It has been a challenging few weeks. Thank you to all of you surgeons and your families who have accepted personal risk to uphold your commitment to your patients, hospitals, and communities. Our individual roles and burdens have varied, but we have all been called upon to adjust to ever-changing realities and have been thrust into roles we were likely not playing a mere six weeks ago.
Amidst the constantly changing response that reflects the new knowledge we are continually learning about this pandemic, often I have reflected that the challenges I now face in my US-based practice were ones that I thought were unique to my global surgery work. We have now all experienced first-hand the dramatic impact that supply shortages can have on the ability to provide surgical care for patients. Limited PPE and concerns for competing needs in the health care system led most states to delay elective and even semi-elective surgeries, to ensure the safety of patients and providers. Limited access to elective or non-urgent surgeries is a reality most non-pandemic days in many countries with lower investments in health infrastructure. While hospital and public health leaders have worked to develop guidelines to help allocate scarce resources, the psychological impact of this scarcity on front-line providers who must limit care and triage in new ways with immediate visible effects on patients and families when we don’t have enough of the right equipment at the right place at right time is real. It is similar to the stress of daily decision making for many of our surgical colleagues around the world even when there is not a pandemic. I find myself regularly adjusting the care I provide to account for the realities of the current situation, advising my trainees, “in non-COVID times I would…”, often accompanies by the rational of my current different decision making. This situation reinforces that “right” answers are context dependent. We need better decision support tools that can help providers adjust guidelines and standards of care to new contexts so they can use that knowledge to optimally care for their patients in their particular situation.
This pandemic has also called on us as surgeons to be flexible and for many to stretch beyond our comfort zones. I applaud the surgeons around the country and the world who have stepped into new roles in these past few weeks, perhaps returning to the intensive care unit to manage vents and pressors for the first time in decades. I am not surprised by surgeons’ willingness to help in different ways, just as many global surgeons do when they find themselves in a new situation where they are asked to perform a procedure they may not have done for years, or that are not part of their specialty training (e.g. a c-section). These new demands have highlighted that better tools and resources must be available to help people stretch safely into new roles. I have been impressed with numbers of new resources, like online learning course on ventilators, and COVID management handbooks that have been quickly produced to help doctors in new situations. We must evaluate these efforts to identify the best learning strategies and ensure wide access to essential educational resources going forward. I see a tremendous opportunity to improve the dissemination and best practices for intensive care globally, as these resources are incredibly sparse in many low- and middle-income countries. And as the numbers of critically ill patients rise in places like sub-Saharan Africa, innovative strategies can ensure more providers have access to the knowledge they need to best care for their patients.
As with many challenges, the COVID pandemic has also highlighted what we can accomplish together. I have learned so much from the different online symposia and webinars on which surgeons from places like China, Italy, and New York made the time to share their experience and answer the questions of providers who were just starting to see pandemics. Learning of the creative ideas and unanticipated pitfalls of different approaches helped me to be better prepared for my patients and, I hope, the surgeons in the midst of the struggle to feel that their and their patient’s suffering could help avoid the same for others. However, as in global surgery, a key way for us to learn is to capture the most useful data on a timeline that is clinically relevant. With many restrictions on researchers in hospitals and providers consumed with clinical care, the challenge of data capture and ongoing learning in this environment is notable, just as it is on a daily basis for many surgeons who practice in low-resource settings.
This pandemic has highlighted that, now more than ever, we are all global surgeons, facing varying degrees of the same challenges as we struggle to provide the best care for surgical patients. I hope as we all come through the acute stage of fighting the virus and start to return to our new normal that personally experiencing the challenges faced by many surgeons around the world of the best of days leads us to innovate. By leveraging our international surgical community, we can optimize the care for all surgical patients around the globe if we prioritize developing tools, approaches, and collaborations to address supply shortages, improve knowledge sharing and help develop local and context-appropriate care strategies.
Dr. Maine with improvised PPE in Kigali, Rwanda (2014)
Rebecca Maine, MD, MPH
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