Doctors and Architects Come Together to Create An Aerosol Box Amid Covid Outbreak
“It kind of gets to you a little bit and I think driving home that day [after placing the first breathing tube], I was a little bit hesitant: do I walk in the door, give the kids a hug, kiss my wife?” reflects Dr. Brian Kelly, an anesthesiologist at The Christ Hospital in Cincinnati, Ohio. “[It’s] the fear of the unknown I think, it becomes much more real when you face it yourself and think about the what-ifs.”
Dr. Kelly is a member of the airway team at The Christ Hospital. The newly-formed team is dedicated to performing skilled intubations as more and more patients who contract the virus need to be placed on ventilators to receive more oxygen. Dr. Kelly, like many doctors around the world during this pandemic, quickly realized the need for more protective gear to prevent the spread of the virus through the hospital.
Story, video and photos by Hannah Schroeder
“Our work flow is designed to take the best care of the patient and all of the sudden we are caught in this sort of bind. Do we compromise and change our work flow in a way that we wouldn’t usually, in an effort to shield ourselves and avoid contaminating the room and others? You know… why don’t we create something where I can do my job the right way, where I can also protect the environment around us,” Kelly said about his initial goals for developing an aerosol box.
Dr. Kelly reached out to the Krazters at Reztark Design Studio, an architecture and design firm in Cincinnati, Ohio. They met on Sunday, March 22, 2020. From there, Reztark contacted GeoGraph Industries, whose help they would require for manufacturing the box. By Monday afternoon they put together a team and began planning their designs for the aerosol box.
The team went through various product concepts, starting with a floor to ceiling box that encloses the surgeon; though such a box provided protection, mobility was limited. Other concepts involved surrounding the patients in wire tents and securing an oxygen filled “bubble” over the patient’s head. They ultimately chose to develop an aerosol box, given that it satisfied the greatest number of parameters for protecting the surgeons and their environment.
Initial plans for a box were inspired by the design of a Taiwanese doctor, Lai Hsien-yung (賴賢勇), who posted pictures of his box and its dimensions on his Facebook page in late March.
“We need it now, ASAP, we’re working and put in these scenarios on a daily basis, it’s not something people are contemplating and going through months of development to produce,” said Kelly about the urgent need for more protective equipment. In addition to the standard PPE and face shield that anesthesiologists have begun to wear, this box would provide another layer of protection against the virus.
Anesthesiologist Dr. Brian Kelly takes a selfie inside of the aerosol box he helped design for treatment of patients with Covid-19 at the Christ Hospital in Cincinnati, Ohio. Dr. Kelly placed himself inside the box to empathize with patients and see if it would be anxiety producing in a live ER or OR scenario on March 7, 2020. He worked with fellow doctors, Reztark Design Studio, and GeoGraph Industries to develop this prototype and simulate in the OR at The Christ Hospital. Dr. Kelly said It is important to be, “simulating it as much as possible, dry run after dry run after dry run, and then getting a lot of people into the room and trialing it themselves, I mean if on the trial and the simulations people didn’t like it we would throw the thing in the garbage and scrap it. We’re not gonna compromise patient care just because we’re nervous.”
After 18 days of planning they brought the third prototype into the hospital so doctors could test the concept and provide feedback.
Many doctors at The Christ Hospital were concerned about their range of motion, others if they would be able access all of their necessary instruments inside of the sealed box once the procedure begins. However, the main concern was if the breathing tube could still be placed as accurately and efficiently.
Dr. Kelly was unwilling to compromise on or overlook his key components. The box should allow doctors to provide oxygen and care as they normally would in an emergent situation, the gloves should fit properly and ensure dexterity, and the box must be a closed system as to not contaminate the room with the virus.
Christie Kratzer, President of Reztark Design Studio, commented, “By doing [it] the way we did it, we made our box very different. The other boxes had holes cut into them for the doctors to stick their arms in, but there was no seal around those holes. And his gloves, once he pulls them out of the box, were already covered with all kinds of the virus… the goal was to protect the patient [and] protect the PPE so they weren’t having to take [it] off and get new PPE.”
The gaskets on the side of the box allow doctors to run oxygen and suction tubes to the patient. With the instruments they will preload inside, the box allows them to push medication, make a patient go to sleep, deliver oxygen normally, intubate a patient, or place them on a ventilator. There is also a port that allows an additional doctor to assist with the procedure inside the box. Whereas other aerosol boxes have an open system, the plastic drape secured around the patient’s neck seals in the virus and creates a closed system—where respiratory droplets are suctioned out from the top through a viral filter.
Dr. Kelly hopes this box will reduce the number of patients requiring ventilators. He explained, “Typically when a patient comes in to the hospital and they’re struggling to breath, their oxygen levels are low, and they have something going on in their lungs —, there’s a process of escalation before you get placed on a ventilator. Unfortunately, those things as you turn up the pressure and you turn up the flow [of oxygen], risk aerosolization.… We would usually take a step-wise approach and hopefully prevent someone from going on a ventilator, because going on a ventilator has its own set of complications.”
With this box as containment for the aerosolized particles, doctors would ideally use respirators more sparingly as the pandemic continues, given that less intensive respiratory support could be used to meet patients’ breathing needs.
It was a challenge for Reztark to source all necessary parts for the box, given the many companies that shut down during the pandemic. The team was able to develop an initial six boxes for testing at The Christ Hospital. They were placed in the ICU, OR and ER. The hospital has taken a number of precautions to protect workers and patients from the virus. In addition to all elective surgeries being postponed, there are check points, temperature checks, and visitor restrictions. Dr. Kelly is hopeful this box will serve as another protective feature to mitigate the risks of contracting the virus.
Greg Freudiger (left) and Mark Freudiger of GeoGraph Industries help seal gloves onto an aerosol box before a test run of the protective equipment at The Christ Hospital in Cincinnati, Ohio.
Tools for the aerosol box sit on a table in an OR at The Christ Hospital in Cincinnati, Ohio. Gear for intubation and delivering oxygen will be preloaded into the aerosol box, so it is ready to be used for a patient who may have contracted Covid-19.
Dr. Kelly commented, “In Cincinnati [we’re] nowhere near where they are in New York or Seattle, I have friends in those places and I really feel for them. It’s hard to get a sense of how they feel until you’re put in that situation.”
As of April 18, 2020, Dr. Kelly traveled to where additional doctors, nurses, and other healthcare workers are most needed, New York City— the U.S. epicenter of the coronavirus outbreak. Five of the boxes are currently at The Christ Hospital in Cincinnati, Ohio, and Dr. Kelly has taken one to assist in his duties at the NewYork- Presbyterian Queen’s Hospital.