ENT doctors timid in face of COVID-19
Some private specialists close doors to limit exposureSunday, April 05, 2020
BY KIMBERLEY HIBBERT
FRONT line medical staff across the island have expressed their personal fears as they put on a brave face in the battle against coronavirus, but for ear, nose and throat (ENT) specialists the inhibitions are greater.
In an interview with the Jamaica Observer, Dr Myrton Smith, president of the Jamaica Association of Otolaryngologists — Head and Neck Surgeons, disclosed that his colleagues are timid because they are not fully equipped to practise universal precautions.
“We're not testing widely. We're not testing health care workers. We're not testing all the patients who have flu-like illnesses. We're not testing all patients, who are going to have procedures that can result in the transmission of COVID-19. So we are working with a lot of patients with unknown, and we think that that is not ideal because if you think about when HIV came around, after a while, there was a general recommendation that we should just test everybody, even while at the same time taking universal precautions,” he shared.
Dr Smith added: “If you're going to say, okay, we don't want to test everybody, then at least give us enough to do universal precautions with every patient. But then they're telling us that we don't have enough of the right gear. It's as if we're not getting the kind of assistance that we would need to feel comfortable while going about our duties.”
In relation to COVID-19 infections, the risk of transmission is higher among ENT specialists, head and neck surgeons and anaesthesiologists due to the nature of their work and their interaction with the mucus membranes of patients. Also, many of the physicians that have come down with the COVID-19 have actually been ENT surgeons, ophthalmologists and anaesthetists.
In addition to the fears, many ENT specialists in the private sector have closed their doors as a means to limit their exposure.
“Some people have scaled back and some people are only seeing urgent cases that come to the office. In the public sector there's a general kind of shutdown on elective surgeries and clinics, which makes it easier, but we still have to deal with emergencies and the urgencies. [And] we would have wanted to get the right equipment to deal with that. It is my hope that as we go along, that things will get better in that regard. I heard that they're planning to ramp up the testing protocols. So, hopefully that comes to pass and we'll see more testing done,” Dr Smith said.
Further, Dr Smith pointed out that privately, many of his colleagues have ramped up screening procedures and have introduced a questionnaire that probes patients' travel history and their history of symptoms related to COVID.
Of note, Dr Smith said through collaboration with colleagues in other countries, Jamaican ENTs have also been screening for other symptoms not often mentioned,
“It's been recommended that we as ENTs don't just ask about fever, the coughs, headaches and shortness of breath, but that we also asked about changes in your sense of taste and loss of the sense of smell. Our ENT colleagues in other countries that have studied it have found that there seems to be some correlation between that as well. So we've been looking at those, and we also inquire about their contact history and all of those before they come into office. When they get into office, we screen them again using the same questions and if a patient is coughing when they present, then right away we issue them with with a mask and we will make a decision based on what else is going on, whether or not we're going to see them in office or refer them out of office in a hospital or send them home to quarantine themselves,” Dr Smith said.
“There are certain procedures that we have stopped doing during this time. Those procedures were generally referred to as aerosol generating procedures. So, procedures that will make a patient cough or breathe hard in into our faces. We're not looking at people's voice boxes, we're not putting cameras in the nose unless they're absolute emergencies. If that is the case we just put on the N95 masks, put on caps, waterproof gowns, gloves, and protect ourselves before we do anything. That's the kind of precaution that we are taking in the private sector where we have more control,” he said.
But the concerns in the public sector, according to Dr Smith, remain worrying.
“That's what we've been asking for in the public sector, but we're not always going to be in receipt of that. So, we'll try our best on working there but we're starting to cut back and like everybody else we're doing emergencies and urgent cases like cancers. We're not really doing outpatient clinics right now until we have a better handle on it, because if you've been to the the public sector clinics you realise it's more than 10 people gathering when you have two or three clinics running in one place. So it's very difficult to understand. So for that reason, the clinics have been cut back and we're just dealing with emergencies,” Dr Smith said.
With regards to personal protective equipment, specifically the masks, there is an element of contention regarding whether the N95 masks are sufficient.
Ideally, ENT surgeons should be using a higher grade mask — the PAPR, which offers respiratory, head, face, eye and hearing protection and/or the FFP3 mask, which has been recommended for routine ENT examinations in the UK.
In responding to concerns over the sufficiency of the N95 masks, Dr Smith said, “Whenever we have to have any kind of surgical procedure that we think there is going to be a higher potential for us to get respiratory pathogens, then we do try to put on the N95 masks, waterproof gloves, and we should really have a face shield, but those are in short supply. Some people have their own goggles but they certainly don't have to give us. But those are some of the things that we know at the minimum we should have.
“In Jamaica we've always been good at turning our hands and making fashion. I see a group of guys doing 3D printing of the face shields we need. I hope they are acceptable and last I heard they were meeting with the Ministry of Health. The design I saw replicated the real thing and this is something that will be useful because as we continue to expose ourselves to the risk, part of the Government's responsibility is to make sure that we're not only protected, but that we feel like we are protected,” Dr Smith said.
Meanwhile, Dr Smith said despite the fears and concerns of ENT doctors, in accordance with their oath and ethical imperatives, they maintain a presence as a provider to ensure that should any patient need them, they are available.
Dr Smith also lauded the national response to COVID-19 and encouraged members of the public to follow the instructions and updates given by the Ministry of Health.
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