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\begin{document}

\title{Ethical Surgical Triage of Head and Neck Cancer Patients during
the COVID-19 Pandemic}



\author[1]{Francisco J. Civantos MD FACS}%
\affil[1]{University of Miami Miller School of Medicine}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
\let\center\flushleft
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\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
BACKGROUND

Coronavirus has serially overtaken our metropolitan hospitals. At peak,
patients with acute respiratory distress syndrome may outnumber
mechanical ventilators. In our Miami hospital system COVID-19 cases have
multiplied for 4 weeks and elective surgery has been suspended.

METHODS

An otolaryngologic triage committee was created to appropriately
allocate resources to patients. Hospital ethicists provided support. Our
tumor conference screened patients for non-surgical options. Patients
were tested twice for Sars-CoV-2 before performing urgent contaminated
operations. N95 masks and protective equipment were conserved when
possible. Patients with low-grade cancers were advised to delay surgery,
and other difficult decisions were made.

RESULTS

Hundreds of surgeries were cancelled. Sixty-five cases supervised over
three weeks are tabulated. Physicians and patients expressed discomfort
regarding perceived deviations from standards, but risk of Covid-19
exposure tempered these discussions.

CONCLUSIONS

We describe the use of actively managed surgical triage to fairly
balance our patient's health with public health concerns.%
\end{abstract}%



\sloppy


\textbf{Francisco J. Civantos MD FACS}

Virginia M. Horner Professor of Research in Otolaryngology

CoDirector H \& N Division/Sylvester Cancer Center/University of Miami
Miller School of Medicine

fcivanto@med.miami.edu; 305 726 4058

\textbf{Jason M. Leibowitz MD FACS}

Assistant Professor of Clinical Otolaryngology/Sylvester Cancer
Center/University of Miami Miller School of Medicine

JLeibowitz@med.miami.edu; 305 243 5276

\textbf{David J. Arnold MD FACS}

Associate Professor of Clinical Otolaryngology/Sylvester Cancer
Center/University of Miami Miller School of Medicine

DJArnold@med.miami.edu; 305 243 5276

\textbf{Vanessa C. Stubbs MD}

Fellow in Head and Neck Surgery/Microvascular Reconstruction/Sylvester
Cancer Center/University of Miami Miller School of Medicine

vxs493@med.miami.edu; 305 243 5276

\textbf{Jennifer H. Gross MD}

Fellow in Head and Neck Surgery/Microvascular Reconstruction/Sylvester
Cancer Center/University of Miami Miller School of Medicine

jxg1884@med.miami.edu; 305 243 5276

\textbf{Giovana R. Thomas MD FACS}

Associate Professor of Otolaryngology/Sylvester Cancer Center/University
of Miami Miller School of Medicine

GThomas@med.miami.edu; 305 243 5276

\textbf{Zoukaa Sargi MD MPH}

Associate Professor of Clinical Otolaryngology and Neurosurgery

Sylvester Cancer Center/University of Miami Miller School of Medicine

ZSargi@med.miami.edu; 305 243 5276

\textbf{Roy R. Casiano MD, FACS}

Professor and Vice Chairman Department of Otolaryngology

University of Miami, Miller School of Medicine

Phone: 305 243 5290

\textbf{Elizabeth J. Franzmann MD FACS}

Associate Professor of Otolaryngology

Sylvester Cancer Center/University of Miami Miller School of Medicine

EFranzman@med.miami.edu; 305 243 5276

\textbf{Donald Weed, MD, FACS}

W. Jarrard Goodwin Professor and Vice Chairman, Department of
Otolaryngology

Sylvester Comprehensive Cancer Center/ Co-Director H\&N Site Disease
Group

DWeed@med.miami.edu 305 243-9095

\textbf{Cesar Perez MD}

Assistant Professor, Department of Medicine

Sylvester Cancer Center/University of Miami Miller School of Medicine

cesar.perez@med.miami.edu; 305 243 4900

\textbf{Michael Samuels MD}

Professor, Department of Radiation Oncology/ Co-Director H \& N Site
Disease Group

Sylvester Cancer Center/University of Miami Miller School of Medicine

msamuels2@med.miami.edu; 305 243 1000

\textbf{Kenneth W. Goodman, PhD, FACMI, FACE}

Professor and Director, Institute for Bioethics and Health Policy

University of Miami Miller School of Medicine, Institute for Bioethics

KGoodman@med.miami.edu; 305 243 4900

\textbf{W. Jarrard Goodwin MD, FACS}

Sylvester Professor Department of Otolaryngology

Associate Chief Medical Officer for Sylvester/University of Miami
Hospital and Clinics~

WGoodwin@med.miami.edu 3052434386

~

We would like to acknowledge Fred Telischi, Chairman of Otolaryngology,
University of Miami Miller School of Medicine, for envisioning and
supporting the role of our Surgical Triage Committee.



\textbf{ABSTRACT}

\textbf{BACKGROUND}

Coronavirus has serially overtaken our metropolitan hospitals. At peak,
patients with acute respiratory distress syndrome may outnumber
mechanical ventilators. In our Miami hospital system COVID-19 cases have
multiplied for 4 weeks and elective surgery has been suspended.

\textbf{METHODS}

An otolaryngologic triage committee was created to appropriately
allocate resources to patients. Hospital ethicists provided support. Our
tumor conference screened patients for non-surgical options. Patients
were tested twice for Sars-CoV-2 before performing urgent contaminated
operations. N95 masks and protective equipment were conserved when
possible. Patients with low-grade cancers were advised to delay surgery,
and other difficult decisions were made.

\textbf{RESULTS}

Hundreds of surgeries were cancelled. Sixty-five cases supervised over
three weeks are tabulated. Physicians and patients expressed discomfort
regarding perceived deviations from standards, but risk of Covid-19
exposure tempered these discussions.

\textbf{CONCLUSIONS}

We describe the use of actively managed surgical triage to fairly
balance our patient's health with public health concerns.

\textbf{INTRODUCTION}

Our tradition in medicine, dating back to the Hippocratic oath in the
fifth century BC,\textsuperscript{1} has emphasized the importance of
putting our patient first, avoiding choices that might harm them, and
not considering issues unrelated to that particular patient's health as
we make our medical decisions. Public health considerations involving
risks to providers and other patients have not normally been factored
into the decision. Furthermore, what we have known to be best for the
patient in the past, has not involved calculating the risk of
contracting a potentially fatal infectious disease while merely walking
into the hospital.

Recently, however, the unprecedented and now-familiar events related to
the COVID-19 pandemic have affected communities all over the
globe,\textsuperscript{2,3,4} including South Florida. By the time of
this writing, Newsweek reported, based on U.S Center for Disease Control
and Prevention (CDC) data, that coronavirus had surpassed heart disease
and cancer as the number one killer of Americans on a daily
basis.\textsuperscript{5}

On March 14, US Surgeon General Jerome Adams recommended in a tweet that
hospitals stop all elective procedures amid the COVID-19
outbreak.\textsuperscript{6} The same day our two hospitals'
administrations issued an electronic communication asking surgeons to
cancel all elective surgeries at our facilities. On March 20 the
Governor of Florida issued a formal ban on elective
surgery\textsuperscript{7}. Permissible procedures included ``removal of
cancerous tumors, transplants, limb-threatening vascular surgeries,
trauma-related procedures, and dental care related to the relief of pain
and management of infection.''\textsuperscript{7} In practice, in
oncologic surgery, it was left to each institution to determine what was
urgent, and which patients would be best served by receiving surgery,
despite increased risk to the patient, providers, and other patients
during the pandemic.

Our approach, as we addressed surgical triage, was to consider each
patient's risk of complications related to receiving surgery in the
midst of the pandemic and deciding if that risk ''tipped the scales''
towards delaying care or planning an alternative treatment. Though data
was scarce, experience in China and Italy indicated that the risk of
either directly developing a coronavirus infection, or of ending up with
a complication requiring care in the midst of a situation of inadequate
medical resources, might outweigh the benefit of receiving cancer
surgery earlier in certain cases.\textsuperscript{3,4,8}

The greatest paradigm shift that occurs in times of crisis, however, is
the concept that the good of society, and the health of the caregivers
and other patients, may have some weight in the equation, even as
clinicians continue to make our patients' well-being our primary goal.
Considering these additional factors is the part that we may find most
difficult to adjust to. Furthermore, as we approach so called ``surge''
conditions in any disaster, and resources approach the point of being
overwhelmed, these factors may become more important, and even approach
or surpass those of the patients themselves.\textsuperscript{9,10}

In times of crisis, it is clearly recognized that standards of medical
care may have to be altered. In an almost clairvoyant publication,
intensivist and disaster management expert Michael Christian, MD,
published an essay entitled ``Triage'' in October
2019,\textsuperscript{9,} just before anyone imagined the events that
were about to unfold in Wuhan, China. He defines triage as ``allocating
scarce resources in order to do the greatest good for the greatest
number''. He emphasizes that appropriately performed triage, while
difficult, can save large numbers of lives, by preserving resources for
''salvageable'' patients. One must add to this equation the need to
protect caregivers so they can attend to other patients. There is an
extensive literature on appropriate crisis triage, based on experience
during warfare \textsuperscript{11,12,13} and natural
disasters.\textsuperscript{14,15} This was most recently seen in our own
country with the crisis in New Orleans in the aftermath of Hurricane
Katrina, when physicians in hospitals had to triage civilian patients in
a manner normally seen only in the midst of
battle.\textsuperscript{14,15}

While we can extrapolate from triage and management models developed for
times of war or natural disaster, this global pandemic is a different
entity entirely, affecting almost the entire planet at
once.\textsuperscript{2,3,4} It involves an ascension to a peak volume
and then a descension, rather than a single disaster date as would occur
with a natural disaster or act of war, and it is affecting Asia, Europe,
Africa, and the Americas within months of each
other.\textsuperscript{2,3} The SARS-CoV-1 epidemic of
2001-2004,\textsuperscript{16} the H1N1 influenza epidemic of
2009-2010,\textsuperscript{17} the Middle Eastern Respiratory Syndrome
(MERS) of 2012,\textsuperscript{18} and the West African Ebola
epidemic\textsuperscript{19} of 2013-14, were much more geographically
confined. Perhaps for this reason, there are no published reports of a
need for cancer patient triage during such epidemics. H1N1 Influenza, in
particular, was known to be virulent in patients with hematological
malignancies \textsuperscript{17}, especially if undergoing treatment,
but we found no reports that access to health care was threatened,
requiring triage of solid cancers. There were limited anecdotal reports
of health access issues during the Ebola crisis in West Africa; they
hinted at some of the issues we currently
face.\textsuperscript{20,21,22}

The ethics of triage and management in situations of crisis including
pandemics have been extensively discussed, modeled and prepared for, and
it is widely accepted that the rules need to be adjusted to each new
situation.\textsuperscript{9} Biddison et al.,\textsuperscript{10}, in a
consensus statement in the critical care literature, identify 23 ethical
guidelines for crisis situations. The importance of communication with
patients and families and the possibility of consulting ethicists is
emphasized. Moreover, they comment: ``We suggest critical care resources
be allocated based on specific triage criteria, irrespective of whether
the need for resources is related to the current disaster/pandemic or an
unrelated critical illness or injury. ``

Our purpose here is to provide a practical working example of how one
large head and neck oncology group sought to ensure that patients
requiring head and neck surgery received appropriate triage during the
pandemic, and were neither put at increased risk of a poor outcome from
their tumor nor from Covid-19 infection.

\textbf{MATERIALS AND METHODS}

As of this writing we continue to experience the ascending portion of
the COVID-19 crisis, where resources are being protected but are still
available. We have not had to deny access to surgery in a way that would
not meet normal standards of care, but we did have to make choices that
would not have been made in normal times. We would like to share the
process and approach that was used to make these decisions in three
example cases, and provide a table listing 65 patients triaged over a
three-week period with their diagnosis, history and disposition (Table
1).

Our system of triage evolved over this period of time, both in terms of
the number of negative SARS-Cov-2 tests required to approve patients for
surgery, and in terms of the emphasis on avoiding surgery. We sought to
maintain current standards of care, while making adjustments based on
the ascending COVID-19 crisis. The primary goal was always the
well-being of the patient. If any potential harm from not proceeding
immediately with surgery was not felt to be outweighed by the benefit of
keeping the patient away from the hospital during the pandemic, then the
surgery was performed, albeit with technical modifications to increase
safety. In cases where delays were believed to have little impact, or
where non-surgical therapies were thought to represent reasonable
alternatives, the benefit of keeping the patient safe from viral
infection or the risk of unknowingly operating during the prodrome of a
COVID-19 infection,\textsuperscript{20} might be judged to tip the
scales away from surgery. The public health benefits related to other
patients and providers were noted but assigned lower weight.

We created a committee of six senior faculty from a department of 32
clinical otolaryngologists. This Surgical Review Committee reviewed all
proposed operative cases from our university and county hospitals,
nearly all of which involved head and neck tumors.

There were five stages to the triage process:

The primary surgeons evaluated their preoperative (preop) patients and
made decisions with each patient regarding treatment adjustment. If a
variation occurred relative to the original plan or to our standard
practice, it generally was one of the following:

a. Delay of surgery for two to three months b. Transfer to a
non-surgical treatment, only if that approach met normal standards of
care.

c. Change in surgical approach (i.e. reduction of powered
instrumentation during endoscopic transnasal resection of neoplasms).

\begin{enumerate}
\tightlist
\item
  In all but the most straightforward cases, the surgeon as a next step
  would consult electronically with a colleague from the Surgical Review
  Committee. This allowed for an initial review of the case prior to the
  formal committee discussion.
\item
  Multidisciplinary questions were taken to a Head and Neck Tumor Board
  (conducted virtually), where issues related to triage during the
  pandemic drove the discussion. Subspecialized medical and radiation
  oncologists participated and could confirm agreement with the plans
  and acceptance of patients in those cases where a shift to nonsurgical
  care was advised.
\item
  For those cases in which the surgeon felt surgery was essential, the
  discussion was taken to the formal Surgical Review Committee again
  conducted ''virtually''. Presentation at the committee could result in
  suggested alterations of the surgical plan, delay of surgery, or
  transfer to a non-surgical approach.
\item
  If the surgeon, colleagues, or committee members, felt uncomfortable
  with the committee recommendations, consultation with our hospital
  ethicists was an option. Later, if uneasiness was expressed by the
  patient or family, involvement of the ethicist was again considered.
  In fact, we consulted with individual ethicists intermittently
  regarding our processes and approach, but never needed to involve the
  formal university ethics committee regarding specific patients.
\end{enumerate}

Various new standards evolved during this process. Some of these overlap
with those suggested by Day et al in their recent
guidelines.\textsuperscript{23} Some were uncontroversial, such as a
delay of surgery for most benign diagnoses. Yet even a benign diagnosis
can entail critical airway obstruction or aspiration, or other acute
loss of vital function for which the window of intervention could not be
extended. When MRI or CT findings suggested a more aggressive and
rapidly evolving process despite a benign biopsy, clinical features and
imaging took precedence. An example of this was an intranasal mass,
suspected to be a benign inverted papilloma or juvenile angiofibroma,
with progressive optic nerve compression and increasing vision loss. A
second standard was to consider delay of surgery for slow-growing
low-grade malignant tumors. Equivocal fine needle aspiration cytologic
results could create uncertainty, but these situations were usually
resolved by examining the clinical scenario and comparing serial
imaging. In some cases, repeat biopsy or imaging was suggested, but the
additional risk of more medical interventions to the patient and staff
in the coronavirus setting was always weighed. Delays were justified for
these more indolent malignancies, particularly if serial observation
confirmed stability on physical examination and/or imaging, and if the
patient had risk factors for a worse outcome with COVID-19 infection.
However, given the reports of poor outcomes in healthy patients operated
on during the prodrome of a COVID-19 infection \textsuperscript{8}, even
healthy patients were considered at risk. A third standard was the
transfer of the patient from a high-risk surgical procedure to
non-surgical therapy when this represented an equivalent standard of
care. The most common type of surgery for which this transition occurred
was for T1 and T2 oropharyngeal cancer, with negative or early stage
neck disease, where radiation with or without chemotherapy is a standard
alternative treatment. Endoscopic LASER resections (Transoral LASER
Microscopic Surgery or TLM), usually performed for supraglottic or
glottic cancer at our institution, represented a similar category. The
possibility of inhalation of smoke plume and the proximity of the
surgeon to the endoscope and the patient's oral cavity make these
high-risk procedures for viral transmission in either direction. A
fourth standard was that if delay or transfer to non-surgical therapy
could not be justified, such as for high-grade cancers, an unsafe wound
needing reconstruction, or respiratory issues, then surgery should
proceed as soon as possible, but - with the exception of immediate life
or death emergencies - should wait for appropriate COVID-19 testing. We
quickly realized however, that even with negative testing we still
needed to proceed with full personal protective equipment (PPE)
especially for high risk procedures involving mucosal incisions or use
of instrumentation resulting in potential aerosolization of viral
particles, as testing could give a false sense of security. Initially
one negative SARS-Cov-2 test was required, but early on, after Case 3
(below), this was converted to two negative test results with the last
negative result within 24 hours of surgery. Apparent false negatives and
false positives occasionally occurred, disrupting surgical planning and
postoperative care. This is consistent with early reports from China,
which report false negative rates as high as 30\% in known COVID-19
patients.\textsuperscript{24} No data is available on sensitivity and
specificity of routine testing of asymptomatic preop patients. We were
greatly assisted by the rapid institution of reverse transcription
polymerase chain reaction (RT-PCR) testing for Sars-CoV-2 by our
clinical laboratories, progressing within 10 days from a test that took
3 or 4 days to produce results to one that produced results in a few
hours. Quigen Rotorgene Platform using U.S. Centers for Disease Control
and Prevention primer pairs and the Genmark platform were the two types
of tests used. \textsuperscript{25,26}If proceeding with surgery,
suggestions were often given to reduce the scope of surgery or make the
surgical technique safer. For example, in one case it was thought
unjustified to send an early, relatively superficial T1 supraglottic
cancer in a young patient to radiation, but it was excised by cold
technique instead of LASER, in order to avoid the aerosolized LASER
plume. Another modification was the use of plastic covers for nasal
endoscopic skull base surgery (Figure 1) along with additional suctions
used to evacuate bone dust and cautery induced plumes, similar to smoke
evacuators used in LASER surgery. A fifth standard was that scheduling
of tracheostomy required special consideration. Tracheotomy is
potentially one of the highest risk operations we perform for possible
COVID-19 transmission due to the possibility of aerosolized secretions.
At the same time, tracheostomy on an intubated patient may allow for
weaning from the ventilator and exit from the intensive care unit (ICU),
freeing the spot for another patient. Tracheostomy in a COVID-19
positive patient presents a high risk. The likelihood that tracheostomy
would truly facilitate weaning for a particular patient was carefully
considered, and several guidelines and publications and recommendations
from our recently created departmental covid-19 tracheotomy advisory
committee were seriously weighed. Our department developed institutional
guidelines and protocol for tracheotomy during the pandemic based on
available published national and international guidelines, taking into
account the specific situation of our institution during the pandemic.
Current guidelines recommend delay of tracheostomy when appropriate in
the setting of acute SARS-Cov-2 infection until the patient becomes less
infectious.\textsuperscript{27}\textbf{RESULTS}From February 14 to April
10, 2020, we saw 129 new or suspected head and neck cancers and 83
benign tumors at our NCI designated cancer center. Suspected benign
processes were all rescheduled from clinic after March 9, so the benign
tumors were all seen before that. In addition, 13 new cancers were seen
at our county hospital over the same period, along with 8 benign tumors.
Patients needing surgery from among the patients seen at both
institutions would largely have been operated on in March and April.
Between March 15 and March 20, 2020, when our hospital instituted the
policy forbidding ''elective'' surgery, 281 otolaryngology procedures
already on the surgical schedule were cancelled at the University
hospital based on the initial determination by the surgeons and their
coordinators that they were elective. Another 215 patients had been
pending surgical scheduling in our otolaryngology department but did not
yet have an assigned date. An additional smaller number of scheduled
ears, nose, and throat procedures were at some point in scheduling at
our county hospital and were also cancelled or not scheduled,
approximately 50 cases. One hundred and eleven cases were left on the
surgical schedule by otolaryngologists after March 20, for consideration
as urgent. In addition, an unquantified, and probably larger group of
patients were in the process of being prepared for surgery, and soon to
be scheduled, and were ''self-triaged'' to wait or treat non-surgically
by the surgeons or by patients who were themselves concerned about
coronavirus infection despite having another serious diagnosis. Thus,
hundreds of patients were cut off from ''normal'' head and neck surgical
care. Those with urgent, mostly neoplastic diagnoses, were triaged
through the processes described under ''Materials and Methods''. Table 1
lists the first 65 patients that were triaged during the initial three
weeks after suspension of elective surgery. All patients who made it on
to the surgical schedule during these three weeks are listed. Diagnosis,
patient history, original surgical plan, and committee recommendations
and disposition are included. Patients who were transferred to
non-surgical care or delayed at the time of the primary surgeon's clinic
evaluation or through our tumor conference are not all included. Benign
tumors without airway issues are not included unless the surgeon decided
to request approval for surgery. Surgeries presenting through the
Emergency Room or Trauma Unit were also not included, but transfers from
other hospitals were evaluated just as outpatients would be. Our goal is
to provide an overview of the process that occurred. Three unique cases
are described below:

\textbf{CASE PRESENTATIONS}

Case 1 Suspected Malignancy in Retropharyngeal Nodes

An asymptomatic 37-year old woman with a history of papillary cancer of
the thyroid, presented in December 2019, referred for suspected
malignancy involving high retropharyngeal lymph nodes bilaterally,
detected on a contrasted Computed Tomography (CT) in October 2019
(figure 2).

The patient had four previous surgeries for well-differentiated
papillary thyroid cancer at other institutions. In 2006 she underwent
total thyroidectomy, removal of one central compartment node, and 9
lateral neck lymph nodes of which 6 contained malignancy. Based on
abnormal ultrasounds and thyroglobulin levels over the years, the
patient was taken back to surgery on three subsequent occasions,
including a comprehensive procedure in 2018, with revision neck
dissection bilaterally including level 6 and left level 5. Seven of 31
lymph nodes were positive.

Her only medication was oral levothyroxine. Head and neck physical
examination was notable only for surgical scars.

Due to the unusual location of these lymph nodes, there was concern that
these might represent a more aggressive lesion. The CT was indistinct in
evaluating the borders of the lesions. There were additional involved
lymph nodes more inferiorly in the right neck and some questionable
lymph nodes by CT criteria on the left. Review of her surgical pathology
from 2018 confirmed classical papillary thyroid cancer. Her
Thyroglobulin was 6.0 unstimulated. Stimulated Thyroglobulin elevated to
29.3.

We advised contrasted magnetic resonance imaging (MRI), and Positron
Emission Tomography/ Computed Tomography (PET-CT) to further evaluate,
along with presentation at our multidisciplinary head and neck tumor
conference. The MRI showed the well-encapsulated cystic retropharyngeal
lymph nodes more distinctly (figure 3), with 2 cm as the largest
dimension. The PET-CT was negative for Fluorodeoxyglucose uptake,
suggesting low-grade lesions. The retropharyngeal lesions were felt to
be inaccessible for fine needle aspiration.

We recommended bilateral revision neck dissection followed by bilateral
exploration of the parapharyngeal space, carefully following the carotid
upwards to excise the retropharyngeal lymph nodes. Laryngeal nerve
integrity monitoring would be used. Mobilization of the tail of parotid,
ligation of the external carotid artery, and possible identification of
the facial nerve in the parotid were felt to be potentially necessary to
achieve the exposure of the retropharyngeal nodes. The patient was
consented appropriately regarding risks, including cranial neuropathies
and first bite syndrome.

The patient obtained second opinion and presented again in early March,
and surgery was scheduled two weeks later. By March 15 the COVID-19
pandemic was in ascendance and elective surgery was suspended. The
working rule in our Case Review Committee had been to delay surgery for
well-differentiated thyroid cancer. This case was pre-reviewed by
committee members because of the unusual anatomic location of the
lesions. The recommendation was to repeat the MRI to confirm stability
on two similar studies. Repeat MRI confirmed no changes in the lesions
between January and April. Based on this, we recommended not to
hospitalize during the pandemic and planned surgery in three months.

CASE 2 Massive Goiter with Severe Tracheal Compression

A 62-year old woman presented to our county hospital emergency
department reporting dyspnea on exertion.

She now was noted to have reduced oxygen saturation after exertion. CT
with iodinated contrast at our facility confirmed severe tracheal
compression and a 5 mm tracheal width (figure 4). The compression was
positional and on certain axial images the tracheal lumen appeared
completely obscured (figure 5). The patient received intravenous
dexamethasone during this admission, respiration improved, and she was
discharged and counseled to avoid heavy exertion and avoid laying on the
right side.

The patient also had several elevated calcium levels and parathyroid
hormone levels (PTH), with her highest preoperative PTH at 110 pg/ml and
calcium at 11.4 mg/dl. Subsequent ultrasound and ''Four Dimensional'' CT
(Respiration correlated /parathyroid protocol CT) did not localize a
parathyroid adenoma.

The next week the patient was back in the emergency room with dyspnea.
Due to breathing difficulties we cancelled a planned parathyroid
(technetium 99 sestamibi) nuclear scan, and surgery was scheduled
urgently. The plan for airway management was awake fiberoptic intubation
with the smallest reinforced endotracheal tube that would fit over a
flexible bronchoscope and was long enough to reach beyond the narrowing
of the trachea, which was estimated to be a size six tube. We would not
be able to use the larger diameter tubes with electrodes for nerve
integrity monitoring. The emergency backup plan for airway management
was a cricothyroidotomy to allow placement of a smaller diameter,
shorter, pediatric size tube. At this point the pandemic was in its
ascendance. Significant questions were raised regarding the risk of
infection of the team during emergency airway management. Therefore,
given that she was comfortable on room air at rest, the patient was
discharged, and surgery was delayed for a few days so that it could be
moved to a cardiac bypass operating room which was set up for
extracorporeal membrane oxygenation (ECMO). She also was tested and
negative for COVID-19 by nasopharyngeal swab polymerase chain reaction
(RT-PCR) assay.

At surgery all staff in the room wore N95 masks and full PPE, including
face shields, hats and gowns. Under local anesthetic, the patient
underwent bilateral femoral line placement to allow for more rapid
conversion to ECMO if necessary. The nose and throat were topically
anesthetized with sparing use of topical lidocaine cream, avoiding
aerosolized topical anesthetic. She was successfully intubated awake
using a fiberoptic bronchoscope and size 6 reinforced tube, which just
reached the distal obstruction. The plan had been to initiate ECMO if
fiberoptic intubation failed, in order to reduce risk of aerosolization
of viral particles during an awake cricothyroidotomy.

The multinodular goiter was excised with visualization and preservation
of the recurrent laryngeal nerve. The goiter was bluntly delivered from
the mediastinum. Two obviously enlarged parathyroids were encountered,
and frozen section biopsy suggested parathyroid hyperplasia. We removed
both ipsilateral parathyroids and the intraoperative PTH dropped to 48.
Representative frozen section biopsy confirmed benign colloid nodule. At
this point, we elected not to explore contralaterally.

The patient recovered uneventfully with no respiratory issues and was
discharged 24 hours after surgery. Final pathology confirmed the
intraoperative diagnoses.

CASE \#3 Advanced Oral Cavity Cancer With False Positive COVID-19 RT-PCR

A 60-year old man presented with a 7-month history of a right sided oral
lesion, progressive over time and increasingly painful.

A biopsy showed invasive moderately differentiated squamous cell
carcinoma. Past medical history included myocardial infarction and
angioplasty 3 years before. His only medication was aspirin. Patient had
smoked cigarettes for twenty-five years, used chewing tobacco, and drank
4 drinks of liquor daily.

Physical examination revealed a right posterior buccal lesion, bulging
into the cheek and extending from inferior alveolar ridge to superior
alveolar ridge with trismus.

CT with iodine-based contrast media and PET-CT demonstrated the oral
lesion with limited bone erosion at the superior alveolar ridge. A
one-centimeter round level 1B node was positive on PET-CT.

The patient was scheduled for tracheostomy, full-thickness buccal
resection, marginal mandibulectomy, partial maxillectomy, right neck
dissection, and anterolateral thigh free flap reconstruction. Committee
review classified surgery as urgent and without equivalent non-surgical
alternatives. He had one negative COVID-19 RT-PCR performed three days
before surgery.

Shortly before surgery our policy changed to require that all urgent
mucosal surgeries have two COVID-19 RT-PCR tests. Since testing had a
3-day turnaround time, a second test was sent on the morning of surgery,
but surgery proceeded. The operation was uncomplicated. Staff wore N95
masks, face shields, and gowns. His postoperative course was typical,
but on postoperative day 3 his preop COVID-19 RT-PCR test resulted
positive and the patient was moved to a COVID-19 ward. The patient never
had symptoms.

Significant controversy arose because residents and nurses had been
caring for his tracheostomy using N95 masks and face shields, but not
always with full PPE. The surgeons involved had to defend the ethics of
proceeding to surgery with a pending COVID-19 RT-PCR. All future mucosal
cases were subsequently required to have two tests with results
completed before surgery. Fortunately, our facility concurrently
acquired a rapid test with two-hour turnaround time, and a third test
performed on postoperative day 4 which returned negative. Given the two
negative tests, and absence of symptoms, it was decided that the second
test was likely a false positive. The patient spent only one night on
the designated coronavirus floor.

One member of the operative team, a ``scrub'' technician who entered the
procedure briefly, later became mildly symptomatic and tested positive
for coronavirus RT-PCR. Other members of the surgical team and nurses
and housestaff performing postoperative care all tested negative. The
origin of the exposure of our technician is difficult to determine.

The patient was discharged home on postoperative day 9 with a
nasogastric feeding tube and a tracheostomy tube with a plan to remove
both soon in the office. Final pathology revealed negative margins,
perineural invasion at the primary site, and a 9-millimeter lymph node
grossly involved by cancer at level 1B with extracapsular extension,
leading to a recommendation for chemoradiation postoperatively.

\textbf{DISCUSSION}

No randomized trials provide data regarding the appropriate systems and
policies for the triage of patients with potentially fatal cancers
during a global pandemic. The infrastructure and regulations for
appropriate triage of the ill and injured that have been developed for
crisis triage during war and natural disaster serve as guides, but these
situations are not the same, as they may be more intense, but are more
limited in time and area of geographic involvement. What is safe, fair
and appropriate may not always be clear as the availability of medical
resources decreases over time, and while these are threatened in the
future, they are still selectively available in the present. Our
policies must change and evolve depending on the magnitude of the
situation.\textsuperscript{9,28}

In the absence of data to guide us, we involved the most experienced
surgeons available, and extensive open discussion in multiple forums was
followed by formal committee review in order to make decisions. While in
theory the committee chairman had the final word, there was always a
consensus regarding the appropriate approach. Even primary surgeons who
were advocating for a surgical plan on their specific patient accepted
the magnitude of the situation and the reasons for decisions that were
made.

In the escalating phase of an epidemic when the hospital is trying to
keep beds open in anticipation of patient needs, what is appropriate and
ethical may be very different from when the pandemic is at its
peak.\textsuperscript{9,28} Difficult decisions may seem unjustified at
a point where we are preparing for expected volume, but still have
unoccupied beds, compared to later when the system enters crisis mode.
However it would be a fallacy to think that we can ``catch up'' later,
and modeling studies of pandemic crises generally confirm that proper
early triage can save lives dramatically over a ``first come first
served'' approach.\textsuperscript{9,28} At the same time others have
pointed out that triage poorly done, based on improper clinical
parameters, can actually lead to worse
outcomes.\textsuperscript{9,28,29,30} This could occur due to
underestimating or overestimating the severity of a patient's condition,
and underutilizing or overutilizing resources, and can actually save
fewer lives rather than more.\textsuperscript{28,29,30} Thus recommended
decisions must be based on appropriate in depth criteria, including
understanding and reviewing histology or cytology when possible, and
reviewing or repeating imaging when appropriate.

In the absence of exact data, even more problematic is how to factor in
the changing level of risk over time of coronavirus infection in these
cancer patients, some of whom fall in high risk groups for COVID-19,
while also considering the public health goals of conserving intensive
care unit beds, ventilators, and PPE. Furthermore, we must then
calculate the risk level and relative importance of protecting
providers, not only out of fairness to the provider, but also because
the provider is a valuable resource in short supply who will be able to
treat other patients during the pandemic.\textsuperscript{9,28,29,30} At
the time of writing this manuscript, our healthcare systems (UHealth and
Jackson Memorial Hospital) have so far reported the death of one nurse,
one MRI technician, one physician faculty member and one radiology
technician as a result of COVID-19.

We emphasize the importance of communicating well with patients and
surgeons throughout the process, and reminding them to consider all
risks, including risk of COVID-19, emphasizing the Surgeon General
recommendations regarding elective surgery, and providing data as needed
regarding alternatives for cancer treatment.

Several specialty societies have published guidelines regarding cancer
management during the pandemic. These do not specify at what point they
should be instituted, and how severe the situation should be. Some of
the recommendations, allow potential misinterpretation. For example, the
Society of Surgical Oncology has suggested delay of treatment for thin
invasive melanomas, and prioritization of surgery only for thicker
melanomas.\textsuperscript{31} While the reasons for this recommendation
are understood, and there are many details to consider, the approach
seems debatable in a situation where resources are being protected, but
some are still available, as this early group of invasive melanomas are
those most likely to be cured by surgery.

The American Head and Neck Society has not published specific
guidelines. We have referred here to the publication by Day et
al\textsuperscript{23} that provides some reasonable guidelines and we
add our suggestions here. Our recommendations, in the absence of
randomized data, come from practical work triaging surgeries during this
process:

1)All head and neck cases for which a change in plan is under
consideration should be reviewed by a multidisciplinary tumor conference
to provide care recommendations specifically in the context of COVID-19
with appropriate documentation of how the pandemic has impacted
treatment recommendations.

2)A departmental surgical review committee should be established to
evaluate all cases proposed for surgical care to provide independent
review of appropriate urgency for surgical scheduling. This committee
provides a second level of review that is guided by the primary
physician's assessment and recommendations, multidisciplinary
recommendations from tumor conference, as well as the important
independent perspective of non-head and neck surgeons with regard to
resource utilization and patient and staff safety concerns. The surgical
review committee should have real-time access to hospital ethics
committee consultation when necessary.

3) We suggest delay for 2 to 3 months of surgery for low-grade
malignancies, including well differentiated thyroid cancers and
low-grade parotid cancers, and skin cancers not threatening vital
functions.

4)We recommend that these patients be followed closely with
consideration for repeat imaging during this period to allow for
correction of the approach if the tumor is progressing.

5)When surgery is clearly the superior option for a high-grade mucosal
cancer, such as for oral cavity cancer, we would recommend proceeding to
surgical treatment. At the height of the pandemic surge this may to be
interrupted, but when capacity is still available, these patients'
survival is at stake and they should have a fair claim to available
resources.

6)The importance of available rapid accurate testing for active
Sars-CoV-2 infection in order to allow surgical care to be offered
cannot be overstated. Naturally, given the novelty of this virus,
current testing technology is in its early stages. We eagerly await more
accurate and reliable testing, including well validated data for false
negatives and false positives in the setting of preoperative patients
without symptoms of COVID-19.

7)During this brief point in time, mucosal cancers for which
non-surgical options are considered appropriate should be considered for
non-surgical treatment. Specifically, TORS and TLM are often used in
clinical scenarios where non-surgical options offer equivalent survival,
and both represent high risk procedures.

During endoscopic surgery the surgeon's face is sometimes in close
proximity to the rigid laryngoscope during parts of the procedure. Even
when behind the microscope, they could, in theory, inhale Sars-CoV-2
particles in smoke plume. Given the significant false negative
rate\textsuperscript{24} of available tests for COVID-19, even with two
negative tests, there is still some risk to the surgeon and staff. We do
have information reporting that the rate of acquiring COVID-19 is higher
for head and neck surgeons, ophthalmologists, and oral surgeons than it
is for radiation oncologists, presumably due to the greater risk of
exposure to aerosolized or touched secretions.\textsuperscript{33}

It should be acknowledged, in terms of ethics, that the decision to
irradiate patients instead of operating endoscopically is one of those
situations where we are weighing the public health risk, including the
risk to the surgical team, and transferring risk to another setting with
limited data to support it. The risk to the patient, in particular, of 6
weeks of radiation with multiple trips to the facility has not been
proven to be less than a single endoscopic intervention. Since there are
risks associated with an inpatient stay and possible lack of access to
medical resources during a surge, in addition to risk of viral exposure,
it is very hard to quantify this ''moving target'' relative to 30 to 35
visits to radiation oncology. Some have pointed out that for
immunocompromised patients in particular, multiple trips to the hospital
also represent a significant risk,\textsuperscript{32} but the answer is
just not known.

Currently at our institution, all patients undergoing radiation and
chemotherapy are being tested for COVID-19 prior to start of treatment,
but not repeatedly. Patients testing positive on that first test get
treated separately at the end of the day. There is a risk that a patient
could have a true-negative test at the outset, only to develop COVID
infection later and then unknowingly expose other patients or radiation
oncology staff during any period in which the infection was not
clinically evident.

The most significant concern in the definitive radiation setting is the
risk, not to the staff, but to the patient. In our institution, there is
no routine testing of unexposed faculty or staff for COVID-19 infection.
The use of PPE by staff varies by role, with many staff members wearing
simple masks only. Radiation therapy technologists wear N95 masks, face
shields and gloves while treating head/neck cancer patients, but the
nursing staff and some physicians wear only gloves and simple masks.
Fundamentally, the difference in testing policy regarding patients
(mandatory testing) and staff (no routine testing) has the potential for
significant risk to patients over the extended timeframe of radiation
treatment.

As we move from a complete ban on elective surgery, towards
reincorporating some relatively important cases that have been awaiting
institutional clearance for surgery, significant stress will likely
occur as we try to determine to which of these patient's medical
resources should be allocated first. This will create new conversations
and may lead to tension between services as debates develop about the
relative value of investing resources in ''sicker'' patients versus
''more salvageable patients''.

The head and neck patients triaged to delay in surgical care, primarily
the low-grade malignancies, will be the first group for re-consideration
by the surgical review committee. These patients will now face perhaps
an even more complex path on their journey to finally achieving the
surgical care they need in this unprecedented time. They will now be
evaluated alongside non-malignant cases with the potential for serious
complications with ongoing delay. Such cases might include erosive
cholesteatomas with bone loss and risk of cerebrospinal fluid leak, or
similar patients with aggressive but benign paranasal sinus disease. In
our system these will compete for operative time that has been assigned
to the Otolaryngology Department. Such comparisons are likely to be much
more nuanced than the decisions the surgical review committee has faced
to this point and may present even greater challenges to decision
making.

Prachand et al, in a general surgical setting, recently published online
regarding this dilemma and their own ''Cumulative Medically-Necessary
Time-Sensitive (MeNTS) Score'', which attempts to introduce objectivity
into this process. While we have not attempted to use this tool, such
efforts at maintaining objectivity may help introduce greater fairness
into this process. \textsuperscript{34}

\textbf{CONCLUSIONS}

The Coronavirus pandemic has forced us to rethink our usual paradigms in
head and neck surgery. We describe our department's choice to use a
``top down'' approach, with supervision and control of the operating
rooms at an administrative level. We recommend that triage be conducted
with the patient's personal health interests as the guiding principle,
and that public health concerns be weighed as a strong secondary
consideration.

REFERENCES\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
1. Hippocrates. Oath of Hippocrates. The Hippocratic Oath and the Ethics
of Medicine. Ed. Steve Miles. New York: Oxford University Press, 2004,
xiii-xiv. 2. Sheng-Qun Deng, Hong-Juan Peng. Characteristics of and
Public Health Responses to the Coronavirus Disease 2019 Outbreak in
China. J. Clin. Med.~2020,~9(2), 575-585. 3. Gabutti G, d'Anchera E,
Sandri F, Savio M, Stefanati A. Coronavirus: Update Related to the
Current Outbreak of COVID-19. Infect Dis Ther. 2020 Apr 8. doi:
10.1007/s40121-020-00295-5. {[}Epub ahead of print{]}. 4. Ahn DG, Shin
HJ, Kim MH, Lee S, Kim HS, Myoung J, Kim BT, Kim SJ.Current Status of
Epidemiology, Diagnosis, Therapeutics, and Vaccines for Novel
Coronavirus Disease 2019 (COVID-19) J Microbiol Biotechnol. 2020 Mar
28;30(3):313-324. doi: 10.4014/jmb.2003.03011. 5. Coronavirus Becomes
Number One Cause of Death Per Day in U.S., Surpassing Heart Disease and
Cancer. Mathhew Impelli. Newseek (online), April 9, 2020 (Based on CDC
statistics).\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
1. Hippocrates. Oath of Hippocrates. The Hippocratic Oath and the Ethics
of Medicine. Ed. Steve Miles. New York: Oxford University Press, 2004,
xiii-xiv. 2. Sheng-Qun Deng, Hong-Juan Peng. Characteristics of and
Public Health Responses to the Coronavirus Disease 2019 Outbreak in
China. J. Clin. Med.~2020,~9(2), 575-585. 3. Gabutti G, d'Anchera E,
Sandri F, Savio M, Stefanati A. Coronavirus: Update Related to the
Current Outbreak of COVID-19. Infect Dis Ther. 2020 Apr 8. doi:
10.1007/s40121-020-00295-5. {[}Epub ahead of print{]}. 4. Ahn DG, Shin
HJ, Kim MH, Lee S, Kim HS, Myoung J, Kim BT, Kim SJ.Current Status of
Epidemiology, Diagnosis, Therapeutics, and Vaccines for Novel
Coronavirus Disease 2019 (COVID-19) J Microbiol Biotechnol. 2020 Mar
28;30(3):313-324. doi: 10.4014/jmb.2003.03011. 5. Coronavirus Becomes
Number One Cause of Death Per Day in U.S., Surpassing Heart Disease and
Cancer. Mathhew Impelli. Newseek (online), April 9, 2020 (Based on CDC
statistics).\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
1. Hippocrates. Oath of Hippocrates. The Hippocratic Oath and the Ethics
of Medicine. Ed. Steve Miles. New York: Oxford University Press, 2004,
xiii-xiv. 2. Sheng-Qun Deng, Hong-Juan Peng. Characteristics of and
Public Health Responses to the Coronavirus Disease 2019 Outbreak in
China. J. Clin. Med.~2020,~9(2), 575-585. 3. Gabutti G, d'Anchera E,
Sandri F, Savio M, Stefanati A. Coronavirus: Update Related to the
Current Outbreak of COVID-19. Infect Dis Ther. 2020 Apr 8. doi:
10.1007/s40121-020-00295-5. {[}Epub ahead of print{]}. 4. Ahn DG, Shin
HJ, Kim MH, Lee S, Kim HS, Myoung J, Kim BT, Kim SJ.Current Status of
Epidemiology, Diagnosis, Therapeutics, and Vaccines for Novel
Coronavirus Disease 2019 (COVID-19) J Microbiol Biotechnol. 2020 Mar
28;30(3):313-324. doi: 10.4014/jmb.2003.03011. 5. Coronavirus Becomes
Number One Cause of Death Per Day in U.S., Surpassing Heart Disease and
Cancer. Mathhew Impelli. Newseek (online), April 9, 2020 (Based on CDC
statistics).\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
6. Tweet from @Surgeon\_General, March 14, 2020. Twitter. 7. State of
Florida, Office of the Governor, Executive Order EO 20-72. Emergency
Management -- Covid-19 -- Nonessential Elective Medical Procedures. 8.
Lei S., Clinical characteristics and outcomes of patients undergoing
surgeries during the incubation period of COVID-19 infection. EClinical
Medicine. March 14, 2020,
\url{https://doi.org/10.1016/jeclinm.2020.200331} 9. Christian MD.
Triage. Crit Care Clin. 2019 Oct;35(4):575-589. 10. Biddison LD,
Berkowitz KA, Courtney B, De Jong CM, Devereaux AV, Kissoon N, Roxland
BE, Sprung CL, Dichter JR, Christian MD, Powell T; Ethical
considerations: care of the critically ill and injured during pandemics
and disasters: CHEST consensus statement. Task Force for Mass Critical
Care. Chest. 2014 Oct;146(4 Suppl):e145S-55S. 11. Mansky R, Scher C.
Thoracic trauma in military settings: a review of current practices and
recommendations. Curr Opin Anaesthesiol. 2019 Apr;32(2):227-233. 12.
Strous RD, Gold A. Ethical lessions learned and to be learned from mass
casualty events by terrorism. Curr Opin Anaesthesiol. 2019
Apr;32(2):174-178. 13. Falzone E, et al. Triage in Military Settings.
Anaesth Crit Care Pain Med. 2017 Feb;36(1):43-51. 14. Pou AM.Ethical and
legal challenges in disaster medicine: are you ready?South Med J. 2013
Jan;106(1):27-30. 15. Pou AM. Hurricane Katrina and disaster
preparedness. N Engl J Med. 2008 Apr 3;358(14):1524 16. Demmler GJ,
Ligon BL. Severe acute respiratory distress syndrome (SARS): a review of
the history, epidemiology, prevention, and concerns for the future.
Semin Pediatr Infect Dis. 2003 Jul;14(3):240-244. 17. Vilar-Compte D, et
al Chemaly RF. Influenza in patients with hematological malignancies:
Experience at two comprehensive cancer centers. J Med Virol. 2018
Jan;90(1):50-60. 18. Azhar EI, et al. The Middle East Respiratory
Syndrome. Infect Dis Clin North Am. 2019 Dec;33(4):891-905. 19. Hasan S,
et al. Ebola virus: A global public health menace: A narrative review. J
Family Med Prim Care. 2019 Jul;8(7):2189-2201 20. Pottie K. Cancer~in a
time of~Ebola. Canadian Medical Association Journal.
2016~188~(10)~759-760. 21. Wang S, et al.Advances in addressing
technical challenges of point of care diagnostics in resource-limited
settings. Expert Rev Mol Diagn. 2016;16(4):449-59. 22. Bolkan HA,
Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and indirect
effects on health service function in sierra leone. PLoS Curr 2014. 23.
Day, A et al Head and neck oncology during the COVID-19 pandemic:
Reconsidering traditional treatment paradigms in light of new surgical
and other multilevel risks. \emph{Oral Oncol}. 2020 Apr 6 :
104684.doi:~\emph{10.1016/j.oraloncology.2020.104684}~{[}Epub ahead of
print{]} 24. Yang Yang et al. Evaluating the accuracy of different
respiratory specimens in the laboratory diagnosis and monitoring the
viral shedding of 2019-nCoV infections
\url{https://doi.org/10.1101/2020.02.11.20021493} 25. Schmitz JE, Tang
YW. The GenMark ePlex\selectlanguage{ngerman}\textsuperscript{®}: another weapon in the
syndromic arsenal for infection diagnosis. Future Microbiol 2018.
1697-1708. 26. Adams JA et al. Performance evaluation comparison of 3
commercially available PCR based KRAS mutation testing platforms. Appl
Immunohistochem Mol MOrphol. 2014: 231-5. 27. Luiz P Kowalski, et al
OVID-19 pandemic: effects and evidence-based recommendations for
otolaryngology and head and neck surgery practice. ISSN:~1043-3074 ,
1097-0347. 28. Ross SW et al. Maximizing the Calm Before the Storm:
Tiered Surgical Response Plan for Novel Coronavirus (COVID-19). JAm Coll
Surg. 2020 29. Gall C, Wetzel R, Kolker A, Kanter RK, Toltzis P.
Pediatric Triage in a Severe Pandemic:Maximizing Survival by
Establishing Triage Thresholds. Crit Care Med. 2016 Sep;44(9):1762-8.
30. Kanter RK. Would Triage Predictors Perform Better Than First Come
First Served in Pandemic Ventilator Allocation? Chest 2015.
147(1):102-108. 31. Resource for Management Options of Melanoma During
COVID-19, Society of Surgical Oncolog, March 30, 2020.
\url{https://www.surgonc.or/wp-content/uploads/2020/03/Melanoma-Resourc-during-COVID-19-3.30.20.pdf}
32. Civantos AM et al. Care of Immunocompromised Patients with Head and
Neck Cancer During the COVID-19 Pandemic: Two Challenging and
Informative Clinical Cases. Head Neck. 2020 Apr 16. doi:
10.1002/hed.26165. {[}Epub ahead of print{]} 33. Givi G et al. Safety
Recommendations for Evaluation and Surgery of the Head and Neck During
the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020 Mar 31. doi:
10.1001/jamaoto.2020.0780. {[}Epub ahead of print{]} 34. Prachand VN et
al. Medically-Necessary, Time-Sensitive Procedures: A Scoring System to
Ethically and Efficiently Manage Resource Scarciyt and Provider Risk
During the COVID-19 Pandemic. Journal of the American College of
Surgeons. \url{https://doi.org/10.1016/j.jamcollsurg.2020.04.011}

\subsubsection*{}

{\label{section}}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
6. Tweet from @Surgeon\_General, March 14, 2020. Twitter. 7. State of
Florida, Office of the Governor, Executive Order EO 20-72. Emergency
Management -- Covid-19 -- Nonessential Elective Medical Procedures. 8.
Lei S., Clinical characteristics and outcomes of patients undergoing
surgeries during the incubation period of COVID-19 infection. EClinical
Medicine. March 14, 2020,
\url{https://doi.org/10.1016/jeclinm.2020.200331} 9. Christian MD.
Triage. Crit Care Clin. 2019 Oct;35(4):575-589. 10. Biddison LD,
Berkowitz KA, Courtney B, De Jong CM, Devereaux AV, Kissoon N, Roxland
BE, Sprung CL, Dichter JR, Christian MD, Powell T; Ethical
considerations: care of the critically ill and injured during pandemics
and disasters: CHEST consensus statement. Task Force for Mass Critical
Care. Chest. 2014 Oct;146(4 Suppl):e145S-55S. 11. Mansky R, Scher C.
Thoracic trauma in military settings: a review of current practices and
recommendations. Curr Opin Anaesthesiol. 2019 Apr;32(2):227-233. 12.
Strous RD, Gold A. Ethical lessions learned and to be learned from mass
casualty events by terrorism. Curr Opin Anaesthesiol. 2019
Apr;32(2):174-178. 13. Falzone E, et al. Triage in Military Settings.
Anaesth Crit Care Pain Med. 2017 Feb;36(1):43-51. 14. Pou AM.Ethical and
legal challenges in disaster medicine: are you ready?South Med J. 2013
Jan;106(1):27-30. 15. Pou AM. Hurricane Katrina and disaster
preparedness. N Engl J Med. 2008 Apr 3;358(14):1524 16. Demmler GJ,
Ligon BL. Severe acute respiratory distress syndrome (SARS): a review of
the history, epidemiology, prevention, and concerns for the future.
Semin Pediatr Infect Dis. 2003 Jul;14(3):240-244. 17. Vilar-Compte D, et
al Chemaly RF. Influenza in patients with hematological malignancies:
Experience at two comprehensive cancer centers. J Med Virol. 2018
Jan;90(1):50-60. 18. Azhar EI, et al. The Middle East Respiratory
Syndrome. Infect Dis Clin North Am. 2019 Dec;33(4):891-905. 19. Hasan S,
et al. Ebola virus: A global public health menace: A narrative review. J
Family Med Prim Care. 2019 Jul;8(7):2189-2201 20. Pottie K. Cancer~in a
time of~Ebola. Canadian Medical Association Journal.
2016~188~(10)~759-760. 21. Wang S, et al.Advances in addressing
technical challenges of point of care diagnostics in resource-limited
settings. Expert Rev Mol Diagn. 2016;16(4):449-59. 22. Bolkan HA,
Bash-Taqi DA, Samai M, Gerdin M, von Schreeb J. Ebola and indirect
effects on health service function in sierra leone. PLoS Curr 2014. 23.
Day, A et al Head and neck oncology during the COVID-19 pandemic:
Reconsidering traditional treatment paradigms in light of new surgical
and other multilevel risks. \emph{Oral Oncol}. 2020 Apr 6 :
104684.doi:~\emph{10.1016/j.oraloncology.2020.104684}~{[}Epub ahead of
print{]} 24. Yang Yang et al. Evaluating the accuracy of different
respiratory specimens in the laboratory diagnosis and monitoring the
viral shedding of 2019-nCoV infections
\url{https://doi.org/10.1101/2020.02.11.20021493} 25. Schmitz JE, Tang
YW. The GenMark ePlex\selectlanguage{ngerman}\textsuperscript{®}: another weapon in the
syndromic arsenal for infection diagnosis. Future Microbiol 2018.
1697-1708. 26. Adams JA et al. Performance evaluation comparison of 3
commercially available PCR based KRAS mutation testing platforms. Appl
Immunohistochem Mol MOrphol. 2014: 231-5. 27. Luiz P Kowalski, et al
OVID-19 pandemic: effects and evidence-based recommendations for
otolaryngology and head and neck surgery practice. ISSN:~1043-3074 ,
1097-0347. 28. Ross SW et al. Maximizing the Calm Before the Storm:
Tiered Surgical Response Plan for Novel Coronavirus (COVID-19). JAm Coll
Surg. 2020 29. Gall C, Wetzel R, Kolker A, Kanter RK, Toltzis P.
Pediatric Triage in a Severe Pandemic:Maximizing Survival by
Establishing Triage Thresholds. Crit Care Med. 2016 Sep;44(9):1762-8.
30. Kanter RK. Would Triage Predictors Perform Better Than First Come
First Served in Pandemic Ventilator Allocation? Chest 2015.
147(1):102-108. 31. Resource for Management Options of Melanoma During
COVID-19, Society of Surgical Oncolog, March 30, 2020.
\url{https://www.surgonc.or/wp-content/uploads/2020/03/Melanoma-Resourc-during-COVID-19-3.30.20.pdf}
32. Civantos AM et al. Care of Immunocompromised Patients with Head and
Neck Cancer During the COVID-19 Pandemic: Two Challenging and
Informative Clinical Cases. Head Neck. 2020 Apr 16. doi:
10.1002/hed.26165. {[}Epub ahead of print{]} 33. Givi G et al. Safety
Recommendations for Evaluation and Surgery of the Head and Neck During
the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020 Mar 31. doi:
10.1001/jamaoto.2020.0780. {[}Epub ahead of print{]} 34. Prachand VN et
al. Medically-Necessary, Time-Sensitive Procedures: A Scoring System to
Ethically and Efficiently Manage Resource Scarciyt and Provider Risk
During the COVID-19 Pandemic. Journal of the American College of
Surgeons. \url{https://doi.org/10.1016/j.jamcollsurg.2020.04.011}

\subsubsection*{}

{\label{section-1}}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
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\subsubsection*{}

{\label{section-2}}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/plasticsheetforendoscopicskullbasesurgery/plasticsheetforendoscopicskullbasesurgery}
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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/figure2case/figure2case}
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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/figure3MRIdouble/figure3MRIdouble}
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\end{figure}\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/figure5/figure5}
\caption{{This is a caption
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\end{center}
\end{figure}



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\verb`Table_1.docx`  available at \url{https://authorea.com/users/312328/articles/444990-ethical-surgical-triage-of-head-and-neck-cancer-patients-during-the-covid-19-pandemic}

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