Discussion
The field of Otolaryngology – Head and Neck Surgery has an intimate
relationship with the primary anatomic regions associated with high
viral load in the upper aerodigestive tract. With this realization comes
a critical responsibility to ensure that we are not placing our trainees
at risk in the name of education or as part of “business as usual.”
Early publications and social media interactions have highlighted the
concerns for COVID-19 transmission in our field11–16.
A full understanding of our roles as physicians, however, lays bare the
fact that we cannot avoid risk.
Residents are routinely the front-line provider of care for inpatients
and emergency department consultations. The new infectious risk
associated with each clinical interaction threatens resident wellbeing
– both physical and mental17,18. As a group, faculty
are older and carry more comorbidities than residents, placing them at
significantly higher risk if infected with the novel coronavirus.
Faculty also carry the ultimate responsibility for both patient care and
resident training and well-being; faculty are financially compensated
for these responsibilities. Ultimately we are all physicians who have
accepted the responsibility to care for our patients. We must also
accept the responsibility to care for each other.
Treating patients during a pandemic setting has resulted in a
significant reduction of existing resident learning opportunities such
as in-person conferences, surgical volume and assessment of patients in
clinic and on the floor. The cohorting system was implemented to
diminish risk of spreading infection within our department, but also
created an intimate team atmosphere with enhanced opportunity for
individualized teaching. Each clinical encounter now results in a
careful assessment of risk and determination of the appropriate extent
of evaluation prior to performing an examination. During daily team
discussions, a focus on the determinants of the optimal extent of
evaluation for each patient provides an ideal opportunity for in-depth
discussion of symptoms, pathology, diagnostic tests and treatment
options.
While we are focused on trainee safety, we also recognize that
restricting junior residents from traditional clinical activities may
restrict their ascension to the next training level. The traditional
approach to clinical training has the least experienced trainee
performing the initial evaluation of a patient and reporting those
findings to more senior team members who subsequently repeat the
critical portions of the exam. Clearly, this repeated exposure is
inappropriate for patients with known COVID disease19.
Further, the significant rate of asymptomatic carriers of disease and
limitations with availability and sensitivity of testing require changes
to this protocol for all patient encounters. Development of guidelines
which account for risks presented by both patients and clinical
scenarios facilitates team care by identifying optimal care providers
for each scenario.
The guidelines presented here are neither comprehensive nor universally
applicable, but represent our experience at a major academic center at a
time when viral testing and treatment are limited. There certainly will
be specific patient scenarios in which clinical judgement demands
deviation from guidelines. One example is a true airway emergency in
which delay for the sake of guideline compliance could result in
disastrous patient care consequences. The potential risk of evaluations
as simple as oral cavity examination merits discussion with a faculty
member prior to clinical interaction. In some scenarios, however,
faculty approval may be implied or carried forward. With an inpatient
following oral cavity resection and reconstruction, for example, daily
examinations by the rounding team would be expected. The specifics of
these guidelines are likely not appropriate for all programs. Variations
in geography, practice settings, and most importantly endemic rates of
COVID infection will dictate ideal guideline details for individual
sites. Adapting and adopting guidelines for management of these common
patient interactions, however, provides an opportunity to mitigate risk
to the healthcare team without compromising the quality of patient care.
Our categorization of procedural risk was based on an estimation of the
likelihood of aerosol generation and resultant short-distance airborne
transmission of infectious viral particles during each procedure in
question. While epidemiologic and experimental data is limited, studies
from the 2002-2003 SARS outbreak support that there was a significant
increased risk of transmission of infection to health care workers
performing or involved in aerosol-generating procedures
(AGPs)6,10. In particular, 2014 WHO guidelines note
consistent evidence for increased risk with tracheal intubation,
tracheotomy, non-invasive ventilation, and manual ventilation before
intubation as AGPs based on work including a systematic review published
in 2012 of ten low-quality studies from the SARS epidemic6,7. The data also support that there is a hierarchy
of risk among aerosol-generating procedures included in these studies,
which is reflected in our categorization6.
Significantly, the viral load of SARS-CoV-2 is known to be very high in
both the upper and lower respiratory tract in an infected patient, with
somewhat higher viral loads in the nose than in the
oropharynx20–22. We supplemented the conclusions of
the above studies with additional cohort studies, case reports, expert
opinion, and practical judgment in categorizing procedures for which
either little to no data currently exists (e.g. nasal endoscopy,
laryngoscopy, skull base surgery, control of epistaxis, and drainage of
peritonsillar abscess)7,10,12,23.
Tracheotomy and endoscopic examinations are among those specifically
called out as high risk procedures in our protocol. In the case of
tracheotomy, there is consistent evidence for increased risk of viral
transmission from the SARS epidemic7, presumably due
to likelihood of aerosolization of a high concentration of virus for a
prolonged period. Whenever possible, this procedure should be performed
by the minimum number of experienced providers to complete the procedure
expeditiously. Endoscopy, while frequently thought of as simply an
extension of the Otolaryngologist’s physical exam, carries significant
risk for the clinician as well as staff and technicians who support the
exam and process instrumentation. In our protocol, early faculty
involvement is vital in evaluating the initial request or indication for
the procedure, as they are in a position to efficiently and effectively
decline this procedure in favor of alternative diagnostic evaluations
whenever appropriate. In emergent or urgent scenarios where endoscopy is
required, having faculty perform or directly supervise the exam ensures
efficient and comprehensive evaluation in a single setting.
We have found that a small-team cohorting model with established
guidelines delineating clinical roles and responsibilities can serve to
strengthen the bond between faculty and residents. Strengthening this
bond may be the most critical component of the COVID-19 response in
residency training. Both faculty and residents are at risk; our early
institutional data demonstrates a similar number of faculty and resident
infections3. Recent resident surveys suggest that the
amount of risk perceived by a resident correlates with the trust they
have in their Department administration1. Faculty
should be involved at the earliest stages of patient care including
initial consultation. We are uniquely positioned to decline
non-critical, aerosol-generating scope exams and identify streamlined
evaluations to limit clinician exposure while maintaining patient care.
When faculty join residents on the frontlines of patient care we model
the physicianship central to managing a crisis, diminish risk to health
care providers, and empower residents to remain engaged in meaningful
patient care.