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Table of Contents
EDITORIAL
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 25-29

Surgeons navigating pandemic times-lessons, past & future


1 Department of Laparoscopic and General Surgery, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Radiation Oncology, Maulana Azad Medical College and Associated Hospitals, Delhi University, New Delhi, India
3 Yuma Regional Medical Center, Yuma, Arizona, USA
4 Department of Colorectal Surgery, Zen Hospital, Mumbai, Maharashtra, India
5 Department of Colorectal Surgery, Bombay Hospital, Mumbai, Maharashtra, India

Date of Submission29-Jun-2020
Date of Acceptance19-Jul-2020
Date of Web Publication11-Aug-2020

Correspondence Address:
Nayan Agarwal
F-81&82, Street #4, Virender Nagar, Janakpuri, New Delhi - 110 058
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_12_20

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How to cite this article:
Agarwal BB, Agarwal N, Sharma S, Patankar RV, Agarwal N. Surgeons navigating pandemic times-lessons, past & future. Indian J Colo-Rectal Surg 2019;2:25-9

How to cite this URL:
Agarwal BB, Agarwal N, Sharma S, Patankar RV, Agarwal N. Surgeons navigating pandemic times-lessons, past & future. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 30];2:25-9. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/2/25/291867

“As medicine has advanced, the role of surgery has decreased. The day will certainly come when surgery will be done only to correct the effects of trauma and congenital abnormalities.”

R. H. Meade[1]

Richard Henry Meade, a 19th-century English Surgeon, Justice of Peace, Entomologist, was also an ardent student, scholar, and champion of biodiversity. While reminiscing about the decreasing role of surgery, he could not imagine the catastrophic decline in surgery brought on by the COVID-19 pandemic, which has its origin in the manipulation of biodiversity. The onset of pandemic limited surgeries, to being performed for cancers, transplants, sepsis and trauma, the last having become limited itself due to geographic lockdowns. The biodiversity scientist in surgeon Meade, identified human greed-driven biodiversity dystopia resulting from extreme technologies, extreme environments, and singular pursuit of supremacist instincts.[2] The advances in antisepsis, anesthesia, antibiotics, and technology allowed us to prove our ancestors wrong, who said, “The abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon” (Sir John Ericksen, the Surgeon to Queen Victoria in 1937)[3] and “Anyone who would attempt to operate on the heart should lose the respect of his colleagues” (Theodor Billroth, 1829–1894).[1] Paradoxically, COVID-19 has proved us wrong, limiting our practice and surgical voyages to bare minimums, reminiscent of pretechnology era. We have gone back to conventional approaches, fearful of technology-associated aerosol, and plume generation, which have been identified as vectors of COVID-19. The declining surgery volumes have had a devastating effect on incomes and livelihood of surgeons with more than 95% fall in their practice volumes, the hurt being most for most of us who do not do the already declining trauma and transplant surgeries.[4] In the past 3 months, almost 3 million surgeries have been canceled worldwide. A Bayesian beta-regression model has projected that more than 70% surgeries were canceled, of which more than 90% being for benign conditions.[5] This will also have an impact on “life-saving surgeries” as almost 40% of cancer surgeries and 25% of caesarian sections will be postponed too.[5] Pandemic further restricts us from doing the restricted work because we are sworn to “Primum non Nocere.” The fear of harming our patients is clear from data that show that three-quarters of preoperatively COVID-negative patients are at a risk of developing COVID infection postoperatively, and half of them develop pulmonary complications, of whom almost 40% suffer mortality.[5] Suddenly, surgeons are looking vulnerable and ordinary, unable to shield themselves, their teams, or their patients. It has come as a shock to a community which prided itself in being the smartest, most “date worthy,” superhuman hero creed as always shown in plays, dramas, novels, and movies.[6] The fear of unknown has swarmed us as much as other human beings. Surgeons are the least atheist of scientists. Even while being absolutely atheist, we revere the invisible hand of nature at work and at times proclaim to be God/s, as shown in movie “Malice,” when Jed Hill (Played by Alec Baldwin) says “You ask me if I have a God complex. Let me tell you something: I am God.” Our failures take us further away from atheism, as reminded by Rene Leriche, “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray.” COVID-19 seems to have taken away all that aura of being smart bordering on demi-godliness. Suddenly, whole of humanity is practicing what we thought were unique privileges. Surgeons detest rubbing shoulders outside of surgeries, and now, untouchability is a virtue named “physical/social distancing.” The pride of roaming corridors with surgical mask and cap seems neutralized by everyone wearing sophisticated and fancy masks. Nonsurgeons are preaching the basic rules of hand hygiene in scrubbing. There we stand, like the very normal, the new normal, and with subnormal work. How has our fraternity done or plans to do the phoenix act of rising from the pandemic laden ashes and to fly again like a Kingfisher with an Eagle's eye? In the beginning of pandemic, assuming it to go away soon, we took it head on and became hailed as warriors and feted across globe in regionally unique gestures of appreciation. It has been more than 3 months, and the pandemic refuses to flatten, giving us a scare.[7] Clinical practice, academics, and research all have suffered and need to be started again with a strategic change, may be COVID-19 will help in the required paradigm shift.[8]

All professional bodies and associations have stayed ahead of the curve in guiding and allaying fears of our fraternity. Most of the health-care facilities have become COVID care facilities by choice or by regulations. It has instilled fear of visiting our practice areas in the mind of our patients. To assure them, we should redesign or reorganize our clinics with space allocation and waiting area seats to have proper physical distancing. Climate control should maintain ambience with continuous air cycling with fresh air ventilation. Our team should be protected with adequate personal protection equipment. The patients must be given proper masks on entry and footwear stowed at entry. All visitor's contact data should be recorded to enable testing–tracking–treating if needed. This can be easily helped by having their Unique Identification Authority of India card, i.e., Aadhaar number.[9] Aadhaar should become a part of our informed consent document. Pandemic has created new challenges in protecting our patients from acquiring COVID after coming under our care. Surgery induces immunosuppression, leading to higher susceptibility to acquiring infection and its heightened morbidity/mortality in the postoperative period. Hence, COVID-19-related risks should be part of our informed consent protocol for all patients including asymptomatic carriers and noncarriers alike.[10]

Digital technology has transformed the humanity. India has led the world in transferring the benefits of technology to its underprivileged. Having the highest density of smartphone users, digital payments including social welfare transfers have become efficient and absolutely transparent, a welcome change precipitated by incentivized “cashless economy,” universal banking scheme (Jan Dhan Account),[11] and paperless universal health insurance (Ayushman Bharat).[12] Digitization and communication technology has also helped in running telemedicine clinics based on teleconsultation. Surgeons have always taken lead in adopting technology and driving innovative applications of the same.[13],[14] This has helped in surgeons delivering the best standards of care with additional advantage of avoiding crowding of clinical spaces, spacing the distribution of patients in outpatient, laboratory, imaging, and preanesthesia clinic areas, apart from reducing the traffic commute on city roads.

Our first contact with our patient starts with the seven-step clinical crescendo.[15] The steps being-

  1. Good observation and structured as well as detailed history
  2. General physical and system-specific clinical examination
  3. Knowledge application of anatomy, physiology, and pathology in the context of the first two steps
  4. Mental jugglery and flexing gray matter to postulate a differential diagnosis
  5. Filtration of the differentials with biochemical, bacteriological, or imaging investigations
  6. Quasi-invasive investigations, for example, upper-lower gastrointestinal endoscopy, etc.
  7. Diagnostic-therapeutic intervention/laparoscopy/biopsy/surgery, etc.


All of these except 2nd and 7th steps can be done more holistically and elaborately with media-based teleconsultation, without any compromise and without the need for physical proximity between us and our patients. COVID pandemic has made people more conversant with technologies such as pulse oximeter and various smartphone apps which can give us a fair idea of general physical examination as well. As a colorectal surgeon, I find it easy to examine the inguinoscrotal region including cough impulse, sacrococcygeal region, and perineum and perianal regions including a better assessment of anal Wink.

Surgeons are not only a part of the pool of humanity but also seen as leaders by fellow human beings. The way we conduct, the hopes and fears we display subconsciously are extrapolated on social collective psyche. Society looks up to us, in its quest to get back to normal, a new normal, vivid normal, and Nuevo normal. Social scientist, Brene Brown says, “Our pre-corona existence was not normal other than we normalized greed, inequity, exhaustion, depletion, extraction, disconnection, confusion, rage, hoarding, hate and lack. We should not long to return, my friends. We are being given the opportunity to stich a new garment. One that fits all humanity and nature.” COVID-19 has taught us the fundamental truth of existence, i.e., our universal connectedness with everything in the universe, the interdependence on biodiversity, ecology, and cosmos. No successful treatments to control or eradicate this pandemic are in sight. We would do well to introspect and respect the traditional harmonious pastoral egalitarian living with common sense as our inherent virtue.[16]

COVID-19 continues to ravage globally, defies flattening, and threatens to strike with vengeance of a second wave. Our scientists continue to pursue a vaccine and treatment. They are our new-age saviors, navigating us like those from “Chariots of Gods.”[17]

The pandemic has not only led to disruption, disease, and disasters but also fractured geopolitics along civilizational fault-lines, being exploited by the opportunistic supremacist mindsets. As we trace the footprints of the merchants of misery, we would do well to recall the signatures of various saviors of humanity from times immemorial. International scientists and humanists have recalled how Lord Krishna called upon Arjun to shed inaction and do his best in uncertain times [Figure 1][18] or how Lord Ram vanquished the demons [Figure 2].[19] Our collective pursuits will serve us as well as Christ healed deaf, blind, lepers, and paralytics at Bethesda [Figure 3] or as Moses distanced us from plagues [Figure 4]. Scientists are putting in everything at their command such as Theseus did to slay Minotaur [Figure 5]. They need the proverbial thread of Ariadne to guide the modern Theseus, navigate through the labyrinth of COVID-19 research. COVID-19 is also a warning and lesson to scientists like the ones at Wuhan, China, to be more careful and conscientious to work toward holistic coexistence. If they have to study insects and flying mammals, they would better study, the “Bumble bee paradox,” how the avionics of simple insects beat our best aerodynamic models, and how the Bats still outperform our best sonars and how the small plant leaves outsmart our best energy generation-storage systems.[20] We as scientists would do well to mature as expected by the society, from Adam I to Adam II animals.[21] As always and since eternity, creation sails out of worst times, so it will this time. For sure, we will celebrate with humility, as did our elders at the end of World War II and take a U-turn from “Big-Me” to “little me,” as written in a book “The Road to Character,” by Brooks.[22] The humanity will do a great service to itself in following the 15 propositions of a life well lived in character-
Figure 1: Lord Krishna calling to shed inaction

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Figure 2: Lord Ram Vanquishing our fears

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Figure 3: Christ Cleansing – Christ cleansing a leper by Jean-Marie Melchior Doze, 1864

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Figure 4: Moses distancing us from plagues

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Figure 5: The Minotaur in the labyrinth, engraving of a 16th-century AD gem in the Medici collection in the Palazzo Strozzi, Florence

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  1. We do not live for happiness; we live for holiness
  2. Proposition one defines the goal of life
  3. Although we are flawed creatures, we are also splendidly endowed
  4. In the struggle against our own weakness, humility is the greatest virtue
  5. Pride is the central vice
  6. Once the necessities for survival are satisfied, the struggle against sin and for virtue is the central drama of life
  7. Character is built in the course of your inner confrontation
  8. The things that lead us astray are short term – lust, fear, vanity, and gluttony. The things we call character to endure over the long term – courage, honesty, and humility
  9. No person can achieve self-mastery on his or her own.
  10. We are all ultimately saved by grace
  11. Defeating weakness often means quieting the self
  12. Wisdom starts with epistemological modesty
  13. No good life is possible unless it is organized around a vocation
  14. The best leader tries to lead along the grain of human nature rather than go against it
  15. The person who successfully struggles against weakness and sin may or may not become rich and famous, but that person will become mature


We as surgeons should also add to this list in following what Richard Selzer said “The surgeon knows all the parts of the brain but he does not know his patient's dreams” and remember that our actions leave scars not only on patient's body and mind but also on ours as well.[23]

Acknowledgment

COVID pandemic has flattened the socioscientific hierarchies. This editorial is a collective summation of our experience and interactions with various sections of the society including sufferers, warriors, and administrators. It summarizes the fears from Chinese Corona Virus (as vast section of society prefers to call and communicated to us), aspirations, hopes, and prayers. In the absence of any signs of the curve getting flattened, it reflects the collective socioscientific love/seeking (Philla in Latin) + knowledge (Sophia, the Greek Goddess of Knowledge, akin to Sarawati in Indian history). COVID-19 has flattened the Science-Philosophy divide for the warriors in search of its cure and vaccination.

 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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