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.