Logistics and Resident education
Outside of the clinic and OR setting, our department made several
changes in the residency structure that will be detailed briefly.
Institutionally, residents were not allowed to take care of COVID-19
positive patients or patients under investigation (PUIs). From a
surgical standpoint, only one resident was allowed in a case at a time
to conserve PPE. Beginning on March 19, the residency program was
platooned into two groups, which alternated weekly shifts. The team that
was not actively deployed at the hospital was responsible for continuing
didactics and to remain on reserve in the event residents needed to be
quarantined or became ill. During this time, the head and neck service
accounted for two fellows, a senior level resident, and three junior
level residents. Operative cases were performed with the least amount of
personnel in the room, with the most experienced members performing the
cases. Junior level residents (PGY 1-3) were generally not involved in
operative cases during this time period unless needed. Many cases were
done only by attending surgeons or by fellows. When junior residents
were involved it was for assistant purposes only in order to maximize
efficiency.
In attempts to minimize exposures, inpatient rounds were still performed
by the resident teams with fellow assistance. Only senior residents
examined inpatients and wore appropriate PPE depending on COVID status.
If a patient had unknown status, a gown, gloves, and N95 respirator were
worn. COVID+ patients were only seen in person by attending physicians
wearing appropriate PPE (N95, gown, gloves, face shield).
By order of the Alabama governor, inpatient guest visitation was
extremely limited. This hindered family education of trach care, wound
care, use of nasogastric or gastrostomy tube, among other routine
postoperative care. Residents were tasked with telephone updates
following rounds. We anecdotally suspect this led to slightly longer
inpatient stays due to the decreased hands-on training of family
members. HNS patients are particularly reliant on family assistance
after discharge. We did have some patients cancel their surgeries
initially due to these restrictions. We ultimately were able to have
family members receive in-person teaching towards the end of the
hospital stay. A “compassionate” exception was made for patient with
dementia or other factors requiring close caregiver participation (this
was allowed with two patients). Another unforeseen circumstance of the
visitation restrictions was the occasional cancellation of urgent cases
by patients. In addition, patients were not routinely screened
post-operatively for COVID-19 unless they began to develop symptoms.