key: cord-309735-bwa1zo07
authors: Cerfolio, Robert J.
title: Many Ways to Skin A Cat
date: 2020-07-24
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.07.006
sha: 
doc_id: 309735
cord_uid: bwa1zo07

nan

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Reply to the Editor:

Marudi and colleagues have presented an alternative method for performing tracheostomy in Covid -19 patients [1] in response to our article [2] . We agree that their technique is a feasible alternative. There is a rather gruesome American expression that states, "there are many ways to skin a cat." The problem is the cat ends up not doing well irrespective of the method chosen.

The expression also means that oftentimes, the differences between techniques is not as important as we, as surgeons and self-perceived master technicians might think. We study everminute detail of what we do every day and although there is great value in it we must show the value in the changes we make. In addition, we are unconsciously biased towards the steps that we do select. The gruesome expression of cat skinning may be more applicable when the outcome is "uniformly" fatal as opposed to when the desired outcome is a fully recovered patient via the least operative time, hospital stay and overall medical cost.

There are more similarities between our tracheostomy techniques, then differences. And as most surgeons do I will point out the differences. Permissive apnea may work in many patients but a large number of Covid-19 patients are already hypercapnic and profoundly hypoxic. Further hypercapnia risks acidosis, which may lead to poor cardiac contractility or arrhythmias. In addition, permissive apnea leads to worsening hypoxia and not infrequently, these patients can take a long time to recover given their poor pulmonary function. This creates great angst to the bedside nurses and physicians. The authors found that 12% of the time it became necessary to resume ventilation and apply another period of permissive apnea. For these are reasons, we do not favor this technique but agree it is another feasible alternative, safe and effective in many.

Given these known and admitted disadvantages of this technique what are the advantages? We assume it is because of the perceived lower viral shed and / or great safety to the surrounding health care workers during the tracheostomy. The former has not be shown and the later may be clinically irrelevant since we have shown no conversions to any of our bedside health care workers when properly wearing their protective equipment during 212 tracheostomies that we have now performed.

At the end of the day, we agree with the authors that there are many ways to skin a cat.

We as surgeons need to be open to change everything we do every day in order to get better outcomes for our patients at less cost. We do not care who gets the credit for it as long as all of our patients reap the enhanced value. 

Permissive apnea in CoVid 19 Tracheostomy: alternative healthworkers safe procedure in ICU

Novel Percutaneous Tracheostomy for Critically Ill Patients with COVID-19