Editor’s Note: This interview was done with Richard V. Smith, MD, professor and interim chair of the department of otorhinolaryngology–head and neck surgery at Montefiore Health System, Bronx, N.Y., on March 31, 2020, right after his self-isolation for COVID-19 ended. It has been edited for length and clarity.
Explore This IssueMay 2020
Q: You recently tested positive for COVID-19. How are you feeling? Do you know how you were exposed?
A: I don’t know how I got it. It’s been a source of discussion at the family table. It’s really impossible to tell if it was at work or outside—I have friends and patients who have tested positive. I believe that, to a large degree, it’s irrelevant, because it doesn’t change the fact that I tested positive, and the challenge always is how to deal with that in your family life and at work.
As far as my symptoms, they’re atypical. I had a lot of severe muscle pains in the lower extremities and midsection area, which wasn’t part of the classic COVID-19 symptoms of an elevated temperature, cough, and shortness of breath. I had an accident six years ago and I do routinely get pain in that area, as a sequela of the accident, so that made it harder to differentiate.
Although I followed our institutional and New York guidelines of monitoring my temperature twice a day, I never had a fever, cough, or shortness of breath for the four days after the muscle pains began. I did lose my sense of smell on the fourth day, which by that point was actively discussed in the otolaryngology community to be associated with COVID-19. The rapid communication among our otolaryngology colleagues was pivotal for me to be able to identify COVID-19 infection. It’s what prompted me to get the test, and then to self-isolate once the anosmia developed. I found that the anosmia isn’t something that’s easy to recognize for me—I didn’t realize I couldn’t smell anything until someone made a comment about how our office eating area smelled strongly of disinfectant. I realized I couldn’t sense that at all. After that, I went around trying to smell things; I had some sense of smell in the afternoon, but by the time I got home it was completely gone.
My self-isolation—being in a separate area of the house, wearing a mask—started the morning following my anosmia, after I had my COVID-19 test, even before the results came back. The challenge with isolation is remembering that you can’t do the things you usually do, or need to do, because you don’t want to be a vector to transmit it to somebody else. I was very careful to stay away from my college-age children and my wife, who is also a physician practicing in the Bronx.
I started back to work yesterday [March 30], as that was 10 days after my original symptoms of muscle pain—recommendations from the Department of Health, the CDC, and others are seven days after symptoms begin if you haven’t had fever or any symptom progression. I wear a mask when I’m outside of my office area because my biggest fear is that I could give it to somebody else, although in analyzing the limited data that’s available, it doesn’t seem like I’m contagious at this point. However, I don’t want to take any chances. Sometimes that emotional concern overrides the scientific information.
Q: In some institutions, otolaryngologists have been pulled into other areas of practice to fill the gap. Has that happened at Montefiore? What has it been like for your otolaryngologists and residents?
A: We’ve volunteered and done shifts in other areas, but we haven’t been called en masse yet. We’re the second wave of mobilization, after some of the other specialties. Many of our faculty have volunteered to be in other areas, and our faculty have been part of the national effort to develop protocols for how to safely perform a tracheotomy and care for otolaryngologic diseases in COVID patients. Within our residency, every week we have a group covering otolaryngology emergencies, but two thirds of them are now being called into other areas—actually starting this week in the ICU. (Since the interview, all Montefiore otolaryngology residents have been rotating through the ICUs.)
I personally haven’t been redeployed to another area at this point. But in talking with our residents and the other faculty, besides some initial anxiety from working in an area where they’re not accustomed to being and caring for non-otolaryngologic conditions, they are all committed to delivering the best possible care to their patients. Our otolaryngologists aren’t currently at the front line of COVID-19 or at an increased worry about getting infected, but we are in an area where we’re doing things other than straight otolaryngology. We’ve been preparing for it with some additional online education, and we know that we’re in a supportive environment with other people who are specialists in that area. We’re there to help them and to extend their ability to take care of patients, as our inpatient numbers become higher and higher with the COVID-19 crisis. (Since the interview, Dr. Smith and his colleagues have had universal otolaryngology faculty training on site in the ICU, and have begun redeployment to provide 24/7 coverage to newly created ICU spaces in the hospital.)
Q: How do you think otolaryngologists are coping physically and mentally? Do you have any advice for them in terms of what to expect and how to deal with this extraordinary situation?
A: Everyone understands our role in taking care of people and really wants to help. I’ve heard that from all of our faculty, all of our residents, all of our advanced practice providers, and all of the office staff. I’m sure that all of our colleagues across the country are just like ours, ready and wanting to help in whatever way they can. I believe that having that basic motivation to care for patients and each other gives us all the ability to move past the initial discomfort when you’re in a new area of practice and then rising to the occasion to do our best. We all have the skill set and training necessary to do the things we’re being asked to do; it just isn’t what we do on a regular basis. The kind of behaviors that make you an excellent otolaryngologist will also make you an excellent physician across the board.
Q: How have you been accommodating patients who require cancer surgery?
A: In New York, we’re in a more acute situation than some other programs around the country in that we’ve had a much more rapid increase in the number of critically ill COVID-19 patients. Like many other programs, we’ve had to eliminate elective surgery within our institution for about 10 days at this point. We feel that there could be additional risk to surgical patients right now from being in the hospital unnecessarily, given the nature of COVID-19.
We’re addressing this issue in our cancer patients by consulting with our multidisciplinary team again, knowing that we cannot perform cancer surgery right now. If we were planning to do surgery, we’re looking at effective nonsurgical treatments that patients are getting instead. There are some patients for whom surgery is really their only option, so we’ve looked at methods of temporary palliative radiation, such as the “quad shot,” to control the tumor locally and avoid significant growth in the short term. Our hope is that we can then get these people back on the surgical schedule as soon as the pandemic issues decrease. Postoperatively, the types of procedures that would be most concerning would usually be the ones that require a potential ICU stay, tracheotomy care, or prolonged hospitalization. The smaller ambulatory surgeries are less of a worry, but they aren’t being done either, as again we don’t want to put people at risk, and we need those resources for taking care of the acutely ill across our system. We’ve also treated some patients with preoperative chemotherapy where there’s a reasonable chance of a positive result, and we have tried to avoid toxic therapies that might put the patients at risk of neutropenia.
Q: Are there other treatments you’re postponing? How are you keeping in touch with your regular patients?
A: We’re trying, to the best of our ability, to not have any ambulatory in-person visits in the office right now, just to minimize the risk to the patients. Although we feel it’s quite safe in the office space, we don’t want to have people coming here on the subway, or other public transportation, if they don’t need to be, and we’re doing our best to follow the mandates for sheltering in place. We’ve implemented telehealth measures, both on the phone and via video, and I will say that patients have been incredibly thankful for it—they really appreciate that we’re still there for them. If, while on a telehealth visit, we find that a patient really has an acute problem, we’ll absolutely bring that patient into the office to help manage it, because at that point we feel that the benefits of the in-person visit outweigh the potential risks.
Q: How do you think the COVID-19 pandemic will change what you do at your facility? Will it have a lasting effect?
A: I can’t see how it won’t have a lasting effect. I think this is going to be one of those seminal events in people’s personal histories that will also be evident in medicine. As an example, otolaryngology as a specialty has tended to have not been particularly concerned about wearing masks when routinely performing fiber optic laryngoscopy or even doing mirror examinations in the office—we’re good about gloves, but masks haven’t been part of what we thought was routinely necessary. The COVID-19 pandemic will change that because we understand the importance of the nasal cavities, nasopharynx, and pharynx as a reservoir of virus and potential vector for transmission. I think we’ll approach the way we examine patients differently and be more consistent about using universal precautions.
I also think one of the potentially significant benefits to patients will be the ability to tailor the type of visit to the needs of the patient through a greater implementation of telehealth. There are many patients who now come back for a follow-up visit who could be appropriately managed via a telehealth visit without making them take time off from work. I think we’ll have to define who those patients are, but I believe this will serve as a catalyst for some practice models that will be more beneficial. Our specialty has also developed regional and national educational efforts in response to this pandemic and has implemented remote learning on the local level as well. I do believe we’ll use this experience to drive change in our education techniques, all for the better.
Q: Is there any advice that you would want to pass on to otolaryngologists?
A: One of the things we’ve seen in the news media, and heard from our colleagues, is the exceptional reports about people who get better and then get acutely worse. For me, the challenge has been knowing that I’m going to be okay, understanding that I have colleagues who have been much sicker than I. Every once in a while, I see something on the news that gives me a little bit of irrational fear and makes me question that, but that’s human nature. That makes it important, when we have crises like this, to be able to evaluate the evolving information and make sure that our decisions are as scientifically grounded as possible, and not simply based on emotion.
One of the great things to come out of COVID-19 is that we’ve had a really significant improvement in collaboration among everyone in our field through online educational conferences and lots of email chains across different programs and leadership levels. It isn’t unique to otolaryngology, I’m certain, but it’s really done a lot to demonstrate how we can get out information quickly and how important it is to be connected.
Amy E. Hamaker is the editor of ENTtoday.