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September 3, 2020

Hearing From the COVID-19 Epicenter—A Neurotologist’s Reflection From the Front Lines

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York
JAMA Otolaryngol Head Neck Surg. 2020;146(10):889-890. doi:10.1001/jamaoto.2020.2532

I am a neurotologist, but in April 2020, I worked as a medicine attending physician, staffing an inpatient coronavirus disease 2019 (COVID-19) ward in New York City. As with all hospitals in the US epicenter, Mount Sinai Health System experienced a surge of COVID-19–positive patients; during the peak, there were more than 10 consecutive days with more than 2000 COVID-19–positive inpatients across our 8-hospital health system (with a pre–COVID-19 inpatient capacity of 3184, not accounting for surge beds created during the peak). Charting unprecedented waters, our otolaryngology department responded in a variety of ways, including running a temporary intensive care unit at Elmhurst Hospital, a difficult-airway response team, and an otolaryngologist-run inpatient COVID-19 medicine unit for patients with mild to moderate disease.

During my first night shift running the inpatient COVID-19 ward, I felt like I was reliving my surgical internship more than 17 years earlier. That was the last time I could remember functioning as anything but an otolaryngologist. I remembered the anxious anticipation of an unfamiliar rotation, the weight of recently acquired knowledge, and the overwhelming desire to help. After years in neurotology practice, I did not expect this experience to teach me a valuable lesson about hearing and communication.

Unlike my internship, this time around, my anxiety was nuanced—perhaps I was buoyed by the keen recognition of “knowing what I did not know” and how far I was from the temporal bone. It was also more personal: as a mother with an otolaryngology husband working in a COVID-19 intensive care unit in another New York City hospital, the fear of exposing our children made “doffing” a household word. (A new meaning of the word “exposure” emerged later, as I stripped in our apartment building stairwell upon coming home from a shift.)

In ways that are all too familiar, all anxiety quickly evaporated in the thick cloud of work that hit with entry to the hospital. We opened the ward with 6 patients, and by the end of my first 12-hour shift we were nearly at our capacity of 20 patients. In general, our institutional response was commendably organized: all deployed physicians had undergone webinars created by our own intensivists focused on “COVID-19 care for the nonintensivist,” pearls of pulmonary medicine, and personal protective equipment (PPE). Vetted COVID-19 treatment pathway algorithms were widely dispersed to frontline clinicians and updated on a weekly (or even daily) basis. Although we ran the ward as medicine physicians, we had constant backup by both medicine chief residents and hospitalists, all of whom met our queries with patience and appreciation despite being quite busy in their own right.

In short order, we acclimated to our new, temporary normal outside otolaryngology. Asking patients to put down their phone during a rapid response or intubation reflected a new dissonance forced by the strange physiology of this disease (an experience I shared with many on the front lines, as noted by Dr Levitan in the New York Times article “What Doctors on the Front Lines Wish They’d Known a Month Ago”1). Not only had we transformed, but the hospital itself was almost unrecognizable: the postanesthesia care unit was packed with prone, intubated patients; newly constructed tents surrounded the building; unit entrances were guarded by pathology and psychiatry residents dispensing PPE; and empty patient bedsides echoed the profound loneliness of this illness.

Despite unfamiliar tasks against a formidable enemy, the foundations of patient care were never more salient or instinctual—vigilant monitoring of vital signs, quick recognition of the work of breathing, reassuring patients, and updating families. Yet nearly all of it occurred in a fog of white noise, behind mountains of lifesaving PPE, making even basic conversation an unfamiliar struggle. At first, it seemed as if the COVID-19 ward had stripped me of one of my most honed and treasured skills—communication. Conveying simple information, let alone empathy and reassurance, without much visible facial expression or vocal inflection was awkward at best. Facetiming a patient’s family member through my cell phone (which was inside a plastic bag) in a room filled with the cacophony of beeps; drone from the giant, temporary HEPA filtration machine; and many voices of the rapid response team seemed like an exercise in futility. And for those with a hearing impairment—whether clinician or patient—these communication barriers were literally deafening. Although I am an “expert” in hearing, the COVID-19 ward stretched my understanding of the fear and isolation that accompanies an inability to hear.

As otolaryngologists, the anatomy and functionality of communication is a foundational concept in our specialty. Pathologies related to hearing loss, hoarseness, facial nerve function, and others have well-researched and acknowledged effects on human communication. Yet across medicine and society, the impact of hearing loss remains underrecognized, undervalued, and undertreated. Statistics abound regarding high prevalence of hearing loss, infrequent use of amplification, and minimal attention on prevention. Over the past decade, substantial research has established many relationships between hearing loss and health, including cognitive function, social isolation, depression, and even mortality. Yet untreated hearing loss remains a major public health burden. While complexities of access and cost play a large role in both diagnosis and treatment of hearing loss, so too does personal recognition and acceptance—on the part of both patient and physician.

Perhaps this COVID-19 pandemic represents an opportunity to highlight the importance of hearing in communication—for ourselves and for patients. As noted quickly by the hearing-impaired community, facial coverings impede communication by blocking lip reading, dampening speech, and limiting interpretation of facial expression. With increasing use of face masks in our offices and our communities, perhaps the frustration I experienced—and insight I gleaned—will resonate far outside an inpatient COVID-19 ward.

As we navigate in-person and telehealth visits in the time of COVID-19, let us take the time to acknowledge the impact and burden of hearing loss and support and disseminate solutions. Use of clear masks or hoods, speech-to-text applications, and the chat function during telemedicine visits are just a few items that may facilitate communication during this time.

As otolaryngologists, our leadership and attention to issues of hearing and communication are crucial to command recognition and change. Let us use this opportunity to shine a light on this too-often invisible disability.

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Article Information

Corresponding Author: Maura K. Cosetti, MD, Department of Otolaryngology–Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th St, New York, NY 10003 (maura.cosetti@mountsinai.org).

Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2532

Conflict of Interest Disclosures: Dr Cosetti reported unpaid participation in research on cochlear implants and other implantable devices manufactured by Advanced Bionics, Cochlear Americas, MED-EL, and Oticon Medical outside the submitted work. No other disclosures were reported.

Dwyer  J. What doctors on the front lines wish they’d known a month ago. New York Times. April 14, 2020. Accessed June 1, 2020. https://www.nytimes.com/2020/04/14/nyregion/new-york-coronavirus.html