Dear Editor:
We read with interest the article “COVID-19 outbreak in Northern Italy: Viewpoint of the Milan area surgical community,” which reported the pandemic surge response of our colleagues within tertiary hospitals in Lombardy. This was essentially the experience of “hub” centers. Herein, we would like to relate what goes on in the peripheral or “spoke” areas.
Italy has entered phase 2 of the coronavirus disease 2019 (COVID-19) pandemic after more than 210,000 infections and more than 29,000 deaths, as the peak of the outbreak was reached at the end of the first week of April. As surgeons operating in spoke hospitals, we have paved through the pandemic in an unusual and unexpected way, many of us having to turn from surgical specialists into coronavirus disease (COVID) ward doctors. At a time when guidelines and recommendations were not yet available, we had to reshape our surgical units and the entire surgical path that patients had to follow. Nonetheless, being a surgeon used to emergencies in peripheral hospitals was a valuable resource during the COVID mass casualty incident because of our commitment to patients and acute care background.1
Our daily schedule changed dramatically when we were asked to cancel elective surgery to increase the hospital capacity in mechanical respirators and intensive care personnel for COVID-19 patients. Some of us were forced to transfer cancer patients to distant oncologic hubs, and others had the possibility of reorganizing their surgical activity on a hub and spoke basis. Most of us were left with sporadic emergencies as we witnessed a reduction of them as well. Now that our administrators are considering a gradual reopening of outpatient activity, non-COVID wards, and elective surgery, we strongly believe that what we learned in phase 1 of the outbreak should guide us in phase 2. Based on the immense battle we have just run in our spoke hospitals, we would like to share some considerations.
Our manner of approaching the patient changed dramatically to a more holistic reality that brought us back to the beginning of our practice. Surgery is part of medicine in a general sense; it stands again where it is supposed to stand, strong and sturdy. Multidisciplinary assessment of patients has regained a central role.
The COVID-19 pandemic will stay in the background for many months to come, and looking at the surgical patient, in primis as a potential COVID patient, will influence our choices. Outpatient and inpatient activities will have to be structured in separate flows of COVID versus COVID-free patients. To have COVID-free hospitals or wards is illusory, but an anti-COVID strategy able to provide adequate protection and isolate suspected patients is necessary and feasible.2
As proposed by the American College of Surgeons, our experience with teams composed of surgery, anesthesiology, and nursing personnel has been essential in the daily decision-making process to manage urgent and emergency surgery. When progressively reopening our activities, such multidisciplinary teams can lead the development and implementation of local guidelines, as we need to stratify priorities for elective surgery into essential and nonessential.3,4
Rationing of health care resources has never been so fundamental. At the peak of the outbreak, all postponable urgent surgical procedures needing intensive care unit postoperative assistance were postponed, and only emergency surgery was performed. Spoke hospitals with reduced intensive care unit capacity were penalized and often failed to meet their mission of wide access to acute care surgery.
The hub and spoke model used to centralize oncologic surgery during phase 1 had severe limitations and must be replaced by other strategies to better take advantage of professional competences widely and unevenly dispersed in the regional health network and particularly in peripheral hospitals, which were underused.
Minimally invasive surgery was considered a luxury in COVID patients. One particular point that led us to curtail laparoscopic operations was the need for forced Trendelenburg position that might have interfered with COVID pneumonia. Other than that, we modified our techniques (no inadvertent escape of pneumoperitoneum and need of filters) in accordance with others.5,6
As the father of asepsis Joseph Lister asked himself “if a man is not to take advantage of the opportunities that present themselves to him, what is he to do, or what is he good for?”
It is not our intention to stop the process of human and professional growth that this pandemic has brought about. Nevertheless, after this simplified view of “war-time medicine” that required our availability in spoke hospitals to turn into COVID doctors, we feel that more planning is required to have the right specialists for COVID patients and to manage a second wave of the pandemic not as unprepared as we did. As far as we are concerned, we now need to rapidly move back to the professional competence we as surgeons were trained for, to be able to manage clinical complexity as it is, but with the thought that “being a doctor will never be the same after the COVID-19 pandemic.”5
Andrea Costanzi, MD
General and Emergency Surgery Unit
San Leopoldo Mandic Hospital
ASST Lecco, Merate, Italy
Giulio Mari, MD
General and Emergency Surgery Unit
Desio Hospital
ASST Monza, Italy
Marco Confalonieri, MD
General and Emergency Surgery Unit
San Leopoldo Mandic Hospital
ASST Lecco, Italy
Dario Maggioni, MD
General and Emergency Surgery Unit
Desio Hospital
ASST Monza, Italy
Abe Fingerhut, MD, FACS, FRCPS, FRCS, FASCRS
AIMS Academy Clinical Research Unit
Milan, Italy
Department of General Surgery, Ruijin Hospital
Shanghai Jiao Tong University
School of Medicine
Shanghai Minimally, Invasive Surgery Center
Shanghai, P. R. China
Section for Surgical Research
Department of Surgery
Medical University of Graz, Austria
DISCLOSURE
The authors declare no conflicts of interest.
REFERENCES
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