The entire world is facing an unprecedented medical emergency caused by the novel coronavirus disease (COVID-19). Medical professionals and scientists are working hard to halt the spread of COVID-19 and save lives. Many countries have gone into a lockdown, to stop everyone except emergency services personnel from moving about, in a bid to prevent transmission of the infection.
Healthcare teams are struggling to treat patients who have varying degrees of symptoms. Some may require treatment in the Intensive Care Unit (ICU), and a few may warrant artificial respiration with the use of a ventilator. The warriors at the forefront are the intensivists, critical care specialists, critical care nurses, and anaesthetists.
Although most of the people have understood the seriousness of the problem, a few still want to have planned or proposed elective surgeries done in this period, without realising the possible risks and difficulties involved in getting operated now.
The concern and apprehension is multifold when the diagnosis is cancer. As individuals and teams have not encountered such a situation before, many organisations such as the International Society for Diseases of Esophagus, the American College of Surgeons, SAGES with inputs from WHO and CDC, are coming out with guidelines to be followed to resolve dilemmas. These professional medical societies are guarded in providing these principles, adding a note that they are based on the evidence available as on date and that the recommendations are subject to change every day.
It is time we understood the implications of having a planned elective surgery at the present time.
Any patient who has to undergo surgery has to consult the surgeon and the physician to get medical fitness certified, and the anaesthesiologist for an assessment. For this, he or she has to visit a hospital or a laboratory, where the patient may not be the only one going for tests. There would be people with emergency situation waiting for tests. There is a need to maintain social distancing too as one does not know the status of the others waiting there. Moreover, in the wake of COVID-19, there may be a need for additional testing.
Limited resources
The labs and diagnostic centres will be working with limited staff to handle emergencies.
After the tests are done and you wait for the fitness report from the physician and anaesthetist, you will be intruding into the time which they would like to devote to emergencies.
If you have to undergo surgery, even if it is an outpatient procedure, you have to go with a relative to give consent, subjecting them to the risk in the time of lockdown.
The situation becomes complex if the surgery is a major one necessitating long operating hours, obviously warranting a full-fledged surgical team, anaesthetic team, theatre sisters, theatre technicians and workers from the sanitary department.
After the surgery, there may be need for ICU care and even ventilator support, adding to the burden of the ICU staff. All these resources may be needed for another patient in crisis.
Guidelines from most of the professional Societies across the globe suggest: wherever there is a possibility to continue medical therapy, to do so, and to plan surgery for a conducive time; even if surgery is the only option and but not on emergency basis, it can still wait. There is also a growing concern about doing laparoscopy or open surgery, for which we do not have a clear answer yet.
Patients diagnosed with cancers have different problems: their concern will be about the potential advancing nature of the disease if not operated immediately. The medical team’s concern is about weighing the balance between the benefit and risk of subjecting them to a major surgical procedure, which may warrant long operating hours, involving a bigger team, ICU and ventilator care.
Collective decision
In such circumstances, multi-disciplinary meetings are held via video conferencing and a collective decision is made by the experts on what is best for the patient in the current situation. Sometimes, they resort to a treatment strategy like initial chemotherapy and radiotherapy which halts the progression of the disease.
This policy gives the patient and the team the “window period”, buying time to operate at a favourable juncture. If the risk of surgery, including ICU stay, outweighs the benefits, they may be subjected to non-surgical treatment modalities.
The government and the entire medical fraternity is fighting a serious pandemic, working hard to save society. If elective surgery is postponed, it is only in the interest of the patient.
It is equally important to understand that their help is required for patients who are in need of more immediate care.
Today’s difficult situation calls for understanding from all of us. That advice to postpone elective surgeries is given in the interest of all concerned. We must understand that by waiting, we are not wasting time.
By relieving unnecessary pressure on the health system, based on sound medical evaluation, the patient is actually doing herself a service - saving oneself and society by helping doctors save more lives.
The author is senior surgical gastroenterologist.
