Year : 2021 | Volume
: 19 | Issue : 3 | Page : 188--190
COVID-19 pandemic in India: Should rural secondary care hospitals stop surgical care?
Royson Dsouza, Nandakumar Menon
Department of General Surgery, Gudalur Adivasi Hospital, Nilgiris, Tamil Nadu, India
Dr. Royson Dsouza
Gudalur Adivasi Hospital, Nilgiris - 643 212, Tamil Nadu
The COVID-19 pandemic has been a real test to the healthcare system of India ever since the first reported case in December 2019. Surgical illnesses amongst other diseases have taken a severe brunt during the pandemic due to restriction in operative procedures, lockdown and travel restrictions. The tertiary care centers located in tier three cities are burdened with managing patients with COVID-19 infections. The impact due to cancellation and postponement of surgical illnesses will be tremendous. It is imperative to make rural secondary care hospitals part of the solution in this crisis. In this article, the authors have summarized how best this can be achieved in a manner that protects the patients without putting the health workers at risk.
|How to cite this article:|
Dsouza R, Menon N. COVID-19 pandemic in India: Should rural secondary care hospitals stop surgical care?.Curr Med Issues 2021;19:188-190
|How to cite this URL:|
Dsouza R, Menon N. COVID-19 pandemic in India: Should rural secondary care hospitals stop surgical care?. Curr Med Issues [serial online] 2021 [cited 2021 Sep 24 ];19:188-190
Available from: https://www.cmijournal.org/text.asp?2021/19/3/188/320660
The COVID-19 pandemic has had a tremendous impact on the lives of Indians ever since its inception in December 2019. Just when things started to ease with the government claiming to have successfully confined and controlled the pandemic, the second wave proved to be a nightmare for every single citizen. Toward the end of April 2021, with close to 4 lakh confirmed cases and 4 thousand deaths daily, the coronavirus had the entire nation in its clutches. At the onset of the pandemic, India imposed the world's strictest nationwide lockdown lasting for over a month. The lack of preparedness and impact of the lockdown on surgical illnesses are increasingly being reported.,, During the first wave of the pandemic, most health-care facilities were forced to stop or postpone elective and non-emergent surgeries., These included not only just the patients with hernias, breast lumps, and symptomatic uterine fibroids but also the ones with cancers necessitating operative interventions.,,, The delay in resuming surgeries increased the burden on the already compromised health-care system. The rural secondary care hospitals, although not being in the frontline of the COVID-19 crisis during the first wave, stopped surgical care due to lockdown and fear of contracting the infection.
With the onset of the second wave of the COVID-19 pandemic in India, there has been a desperate need for hospital beds, oxygen, intensive care units, and ventilators. It has been repeatedly exclaimed that the pandemic is not burdening the health-care system of India but only exposing the actual deficiency. The number and severity of the infection have been considerably more in the tier three cities forcing the tertiary care centers located in these areas to convert most of the hospital beds for treatment of COVID-19 patients. The less-equipped rural secondary care hospitals are having to function as a stand-by unit to treat patients with mild-to-moderate symptoms not requiring prolonged oxygen or ventilation. Although the need of the hour in India today is COVID-19, the importance of managing the other illnesses cannot be disregarded.
The COVID-19 pandemic has had direct and indirect effects on the health-care system. The direct effect is by the increasing number of patients acquiring COVID-19 and requiring hospitalization whereas the indirect effect is by causing refusal or delay in treatment of the non-COVID-19 conditions. Surgical illnesses are an important component of the later section. Before the beginning of the pandemic, the Lancet Commission on Global surgery predicted a shocking number of 5 billion people in the world lacking access to safe and affordable surgical care., Low and mid-low income countries like India contributed to the majority of this number. The severity of the second wave is likely to last for a long period which will further hinder the condition. With all focus on treating patients with COVID-19 infection, the tertiary care centers are fatigued beyond capacity. There has been a severe shortage of health-care workers and mandating surgeons to be part of the COVID-19 workforce. Almost all elective surgeries have been stopped, and surgical care has been limited only to life-saving or organ-saving procedures.,, If this continues, the burden of surgical illnesses will be beyond measure.
Making Secondary Care Hospitals Part of the Solution
Interestingly, during the first wave, the hospitals in urban areas requested the health-care workers to come out of retirement but at the same time, many rural hospitals found themselves with excess workforce and capacity. As more and more tertiary care centers reach their working threshold in this pandemic, rural hospitals have a real opportunity to contribute to the solution. Due to the lack of intensive care units and mechanical ventilators, these hospitals will only be able to manage patients with mild-to-moderate COVID-19 infection. In this regard, a regional or national bed grid would ensure that all hospitals are fully utilized. During the COVID crunch, this would make the secondary care hospitals, full of patients with moderate infections and thereby reserving the beds in better equipped tertiary care centers for severely ill patients. The secondary care hospitals can also reduce the burden on tertiary care centers by continuing to offer surgical care. Whether the surgeries should be limited only to emergency/semi-elective cases or even elective surgeries should depend on the other factors such as the number of staff, the local burden of COVID-19 pandemic, and number of available beds.
Surgical conditions posing a threat to life or organ should not be deferred at secondary care hospitals. The common conditions include strangulated hernias, appendicitis with perforation, duodenal ulcer perforation, necrotizing soft tissue infections, ruptured ectopic pregnancy, and ovarian torsion. The patients are likely to have successful outcomes if intervened early at a secondary care hospital rather than being referred to a higher center and having delayed treatment.
Conservative Management v/s Upfront Surgery
Conditions such as acute appendicitis, intestinal obstruction, and thrombosed hemorrhoids can be managed successfully with nonoperative intervention. However, offering nonoperative treatment should be based on clinical, laboratory, and radiological findings rather than owing to the pandemic. A patient with acute appendicitis requiring an operative intervention is likely to recover and get discharged early than when offered conservative treatment. This will also help in resolving the crunch on the hospital beds.
More than 1 million new cancers are diagnosed every year in India. Cancer patients in rural areas are often advised to get treated at the tertiary care or regional cancer centers. Most of these centers are located in the tier three cities of India which are now reporting an all-time high of COVID-19 cases. This, in association with lack of beds, travel restrictions, and lockdowns are a major obstacle for these patients in being treated at these centers. A majority of cancers are treated surgically with or without adjuvant therapy. Cancers requiring mastectomies, thyroidectomies, gastrointestinal resections, and limb amputations can be competently performed in secondary care hospitals and should be offered to patients when needed. There is a possibility that a significant number of these patients could have disease progressions and become inoperable if surgery is deferred on the grounds of not being able to go to a tertiary care center.,
These include noncomplicated hernias, benign breast lumps, varicose veins, etc. It may be considered as an unwise move to continue with the elective surgeries putting the patients at risk of contracting the COVID-19 infection. However, India is a vast nation with significant regional differences in the number of cases. Hence, if the area where the hospital is located is not burdened with COVID-19 and the patient is likely to be COVID-free, elective surgeries could still be continued after a reverse transcriptase-polymerase chain reaction (RT-PCR) test. The financial implications of the surgical shutdown are tremendous, especially in secondary care hospitals., Many health-care workers have been affected by pay cuts and extra hours. Continuing surgical care in a manner that protects the patient and health-care worker is essential to generate revenue in the secondary care hospitals and is thereby imperative to the viability.
Precautions Before and During Surgeries
It is desirable to perform a RT-PCR test preoperatively for all patients scheduled for elective surgeries. Although some studies have shown a less than 1% COVID positivity rate in patients undergoing elective surgeries, we recommend that all patients undergo a screening test. This is crucial in rural secondary hospitals that have a scarcity of adequate personnel in operating rooms. This practice cannot be applied to emergency surgeries due to multiple factors including delay in obtaining the RT-PCR test results. Hence, appropriate measures must be taken in terms of personal protective equipment (PPE) during the surgeries. For emergency surgeries requiring general anesthesia, the use of PPEs should be mandatory, especially for the anesthesia team. The surgical team should distance themselves if possible, at the time of preoxygenation and intubation. Operating with full PPE or hazmat suits is very challenging and can prolong surgeries. However, it is necessary to prevent acquiring the infection, especially in symptomatic patients and ones with COVID-19 contact history. Therefore, this decision should be made on a case-to-case basis depending on the level of suspicion and the local burden of COVID-19.
Patients who have undergone surgeries are likely to attract many relatives and friends to the hospital. This is more so for patients undergoing emergency surgeries and cesarian sections who would not have been COVID tested before the surgery. It is desirable to test these patients after they have undergone emergency surgery and keep them isolated till the results. The number of visitors should be restricted with strict hospital policies on the duration of the visit. Having the same bystander with the patient throughout the hospital stay should be encouraged to further minimize the chance of spreading infection.
COVID-19 has made a significant impact on health-care including surgical illnesses. The burden due to deferred and postponed surgical illnesses will drastically increase if this crisis continues. Rural secondary care hospitals can contribute significantly by reducing this burden. Continuing emergency, semielective surgeries in a manner that protects the patient without putting the health workers at risk is a critical step in this regard.
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Conflicts of interest
There are no conflicts of interest.
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