Published in HARD copy of MIMS DOCTOR June 2020 [Malaysia]
A panel of ENT specialists came together online to discuss the aftershocks of the COVID-19 pandemic and what it means to clinicians and patients alike.
The panel was chaired by Datuk Dr Kuljit Singh, president of the Association of Private Hospitals of Malaysia, with participation by Clinical Associate Professor Siow Jin Keat, National University of Singapore, Department of Otorhinolaryngology, Tan Tock Seng Hospital; Professor Dr Baharudin Abdullah, surgeon in the Department of Otorhinolaryngology–Head & Neck Surgery, Universiti Sains Malaysia; and Dr Jeevanan Jahendran, ENT specialist in private practice.
The COVID-19 pandemic is affecting clinical practice regardless of specialty. The ear, nose and throat (ENT) practice is no exception. For now, non-essential and elective procedures are put on hold, but this cannot go on indefinitely, said Kuljit. Even after the movement restriction is over, things will not go back to pre-pandemic ways for a long time. In such a scenario, how can ENT specialists and surgeons get back to treating patients, asked Kuljit. He added: “Is it ethical for us to keep postponing [attending] to our patients if the Movement Control Order (MCO) goes on for another 1 or 2 months?” The answer is simple: that patients have to be attended to, with special precautions in place to protect the ENT specialist and all healthcare workers (HCWs) sharing the same setting.
Siow presented an overview of the first known super spreader of COVID-19 in Wuhan, China, who supposedly infected 14 HCWs in an operating theatre while undergoing an endoscopic trans-sphenoidal pituitary procedure. However, upon closer inspection, it was revealed that the patient was warded for a prolonged period of time without isolation and that all those who caught COVID-19 were nurses and doctors attending to her during this time. There was no mention of the neurosurgeon who performed the surgery on her ever catching the disease.
However, due to the initial fears, the UK and US guidelines for ENT surgery tend to err on the side of caution. Stanford Medicine recommends patients due for functional endoscopic sinus surgery be tested for COVID-19 48 hours prior to the procedure. If the patient is negative then, then all HCWs should wear an N95 mask. Should the patient be positive for COVID-19, then all HCWs involved would need powered air-purifying respirator (PAPR). Meanwhile ENT UK, UK’s professional membership body representing ENT and its related specialties, recommends the use of FFP3 mask coupled with a surgical mask and visor cover while performing procedures.
The SARS-CoV-2 virus, while small, doesn’t exist on its own, said Siow. It is spread via droplets from the afflicted person. Droplets are usually sized between 5 and 100 microns and can thus be filtered by the respirators. A study by the National Centre for Infectious Diseases Singapore found that the virus could be found up to 72 hours on the following surfaces (in descending prevalence)—floor and air vent; bed rail; electric switch, table, and locker handles; chairs, and toilet seat and flush. Thus, surfaces are important sources of transmission. Siow remarked that HCWs could be infected while doffing their personal protective equipment (PPE).
Based on previous experience with SARS-CoV and the properties of droplets and the N95 masks, Siow came to the conclusion that level 2 PPE, which includes the use of N95 respirator, goggles, gloves, shoe cover, and fluid-resistant gown, is adequate for most untested patients in a COVID-19 situation.
Baharudin touched on the topic of patient suitability and selection in this current environment. He noted that the Director-General of Health Malaysia revealed most HCWs who were infected with COVID-19 caught the infection outside of their work setting and in non-COVID-19 wards.
In light of this, it is better to treat all patients as COVID-19 patients. Some studies find up to 80 percent of COVID-19 patients are asymptomatic. Should there be a lax in protocol, the repercussions can be devastating, as it can spread to a number of the HCWs and effectively disable the ward or hospital.
Baharudin listed a few procedures to be high-risk of infection to HCWs, including intubation/extubation; tracheostomy, endoscopic sinonasal and/or skull base procedures; mastoid and/or ear surgery; and open reduction of facial fractures. “These are the majority of procedures that ENT surgeons or physicians deal with,” said Baharudin. Thus, he recommended that all doctors and HCWs attending to these procedures use PPE. Additionally, the operating theatre should be one that is negative pressure, he said. Of note is the use of powered devices such as the debrider, which has the potential to aerosolize tissue and body fluids and spread it across a large distance.
Another point brought up by Baharudin is the length of time spent in the operating theatre. He said every surgery should be done by an experienced team, which will accomplish all the necessary tasks in the shortest time possible. This reduces the risk of infection to both HCWs and the patient. Such behaviour does not represent an alarmist mindset, he noted. In fact, such precautions will prevent the collapse of the healthcare system by maintaining the health and strength of the healthcare workforce.
Cost, cost, cost
The way medicine is practiced, both in the clinic and operating setting, will see big changes. The COVID-19 situation, said Jeevanan, has turned ENT into one of the most expensive specialties in terms of usage of consumables and single-use instruments. While clinics have been informed to refer patients with influenza-like illness (ILI) and severe acute respiratory infections (SARI), it doesn’t change the fact that doctors will need to adapt to the new norm.
Beyond the basic minimum, the use of a screening questionnaire will help to attenuate the risk faced by triaging staff. This will then lead to the situation whether the patient should be tested for COVID-19. At the end of the day, it’s the cost that weighs in on everyone’s mind. A JAMA article recommends that even for patients with low-risk of COVID-19, attending HCWs should wear N95 masks, surgical masks over the N95 respirators, goggles, double gloves, and protective suits. When it comes to high-risk patients and aerosol generating procedures, the recommendation goes further to call for the use of PAPR, single-use N95 mask, face shields, and double gloves.
On top of PPE, clinics will also need to factor in the cost of installing air purifiers or an air filtration system; additional disinfectants or surgical wipes for cleaning of surfaces after every patient visit; and possibly an ultraviolet light disinfecting system. The question arises, then, of who will take up all these extra costs, said Jeevanan. There is no clear-cut answer here, as patients are already paying for consultation, scopes, and more. Insurance coverage is limited, so it is unlikely the insurance companies will extend their coverage to include these extra costs. Even if they did, Jeevanan hazards that the insurance companies will likely increase their premiums in the next year.
For most doctors in clinics now, the cost hasn’t been a big problem yet as patient count is still low. Once the MCO is lifted and patient numbers increase, it is likely the cost of PPE will factor into the expenditure of the clinic.
In the hospital setting, costs are likely to increase as all patients will be treated as COVID-19 cases and boarding will likely be single room only to isolate them. Jeevanan said, “A patient’s insurance may only allow for a double or three-bedded room. What becomes of them?” Moving on to the OT, cost is again compounded.
Not everything is doom and gloom. While he does expect some semblance of normalcy to return after the MCO, some changes to day-to-day practice will be permanent, said Jeevanan. There is hope that rapid testing will bring down the cost of diagnosis and that a vaccine will be available soon. For now, he advises doctors to weather the storm while being optimistic for the future.