um ENOs and throat surgeons or etalaryngologists, because it became apparent very quickly that ENT surgeons were uh at peculiarly high risk of contracting COVID-19 in the workplace, and there were people who suggested that ENT surgeons seem to get worse disease and do worse. So, this was a paper published in the uh International Archives of Ocean Aryngology, which related one of the first um uh first cases uh uh of of COVID spreading in Wuhan, and this related to a endoscopic sinus surgery um procedure. And I I I'm not sure actually how true it is, but the the description is truly frightening that because of the aerosols generated during the procedure, uh everyone in the in the um operating room caught COVID, and a significant number of them did very, very badly indeed. Uh, and and it was this sort of thing that really that really startled and created uh a significant amount of anxiety and panic amongst my colleagues, myself included. And and that was compounded when um a really well-respected and well-loved uh colleague of a number of my uh friends uh who work in the West Midlands died of COVID-19. And he was the first healthcare worker uh in the UK to die of COVID uh caught in the workplace. Uh and this really meant that we were, and this was in um late March, and this was this really meant uh that everyone in hospitals and ENT surgeons um uh uh as much as anybody were incredibly anxious about the idea of catching this disease in the workplace. And at that point, the idea of an aerosol generating procedure um became something that everybody was talking about, uh, and not something anyone really considered up until then. Uh, and numerous surgical procedures would were designated aerosol generating procedures. As an airway surgeon, pretty much everything I did was was designated uh uh an aerosol generating procedures, uh, an aerosol generating procedure, and all of these required aerosol level PPE and also isolation. Now, in terms of tracheostomies, pretty much everything you could do to a tracheostomy was, apart from changing the tapes, was designated an aerosol generating procedure. So changing the tube, doing suction, and of course, what this had was on the top of a really isolating event where everybody had to stay at home, a really isolating effect on children with tracheostomies, both in terms of their health care, their education, and their normal life. So, in the initial phase, the National Tracheostomy Safety Program really was a fantastic example of collaboration of clinicians from multiple centres and multiple disciplines, produced a really fantastic document in very, very short time just to give some advice with regard to pediatric tracheostomy care and long-term ventilation care during the COVID pandemic. And it's a really good document. Um, uh, and it was it was just really heartwarming to be involved in producing that because all of my colleagues from around the country really stepped up. The next phase was really about returning to some kind of normal. And what the NTSP did at this point was was to try and support people in being able to recover back to a new normal. Uh, and in children with tracheostomies, that was all really about return to education. Uh, and the main focus of that was in trying to address some of these issues of the effects of doing aerosol generating procedures or supposedly aerosol generating procedures on children with tracheostomies. Because public health England had some rules whereby, if you had a child with a tracheostomy in the classroom, they needed to be isolated for suction, they needed full PPE for suction, and all of course, of course, what this meant is it was completely impractical for children with tracheostomies to return to school. So we set about challenging public health england's policies uh and basically with a message that tracheostomies don't spread COVID-19. Children did not get a lot of serious disease with COVID-19 with COVID-19, and children with tracheostomies were no more likely to get it or to uh to spread it than children without. And so my colleagues in Great Ormond Street did some fantastic work looking at aerosol and droplet spread and compared children coughing with and without tracheostomies and suctioning of tracheostomies, and showed that actually it was the amount of droplets, the amount of aerosol spread that you got with suctioning of tracheostomy was tiny compared to a child coughing. Uh, and also also emphasized the use of the trach foam device, which is a really good um bit of kit to suction through to minimize any aerosol spread. And so we produced a series of videos, uh, which was uh that's uh me with my lockdown hair um uh being videoed uh in our hospital um uh just talking about tracheostomies and the sort of just the effects of isolation on children uh and how we would propose that that was addressed, and just trying to get some kind of equity of access for education uh for children because that's been a major problem for children over the course of the COVID pandemic. So, what happens next? Well, I think it's really important that we recognize that COVID has changed the way we work, and in a lot of instances, it's changed the way we work for the better. It in our hospital has accelerated a lot of things that we do, which actually, when we look back on it, we should be doing anyway. We have initiated remote consultations, um, and and and that has revolutionized the way that we deliver results uh and prevented people from having to drive several hours to the hospital just for a five-minute appointment. Uh, and it's incredible we didn't do that before. We've we've developed a patient-initiated follow-up system so that people are only seen when they really need to be seen. And that's been on the back of COVID because we don't want waiting rooms full of people unless we need them. Uh, and within our uh hospital, we've we've uh developed a walk-in-walk-out surgery system so that patients are able to come to hospital, um, come to the theatre suite, have their surgery, be discharged home and not be dependent on an inpatient bed, even if they're a day case. So, all of this has allowed better patient-centred care. And a lot of this has come about directly because of the COVID pandemic and the need for recovery from it. So, thank you very much. Uh, it's been a pleasure talking.

SPEAKER_01 14:43

Thanks to Neil and Kat for that overview of pediatric traffic care in the pandemic. As ever, the views and opinions we discussed on the podcast are those and assembly representatives and you can follow us on our social media channels, we can follow us, on our podcast web pages, on our YouTube, on WebD, Podcast, and the first time.