Chapters Transcript Video Module 2: Intra-Operative Session Highlights Explore critical adjustments and precautions to consider in the operating room Discuss consensus regarding wound closure in patients undergoing elective surgery Good evening. Thank you for joining our program. I'm Janine Hartfield. On behalf of three m medical education. I'd like to welcome you to this webcast titled Resuming Elective Orthopedic Surgery and New Processes Post Co Vid 19 guidelines developed by the International Consensus Group. We are very excited to bring this program together. This is Module two of a three part series that assembles top surgeon leaders to discuss a comprehensive set of consensus guidelines and protocols for resuming elective surgery developed by the International Consensus Meeting on Musculoskeletal Infection led by Dr Javad Parcheesi. Today's module will be covering recommendations for intra operative protocols for returning to surgery. Okay. No, I'm very happy to introduce are moderator Dr Javad Parcheesi of the Rothman Institute at Thomas Jefferson University Hospital in Philadelphia, as well as our esteemed Panelists, including Dr Tim Alton, Frump Reliance Orthopedics in Washington State, Dr John Cooper from Columbia University in New York City, Dr Michael Cross from the Hospital for Special Surgery in New York City, and Dr Michael Melo from the University of Montreal in Quebec. Thank you very much, James. And thank you to all of you for logging into this webinar I want to also thank the faculty have taken very valuable time out of their work and family time. Teoh be able to be on this coal. We will go through the second module this this'll week resuming elective orthopedic surgery. And you just heard about this theme faculty that we have on the webinar? I wanna thank three m k c for their generous support of the this educational activity. And we want to thank you, Madi for their expertise and making the webinar possible. The disclosures are on the slide. This is my disclosure, but and most important, disclosure to mention is the fact that I am a consultant of three M and K c I. And in the past we have received research support from 3 a.m. And Dr Alton, Dr Cooper and Dr Mellows, uh, conflict of interest around this slide and Dr Crosses. Conflict of interest is on this slide again. We want to thank you all for being here, and we'll try to keep the sessions somewhat brief, but we'll go through the questions that we have related to intra op the protocols. As you all know, we were facing a fairly big challenge and told to join our capacity. And that was really the terrible Perry prosthetic infection caused by bacteria or fungi, leading thio the minds of some of our patients and also more abilities like this. And because of that challenge, international consensus got together and went through a process off two year Delphi method. To try Thio, ask some of the questions, scour the literature, come up with recommendations, assigning greater recommendation to each and then in a face to face meeting in July of 2018 we went through all the questions, and the questions were voted on. Well, Coronavirus Infection is presents a similar document issue. It's the chain of pathogen transfer that could result in infection. And, of course, it has resulted in a terrible pandemic. The virus may have originated from the bath through an intermediate host, then affects the humans, and it spreads through three main mechanisms. One is through the droplets. Micro macro droplets from the respiratory system. At second is these droplets may reside on four mites on surfaces for a period of time that not infected person, then coming into contact with the full might, may contract the disease and then finally, through aerosolized particles. The viruses may be transmitted to the respiratory system of a non infected person, and it has been a major challenge you don't need. You don't need me to tell you about the major challenge that we have faced. As you all know, Covert 19 originated from China very soon. It affected just about every country in the globe. And, as you can see, majority off. Unfortunately, majority of the country is now are struggling with the issue off pandemic. United States has seen its fair share, and, uh, some of the states are unfortunately still under a very, very high CEO positivity rate. The fatality seems to vary from country to country and mostly influenced by the age of the population. But Italy having the oldest patient population, for example, has a much higher fatality of mortality rate than Iceland. With a younger population, the fatality of the disease still remains unknown, and perhaps thes air older numbers it. The fatality has been dropping as more and more of these asymptomatic patients have been identified, but it certainly has a less mortality rate than conditions like Ebola MERS or even the the N one H H one n one disease that we have seen in the past, but you're dealing with the pandemic. Or, for that matter, in dealing with the chain of fast and transfer. You have three options. Want us to do nothing, in which case the incidence of infection will just continue to rise and rise until everybody in the society has been infected. You can try to mitigate the risk by having some protocols in place. Or you can bring down the hammer, lock down everything and try to restrict or prevent the spread of the disease from individual to another. By having these very strict lock down processes in place at the majority of the countries that the resort to the first option realized that this wasn't a great one and they had to at some point implement some indication strategies. And there are other countries that have done extremely well by having a very strict, locked down protocols in place, which then reduced the transmission of the disease. But pandemics also come in waves, and we all know what happened with the Spanish flu. For example, three or four waves of it was seen. Fortunately, each wave was getting smaller and smaller de pandemic lead Thio to some drastic measures on these lockdowns affected just about every professional person in the society, and we were not spared. We being the surgical, uh, surgical specialties all elective art class cities. An elective orthopedic procedures were canceled. As you can see, there were approximately 82% of elective Our surgeries across the globe, with about 6.2 million procedures have been canceled during the pandemic. And resumption of the elective surgery was one of the questions that everybody asked. And it was important for us that some protocols in place, much like all the other industries, to try to implement processes that would then reduce the risk to our patients, two health care workers and to ourselves. And it's during that one week process where we engaged 80 to 85 international experts. We went through most of the questions related to the resumption of elective surgery, and then we looked at the literature and try to incorporate as much evidence is as possible. Please note that the paper that was published is now almost 2 to 3 months old. J. B. J s was kind enough to allow publication venue for us. The American Association of Hip and Knee Surgeons provided the research committees assistance in, uh, producing this document. And of course, international consensus delegates, some of whom are the faculty here tonight were also involved in this process. And also, evidence also was kind enough. Thio put the documents on their website. So the previous module we went through three operative protocols, general and preoperative. This module is going to deal with the intra operative protocols that we have in place. So I will start by asking Dr Cross. Uh, Thio answer. This question is related to what consideration given to the operating room ventilation systems while the pandemic is is still highly prevalent. Mike, Thank you again. Hey, Thanks, Jay. And thanks everybody for tuning in. Yeah, it's an important question. That's something. We talked and had multiple meetings on eso. Our current system is basically what you had recommended in your consensus document is that we do 21 air changes per hour. We do have a reduced amount of equipment in the room. Most of its kept outside and open as needed basis on we do have HEPA filters. All of our rooms now are positive pressure. There was a discussion whether or not to make some rooms negative pressure, but really negative pressure only helps if the door opens up, so help help people in the hallway. But Wade elected to go all positive pressure for, you know, since we're all doing elective cases right now and we definitely minimalize. The number of people in the room were just starting to allow some some of the research coordinators, research assistance, collecting data as well, some of the implant reps. But it's still less than what it used to be. So we're following. That's great. Thank you, Mike. I don't know any of you. The other faculty do differently, but it appears that the reducing the number of people and personnel entering the room is clearly has always been a great strategy for reducing Paterson transfer. Having HEPA filter is incredibly important and reducing the particulate bacteria and viruses in the air. And of course, having air exchanges also clears the particulate matter in the air. Do you all agree? Yeah, yeah, yeah. We also want to say to we place our HEPA filter is very close to the anesthesiologist to as Well, just kind of mitigate transmission from the patient of any Arizona. Thank you, Mike, Along the same line. John, I'm gonna ask you to try to answer this question for us. Obviously an r two plus the we wear helmets, Surgical protection. Thio, do you Do you utilize them? Do you? Have you changed any protocols? Can you share what? What you're doing right now? Yeah. So this is a This is a great question, and one that we spent ah, lot of a lot of time discussing when we started going back to surgery. The concern here is the and I learned a lot about how these how these helmets work. Ah, lot more than I used to know. But the way the surgical helmets work is there is an intake fan of top that brings air into the hood from outside the room through that white thin, thinner material on top, and that allows air to circulate inside on. Then there's a path of egress. So, as the wearer of the hood, you are bringing mawr of the external air from the surrounding environments into your own personal, you know, bubble, if you will. And if you're wearing those in an environment where there's a higher likelihood of virus in the air, you're gonna put yourself in an increased risk of exposure. Eso There was a period of time where we weren't doing elective surgery, but where we were doing fracture surgery. Um, in cases where we normally would have worn hoods like a total hip or heavy Arthur Classy for federal neck fracture, where we opted not to wear them when we started testing patients, uh, in, um, in resuming elective surgery. And we knew with a high degree of accuracy that the patients were Kobe negative. Um, I think a lot of us became much more comfortable wearing the surgical helmets. Um, personally, I still wear mine with an n 95 because I know I am bringing mawr Aaron from external. And there may be, you know, in theories and some asymptomatic carriers in the room. Um, another interesting point about this is that the group of Duke, led by Melissa Erickson, has a spine surgeon there, um, published a paper back in May in journal Larger velocity showing how you could modify, uh, these striker flight helmets into a personal power air purifying respirator or paper, where you can change the intake from the top of the top of the hood to a HEPA filtered line that brings an air and filters it virus particles and anything else in the air on the way in. And actually use this to treat the treat. Covert patients, Um, which I think you know, had to be maintained ourselves in that environment for for longer than we did. We would have done the same thing at Columbia and New York Presbyterian. Great. Thank you very much, John. That's that's excellent input. And for the attendees, it's important to point out that last week one of the questions was whether you should test the patients for the presence of SARS Kobe to prior to elective orthopedic surgery. And I think it's fair to say that majority of us have that protocol in place, that our institutions. So when we're operating on these people, most of them have already been way, know that they're they're negative. That's great. Uh, the third question, I'm going thio. Ask Michael Doctor. Mellow in terms of what type of protective equipment should the surgeons and assistance utilized during the elective surgery performed at the time of the pandemic. Michael. Yes, Thank you, Doctor for Vizier. I think I think it depends on whom is being treated. Uh, that means there's, uh there's in our hospital now, and it z well acknowledged. I mean, there is two different pathways. I mean, first, if you're in an area of high prevalence of the cove in 19 as you know, we are in Montreal. And if you do surgery on patients who have not bean tested for could be 19 then I mean, as the recommendations are Well, uh, explain. I mean the surgeons and the entire surgical team. During the case, I should wear a mask and preferably in nine and 95. So using n 95 mask in the face shield is what's recommended if the patient has not been tested for cov 19. If in the other pathway, if the patient has been tested on, that's what we do now on a regular basis in our hospital, every patient going for elective surgery, they're tested within three days of surgery and with a negative result, then regular protective equipment should be used. And as a quick return thio the first session last week, we talked about the importance of screening and testing, and this is exactly you know why? Systematically, as you just said, I mean, pre up testing on every patient scheduled for elective surgery is, uh, mandatory to minimize the unnecessary use of special equipment such as the nine the N 95 mask. So you get the green light doing that way, and you make sure that you do it on the secure matter. So this is it. Great. Thank you very much, Michael. That's very, very important. So to summarize patients who have been tested and not negative, you can probably get away with the standard PPE, which we used to wear anyway. But if you don't know the status of the patient and you're in the high prevalence area, you should probably consider the full PPE, which includes the in 95 99 masks, etcetera. That's great. That's very useful. Thank you very much. Um, Tim, I was gonna ask you to weigh in on this question. What does the type of anesthesia in your opinion influence the trans transmission of covert 19? Yeah. Thank you, Dr. Part of Easy. I think the answer to this question is yes. Um, general anesthesia that requires manipulation of the airway could potentially, uh, increase the chances of spreading viral particles and the anesthetic team and and also the other people in the operating room, as opposed to a regional anesthesia where patients don't have their airway manipulated in the same way. So I think that, yes, it does matter. And using regional anesthesia whenever possible is advantageous. And unfortunately, for the majority of our cases, you know, elective hip and knee replacement type surgeries. Spinal anesthesia with a peripheral anesthetic is sort of our standard practice anyway, So those sort of overlap nicely. This is great. So again, for the sake of the audience, this beautifully answered by Dr Alton is the air civilization of the virus during intubation and excavation. That's thought to be the issue here. And on top of that, I think it's fair. I know this is outside the pandemic question, but it's fair to state that, uh, regional anesthesia has a better outcome than general anesthetics related to every aspect of outcome, in particular poor, morally complications. And Mike, you will know obviously natural sharks work and now establishment to sue this. They published that beautiful, systematic review and the recommendations that most, if not all, the elective orthopedic procedures should be performed under regional anesthesia. And is it fair to say that most of you do regional anesthesia for for your cases anyway, right? Yeah, for me. Almost 100%. Unless they just can't get the epidural. For whatever reason, Doctor, I'm curious. During during the in division procedure, even with a negative test, does your team encourage, uh, you know, the non anesthesia providers to leave the room? Oh. Are you comfortable being in the room? Yeah. Thank you, doctor. But that's a good question. And, um, early on, when we didn't have as much access to the n 95 respirators for our scrub text or surgical text, everyone in the operating room if we didn't know the covitz status of the patients, they had to be intubated. They would intubate the patient and there would be a waiting period as the air cycled in the room before patients before the staff came in on use just regular standard protective equipment. But with the increased access to the 95 the various respirators and P p e. Um, Then you know, we are able to avoid that wait period if we don't know the patients covitz status. But it just speaks again to the common theme that I've heard echoed by all of you guys. Is that the importance of testing and access to proper PPE eso We have seen that evolution on our practice, right? Thank you, Dr Melo, I'm gonna ask you, Thio, weigh in on this particular question. What precautions should be taken by the opera to the staff during elective surgery performed at the time of the epidemic? Well, there's there's many actually. First, I think as it z it's it's shown on the slide. I mean, you way should limit the number of people in the in the operating room. This is part of universal precautions. We all know that there is strong evidence that degrees decreasing the number people within the operating room can decrease the risk of combination of surgical wounds and also reduce the risk of infection in patients uh, undergoing a total joint or capacity. And also, by doing so, decreasing the number of people in each operating room will help implement the social dispensing concept. Also uh, reducing door opening in the operating room is very important. Uh, and because we do know that increase there was an increased flow of particle matter and disruption of the ventilation system in the operating room that you're is by door opening and the entry of people. And we know since theme, the club in 19 or the coroner viruses mainly transmitted by aerosolized droplets. Therefore, if we decrease the air turbulence and the number of their particular, uh, there should help decreasing disease transmission another another percussion would be reducing area of Seoul, producing with cautious use of the like electric artery and also any high power tools. When using such a tool, I think we should keep the power setting to as low as possible and again is through. The rational is to decrease the formation of any particle is since power tools. We do know that that generate aerosols and finally keeping the equipment in the in the room to a minimum. Eso. There's been data showing that the coronavirus, uh, can survive on in eminent surfaces for relatively long time, so I think it's important to keep any non essential equipment outside of the operating room, right? If we have just a moment Thio, jump back to the previous question about think things that we do differently in the operating room. Um, one of one of the recommendations was minimizing the number of people in the operating room. And I think this was something that way tried to do early on. But as as it became clear that things were, you know, circumstances were improving enough to allow us to do elective surgery back back in New York, um, we balanced. You know, how few people we could, you know, safely do an operation with, You know, in many cases, it was, you know, myself in one assistant or ah, fellow versus the need to continue education and continue having residents in the room and continue having, you know, students exposed toe learning during this time. And, um, we haven't really changed much in the number of people in the room there. They're certainly more people than are necessary a minimum to do the case. And I think we've made that decision, you know, as a group and as a faculty and as a institution, um thio, you know, allow some learning to still go on, um, during this time, rather than just trying to keep things as Titus possible. That's different than it was back in March in April, when we were doing non elective surgery during the height of the pandemic, for sure. Um, so I think, John, you wait in last time, you're not allowing international visitors or extra people in the room, etcetera. Is that external visitors? But but in terms of okay, the people who may not be, you know, crucial to doing the case but are still participating and learning in the case from internal. Um, you know, I still have three people scrub with me for, you know, for every joint when I, you know, could do it with one. And at our I think that's in current circumstances. Still still safe to dio? Sure. My institution. It takes three or three or four people to really get the job done, So unfortunately, we need all of them. Tim, I'm gonna ask you to answer this one. Should additional cleaning or sterilization on instruments be performed for elective procedures during the pandemic? I think that, um to the best of our understanding, the stuff that we do on a routine basis to clean and sterilized between cases should be adequate. Um, in this in this current time and I don't know of any additional steps for cleaning or sterilizing the instruments that need to be taken. I don't think we're taking any at our facility. Be upset to hear from the panel. Yeah, because I think you're absolutely right. The RNA viruses, including enveloped viruses, are very sensitive to heat, to disinfectants and to any type of cleaning. So the process we have in place for sterilization of instruments, etcetera is so, so good in, uh, inactivating even sports, let alone are on a virus is so it's not like they're tenacious and they persist. Or they can survive with these type of protocols. So the protocols we have in place is definitely adequate to get rid of the RNA virus. So we haven't changed any of the process. I don't know if anybody else in their institutions have made any changes. Yeah, uh, that's that's great. So, Mike, uh, Michael Crust, how about this one? How should each operation will be cleaned in between cases during the epidemic? What are you doing that that yourself? Yeah. Yeah, we we? It's a good question. I mean, I think the biggest question we decided on was whether or not to do it terminal cleaning or whether or not our current standard of care of cleaning was effective enough. Eso We've actually gone back to our previous standard of care. We just do a terminal cleaning at the end of the day rather than a terminal cleaning in between each case. Um, yes, the 21 minutes of air cycle. And they are definitely we dio, um, but UV lights at the end of the day, we don't do as well. So, um, just the regular cleaning and then terminal cleaning at the end of the day. In the patient rooms, we do do some testing of the surfaces. Random testing as well, but not in the You have a special type of a kid to do the surface testing Or are you just using the same nasal swab that we're using for human testing right now? It was the same swap Any anybody else does anything different? No. I assume all the faculty agree with this process. Great, John, how about the next question? How should the surgeon and the surgical team clean themselves following conclusion of each procedure during South Kobe, too. Sorry, John Cooper. Do anything. So it's a It's a good question. Um, yes. Yes, I'm here. Can you hear me? Yeah. Yep. Okay, so it's a good question. How should we do things differently? Um, so there's a recommendation that was made made by the consensus panel Toe change scrubs frequently during during the surgical day. This is something that you know, I think a lot of people dio as a routine basis. Anyway, um, especially after big revisions already infection cases. I encourage our entire team toe change scrubs on. I'm changing and probably once throughout the day. I don't change it after every case. And I don't think many people at our institution are doing that, but it's It's a reasonable consideration if the prevalence is is high or if we're not testing. Um, in terms of masks and respirators, our policy is thio. You know, use the same. A mask or respirator in 95 Respirator. If you choose to use one throughout a day, don't necessarily change it after every case. But change it every day on def. We're using surgical masks that we do change and, you know, on a every case basis. Thank you. That's, um you know, today I wanted to say we do the same we but it's been kind of evolving. And I think certainly when when we first started, you know, treating patients after cov e think a lot of us were very cautious about changing scrubs every single time. But to everybody's point that we brought up Now that we're testing mawr, we know that there's the patients going in for surgery are testing negative prior to surgery. I agree with John. I think we've gotten a little bit more lax on changing in every case. Um, the last question. And, Tim, I think you even have a case to show us here. Is that right? Uh, about the, uh, please, if you don't mind answering this question for us and sharing with us what you do? Yeah, absolutely. I think the take home point here is trying to decrease the number of touch points for your patient in the post operative period. And that speaks to some of the things that I'm sure we'll get into next week about telemedicine and follow up in things. But you know, one of those touchpoints being if you're using something that has to be removed from the patient, um and you have a choice where you could use absorbable items, you know, go towards the absorbable items so you don't have to have them come back in. Three. Other thing that we do commonly here is utilized a special dressing on the skin and negative pressure dressing over our surgical incisions. Um, toe help with the wound. Healing is pretty good. Basic science evidence showing increasing skin itch, profusion. And, uh, Dr Cooper has a nice paper is talking about less complications and revisions and very prosthetic fractures. And some of them may be less elective but still, uh, important to do type cases. So if we could show the slides here, this is an example that I put together a 56 year old lady with a very, very large knee. She's got that arthritis on that right side, relatively healthy hypertension, hyperthyroidism. But she comes into my office and this next slide showing you the incision that she has on the other side from your partner that did her knee replacement in the past So I look, everything went perfect. You know, I need my knee replaced. And so, yeah, she's had an elevated risk of having problems because of her body mass index. And that's really, you know, well reported. I don't think a lot of people argue that, but, um, you know, we elected to do her knee replacement for her, Um and so he had just looking at her preoperative images. And then you do the knee replacement if you get it all closed up. And these were the two negative pressure options that I have at my disposal. One of them is called a restored dressing. That's the large sponge that wraps around the knee, and the other one is more of appeal in place type dressing. But that goes right over the skin. You know, we use of running some particular absorbable future, and then this goes on top of, on top of that to help protect everything and apply that negative pressure to the wound on DSO. Then when we see these folks back, you know, standard X rays of a knee replacement. Everything goes fine and then, most importantly, next slide there next important. Most importantly, there incisions heal up and they're doing, they're doing pretty well. And you get an incision that looks like this. So I think the advantage of maybe adding this to some of your at least you're high risk primaries. Definitely revisions. And Perry prosthetic fractures assed you could decrease some of those wound healing issues. Less draining wounds, less touch points in the postoperative period. That makes that makes great sense. I don't know, John. You've done a lot of research on negative pressure dressing. Can you share with us right now what your protocol is for routine wound closure and dressing. And then at what time points dio consider the use off, uh, back on these patients, you know, great, great great questions. Intend. That was a great case in a great discussion of, ah, a lot of relevant issues. So my my routine closure is, um, you know, for almost every case I do is a, uh, three layer barbed absorbable sutures. I rarely use suitors that need to be taken out. Um, I almost never use staples unless it's, you know, nearing the midnight hour, and everybody's trying to get home. But the vast majority of the time um, you know, absorbable suitors and my preferences. Barb Suitors Onda. That's a little bit controversial. Um, about skin complications, But patients like not having to have things taken out. And I agree, particularly now when we're trying to move a lot of the post up appointments to telehealth. Um, not having to come back to have things taken out is helpful. Eso even those who are doing like robotic pin sites that we would traditionally close with a little nylon sister were doing absorbable suitors there so they don't have to come back at the two weeks or three week visit toe. Have those supers taken out? Um, doctor, you brought up a good point about, you know, trying to minimize risk of wound complications. And there's some good papers that look at risk of readmission after elective hip and knee replacement. Both primary and revision, uh, surgeries. One of the great papers out of out of Thomas Jefferson Rothman Institution publishing DVDs a few years ago, And the consistent statistic is that of all the unplanned readmissions, or er, visits after joint replacement, 50% of them are related to the incision or the wounds. Um, and at a time where were particularly sensitive about trying to minimize unplanned e r visits? Unplanned readmissions? Um, you know, paying careful attention to the wound and minimizing wound complications is should be paramount to all of us. I am. So, uh, my protocol is is the kind of stratify between a kind of A standard, low risk patients and the high risk patients. And I used these these negative pressure dressings in all of my high risk patients. We published the protocol on how we determine this in our capacity today in 2018. I'm happy to share with anybody they wanted. Type your email in. I'm happy to share that with anybody about our decision making for primary patients and for revision. Patient. It's almost 100% just because the risks are so much higher in that make, uh, Michael both both Michael's. Any other comments related thio either the use of back or wound closure. Uh, well, thank you, Dr. Part of it is I mean, personally. Yeah, I agree with Dr Cooper. I mean, very, very important not to avoid any, uh, one complication postoperative Lee. So I personally still use interrupted, uh, suitor for the deep the deep area for let's say, for the the capsule of the knee joint. I wanna make sure that I have a tight closure and there will be no lake ID. And I agree with Dr Alton as well. I mean, for a touch point less as possible. So we will use absorbable suitors make with with or without glue. This is something that you know with tried. And on top of that, I with tested many, many different type of dressings and the negative pressure one is definitely a good option. But what we've been doing for so many years is after trying a different type of dressing way use now the ticket. Um, we've been using it for many years because we can leave it in place for for many, many days until a wound healing eso itt's. You know, I like the transparency. I like the absorption capacity and para memorable and breathable comfortable on. And that type of dressing also fits perfectly in a fast track protocol with early discharge and ah following early range of motion for the patient. So this'd is This is what we do thistles our protocol, and that fits perfectly now in the the actually the situation that way. Deal with great Mike. Anything you wanna add also, Not too much, Tad. I use an interrupted by Kroll suitors for the Earth Arata me and then deep subcutaneous tissue. And then but the skin. A lot of times, you know, either Staples or, you know, running suitor most time actually do use the Staples simply because I still use a visiting nurse to take out the staples at home. But I do use have increased probably my use of negative pressure dressings just because, you know, I think I do it 100% of revisions, but because there's gonna be less follow up. I agree with what everybody said might initially started with obese patients, but it's kind of involved in, you know, Now it's, you know, smokers, rheumatoid arthritis on medications, a demon skin, uh, number of high risk factors. And John, as he said, has published a lot of good risk stratification data. And so the high risk patients get a negative everybody. And this is great closure of the session tonight. Um, I don't know if anybody has any additional comments or if any of our audience of any questions. But, uh, it looks like this was again another great educational session. One of the question that we are all still facing is when does this pandemic end? And when are we going to see an end to this whole problem? Do any of you have sort of connections with God? Thio, Give give an answer to that question. I think you're all laughing. E not, uh I guess that still remains in an unanswered. You're The amazing thing is, in New York, you guys have done so well. You are the epicenter, and you've really got your arms around this problem so well. Unfortunately, across the country, even though the number of Syria positive cases continues to rise, the mortality is not proportionately going as high. So we're hoping that perhaps the viruses mutating out of violence or some or were better at diagnosing these earlier and perhaps a large number number of those positive cases may be asymptomatic. I I'm trying to read as much as possible on a daily basis, but I think there's a lot, a lot of unknowns. Still, eso the one of the questions that Doctor Liu is asked is uh, what about patient warming? Are you using patient warming? And if so, which one? Mike will just go down that line? Yeah. I still use that. We use the bear hugger kite device. Well, how about you, Dr Mayo? Same. We do the same. I will still continue to use the bear harder. How about you, Tim? Same Bair hugger and job saying e r anesthesia love it also because they can sometimes get some of that fan and warm themselves as well. So no, no issue with the transmission. A to this point, unless there are any other questions, I think we will stop the session here and again. I want to thank three m n k c i for sponsoring this educational venue tonight. For Boumeddiene, doing an amazing job is always forgetting this very smoothly. Uh, completed tonight. And then I think we have one last session, which will be next week. Module three will be discussion off all the protocols for post operative care of patients during depend emmick. Uh, gentlemen, ladies, everybody, thank you so much for your time. And I'm going to wish you all a great evening and see you all next week. Published October 8, 2020 Created by