Neurosurgeons in the Corona crisis: striving for remedy and redemption. A message from the president of the EANS

Hmmmm.

It is difficult these days to keep a clear and unbiased mind: real experts, self-declared experts, and politicians are issuing apodictic statements and restrictive orders with a big impact on our daily lives. Many of those statements are contradictory, and the various countries are reacting in equally different ways. Even within the same country many different public directives may be put in place by the regional governments, due to their federal political organization (i.e. Germany). As a result, I happen to know that in some neurosurgical departments not a single OR had been shut down, and not a single Covid-19-positiv patient had been admitted to their ICU, whereas in my own, for example, we are not allowed to do elective surgeries anymore, and more than 40 ICU beds are taken by intubated and ventilated Corona-patients already (as of March 22, 2020). In other countries with more centralized health care, specialists proposed some sort of a herd immunization of the whole population (i.e. Netherlands). But, with increasing pressure through one or another interest group and/or so-called public opinion, such major decisions may be revised from one day to the other (also Netherlands). In – again – other countries (for example the USA), the danger related to that virus has been denied to a large extent (“hoax by the Democrats”). Now, from one day to the other, and a 180°-turn later, entire US states are preparing for lockdown, and large Navy-ship-based mobile hospital units are being moved around and prepared to anchor along their coastlines. From other mainly Eastern countries (Russia, Kazakhstan etc.,) we don’t hear anything through our usual news channels. Furthermore, it seems that the profound and special European spirit of a common departure, which reigned in the beginning of the 2000s is being jeopardized by specific political interests, and by the lack of solidarity across European borders: supply chains for surgical masks are interrupted for the reason of national egoisms. Tools, and mechanical or electronic components, which are desperately needed to build for example ventilators are no longer delivered straight from one country to the other. All together that will be put on a very big bill, once all will be over, and it will take a long time to reinstall confidence in our political leadership, in our idea of a Europe without limits in humanity, as a model for the world, and as THE place to be.

So, what to make of all of this?

There is a ghostly feeling when looking outside. It is as if somehow we have become figures inside real-world Edward Hopper paintings. All that leaves the strange feeling behind that something big may be going on. But there is no clear and consistent answer, neither from the experts, nor from political leadership, as to how to address this exceptional situation. Important decisions may become triggered by public opinion, and thus the overall situation may entirely spin out of evidence-based control. It seems that the hour of countless experts, of epidemiologists and lab-scientists has arrived. The hour of those who were hidden behind large screens and next to super-computers for big data management and PCR analysis, in remote corners and basements of our hospitals and faculty buildings, and that these people seem to have been prepared for their moment to arrive. That’s what is happening now: We, who are used to treating patients on an individual basis have become subordinates of crisis units and eminent telegenic virologists. That may the right thing for the time being, if there was coherent advice. But I wish these experts would be more consistent in their analysis of the situation and in their recommendations, because even for us as doctors it is difficult to understand what’s right and what’s wrong. How should we expect the public to understand such a situation and to behave accordingly, if we don’t know ourselves what’s going on based on facts? Having tried to drink a beer with one of my colleagues at the lakeside this week, we were driven away by patrolling police. That made me recall dystopic scenarios from stories and movies of the past, depicting totalitarian States, where entirely new professions were generated, such as Stalkers, who used to guide people and take them around to forbidden zones [3] (https://www.youtube.com/watch?v=xB7jVTut3-g).

The current situation is also unmasking in a painful way that there is also an important economic inequality across all European countries. There is a significant lack of doctors and of nursing staff, and in terms of access to ICU-beds with ventilators in some countries, whereas in others, the situation seems to be less precarious. For example, how is it that in the UK, home to some of the finest educational and research institutions and to a good proportion of the richest people in the world, only approximately 4000 ICU beds exist - for a population of approximately 66 million people? Other countries on the other hand, were deprived of their medical staff due to more precarious general economic situations, with doctors and nurses following the westward stream toward politically more transparent and wealthier countries. Medical education is expensive, and there is global competition for well-trained and mobile doctors and nurses. Poor political planning and cultural differences from an all-inclusive state responsibility to more social Darwinist principles may be the reason, and reflect the different approaches across European countries. In times of crisis, nobody wants to be left behind however, and that’s why we are hearing so many outcries from various corners for more social fairness at this time.

Medico-ethical impact

Undoubtedly, there is a clear need for guidance and clarity. It is clear, that a day will come when we will understand what happened. That may become redemption day for some, and it may become pay day for others; Beyond the giant socio-economic impact of this crisis, there will be an accounting of medical and surgical collateral damage, which has been caused by the currently imposed restrictions and postponing of otherwise indicated medical and neuro/surgical care. In our field alone thousands of patients, with degenerative spinal disease, low grade gliomas, cavernomas, epilepsy and other pathologies are put on ever-increasing waiting lists. Meanwhile, mild paresis may become moderate, tumors may grow to more complexity, cavernomas may bleed, and repeated seizures may have deleterious consequences. All that will happen, and it will have to be accounted for, when there will come a time to do so, and after the whole mountain of delayed surgeries will be worked up. Truth will come, and it won’t be comfortable for those, who may be riding on high-tide right now.

Homo homini lupus

This unclarity, radiating from the highest levels of political leadership and from contradictory expert panels, this lack of consistent leadership continues to induce a feeling of insecurity among people. Seeing photos of old people, who were overrun by hysterical crowds during the opening of supermarket doors, or of overworked and tired nurses, who find themselves in front of emptied grocery shelves, and of strong men defending the towers of toilet paper, which they had just bought; All these images, that materialized prove that the taint of civilization is so thin that it’s being blown away after only a couple of complicated weeks, appalls me and it renders it difficult not to lose faith in our species. And it confirms my long-standing notion that sometimes the seemingly biggest and strongest among us seem to have the least compassion in those moments, when one should stay calm and cool and caring. Then, I have to focus my mind on the enlightening idea that not all people are like that, that the majority isn’t in fact. And that’s why we have to continue to strive to deliver the best possible service to our patients and to have confidence in our species. But how will things develop if the situation is not resolved in a few weeks’ time? The current image of humanity leaves a stale feeling. And to relaunch a system with such inertia after weeks and months of deprivation, if many companies no longer exist, will take tremendous effort? Doctors will just go back to work, as usual. But to reboot whole economies and have a labour force with less pragmatic backgrounds returning to their jobs may be less evident.

Neurosurgical contributions

All of us are somewhat trapped in our own inertial systems. We have to adapt to the current state-of-mind and to our regional rules and play the game. It is up to us to stay calm and to transmit an anti-hysterical mindset to our peers, be them professional, nurses, secretaries, cleaners, IT specialists, and all kind of intermediate hospital staff, or patients and the general public.

We have to live up to the current situation, whether the whole hype is justified or not. We have to provide an example to show how to stand together, across all national borders, and with the optimism of pragmatic and generous people, who we should always strive to be. That’s why most of us became neurosurgeons in first place.

That spirit was generated by European neurosurgical leaders many years ago, not long after the European carnage of World War II. That spirit has formed the foundations of the EANS. Even during the iciest times of the Cold War, European neurosurgeons were connected without boundaries. The first European Training Courses started in the 1970s, and the course sites are illustrative for the visionary European thinking of our predecessors. I refer you to our website to see that list and encourage you to upload your own material related to these events, should you happen to have something of interest. Otherwise, be referred to the photography books of John Garfield, who documented that particular spirit from the beginning with his camera.

EANS wants to provide a trans-national and inspiring base for us neurosurgeons. We would like to improve our common platforms for the exchange of thoughts, and we shall stand in for each other. Let’s stay in contact more intensively via social media, telephone calls or video conferences, respectively. I would like to see more networking and information passed on through our own, EANS-based communication channels. We have installed an easy-to-use format to upload your comments, your thoughts, data, and scientific material related to the Corona crisis now. All that may serve us some day to understand better what’s happening currently, and to analyze potential collateral damage associated with it, and to be prepared better should such a situation recur in the future.

Here, the links to our Website:

https://www.eans.org/default.aspx

https://www.eans.org/news/494847/EANS-Presidents-Message-on-Corona-Virus---Feedback.htm

Please feel encouraged to contact the EANS team at any time. In every crisis lies the seed of opportunity. I am sure we will grow from that, and we shall meet and celebrate under liberating circumstances in the near future.

And, should it turn out that Chloroquine may contribute to ameliorate the course of Corona-disease indeed, then be referred to John Garfield again [1, 2]. Neurosurgeons have always been frontrunners, when it came to visionary treatments.

Take good care of yourself, of those next to you, and of your patients. We will retake the drivers’ seats in our natural habitat, in hospitals and in Neurosciences, and we shall meet soon again, hopefully in Belgrade in October 2020!

With my warmest regards,

Karl Schaller.