Tips on online presentations and meetings.

We do so many online meetings and talks now. Here are 3 little tips to help you do well in front of your phone or computer.

Lights.

Camera.

Action.

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Lights

Keep a forward light directed on to your face. No back light. Natural light is great, make sure it’s from in front not from behind you. You can use a simple study table light shining at your face.

Camera

Keep your phone or computer camera at the same level as your eyes. Our tendency is to look down at the computer. Double chins and nostril hair! Elevate the computer on a platform or a stack of books or lower your seat. Put the phone on a tripod or prop it up on a stand. It’s easy. Changing the angle makes you look 100 times better. Also, please don’t move the camera. The people on the other side watching you camera shakes might get dizzy with all the movements you make.

Action

Look at the camera. Looking at your own image as you talk make you look to your listeners like you’re staring at something else. Get used to focusing on the camera. It also helps you to focus your thoughts as looking at your own image on the screen distracts you.

Other tips

In an online meeting or presentation, mute your microphone unless you need to talk. When listening to a presentation, you may also switch your video off so your image doesn’t distract the presentation and reduces the load on the wifi/servers. If you switch off your video in a presentation, you can do other stuff while you listen. In a meeting I would encourage you to have the video on so your presence and contribution in a meeting will be acknowledged.

Choose words carefully. Do not ramble on. It’s not exactly a normal face to face.

If you’re doing a presentation, you need to continue with creating emotion and intonation with your voice, but remember that your listeners are listening to you in their office, lounge or transport vehicles, avoid yelling and screaming. Speak like you’re speaking to a small intimate gathering.

If you’re a host of a meeting set the rules clearly about speaking in turns and allowing everyone a chance to speak.

Watch your background. Choose a virtual background if you needed to protect your room privacy.

Keep the environmental noise to minimum. Use headphones or ear pods to improve sound quality and stop you yelling at a computer. This also reduces the noise feedback that sometimes happen as the computer microphone captures its own speakers.

This is the simple set up on my desk. A cheap study light, an iPhone tripod and an elevated platform for the laptop.

Any other tips you’d like to add?

Nasopharyngeal swab and nasogastric insertion.

‪The nasopharynx goes back, not up. ‬

‪When you take a nasopharyngeal swab or insert nasogastric tube, NEVER aim upwards towards the brain. ‬

‪Go LOW and go SLOW.‬

‪Correct direction follows the floor of your nose not up towards the roof. ‬

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All hands on deck for COVID19

Some data out there would suggest that 10-15% of people who are infected by the coronavirus are health care workers (HCW). Let’s do a numbers game here. One nurse treats up to 4 patients. They’re the absolute front line. They spend hours caring for patients in close proximity. One allied health clinician or one doctor may be responsible for a handful of patients, somewhere in the order of 10-15 on the ward or up to 30 in a day in clinics. Knock one nurse out or one physiotherapist out or one anaesthetist or surgeon out and see the domino effect on health care service provision? One less nurse or doctor or clinician means a handful of patients are not getting the treatment they deserve. In addition, the remaining staff needs to take up the slack, putting the patients and staff at risk. I can see how difficult this is already in the emergency department where staff members have to be quarantined. One General Practitioner quarantined for 2 weeks would mean loss of service to hundreds of patients.

Now think about the ventilator capacity. Increasing ICU capacity is increasing care for the sickest of the sick. A ventilator is a machine that keeps breathing for the patient while the patient is intubated in an induced coma. These are reserved for the really sick patient. And so far, the mortality rate for intubated patients is in the order of 60% or more based on several papers.

Can you now see where the upstream and downstream challenge is? If we had all the money and time in the world to prepare for this pandemic we would increase all supplies of Personal Protective Equipment (PPEs) and increase ICU capacity all at the same time. But we don’t have time and we don’t have resources.

Which challenge should we prioritise?

The high complex end of delivering ventilators or the mass protection of all health staff with masks, gowns, gloves and face shields? I wonder if specific technical industries can be mobilised to produce ventilators while general industries can be mobilised to mass produce masks, gowns, gloves and face shields? Protecting health care worker means protecting the health service means providing timely efficient care means protecting the community. It’s all connected. It’s not just about the HCW. Ultimately it’s about keeping the patients safe.

I know that it’s a complex world. I know that this is all very challenging for every institution around the world. I know that it seems an oversimplification of the problem. I know that many people are already working on the solutions. I know that I’m asking a question so obvious that many would already have the answer. But help me. In this simple oversimplification of the problem comes ethical, clinical, leadership and resource challenges. There’s probably no simple answer. It’s a question that will be answered differently by different people in different countries. The reality is what limits our answers.

The most important asset in healthcare is its people. Do not lose the people keeping the care going.

How would you prioritise the solutions? I’m just a simple surgeon I need some suggestions.

Be Kind

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This pandemic is changing the world and changing us. This coronavirus has slowed us down and taught us to live differently, to live carefully. Live CARE-full-ly.

Things I do NOT miss: meetings, KPI, goals, budgets, admin, shopping, competition, keeping up with the Joneses, parties, conferences, presentations.

Things I miss: people, people, people.

Online telehealth clinics have taught me that my facial expression matters and words are precious.

Virtual meetings have taught me that we can communicate with less words.

Having completely zero social events on the calendar taught me the good and bad of just simply being with family.

Having no new fancy restaurants to visit taught me that the family dinner table is the most important engagement of love and sharing.

I feel that the rhythm of the planet has slowed down and finally my body and mind are in tune again. No more running to places. No more hurry. No more rushing.

I am still committed to my patients and my team. Whenever my team is on the forward line operating on virus-laden oronasopharyngeal mucosa, I am fully committed to the wellbeing of the patient and the safety of my crew. The intensity of focus at work is balanced by the solitude of rest at home. We are all in this together.

How is this pandemic changing you?

 

Loss of smell and taste with COVID19

img_0842Here are a few fancy ENT words for you:

Olfactory (smell) disorder:

Anosmia: No smell (I can’t smell coffee)

Hyposmia: Reduced smell (I can smell coffee faintly)

Parosmia: Smelling a different smell (This coffee smells different)

Phantosmia: Smelling something that isn’t there (There’s a coffee smell but no coffee)

 

Gustatory (Taste) disorder:

Dysgeusia: dysfunction of taste

Parageusia: distortion of taste

Hypogeusia: reduced taste

Ageusia: No taste

ALSO, did you know that humans have 5 kinds of taste: sweet, salty, bitter, sour, umami (taste of MSG)

Read here from Europe the latest and so far the biggest study on smell and taste disorder in association with COVID19.

Key findings:

417 patients

85.6% had olfactory disorder, of which 79.6% of patients thought they were anosmic and 20.4% thought they were hyposmic. Phantosmia and parosmia concerned 12.6% and 32.4% respectively during illness.

The olfactory dysfunction appeared before (11.8%), after (65.4%) or at the same time as the appearance of general or ENT symptoms (22.8%).

The olfactory dysfunction persisted after the resolution of other symptoms in 63.0% of cases. For those who recovered their olfactory sense, 72.6% of these patients recovered smell within the first 8 days

88% gustatory disorder. Olfactory and gustatory disorders were constant and unchanged over the days in 72.8% of patients, whereas they fluctuated in 23.4% of patients.

Among the cured patients who had residual olfactory and/or gustatory dysfunction, 53.9% had isolated olfactory dysfunction, 22.5% had isolated gustatory dysfunction and 23.6% had both olfactory and gustatory dysfunctions.

What does this mean for us?
Keep an eye out for loss of smell as a possible early indicator prior to other symptoms. Resolution takes time. There’s still a lot we have yet to discover. Keep an open mind. This is not a protocol or policy. This is something we all should think about. Signals.

ENT Tips:

Check smell with coffee, mint, vinegar, chocolate lip balm, strawberry lip balm, etc. Check taste with salt, sugar, soya sauce (umami)

COVID19 affects everyone

Here’s a report from the Center for Disease Control and Prevention looking at the first 4000+ COVID positive patients in the United States.

https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6912e2-H.pdf

There are 2 graphs in that article that concerns me. This is the first one.

This tells me clearly that people of all age groups get admitted to hospitals. In fact, the big hospital admission burden is in the group between ages 20-74. This is important as we prepare for the incoming surge of patients. Many young people will require hospitalisation. Your youthfulness does not protect you from becoming ill enough that you need to be admitted to the hospital. Hospitalisations are expensive and labour intensive. We need to work hard at preventing these admissions. Community priority: social distancing to prevent spread and admission to hospitals. We can’t just use the number of ventilators as a measure of readiness. We need to look at the big picture of bed management across the service.

Let’s dump that myth suggesting that COVID19 is an elderly person’s disease. No. It affects all age group.

The second table is this.

It’s proving what we have heard from China , South Korea, Italy and the UK. Mortality rate goes up with age. In the oldest group of 85 and above, it appears that there is a case fatality rate of 10-27%. Now that’s a very high mortality risk. It’s critical that we have a frank discussion with patients and their families regarding advanced care plans even before entering the ICU.

Stay the course, friends. We’re all in this together.

3D printed ENT-modified face shield

Speed trumps perfection. Safety is a priority. This coronavirus pandemic has created a tsunami of innovation and collaboration. New problems are identified and creative solutions are offered across specialty lines. Many Ear Nose and Throat Surgeons in Australia and New Zealand use a special spectacle-mounted headlight magnifying loupes to look into ears, noses & throats (Vorotek). Standard face shields are not compatible as the visor hits the headlight. I shared this problem with an orthopaedic surgeon Dr Claudia di Bella who then connected me immediately to the BioFabrication 3D Lab in Melbourne. Ten minutes of discussion of the challenges led to some simple solutions to bring the shield forward. Within 2 days, we have a prototype which was then simplified and refined. Two days after that we have a good solution to the problem. You can put this on with optical loupes up or down, which make patient examination easier. Glare from plastic is minimal and acceptable. The plastic can be detached from the frame easily to be regularly cleaned and washed. Watch it here.

Note: this face shield is a layer of splash/droplet protection over your vorotek. You still need to don other protective measures such as surgical mask (or N95 in an AGP), gowns and gloves. User feedback will improve the design and functionality for the next generation of shields we’re working on.

This is an example of how 3d printing skills are making an immediate difference to clinicians at the front lines facing the patients. Simple, cheap, scaleable solution.

Materials:

1. 200Micron thickness A4 overhead projector sheet from your local stationery shop. You can cut the length and width to size. This sheet can be wiped down with alcohol or soap at every patient encounter.

2. Hair ties, hair elastic band or velcro straps from your local shops. Velcro straps will give a bit more security if you preferred.

3. 3D printed ENT-modified frame. Drop a line at BioFab3d. They can send you the open-sourced file that has been refined by the team at RMIT and BioFab3D. Take the file to your nearest 3D printing facility. If you live in Melbourne, you can pick up the frame from the Lab situated within the campus of St.Vincent’s Health Melbourne. Cathal O’Connell is the man you want to speak to. This is his page at COVID SOS.

Click on this video on how to assemble the face shield. Too easy!

They also have the standard face shield (not modified to allow headlight. The shield sits closer to the face). They are going into production asap.

The stl file for Vorotek modified faceshield to download is here.

For the standard face shield that sits closer to the face, the file is here.

IMG_8514

I’m grateful for innovation and collaboration. We’re all in this together.

CATHAL O’CONNELL of 3d Fabrication Lab, PAUL SPITHILL from RMIT Advanced Manufacturing Precinct & Prof MILAN BRANDT, Director of RMIT Advanced Manufacturing Precinct have donated their expertise, time and effort for free. RESPECT TO THEM. Also catch this development on SBS News. Their website here.

New Zealand ENT News

From my ENT colleagues and for my ENT colleagues across the Tasman as of 31st March 2020. THINGS CHANGE ALL THE TIME, RAPIDLY. THIS ADVICE MAY BE INVALID IN A FEW DAYS.

Note the risk management of Aerosol-Generating Procedures and preoperative assessment. PLEASE CHECK YOUR OWN LOCAL GUIDELINES.

https://umbraco.surgeons.org/media/5148/nzsohns_ppe_letter-recommendations.pdf

Aerosol Generating Procedures in the COVID era

THIS IS NOT A POLICY, PROTOCOL OR GUIDELINE. THIS IS A THOUGHT PRIMER. I AM NOT A PUBLIC HEALTH PHYSICIAN OR AN INFECTIOUS DISEASES PHYSICIAN. THESE ARE THINGS YOU SHOULD THINK ABOUT WITH YOUR TEAM WHEREVER YOU ARE IN THE WORLD. THESE ARE FOR AEROSOL GENERATING PROCEDURES. OTHER PROCEDURES, FOLLOW STANDARD LOCAL PROTOCOLS.

You will be treating a COVID positive patient. Think about the safety of any aerosol generating procedure in this new COVID era. Modifications need to be made to mitigate the risks of spreading the virus. We need to protect the patient and healthcare staff.

What do we know?

The upper respiratory tract (the nose, nasopharynx, mouth, oropharynx, larynx, trachea and bronchi) are areas with high viral load. Evidence suggest that viral load in the nose and nasopharynx of non-symptomatic carriers are as high as those with symptoms. A patient could have no symptoms and yet carry the same amount of virus in the nose, and oral secretions. Data from China and Europe suggests that ENT surgeons have been unexpectedly hit hard with high numbers falling ill and some have died due to the virus. Studies have shown that tracheobronchial secretions carry the highest concentration of virus and followed by mucous and saliva. In some patients the virus can be detected in saliva weeks after the symptom onset. The virus has not been detected in urine or breastmilk.

What does this mean?

If you are an anaesthetist, ENT surgeon, Head & Neck surgeon, dental, maxillofacial surgeon, respiratory physician or anyone else doing procedures in the Airway mucosa, you must modify your procedures based on COVID risks. Any procedures involving the nose, oral cavity and airway pose a risk of dissemination of virus. Any general anaesthetic involving bag and masking, ventilation, intubation, supraglottic airway device, nasal surgery (rhinoplasty, septoplasty sinus surgery, adenoidectomy), oral surgery (maxillofacial, dental, tonsillectomy) and airway interventions (bronchoscopy, laryngoscopy) etc are all high risk aerosol generating procedures (AGPs).

What must we do?

1. Risk assess the patient. Can we get a COVID status on the patient? If we cannot get a COVID test pre-procedure, assess the risk based on history and examination (contact with positive COVID, travel history, etc.). Some institutions may afford you the luxury of doing 2 tests 48 hours apart to confirm the status. This is not possible in all places. Tests are not perfect so they may give a false reassurance and false negatives.

2. Risk assess the procedure and modify accordingly. Can we delay the procedure? Do we have other alternatives? Can we modify the surgical approaches? Can we use a different technique or tool to reduce the aerosolisation?

What if we have to proceed with the procedure?

Modify and mitigate the risks as a team. Communicate. Communicate. Communicate.

Consider 3 possible levels of risk:

These are suggestions. You need to check your local area guidelines.

GREEN: standard precaution for negative COVID patients and non aerosol generating procedure. Surgical mask, eye cover, & gloves for a non-ENT procedure. Eg. Neck dissection, thyroidectomy, etc.

YELLOW: for AGPs with negative COVID or very low suspicion of COVID. N95 mask, face shield, long sleeve gowns and gloves. Eg for mastoidectomy, FESS or tonsillectomy. Should intubation fall into this category?

RED: for COVID positive AGPs. PAPRs and the maximal PPE available at your institution. Eg. an urgent FESS in a COVID positive patient.

This diagram from the Canadian Society of Otolaryngology Head & Neck Surgery. THIS MAY NOT BE POSSIBLE IN EVERY PART OF THE WORLD.

Pre-operative considerations

Mask on the patient. Isolation. Reduce staff contact. One family member, one staff, reduce movements. Reduce exposure to other patients. Do not wait at holding bay or waiting room. Bring patient from emergency or ward direct to operating theatre.

Induction

Standard precautions. Assess level of risk Green, Yellow or Red. Reduce staff contact. Bag and mask, intubate under plastic drape. Seal the airway. Consider avoiding high flow oxygen, CPAP, Laryngeal mask etc. CHECK WITH YOUR LOCAL ANAESTHESIA TEAM.

Procedure

Modify techniques. Can you operate under a plastic drape? Example here. Any mucosal specimens (eg sinus debris, tonsils etc, need to be placed in a sealed container immediately). Pictures of modifications to surgical techniques below. Modify your technique accordingly so as to mitigate the risks to the staff in theatre. Reduce personnel present. Add suction device. Negative pressure theatre. Check theatre airflow. Meticulous PPE. Buddy up so someone is always catching you and checking on you. Modifications offered here. CHECK YOUR LOCAL AREA GUIDELINES.

Modification to oral surgery under a plastic drape.

Emergence & Recovery

Wake the patient in theatre. Avoid coughing in recovery. Mask on patient. Go to an isolated area in recovery. One staff member to recover. Then straight to the ward. ASSESS RISK AND DISCUSS WITH YOUR LOCAL AREA TEAMS.

Turnover

Time to allow clean up and air circulation in theatre. Wipe down everything based on levels of risk.

Closure

Communicate, Communicate, Communicate. In my experience, every single time I ask the team to do a COVID run or simulation, new gaps in knowledge and practice are identified and resolved. Morale and team work is strengthened.

Practice it. This is our new normal for the next few months.

REMEMBER TO WORK WITH YOUR LOCAL AUTHORITIES WHO ARE BALANCING INDIVIDUAL NEEDS, PUBLIC HEALTH NEEDS AND THE REALITY OF FINITE RESOURCES.

COVID19 and ENT Surgeons

ENT Surgeons and the COVID19 Pandemic

Updated 22nd March 2020

Key findings from literature as of today.

1. ENT surgeons are at higher risk and have higher rates of contracting the virus SARS-CoV2.

2. Thought to be due to high virus load in nose, nasopharynx and oropharynx, even in asymptomatic carriers hence we may be examining and operating on asymptomatic patients with high viral load.

3. Airway procedures are aerosol-producing activities therefore placing staff at risk (nasoendoscopies, cautery, even oral examinations). Delay if possible.

4. Urgent need for protection with N95 masks, gowns and gloves in clinic. We should ask authorities to provide ENT clinics with them.

5. Any airway intervention, in particular but not limited to, sinonasal surgeries, adenotonsillectomies, laryngobronchoscopies should be delayed if clinically appropriate. Severe, urgent, cancer, critical airway cases may go ahead on a case by case basis and intraoperative risk reduction strategies should be employed (masks during intubation, reduce personnel in theatre, N95 masks, smoke suction, etc.)

6. Testing is still limited in Australia and at this stage we cannot screen everyone for COVID19.

7. Ultimately we should screen all patients pre clinic or pre op but that’s not possible yet.

8. Please be reasonable and be cautious. There are still many patients requiring emergent and urgent ENT services. This does not mean we stop all ENT services. Please be supportive of your emergency colleagues. Wear a full PPE gear. Here’s a snapshot of ASOHNS recommendations. Full statement linked below.

9. Data is limited and imperfect. We are in a pandemic. Time to use whatever limited data we have to inform practice. Time to learn, support and not criticise colleagues.

10. Look out for anosmia. See this. Could be a red herring, could be true. Don’t know yet but be aware.

Resources to support the above statements:

1. Interview with Dr Jason Chan on managing ENT Services during Pandemic in Hong Kong. Excellent. https://edhub.ama-assn.org/jn-learning/audio-player/18326041?utm_source=twitter&utm_medium=social_jamaoto&utm_campaign=article_alert&utm_content=automated_rss

2. News of China Experience with higher number ENT Surgeons infected. https://www.bloomberg.com/amp/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say?__twitter_impression=true

3. Paper on nasal viral load. Just as high in asymptomatic patient. https://www.nejm.org/doi/full/10.1056/NEJMc2001737

4. Paper on asymptomatic carriers. https://link.springer.com/content/pdf/10.1007/s11427-020-1661-4.pdf

5. Fever and cough are most common symptoms. But asymptomatic period really uncertain. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032

6. ENT UK RECOMMENDATIONS https://www.entuk.org/entuk-guidelines-changes-ent-during-covid-19

7. ENT UK general guidance. https://www.entuk.org/guidance-ent-during-covid-19-pandemic

8. American Academy Recommendations. Specific mention of high virus carrier rate in the nose, nasopharynx and oropharynx. https://www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy

9. Reliable personal sources have also reported the following: transsphenoidal pituitary case in Wuhan infecting 14 health care workers. One ENT surgeon in the UK has died, 2 intubated and 1 on ECMO.

10. COVID19 repository of papers, guidelines etc collated by Australian Crit Care clinicians. https://www.covid19repository.com/about/

11. Australian Society of Otolaryngology Head & Neck Surgery recommendations. http://www.asohns.org.au/about-us/news-and-announcements/latest-news?article=78

11. British Laryngological Society President. http://www.britishlaryngological.org/news/message-bla-president-covid-19

12. SkyNews on 2 intubated ENT Surgeons in the UK. https://news.sky.com/story/coronavirus-two-nhs-medics-on-ventilators-after-contracting-covid-19-from-patients-11961531

13. Suggested modifications to Sinus surgeries. Pre and post op concerns discussed. 12 minute lecture. https://youtu.be/ZEQPVnt7II8

14. American Academy update recommendations 23 March 2020. http://msg.entnet.org/q/1tgWzg1impN6Y2lbIZSAurCZ/wv

15. Be kind. Be kind. Be kind. This is an unprecedented Medical Emergency. We need to give every staff member the support that they need. This is the new normal for the next 3 months at least.