|Year : 2020 | Volume
| Issue : 2 | Page : 73-74
Management of cleft deformities in the times of COVID-19
Department of Maxillofacial Surgery, Jain Unit of Smile Train, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
|Date of Submission||19-Jun-2020|
|Date of Acceptance||19-Jun-2020|
|Date of Web Publication||31-Jul-2020|
Dr. Krishnamurthy Bonanthaya
Jain Institute of Craniomaxillofacial Surgery, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bonanthaya K. Management of cleft deformities in the times of COVID-19. J Cleft Lip Palate Craniofac Anomal 2020;7:73-4
The editor requested me to write this guest editorial, probably with two things on his mind. One being my current status as the President of the ISCLPCA and the other probably being our unit, restarting functionality very early during the recent lockdown. This write up will primarily be anecdotal personal experience; I will however, try and rationalize my actions. It will also try to consider the raging pandemic from the perspective of a cleft caregiver, and mull over the immediate future for us and our patients.
Like everybody else in India, we shut down our cleft unit (except for an emergency on call) in the last week of March. Considering how busy the months of April and May are every year, this was indeed a very wrong time for such a disruption. However, the virus obviously could not care less! These are the summer holiday months, and secondary procedures are generally booked months in advance, with very little room for maneuvering appointments. We were fully booked for the succeeding 2 months, and at the time we stopped operating, we had no definitive idea when we would resume again.
What followed was the longest ever period of inactivity, probably in the history of our nation, the consequences of which may be far-reaching and difficult to predict at the moment. In the early days of the lockdown, as the COVID curve started its slow upward climb, video-conferencing platform providers made hay, luring all of us into a new educational experience of webinars and online classes (which may now become the norm in the years to come). All this while, anxious parents started calling to find out when we would start operating again. A couple of weeks in, my orthodontist started to see her ongoing cases of nasoalveolar molding (NAM); at least those who could make it to the hospital amidst the strict lockdown. Initially, they were few and far between, but by the end of May almost half of them had turned up. During this period, she also started seven new cases of NAM.
The hospital took a call to restart “elective” surgeries in the 4th week of April, and we resumed our services as well, although in a partial and circumspect manner. Only, a handful of primary cleft lips and palates were operated in the month of April, keeping in mind recommendations such as the one issued by the ACPA. There were obviously problems aplenty. Particularly, with regard to understanding preventive measures to be taken to protect everybody; including the babies during anesthesia and surgery in particular, and during their hospital stay in general.
By early May, the COVID-19 case numbers apprehension overtook and we took a call again to stop operating. Three weeks later, on the May 18, we opened up again and have been providing our services to a greater degree of normalcy, except speech therapy on-site, which is now being carried out telephonically.
The publication that helped make up our mind was from the Journal of the American College of Surgeons which presented an evaluation tool to decide on when to proceed with medically necessary operations in the face of the resource constraints and increased risk posed by the coronavirus disease. This process is called Medically Necessary Time Sensitive (MeNTS) prioritization. This new terminology gave clarity to the so called “elective procedures,” for example, cleft lip and palate repairs. These are procedures which are carried out for disorders which cannot be treated nonsurgically and delay itself could give rise to challenges in future. This scale scores 21 factors in all, on a scale of 1–5, and the total score ranging from 21 to 105 is computed for each case. The higher the score, greater the risk to the patient and higher the utilization of health-care resources and risk to the health-care workers. With this scoring system a fit and well-baby, with cleft lip and palate scored only 46 which was within the range of OK to proceed [Figure 1].
One of the major challenges we faced, in the initial days, was the preoperative testing of the babies. Due to the scarcity of testing kits, COVID testing was not accessible to a patient for preoperative screening purposes alone. Things have improved since then, and we are routinely testing all our patients before surgery now. After a thorough historical and clinical screening of the patient and the family, the reverse-transcription polymerase chain reaction testing is carried out 48 h before the surgery. The nasopharyngeal and nasal swabs are taken by us and sent to the laboratories which report in about 6–12 h, and only negative patients are operated on. Even with this COVID-negative status, all necessary precautions including appropriate personal-protective equipment's donning and doffing, care during and after anesthesia are taken. The patients are routinely discharged 24 h post operatively, if they are afebrile and back to their normal feeding routine. Currently, we are doing both primary and secondary procedures. Outpatient clinics and ward care also are carried out with appropriate precautions.
There has been a great deal of anxiety regarding performance of so called “elective procedures” during this pandemic, and rightly so. People who are at risk, for e.g., those aged above 60 years, particularly with comorbidities, whether patient carer or health-care workers, should definitely refrain from exposing themselves. However, it would be prudent to keep in mind that whether we like it or not, this pandemic is likely going to be with us for a long time. The situation is ever-fluid, all data pertaining to the disease are dynamic and ever changing, and we must adapt accordingly. The authorities have been moving their predictions for the peaking of the pandemic down the road by months (ICMR studies reported in The Hindu dated June 15, 2020, predicts us peaking in November!). Therefore, it is important to devise strategies to restart and stop surgeries depending upon the local circumstance rather than postponing them indefinitely in the hope of some positive news.
In this scenario, the new normal will involve the testing of patients (a new point-of-care rapid antigen testing has been approved by the ICMR) preoperatively. Using the cumbersome and at times, uncomfortable protective devices and gear will also be necessary, and it is better for us to get used to working with them sooner rather than later. Obviously, if they are deemed unnecessary (i.e., safe without them) down the road, so much the better. Until then, stringent precautions need to be taken to protect both our precious patients and ourselves as we go about restarting the cycle of care slowly but surely.
| References|| |
Prachand VN, Milner R, Angelos P, Posner MC, Fung JJ, Agrawal N, et al
. Medically necessary, time-sensitive procedures: Scoring system to ethically and efficiently manage resource scarcity and provider risk during the Covid-19 Pandemic. DOI: 10.1016/j.jamcollsurg.2020.04.011.