Category Archives: guest blog

Guest post: Angst among surgeons during the COVID-19 crisis

Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
 
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
 
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
 
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
on behalf of S-COVID Collaborative Group

The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,1which seems to be occurring again in countries that are being hit by the second wave.2

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The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.

Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.3 Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job. 

China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.4 The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.5

Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.6 Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.7 Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.8, 9

In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.10, 11

Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.

Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.12, 13 A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.14

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A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.

Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;15 a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.16During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.17

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A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group

Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,18 and additional supply strategies have been established,19 the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.20, 21

Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,22 the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.23

It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.24 However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.25 It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,26 and to help HCW who are struggling, left alone.  

References

1.         Con le nostre azioni influenziamo la vita e la morte di molte persone. https://www.ecodibergamo.it/stories/bergamo-citta/con-le-nostre-azioni-influenziamola-vita-e-la-morte-di-molte-persone_1344030_11/.

2.         Coronavirus pandemic: Tracking the global outbreak. https://www.bbc.com/news/world-51235105.

3.         Scalea JR. The Distancing of Surgeon from Patient in the era of COVID-19: Bring on the Innovation. Annals of surgery 2020.

4.         Wuhan hospitals resume regular services amid COVID-19. https://news.cgtn.com/news/2020-03-16/Wuhan-hospitals-resume-regular-services-amid-COVID-19-OTRxkICEr6/index.html.

5.         Fu D, Yu X, Wang L, Cai K, Tao K, Wang Z. Gearing back to normal clinical services in Wuhan: frontline experiences and recommendations from mental health perspective. The British journal of surgery 2020;Epub ahead of print. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11912

6.         Surgeon reveals fear of dying on frontline in coronavirus fight. https://www.examinerlive.co.uk/news/west-yorkshire-news/surgeon-reveals-fear-dying-frontline-18025220.

7.         Balasubramanian A, Paleri V, Bennett R, Paleri V. Impact of COVID-19 on the mental health of surgeons and coping strategies. Head & neck 2020.

8.         #COVID19ESCP TweetChat: Antonino Spinelli shares insights from the frontline in Italy. https://www.escp.eu.com/news/2069-covid19escp-tweet-chat-antonino-spinelli-shares-insights-from-the-frontline-in-italy.

9.         Doctors reveal they are moving into their garages and basements to isolate themselves from their own families while they fight coronavirus – as they urge others to stop going out. https://www.dailymail.co.uk/femail/article-8136037/Doctors-isolating-FAMILIES-prevent-spread-COVID-19.html.

10.       Fear, guilt, and a surgeon’s wait for Coronavirus. https://exponentsmag.org/2020/03/21/fear-guilt-and-a-surgeons-wait-for-coronavirus/.

11.       The second wave of COVID-19: another potential tsunami – prepare to avoid being swept away. https://www.escp.eu.com/news/2093-the-second-wave-of-covid-19-another-potential-tsunami-prepare-to-avoid-being-swept-away.

12.       Ielpo B, Podda M, Pellino G, Pata F, Caruso R, Gravante G, Di Saverio S. Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11999

13.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.

14.       Life as a vascular surgeon in Mexico during the COVID-19 pandemic. https://vascularnews.com/life-as-a-vascular-surgeon-in-mexico-during-the-covid-19-pandemic/.

15.       Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).

16.       Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).

17.       An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).

18.       Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.

19.       Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.

20.       Wuhan completes mass COVID-19 screening. http://www.chinadaily.com.cn/a/202006/03/WS5ed6f96ea310a8b24115a6a8.html.

21.       Xiong Y, Mi B, Panayi AC, Chen L, Liu G. Wuhan: the first post-COVID-19 success story.n/a(n/a).

22.       Collaborative C, Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. BJS (British Journal of Surgery). https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11746

23.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).

24.       Kadhum M, Farrell S, Hussain R, Molodynski A. Mental wellbeing and burnout in surgical trainees: implications for the post-COVID-19 era. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11726

25.       Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

26.       Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

worried woman in mask looking out of the window

Guest post: Mental health and BRCA

Exploring psychological consequences for BRCA+ women in the post-Covid era

by Grace Brough1, Douglas Macmillan2, Kristjan Asgeirsson2, and Emma Wilson1
1Division of Epidemiology and Public Health, University of Nottingham
2Nottingham Breast Institute, Nottingham University Hospitals NHS Trust

Whilst the global female population has a 12.5% overall lifetime risk of developing breast cancer and a 1.3% risk of ovarian cancer (Howlader et al), the risk for those with a pathogenic BRCA1 or BRCA2 mutation is 60-70% and 10-20% respectively (van Egdom et al). BRCA1 mutation carriers have a particularly high incidence of triple-negative breast cancer (TNBC) (Greenup et al) for which treatment options are more limited and always include chemotherapy (Bianchini et alCollignon et al). 

In the NHS, asymptomatic women with at least a 10% estimated chance of having a BRCA mutation are offered testing (NICE).  Knowing you are at high risk of breast cancer and the increased likelihood of TNBC is a well-documented  cause of anxiety (Wenzel et al) and many women describe having a BRCA gene mutation as living with a ‘ticking time bomb’. Bilateral mastectomy with or without reconstruction is the only proven method of drastically decreasing risk and can improve quality of life (McCarthy et al) and decrease anxiety (Rebbeck et al) for correctly selected cases, despite its potential negative outcomes (Gahm et al). 

The strongest predictor for choosing to undergo risk reducing mastectomy is having a first or second degree relative die from breast cancer (Singh et al), a factor associated with fear, anxiety and vulnerability to this disease.  Most women choosing it have clear and long-considered reasoning and have been prepared for it through well-established pathways guided by genetic counsellors, specialised surgeons and nurses.  It is however, classified as elective surgery. As such, waiting lists for risk reducing mastectomies are impacted by other healthcare challenges and needs. 

Being on NHS waiting lists causes anxiety across all specialities (Carr et al). With an estimated 10 million people on NHS waiting lists in the post-COVID era, levels of health-related anxiety within the population are anticipated to significantly increase. For BRCA mutation carriers, the prevailing fear is that they will develop breast cancer whilst on the waiting list.  This reality is related to the length of time on the waiting list and represents potential conversion of a risk reducing scenario to one of chemotherapy and cancer surgery, often with other treatments, and all the life changing and life threatening implications of cancer diagnosis.   

In pre-COVID times, there was a 18 week target time from referral to treatment for risk reducing mastectomy (UK GOV). Due to COVID, the majority of elective surgery has been put on hold and Breast Units now anticipate at least a 2-year waiting list for non-cancer surgery, such as risk reducing mastectomies, delayed reconstructions, and revisional surgery. Prioritisation is a difficult necessity.

In addition, breast screening services ceased or were significantly curtailed as a result of COVID related restrictions, and this adds to an already complex situation for BRCA mutation carriers.  Not only may they now get breast cancer whilst on the waiting list, but they are denied the reassurance afforded by negative screening, or potentially a diagnosis may be delayed (Maringe et al). 

Combining pre-existing anxieties of being a BRCA mutation carrier, new waiting list anxieties, and wider COVID general health anxieties, the post-COVID era has the potential to see significant levels of psychological burden in this population, which could negatively impact mental health and quality of life. Providing additional psychological support is likely to be the short-term solution, though this is also resource limited. In reality the collateral impact of pandemic related consequences for healthcare in this particular group may not be realised for some time. 

My first time.

Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

(a follow-on to “With the End in Mind”1)

Who was the first patient you discussed their own death with? 

For me, it was my grandmother. I was a medical student and she was slowly declining from heart and renal failure. During her last admission to hospital, she was clearly fearful of impending death – she told me that she felt better when I sat with her as she slept – which she did more frequently than, previously  – as she feared that she might not wake up from her nap. 

I assume that the medical staff noted our relationship. It was suggested to me that I might discuss resuscitation orders with her. I agreed that this was a timely discussion for her. Having participated in resuscitation during my rotation in the Emergency Department wanted to spare her this futile treatment.

I can only imagine how bumbling I was in that conversation. My mother had noted when I started medical school that I would have to work on my “bedside manner”.

On reflection

I definitely lacked the requisite vocabulary to not frighten her more. However, I do remember trying to reassure her that this was to prevent harmful treatment, that wouldn’t help her. And I would have loved to have had the phrase “It’s an order so that we hold your hand when you are dying rather than pound your chest”( see here2 and here3 for more).

I would have loved to have known better to narrate the process of dying to her; to relieve her of her fear that slipping away would be painful and something that she should fight. That her increasing need for sleep was normal and it differed from slipping into unconsciousness so that she could sleep more easily.

An ending

In the end, I failed her. As her medical team predicted, she had a cardiac arrest watching a soap on TV a few weeks later. And I failed her, because I hadn’t had that delicate conversation with her wider family. In my naïve medical student approach, she was the patient and I and the medical team knew her wishes. But I forgot that she existed surrounded by a devoted family who wanted to keep her forever. 

She arrested, panic ensued, an ambulance was called, CPR was commenced and she had cardiac compressions en route to the hospital where she was pronounced dead. Family members arrived to the resus bay to sit with her and hold her hand. With better communication, we could have done that in her own home. 

What I wish I’d known

In the world of surgery, we are always learning4. I regularly wish that I had already mastered all of the communication skills that I need. In a recent blog post1 I wrote about an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. Dr Lara Mitchell has produced resource materials with Open Change, an educational design company, to give healthcare professionals a visual approach to support these difficult conversations  around dying with compassion and honesty. It aims to give framework, concepts and phrases to support these conversations for health and social care.

She has now produced a video discussing the framework in more detail and with references to other sources5. I found it useful and hope that you do too. In the meantime, I’ll continue to work on my bedside manner, aiming to communicate with openness, compassion and empathy.

References

1. Donohoe C. With the End in Mind. 2020.

2. Mannix K. 2020. Available at: https://ne-np.facebook.com/DrKathrynMannix/posts/today-i-was-asked-a-great-question-about-deciding-whether-or-not-a-ventilator-is/2949195348436749/. 

3. Mannix K. Dot MD talk. 2019.

4. Chamberlain C, Blazeby JM. A good surgical death. BJS (British Journal of Surgery) 2019; 106(11):1427-1428.5. Mitchell L. Difficult conversations- we need to talk about dying. 2020.

Prioritising Surgical Treatment in Coronavirus Pandemic “Salford Score”

Prof Gordon Carlson CBE FRCS

Background

In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.

The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.

Cancer Surgery Priority

The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.

PriorityDescription
Priority level 1a• Emergency: operation needed within 24 hours to save life
Priority level 1b• Urgent:operation needed with 72 hours
Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2Elective surgery with the expectation of cure, prioritised according to:
• Surgery within 4 weeks to save life/progression of disease beyond operability.
Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers

NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
Priority level 3Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery

However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;

The “Salford Score” simplifies this to:

  • Priority 1a = score (P)1
  • Priority 1b = score (P)2
  • Priority 2 = score (P)3
  • Priority 3 = score (P)4

Vulnerability

A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).

Vulnerability scoreOutcome in case of COVID infection
Vulnerability level 1• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection
Vulnerability level 2• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality
Vulnerability level 3• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality
Table 2: Vulnerability score

Salford Score

A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.