Coronavirus Pandemic and the U.S. Surgeon: A Dilemma with many Facets

18 Mar 2020

By Estell J. Williams, MD*

It goes without saying that we are in a unique time in world history. We are facing a public health crisis unlike anything seen in our lifetimes. We can look to prior pandemics in history such as the Spanish Flu of 1918 to give us some context about response and expectations. However, we now face these public health challenges amidst healthcare advances that have resulted in a larger portion of our population enjoying life over the age of 60, with chronic medical illnesses, and in immunosuppressed states– variables which were not factors in prior pandemics. This is also true within surgery. We operate on patients at more advanced ages and with complex medical histories that have expanded the boundaries of medicine. As an acute care surgeon in Seattle, WA, a routine acute care week may include operations on patients with intra-aortic balloon pumps (IABP), ventricular-assist devices (VADS, used to extend life in heart failure), immunosuppression after chemotherapy for a cadre of malignancies, and a problem list consisting of at least 5 medical diagnoses. As I reflect on current times and the bombardment of media and social media “experts” on our current public health crisis, I find myself grappling with three major perspectives: as a layperson, as a physician, and as a surgeon. 

As a layperson, I hear the comments of young healthy able-bodied individuals who feel this pandemic is all propagated by the media and just “don’t understand the hype.” However, as a physician, I have the advanced medical knowledge to understand the real risk this pandemic poses as a public health emergency. I carry the fear of being a mother, daughter to elderly parents who live in another state, and a relative to individuals who fit the description of the “high risk” population. As a surgeon in an epicenter of COVID-19 disease in the United States, I am in awe of my colleagues– anesthesia, emergency medicine, internal medicine, intensivists, nurses, ancillary support teams, and administrators –who have rallied, worked longer and harder to care for the most vulnerable and keep daily communication with employees. Within the medical community lies an intersection of these perspectives unique to the surgical community, minimizing the spread of COVID by delaying non-urgent operations. Additionally, efforts to maximize resource allocation such as personal protective equipment, has led to recommendations form the American College of Surgeons to restrict surgical case volume as the numbers of infected continue to grow across the U.S. 

The University of Washington has been a leader in addressing COVID-19 and was one of the first institutions to develop its own test, develop disaster teams with COVID-19 units for rule-out and confirmed patients and COVID-19 teams to streamline information and minimize exposure to staff. But what does all this have to do with surgery? Well, surgery does not exist in a vacuum. Although we cannot operate on someone to save them from COVID-19, we can minimize the risk of our surgical patient contracting the illness. And while the number of cases continue to expand in Washington, prior to the ACS recommendations, our elective operations were cancelled except for  urgent operations such as cancer operations. And within days of cancelling elective operations we are now anticipating the needs to minimize cancer operations as the number of COVID positive hospitalized patients continue to grow, to limit exposure and spread. As things rapidly change we have now encountered cases of COVID-19 positive patients, likely from community spread, becoming symptomatic within the postoperative period, one requiring ICU admission. As a result of the real impact of provider interaction with these patients while asymptomatic and the conversion to severe symptoms while under surgical care, we as surgeons must consider the direct impact we have in the fight to contain this pandemic. So when we hear the ACS recommendations and consider, Is there a more effective way to ensure we continue to deliver care to surgical patients without increasing their exposure to COVID-19? Without cancelling operations? As a physician on the frontlines I personally believe the answer is a resounding NO. Our only job as layperson, physician and surgeon is to do our part to contain this pandemic. We must be proactive and not retroactive in our efforts to contain the spread of COVID-19. We are in this with our colleagues across the nation and must continue to be surgeon leaders, advocating for resource allocation as PPE shortages begin, patients who were asymptomatic when we brought them to the operating room with no consideration of testing needing converting to a positive case with symptoms requiring escalated care. If we fail as a profession to act in unison with our emergency department and medicine colleagues to minimize spread, It is not a matter of if it will happen in your practice, but more a question of when. In response to this we have now reorganized our general surgery services. 

Here in the front lines of the disease outbreak in Seattle, we must also consider the impact on our surgical workforce. While none of the below questions have concrete answers, and protocols will continue to change as we learn more, these are all important to discuss and keep in consideration. If our surgeons become infected, who will maintain the workflow for the emergent operations? Are we going to be flexible as an academic institution in ensuring our residents receive the necessary training during this interruption in their education? The preliminary answer to this question was developed within the last day as we completely reorganized our general surgery service structure to ensure we preserve our workforce. This is a model we have developed at UW but each institution must find whatever work best for their institutions. We have developed alpha, bravo and charlie teams to manage all general surgery inpatient, OR and clinic, respectively. With the idea that the clinic team will function as a “cold” team and take home-call to minimize exposure and only return to the hospital if needed. The inpatient team will round and manage all general surgery inpatients. The OR team is staffing all cancer and urgent operations. Our acute care surgeon is on day call for 5 days with a back-up attending if they are needed to operate on a COVID positive patient, as that will render them unavailable after that case for decontamination. 

While I recognize the need to control the pandemic and act quickly, I also would be doing a disservice to the core value that was my driving factor for entering the field of medicine. We must consider the lasting effects of this pandemic on our most marginalized and medically at-risk populations.The crushing economic implications of this pandemic will leave our metropolitan city Seattle, and many cities across the U.S., which already struggled with crippling rates of homelessness, economic insecurity, wealth gaps, and inequities in shambles. One cannot dismiss the impact that this will continue to hold in the months to come for so many communities who have suffered unemployment and no longer have access to health insurance as businesses have either shuttered or are unclear if they can weather this storm. For all those I cannot help but consider, how many will suffer further health crises? 

As a surgeon, what concerns you the most?

Join the American College of Surgeons and the Association of Women Surgeons as we discuss the COVID-19 global pandemic from the surgeon’s perspective. This special Tweetchat will be hosted on Thursday March 19th at 8pm Eastern Time. We will be guided by our moderators Drs. Estell Williams (@drwooda), Patricia Turner (@pturnermd), and Sharon Stein (@slsteinmd1).

To participate, follow @womensurgeons and moderators, then tag your tweets with the hashtag #AWSChat. Be sure to keep an eye out for Tweets from members of the AWS Communications Committee Leadership who helped to organize this TweetChat: @minervies, @LillianErdahlMD, @ainhoac63, and @kpmcguiremd.

If you haven’t participated in a tweetchat with us before, check out this tutorial written by Dr. Heather Yeo (@heatheryeomd) to know more!

We’ll be discussing the following questions:

  1. How has the COVID-19 pandemic affected your surgical sphere?
  2. What distinguishes an elective case that can be postponed? How should surgeons select which patients they should push through?
  3. Will this pandemic impact the education of surgical trainees? What accommodations should be made to avoid compromising their education without unfair consequences?
  4. Should medical students be allowed to continue clinical rotations? What meaningful lessons can they gain from continuing on the front with us?
  5. How are we protecting our workforce? Who will continue to care for patients when our first responders, nurses, and doctors get sick?
  6. What impact will this have on our patients and communities beyond an operation?

*The views expressed in this blog are those of my own and do not reflect my institution. 

Dr. Estell WilliamsEstell J. Williams, MD (she/her/hers) is anAssistant Professor of Surgery in the Division of Emergency General Surgery at University of Washington School of Medicine. Dr. Williams grew up in Oakland, CA and studied biology and chemistry double major at Xavier University of Louisiana before being displaced by Hurricane Katrina and completing her undergraduate degree in biology from the University of San Francisco. She earned her Medical Doctorate from the University of Washington, where she also trained in general surgery and was recruited to join the faculty after graduation. She also is the Executive Director of the Doctor for a Day Outreach Program through the University of Washington School of Medicine. Outside of work, Dr. Williams enjoys spending time with her husband, a critical race theorist who also works at the University of Washington, running a social justice library with her husband named after their 2 year old daughter and raising her young daughter and 14 year-old niece. You can find her on twitter.

Dr. Patricia TurnerPatricia L. Turner, MD, FACS is the director of the Division of Member Services at the American College of Surgeons and a clinical associate professor at The University of Chicago Medicine. Prior to joining the American College of Surgeons, Dr. Turner spent eight years in full-time academic practice on the faculty of the University of Maryland School of Medicine, where she was the surgery residency program director. Roles in national professional organizations include her recent appointment to the Board of Directors of the Council on Medical Specialty Societies, chair of the American College of Surgeons’ Delegation to the AMA House of Delegates, past chair of the AMA Council on Medical Education, past chair of the Surgical Section of the NMA, and past president of the Society of Black Academic Surgeons. A graduate of the University of Pennsylvania and the Bowman Gray School of Medicine at Wake Forest University, Dr. Turner continued her training as an intern and resident in surgery at Howard University Hospital in Washington, DC. Her fellowship training in minimally invasive and laparoscopic surgery was completed at the Mount Sinai School of Medicine, Weill-Cornell University School of Medicine, and Columbia University School of Medicine in New York City. Dr. Turner is board-certified in surgery, and is a Fellow of the American College of Surgeons. You can find her on twitter.

Dr. Sharon SteinSharon L. Stein, MD, FACS, FASCRS, is a colorectal surgeon at University Cleveland Medical Center (UH) and Associate Professor, Surgery at Case Western Reserve University (CWRU) School of Medicine. She is also the Director of UH RISES: Research in Surgical Outcomes and Effectiveness Center.  She was recently appointed at the Murdough Master Clinician in Colorectal Surgery for outstanding contributions to her patients and University. She is the President elect of the Association of Women Surgeons. You can find her on twitter.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

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