Discussion
At the current time (April 26, 2020), there are 943,865 cases of
COVID-19 in the United States, 6,213 of which are in Alabama6. For comparison, surrounding southern states
Louisiana, Georgia, and Mississippi have 26,512, 23,401, and 5718 cases
respectively while New York has 282,143 cases25. These
numbers highlight the variability to which the pandemic has affected
different states thus far, even within the same geographic region. New
York State contains 411.2 people per square mile compared to 168 people
per square mile of neighboring Georgia, 94.4 people per square mile in
Alabama and 63.2 people per square mile in Mississippi26. While there are many factors involved, the overall
low population density, early mitigation in Alabama’s largest urban area
(Birmingham), and limitations in testing have contributed to lower
COVID-19 case numbers.
Due to the trajectory and distribution of new COVID-19 cases, our
department has been able to implement strategies used in other states
and countries15,16,18,27-30. The authors would direct
you to Patel et al. for a recent description of HNS practice patterns
nationwide during the pandemic 24. Since the beginning
of the pandemic, the maximum number of COVID-19 patients at our
institution has not exceeded 62 and therefore, our institution has not
yet experienced ventilator or PPE shortages suffered by other health
care centers. We feel that thus far our division has been able to
effectively triage HNS patients and complete their oncologic surgeries
safely, while simultaneously reducing non-urgent surgeries. We reduced
our surgical volume by 55% during the critical time period and this was
predominantly by postponing elective, outpatient surgeries. Of note, we
feel strongly that a team-based approach toward completing surgical
cases is of the utmost importance in this situation. This requires
inter-provider consistency with regard to management strategies, a high
level of communication, and an understanding between the patient and
provider that another surgeon may be involved or primarily responsible
for their care. A foundation of trust between the patient and provider
is elemental in the success of this model. We would advocate a high
level of detail with regard to documentation and completion of the
surgical consent with these principles in mind.
An early and constantly evolving response to the COVID-19 crisis remains
critical to avoid an overwhelming surge on our medical system. At this
time, ORs both at our institution and around the country are beginning
to re-open to clear the logjam of semi-urgent and elective cases. We
feel the keys to safely moving forward with increased head and neck
surgical volume is with widespread, reliable pre-operative COVID
testing, adequate PPE and a clear mechanism to triage cases according to
urgency and safety via a team-based approach. While our experience may
not be reproducible for smaller community hospitals or tertiary centers
located in more urban settings, they do serve to highlight the response
and experience of a high-volume head and neck cancer tertiary center
situated in the deep South.