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Julie A. Dodds, MD, FAAOS, the “maskologist,” is hard at work sewing masks to protect frontline workers.
Courtesy of Julie A. Dodds, MD, FAAOS

AAOS Now

Published 7/7/2020
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Julie Balch Samora, MD, PhD, MPH, FAAOS

Personal Protective Equipment: Orthopaedic Surgeons Face Ongoing Supply Chain Crisis

Many individuals demonstrated not only altruism but also innovation to help manage a shortage of personal protective equipment (PPE) during the height of the COVID-19 crisis, a few of whom are highlighted in this article. PPE can include cloth masks, made of woven fabric, often of natural fibers such as cotton; medical/surgical masks with nonwoven fabric, often of manufactured fibers such as polypropylene; and respirators such as N95s and, in Europe, FFP2s, which are made of even more tightly meshed polypropylene, which can exclude viral particles.

Using existing materials and skills to make PPE

Julie A. Dodds, MD, FAAOS, is an orthopaedic sports surgeon at McLaren Greater Lansing Hospital in East Lansing, Mich. Her sports practice was shut down in mid-March due to COVID-19, so she expanded her healthcare reach into voluntary mass production of masks. She realized early on that she had time on her hands, had the prerequisite skills, and wanted to help as much as possible. She now considers herself an official “maskologist,” as she has done a fair amount of research on masks, including medical masks, cloth masks, and N95s.

Dr. Dodds’ enterprise began when she heard from her colleagues in The FORUM (a national group of Board-certified, female orthopaedic surgeons who are fellowship-trained in sports medicine) that some folks could not access appropriate PPE. Dr. Dodds began figuring out how to make the best possible mask to help her orthopaedic brethren. From her early research, she realized that one of the main concerns with cloth masks is the moisture they retain compared to standard healthcare masks. Fortunately, the COVID-19 virus does not thrive well in moist environments, so for this particular pandemic, cloth masks seemed to be a viable option. She also looked at various options for cloth masks and settled on developing a triple-layer cloth mask, which truly rivals the standard healthcare mask, which has a pocket to place a filter for added protection.

Anand M. Murthi, MD, FAAOS, chief of shoulder and elbow surgery at MedStar Union Memorial Hospital, sporting a face shield made by ECD Lacrosse.
Courtesy of Anand M. Murthi, MD, FAAOS
Anand M. Murthi, MD, FAAOS, chief of shoulder and elbow surgery at MedStar Union Memorial Hospital, sporting a face shield made by ECD Lacrosse.
Courtesy of Anand M. Murthi, MD, FAAOS
Julie A. Dodds, MD, FAAOS, the “maskologist,” is hard at work sewing masks to protect frontline workers.
Courtesy of Julie A. Dodds, MD, FAAOS

Dr. Dodds has personally created hundreds of masks, plus helped others to create thousands of masks. She owns a quilting retreat in Iowa (the Quilted Steeple), and, in mid-March, most of the folks in Iowa had no exposure to COVID-19 and were happy to help. Dr. Dodds organized a mask-a-thon. The quilting group created 5,000 masks, most of which stayed local, but some were sent to women of The FORUM. Dr. Dodds likes to make custom masks. For example, she had an order to create 50 masks for Duke Univeristy residents with their logo. All the masks she has made have been donated. The nice thing is that the supply costs have been low, because she already had an excess of materials, given that she is an avid sewer. The main “cost” is her time, which she has been happy to donate.

Collaboration and innovation led to new options 

In the early stages of the U.S. COVID-19 pandemic, Melissa M. Erickson, MD, FAAOS, an orthopaedic spine surgeon at Duke University, and other leaders of Duke’s perioperative leadership team were preparing for the effects of COVID-19 to reach North Carolina. They were feeling the same pressures as most of the country. At the time, limited availability of COVID-19 testing, limited PPE supplies, and uncertainty about how the virus would impact different U.S. cities were challenges plaguing most healthcare systems.

At the time, North Carolina was still using state tests with a two- to three-day turnaround time (Duke now uses an in-house test for COVID-19). Because it was unknown when additional replenishments would arrive, PPE usage rates were being monitored closely, specifically N95 masks and powered air-purifying respirators. The team noted an increase in the number of overnight intubations in patients who were presumed or known to be COVID-19-positive. Multiple organizations, including the Centers for Disease Control and Prevention, were making recommendations regarding PPE use when caring for patients during the COVID-19 crisis, but there was a disconnect with the amount of PPE available.

During that transition period, Dr. Erickson noted that elective arthroplasty cases were on hold and surgical helmet systems were going unused. She explored the use of arthroplasty helmets and disposable hoods as PPE. It was agreed that the helmets and hoods could be used safely in conjunction with N95 masks. Dr. Erickson was encouraged to collaborate with the Pratt School of Engineering at Duke. After multiple meetings, the team devised a solution.

With the devastating news concerning healthcare worker infections and mortality in New York and other cities, there was a definite sense of urgency to develop something quickly. The team created a modification to a surgical helmet system utilizing materials that were readily available in the hospital. Normally, the arthroplasty suit works by pulling air from the top of the hood, which is Association for the Advancement of Medical Instrumentation class 3 filtration and does not provide adequate protection against COVID-19, in contradistinction to the rest of the hood, which is class 4. They modified the system by sealing off the more permeable class 3 portion with Tegaderm.

A manifold adapter was three-dimensionally (3D) printed and attached with a gasket on top of the fan. The fan, in turn, was connected to a filter and anesthetic tubing pulling in room air. Pressure testing, CO2 testing, and particle flow studies verified positive pressure, lack of CO2 buildup, and adequate filtration (higher than N95 grade), respectively. With the extensive burn rate of N95 masks and shortages of PPE, this was an incredible development, as replenishments were being appropriately redirected to the cities in greatest need. The team engaged with anesthesiologists to develop formal protocols for donning and doffing to minimize risk of self-contamination when treating COVID-19-positive patients. Dr. Erickson and the team thought it was important to share the information widely. “It wasn’t about developing a product to sell, it was about providing a PPE alternative and keeping healthcare workers safe,” she said. Visit https://olv.duke.edu/covid-19/technologies-and-startups/#surgical-hoods to learn more.

Upper-extremity surgeon and SWIS Surgical Video create and donate a new total joint hood system

Ryan Grabow, MD, FAAOS, an orthopaedic hand to shoulder surgeon practicing in Las Vegas, is an innovator who founded SWIS Surgical Video, which provides custom-designed, wireless point-of-view surgical video systems for teaching and remote education. When the coronavirus crisis surged, Dr. Grabow was moved by the tremendous grit, determination, and sacrifice of his colleagues serving on the front lines in the battle against COVID-19, with many having to face the deadly virus wearing nothing more than a simple face shield or ski googles and a mask. He realized he was better protected doing a shoulder replacement in a total joint hood than most of the frontline healthcare warriors with limited PPE.

Unfortunately, Dr. Grabow also knew there was realistically no way to provide total joint hoods to all the doctors, nurses, and technicians working in emergency rooms and intensive care units around the country. With orthopaedic cases shut down, there were plenty of total joint hoods at every hospital but no way to use them on a large scale. Therefore, he and his SWIS Surgical Video team went to work. Having a track record of solving the challenges of creating 3D-printed mounts for wireless point-of-view cameras on total joint hoods, surgical headlights, and anything else a surgeon wears in the operating room (OR), and with a battery of 3D printers at their disposal, Dr. Grabow and the SWIS Surgical Video team were uniquely equipped to tackle this dilemma.

With the knowledge that the solution needed to be reusable, be easily sanitized, work with any total joint hood, and utilize any clear plastic sheeting as a standard face shield, Dr. Grabow put his computer-aided design skills to work and, within 48 hours, was creating the Stay Strong Face Shield System. Inspired by his colleagues’ tireless service throughout the country, the shield visor was emblazoned with the same message of hope, grit, and determination exhibited by his healthcare colleagues on the front lines: STAY STRONG!

Dr. Grabow and the SWIS Surgical Video team quickly went into 24/7 production and donated face shields to hospitals throughout Las Vegas and Henderson, Nev. Once the local need was met, they quickly began shipping shields to frontline warriors throughout the country. Recognizing the life-saving potential of his creation and the need to share it with as many people as possible, Dr. Grabow has been reaching out to fellow surgeons and industry companies to share the Battle Born Maker Corps mission and website with their colleagues, hospitals, residency programs, families, friends, and anyone who wants to help outfit frontline healthcare workers. Dr. Grabow founded Battle Born Maker Corps to help freely share and coordinate the Stay Strong Face Shield printing files for download with 3D printing enthusiasts around the world. The message of the Battle Born Maker Corps to frontline healthcare warriors is simple: Dig in, stay strong; we’ve got your back. Visit www.battlebornmakercorps.com to learn more.

Lacrosse company pivots to create PPE

Greg Kenneally, president and cofounder of ECD Lacrosse, based in Baltimore, describes how his company, which is one of the leading manufacturers of lacrosse sticks and accessories, transitioned to supplying PPE to healthcare providers. Once lacrosse season was canceled, his staff and warehouse were idle, and they were aware of the universal PPE shortage. They wanted to find a way to help and quickly sourced the raw materials and shifted in very short order to make medical face shields. Mr. Kenneally’s team found that many doctors’ offices and other organizations were faced with price gouging and long shipping times when trying to source shields. Because they are a small and nimble startup company, they were able to act quickly and provide a reliable product, made in the United States, with same- or next-day shipping. His company converted existing packaging, assembly, and logistics to streamline the new process. Mr. Kenneally acknowledges that his company’s part in the grand scheme of the pandemic may have been small, but to those who were able to protect their employees, family, and loved ones, it was extremely important.

Anesthesiologist and Augustine Surgical create a new face shield and respirator

Robert Gauthier, MD, is an anesthesiologist in Edina, Minn., who has a long track record of working with engineers and companies to improve healthcare provision and safety. Early in the pandemic, he teamed up with Augustine Surgical to create the Covex™ Face Shield and Respirator. Augustine Surgical has expertise in air-contamination control in the OR and developed the Covex Face Shield to integrate a clear, protective, full-face shield with a comfortable, easy-to-wear respirator. It is modeled after the anesthesia mask to provide a gasket-like seal that conforms to the user’s face rather than forcing the face to conform to the mask.

The design emphasizes comfort to allow for prolonged daily use. The shield is designed to guard vulnerable facial orifices (eyes, nose, mouth) and the respirator. A high-efficiency filtration fabric, tested by independent labs to N99-level filtration, is replaced daily or as necessary. Other design features include fog prevention, efficient and easy doffing, and a moisture-reducing exhaust valve that can easily be converted from an active to inactive state. The shield is reusable, is washable with soap and water or disinfecting wipes, and should last approximately one month. The costs of the shield and replacement filters are competitive with N95 masks.

Julie Balch Samora, MD, PhD, MPH, FAAOS, is a pediatric hand surgeon at Nationwide Children’s Hospital in Columbus, Ohio, where she serves as associate medical director of quality for the hospital. She is the deputy editor of AAOS Now. Dr. Samora can be reached at julie.samora@nationwidechildrens.org.