Why our surgeons appear quiet
As we mark three weeks of level four, a small but vocal number of critics of the stringency of the policy note that many hundreds of public hospital beds are empty.
The inference is that the health system has been remiss in not performing more elective surgery in recent weeks. But such an inference is wrong.
The reasons for this deliberate decision are simple, yet the underlying thinking, work and planning has been complex and timeconsuming – all to ensure the health system was not caught ill-prepared.
It is vital to appreciate the impact of Covid-19 on an ill-prepared health system. The impact of the disease on well-developed health systems such as those of the UK, Spain, Italy and the United States shows how rapidly the disease accelerates and how severe cases can rapidly overwhelm the health system.
It is the volume of such cases that cripples the system, and most cases need prolonged intensive care, thus blocking the next critically ill person from life-saving treatment.
Preparedness has been critically important, and it has involved many things. For example, staff training for Covid-19 in hospitals not specifically designed for a pandemic has been extraordinarily challenging.
Engineers have worked tirelessly to create additional negative pressure rooms in our wards – these rooms are essential to keeping viral particles in the patient’s room, as opposed to the usual design of preventing the inflow of infections.
Intensive care units have worked to expand capacity to levels undreamed of when appropriate hospital design was carried out. This has all impacted on our capacity to treat non-urgent elective cases.
So why not do more surgery now these changes have been implemented? It can be summarised as due to two things: risk, and the redeployment of staff.
Risk exists for healthcare workers, the system, and patients. As yet, there is no laboratory screening test to reliably determine immunity to the disease, and a negative swab test for Covid-19 does not mean the patient is free of the virus. Thus, case selection other than by the clinical urgency of each case is well-nigh impossible.
A ‘‘business as usual’’ approach would expose healthcare workers to an avoidable risk and use valuable stocks of personal protective equipment. This would in turn threaten the wider health system.
Even if we could rely on a negative swab and offer elective surgery to many more people during this time, there is increased risk to those patients from surgery. Any significant operation may cause a temporary reduction of the patient’s immune system, at least for some days. If a patient was to catch Covid19 in the post-operative period, it could be even more aggressive.
Furthermore, we expected that, in a pandemic, access to the district nursing and community services necessary for care would be dramatically reduced, again putting patients at increased risk when their surgery was not urgent at this time.
Finally, any major complication from surgery may require intensive care support to offer a chance of recovery, but the speed at which this disease can spread means a resource available on the day of an elective operation may well have been absent on the day such a complication arose.
Therefore, we would have deliberately put our patients at increased risk by performing ‘‘deferrable surgery’’ during the expected pandemic peak.
Deployment of staff has also been an important factor. To keep capacity for what was almost universally anticipated to be a massive influx of Covid-19 cases, hospitals have worked hard on ‘‘smart staffing’’.
This has involved the redeployment of surgeons to make early decisions to establish diagnoses and treatment plans for the ongoing numbers of emergency cases presenting to the hospital, whilst other surgeons are deployed to operating rooms. This has resulted in rapid ‘‘progress’’ of acute cases through the hospital, to the benefit of patients and the system as a whole.
It is important to appreciate the system has not been silent on elective work. Cancer surgery and some other time-critical elective surgery have progressed at nearnormal volumes in many hospitals, and we are already actively planning how to deliver increased elective surgery as we exit level four.
But challenges remain, not least of which is how to identify potential Covid-19 cases and to prevent a further rise in this indiscriminate killer.
The clinicians and administrators of our public health system are well aware of the health needs of our communities, and we will get the work done; the timing of that work is our greatest challenge. To allow us to do this work, to catch up, and to keep up, everyone needs to maintain strict social distancing and hand hygiene as we exit level four.
Staff training for Covid-19 in hospitals not specifically designed for a pandemic has been extraordinarily challenging.