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The role of Surgeon in Covid-19 era: Issues and Safeguards

In January 2020, the World Health Organization (WHO) designated the outbreak of a new coronavirus disease, SARS-CoV2 (COVID-19), a Public Health Emergency. Later, in March 2020, WHO declared the outbreak to be a pandemic.

Post by on Tuesday, May 25, 2021

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In January 2020, the World Health Organization (WHO) designated the outbreak of a new coronavirus disease, SARS-CoV2 (COVID-19), a Public Health Emergency. Later, in March 2020, WHO declared the outbreak to be a pandemic. 

This was the time that fear, worry, and panic were building throughout the populations of the world but especially among health care workers.

Health workers are working under pressure, with long shift times in fear of transmitting the infection to their family, and at risk of self-exposure and infection. In addition, avoidance of community also has negative effects on their mental health.

The COVID-19 outbreak is a unique and unprecedented scenario for health workers across the world. The COVID-19 outbreak has led to significant repercussions in health providers. The pandemic is a health crisis that impacts physical and mental health, anxiety due to fear of infection or transmitting the infection to loved ones. The world has experienced various infectious disease outbreaks but   the severity of the COVID-19 pandemic has had a significantly higher impact on mental distress among health workers. The impact of the COVID 19 pandemic has challenged the healthcare system worldwide to provide quality care while restricting transmission to non-COVID 19 patients and health care workers.

Since surgery exposes the surgeon and his team to blood and body fluids of infected patients, surgical specialties have been struggling all this while trying to strike a balance between the evolving guidelines of patient management who need surgical care and at the same time protecting themselves and their team from undue exposure. The path to this struggle is not always easy. It has opened up newer management paradigms, surgical care, and postoperative management. It has also made us many times bend ways to develop newer guidelines which are without evidence or minimal or insignificant evidence at present. In learning newer ways of adjusting to the situation, surgeons have come across pitfalls in areas that were not expected or planned but surely have only made us wiser but sometimes at the cost of exposing us to infection.

Essential surgical services have been defined as those that cannot reasonably be delayed for more than eight weeks without causing significant harm to the patient or progression of disease/disability.  Essential or non-essential surgical services the decision lies with the surgeon, it may be challenging to decide  On  one hand, it can reduce the influx of patients and their attendants in the hospital, but on the other hand, there is data to suggest that this has led to patients presenting in more advanced conditions, which directly has multiplied morbidity. This judgment is very difficult even in simple conditions such as cholecystectomy for calculus cholecystitis. The patient may get acute attacks of cholecystitis, obstructive jaundice, cholangitis, or even worse, pancreatitis during the extended waiting period, which can significantly increase morbidity. Hence, a clear demarcation of essential, semi-essential, and non-essential surgeries is not always possible. Each case needs to be judged based on the guidelines, patient's condition, local resources, and turnaround time.

However indications of emergency surgery remain the same during this pandemic as before, but a balance between timely treatment and protection of the surgeon and his team   from the virus is essential. A narrow surgical time window may not give us the benefit of having a reverse transcriptase-polymerase chain reaction (RT-PCR) test report before surgery, and these patients should be treated as potentially infected. Intervention without the RT-PCR report, the full compliance with tertiary protection regulations and other precautions mentioned should be complied. Despite full precautions in the operating room, staff, anesthetists, and the surgeons have been infected from patients who later turned out to be positive on testing which always bears impact on the whole team during the procedure.

As conventionally, informed consent for surgery focuses on risks, expected benefits, the likely outcome of the proposed procedure, and alternative options. During this pandemic it is essential to know whether patients are aware of this impact and proceed or postpone their surgery. However, in the current crisis, postponement may initiate some enquiries related to morbidity, the medico-legal impact of which is unknown which also bears impact on surgeons mental health and outcome of procedure. Long hours of surgery with full PPE lead to burnout of the surgeon and his surgical team.

As surgeons, we should   discuss with the patient  during admission that there is an increasing risk of infection with COVID-19 and this  should be a part of informed consent for surgery. While discussing the consent we should rather take “enhanced informed consent” with the patients which includes that there is a lack of information on the risks of routine procedures during the pandemic. Secondly, there is an increased risk of acquiring COVID-19   from the hospital. Another significant issue that should be discussed is a possible altered outcome resulting from a shortage of resources due to the pandemic, if applicable.

 The profound effect of the pandemic has left the surgeons and the healthcare industry worldwide in a critical situation. In the altered situation, the crucial things lacking are a management model and adequate training to operate in an unsafe environment, while continuously protecting oneself. Surgeons are always under stress while operating and managing increased medico-legal issues. Most of the current guidelines are based more on observation or experience than on a high level of evidence. Postoperative care has become more challenging. Amongst all these challenges, the surgeon is getting used to a “new normal”.

Dr Farooq Ahmed Ganie
Assistant Professor
Cardiovascular Thoracic Surgery SKIMS

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