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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 6-10

COVID-19 impact on the global surgical practice of cardiothoracic trauma

1 Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
2 Division of Cardiothoracic Surgery, Baylor College of Medicine; Department of Surgery, Ben Taub Hospital, Houston, Texas, USA
3 Department of Cardiothoracic, Catholic University, Surabaya, Indonesia
4 Military Medical Academy, Cairo, Egypt
5 Department of Cardiothoracic, Al-Quds Hospital, Gaza, Palestine
6 Department of Cardiothoracic, Trauma Hospital, Belo Horizonte, Brazil
7 Department of Cardiothoracic, Trauma Hospital, Mexico City, Mexico
8 Department of Surgery, Gold Coast University Hospital, Queensland, Australia

Date of Web Publication24-Dec-2020

Correspondence Address:
Moheb A Rashid
Editor-In-Chief, The Journal of Cardiothoracic Trauma
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_10_20

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How to cite this article:
Rashid MA, Mattox KL, Tahalele PL, Dwintasari M, ElSaid Y, Alzaanin A, Peixoto L, Ruiz Pier JL, Patel B. COVID-19 impact on the global surgical practice of cardiothoracic trauma. J Cardiothorac Trauma 2020;5:6-10

How to cite this URL:
Rashid MA, Mattox KL, Tahalele PL, Dwintasari M, ElSaid Y, Alzaanin A, Peixoto L, Ruiz Pier JL, Patel B. COVID-19 impact on the global surgical practice of cardiothoracic trauma. J Cardiothorac Trauma [serial online] 2020 [cited 2023 Jun 1];5:6-10. Available from: https://www.jctt.org/text.asp?2020/5/1/6/304875

Coronavirus (COVID-19) pandemic has rapidly swept over the globe from Wuhan in China to involve the whole world at the end of 2019. It has affected everything in our daily life with significant negative impact except for the numbers of trauma deaths as seen in “Europe” chapter in this editorial. This virus affects mainly the lungs that are vital organs in the cardiothoracic territory. As we are dedicated to the surgery and acute care of cardiothoracic trauma patients, so we are directly involved in the traumatic lesions of the lungs whether patients are infected with COVID-19 or not. Therefore, we are the most directly exposed health personnel to this virus as the main host of it is the lungs that are usually injured with direct communications with pleural space where a chest tube is usually placed, and this is the most common procedure performed in cardiothoracic trauma.

We hope that this editorial will reflect some of the global impact of COVID-19 on the surgical practice of cardiothoracic trauma. This is simply shown here with invited editorials from the World's six continents. Although each editorial is not exactly representative to each continent, it provides us with some insights of the impacts in each continent or world region as shown alphabetically;

  Africa (Egypt) Top

In general, the major bad effect of COVID-19 in Africa in general and especially in Egypt is freezing the general routine work, especially that related to the economy. This affected the direct and indirect ways on the normal life of the people and reduced the end product to the country to be able to live normally.

According to the local health system, it becomes very loaded and disturbed in facing this crisis that changed the priority of services and postponed many medical services to be done later on, including many surgical operations to give priority to the emergency cases. This was also seen in cardiothoracic trauma surgery patients. We lost many colleagues due to this pandemic; many of them are surgeons and also nursing staff (12 doctors and 21 nurses).

Dr. Yasser ElSaid; MD, PhD, Cairo, Egypt

  Asia (Indonesia) Top

COVID-19 or novel coronavirus has been spreading around the world including Indonesia. This virus came from Wuhan, China. The WHO has declared COVID-19 as a global pandemic on March 11. Until now (October 28, 2020) in Indonesia, there are 400.483 people with positive COVID-19, 325.793 people recovery from COVID-19, 13.612 people dead because COVID 19, and 169.833 people with suspect cases (Ministry of Health Republic Indonesia). There are a lot of major bad effects of COVID-19 in Asia, especially in Indonesia. Both health and economy are affected. Indonesia is a vast archipelago with approximately 17,000 islands and 6000 inhabited islands, so COVID-19 exerts a great influence and the other problems are transportation, communication, and lack of facilities often encountered. Many health services became limited and insufficient rooms in hospitals. The other factor is waiting times for polymerase chain reaction (PCR) swabs were too long due to the limitations of PCR swab tools at the beginning of the pandemic period even though all of these things gradually began to improve.

For elective surgery, COVID-19 holds important role. Before elective surgery, anamnesis and screening must be done. Such as complete blood test (leukopenia, thrombocytopenia, absolute lymphocyte count with 0.5–1 × 109 for moderate lymphopenia and <0.5 × 109 for severe lymphopenia, and neutrophil lymphocyte ratio >3.13), chest X-ray or chest computed tomography-scan if available, and swab PCR for COVID-19. For summarize all of these, there is a main triage scoring system performed in the emergency room which includes:

If total score >10, 3rd level personal protective equipment (PPE) should be used. This screening score is used in Adi Husada Private Hospital (where Prof Paul. L Tahalele works). Moreover, patient who needs elective surgery must do swab PCR for COVID-19 first.

If all of the results do not lead to COVID-19, elective surgery is scheduled and performed on schedule in a regular operating room. However, if the results show positive COVID-19, then the operation is postponed. In a day, the National Heart Center Jakarta can do approximately 10–15 cases for elective surgery and 2–3 cases for emergency surgery. In Surabaya for elective cardiac surgery can be done 2–3 cases daily and 1 case daily for emergency cardiac surgery.

For emergency cases with screening and rapid test positive, there are two priorities. If cases with low priority, operation is postponed and patient is treated in the isolated observation room. If cases with high priority with suspect or confirmed COVID-19, operation must be performed in special operation room with negative pressure and with level 3 PPE. After the operation, patient was treated in an isolated intensive care unit (ICU) room.

Because of this condition, a lot of health-care workers were died. Until October 2020, the Indonesian Medical Association has seen a total of 253 lives of health-care workers are taken by COVID-19. From 253 health-care workers, there are 141 doctors, 9 dentists, and 103 nurses. From 141 doctors, there are 53 general physicians, 64 specialists, and 18 residents from 18 provinces and 66 cities in Indonesia (tribunnews.com, thejakartapost.com). Finally from all of this, we know that COVID-19 brings a lot of effect in our lives in many fields.

Dr. Paul L. Tahalele, MD, and Dr. Merlinda Dwintasari, MD, Surabaya, Indonesia

  Australia and New Zealand Top

The coronavirus pandemic has stretched every system that the human race has been involved with. Hospital systems worldwide have been overwhelmed with number of cases from the disease.

In Australia and New Zealand, fortunately, the mortality numbers have been relatively low in comparison to the other countries.[1] This might be related to the rapid response by the governments with major input from public health departments leading to increase testing and contact tracing.

The Gold Coast University Hospital is a Level I trauma center located on the border of two Australian states (Queensland and New South Wales). In order to preserve PPE, there was cancellation of all nonurgent elective surgeries at public and private hospitals across Australia. This cancellation policy has led to a major blowout in the elective waiting list at all public hospitals.

The daily clinical routine activity was also tweaked with minimal staff presence on ward rounds and changing our outpatient follow-up program to telehealth.

In terms of elective cardiothoracic surgery, the biggest hurdle to overcome was in patients across the border. This was attributed to the delay in confirmation of infectious status, as rules for isolation are different in every state across Australia. This not only led to a delay in starting the operation list but also cancellation of cases scheduled later due to time constraints.

In Australia and New Zealand, the worst effect on emergency care was reduction in admissions to hospital with acute care and trauma-related presentations. This could be attributed to the restriction of outdoor movements and activities.[2] There was also an emotional toll on the patients as there were no hospital visitors allowed during the pandemic.

Locally for trauma surgery, the cancellation of elective list meant patients with blunt chest wall injury had early access to locoregional pain relief as pain specialists were available on a short notice.

We had to manage all trauma patients from across the border as potentially infectious. In order to overcome this hurdle, we undertook various transitional simulation activities [Figure 1] for the journey of the patient from the emergency department to radiology/theater. This was particularly important to prevent potential contamination and spread of infection among our health-care colleagues.
Figure 1: Transitional simulation for journey of the trauma patient

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Finally, I would like to concur with Prof. Maddern, Evidence, not eminence is essential in the management of coronavirus disease.[3]

Dr. Bhavik Patel, MBBS, MS, Queensland, Australia

  Europe (Sweden) Top

Europe was enormously attacked by COVID-19 with dramatic impact on the Europeans including Scandinavians particularly Swedes where we lost significant numbers of lives early this year. Initially, there was huge difference in the severity of spreading of infection and its impact on the people in each European country. During the peak of pandemic in Europe, almost all European countries practiced different degrees of lockdown except Sweden that had a different approach. Sweden is almost the only country in the world with a natural social distancing even before the coronavirus era and as much as 50% of its population is singly living. Some countries were much more affected than others as Italy and Spain who lost most lives in Europe compared to Finland. During the early quarter of this year, the majority of the European countries closed their borders, applied lockdowns. Schools, universities, factories, and sports facilities were closed and all people-gathering activities were prohibited or extremely limited. Traveling among nations was forbidden except for those with a critical job that is absolutely necessary with restrictions more than in war times [Figure 2]. Although these drastic actions had a devastating impact on the European society, we found a better impact on trauma in general including cardiothoracic trauma and road deaths in Europe specifically. The European Transport Safety Council found that 505 people (36%) were saved in traffic trauma where 910 people died in road accidents in the 25 European Union nations by April 2020 compared to 1415 in the same period of 2019.
Figure 2: This is the very busy Oslo International Airport where the author (Dr. Rashid MA) was almost alone as you can see no one else in the busiest area of the airport. It resembled extreme restrictions more than in war times

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As in all countries worldwide, elective surgeries were delayed giving the priorities to the COVID-19 patients. We temporarily established one military hospital in Stockholm and another one in Gothenburg just in case of exceeding the capacity of the already established health-care facilities.

Dr. Moheb A. Rashid, MD, PhD, Gothenburg, Sweden

  Middle East (Palestine) Top

In December 2019, a respiratory coronavirus has emerged starting from the largest metropolitan area in China's Hubei province, Wuhan. Most of the cases present with fever, dry cough, and tiredness, although clinical presentation ranges from asymptomatic to atypical severe pneumonia. By March 11, 2020, the WHO declared COVID-19 a pandemic. Most Middle East countries (MEC) have a national rapid response for timely investigation and response to public health threats. The COVID-19 pandemic is challenging health systems across the world. Increasing demand for care of people with COVID-19 is compounded by psych social disturbances, misinformation, and limitations on the movement of people and supplies that delay the delivery of frontline health care for all people. When health systems are overwhelmed and people fail to access needed services, both direct mortality and indirect mortality from preventable deaths increase. The results of lockdown and government-enforced restrictions because of the pandemic have been affected all elective surgeries in both private and public health-care sectors. The primary purpose is to reduce the contact between patients and doctors and minimize the chance to be infected with COVID-19, and to preserve equipment for patients presented with severe type of COVID-19. This was very noticeable in nonessential surgical treatment has been less prioritized after the pandemic. Most government MEC announced a statement urging the suspension of any elective, nonessential procedures. Moreover, the issued a protocol of precaution setting out the new considerations for practices when gradually resuming elective procedures. The essential treatments that were allowed: cancer surgeries, cardiothoracic surgery, and trauma surgery. Protective measures to prevent crossinfection were maintained for the team, equipment, and operation rooms. All patients obligated to have PCR preoperatively, 48 h, and rigorous preoperative PCR for the medical staff monthly. Shorten stay in the ICU was recommended for those cases. Further studies are warranted in the MEC context to understand the effects of COVID-19 on cardiothoracic and trauma surgery.
Table 1: Scoring of COVID-19 symptoms

Click here to view

Dr. Abdelghaffar Alzaanin, MD, Gaza, Palestine.

  North America (USA and Mexico) Top

Here, it is referred to the comprehensive first editorial in this volume of the Journal of Cardiothoracic Trauma by Professor Kenneth L. Mattox of Texas, where he discussed in detail the impact of COVID-19 on cardiothoracic surgery in general including cardiothoracic trauma.

Dr. Kenneth L. Mattox, MD, FACS, Texas, USA

What I perceive as the major bad effect in Mexico, not looking at the lives lost as a result of this pandemic, is the economic impact, the loss of jobs, and the detention of the production chains, it is estimated that in Mexico, the economy will be stuck until 2025. The real effect of COVID-19 on the health-care system in general is not known. Officially, the National Health-Care System is announcing that the management of the pandemic was one of the world's best, even when the WHO and other international organizations declare the effect of the pandemic management in Mexico as a tragedy, shamefully the health secretary is under direct presidential control, not being able to report the situation freely. And to finish with this point, the effects were not only about people infected, the attention to other health problems was stopped, and the population with chronic diseases were exposed to exacerbations, decompensations, and progression of their illnesses. A big collateral damage. As in many countries, the elective surgery programs stopped, and to date is starting to “normalize” in some non-COVID units, this has brought a delay and a loss of time in surgical training of surgical residents at almost all levels. Regarding trauma surgery in general when the social confinement started, the incidence of trauma surgery admissions at the hospital where I work diminished almost to 50% and get back almost to normal when the people started going outside again. Another effect is the demand from health-care personnel for personal protection equipment, for the attention at the triage and shock units, and the establishment of new areas and routes for intrahospital mobilization for patients with suspicion or known COVID-19 disease. As in general trauma, but contrary to elective surgery, cardiothoracic trauma must be resolved acutely, even without a complete COVID-19 negative test result. Hence, we apply clinical operational definition since patient arrival, and chest tomography looking for signs of the disease. Unfortunately, yes, I have lost colleagues, friends, and family members.

Dr. Jose Luis Ruiz Pier, MD, Mexico City, Mexico

  South America (Brazil) Top

From its first cases reported in China in late 2019 until nowadays, COVID-19 has changed the way the world social relations, economy, and government works, dramatically reducing population mobility, with people staying more time indoors. COVID-19 impacts can be seen in many different sectors from the health system to the economy.

The biggest negative impact of COVID-19 in Brazil can be measured directly with a big number of cases and deaths during 2020, one of the highest in the world.

Data show some regions suffering more from the disease than others, emphasizing the huge discrepancy between areas in the country with excellent health-care system and others with bad services, bad organization, and more corruption. Both areas were hit by COVID-19, but the situation in the later was notably worse.

COVID-19 social distancing practices resulted in rising unemployment rates related to domains where remote work was not possible, or where market drastically reduced due to social distancing. The consequence was loss of income, especially to vulnerable populations. Some business such as culture and entertainment were destroyed and will take time to recover. Others, like industry, are facing generic consumption reduction and preparing for a possible recession. The loss of income has been temporarily solved by the government assisting vulnerable families and giving them financial help during 2020. However, the recovery in the economy will need more than that.

COVID-19 has imposed a huge pressure in the health system workers due to excess of patients looking for care, (world) lack of information about the new disease, public hospitals not equipped accordingly harming doctors and nurses' safety, and a lack of organized and well-structured directions from government.

As countries focused their efforts on combating rising infection rates, other medical services were left out. Thus, health prevention programs, combating smoking, mental health, dental treatment, vaccines, cancer, and routine examinations were temporarily suspended.

Most public and private services have changed in order to prepare themselves to receive people with the new disease. There were several new sectors created in the hospital, together with new protocols to care specifically for COVID-19 patients. Some general hospitals have been transformed into exclusive COVID-19 hospitals.

Surgeries considered nonurgent were postponed or canceled.

Early cancer detection programs have been discontinued. For those who already had a diagnosis, it took longer before they could start treatment.

The movement in the emergency room decreased.

The number of blood donors has decreased dramatically, due to the population's fear of leaving home and going to a health service and being contaminated.

The other change that happened was in relation to the profile of the traumatized patient.

The total number of traumas fell, mainly at the expense of blunt trauma.

When the numbers are analyzed, there is also a significant 30% reduction in hospitalizations related to car accidents, mainly motorcycle accidents.

On the other hand, there was an increase in hospitalizations due to assault with a gun.

Yes. We lost colleagues from our institution, not connected to our specialty, most of them over 65 years old.

Dr. Leonardo Peixoto, MD, Belo Horizonte, Brazil

  References Top

1. ourworldindata.org.  Back to cited text no. 1
2. McGuinness MJ, Hsee LI. Impact of the COVID-19 national lockdown on emergency general surgery: Auckland City Hospital's experience. ANZ J Surg 2020;90:2254-2258. Available from: https://doi.org/10.1111/ans.16336.  Back to cited text no. 2
3. Maddern GJ. Evidence, not eminence, in coronavirus disease 2019. ANZ J Surg 2020;90:1537-1539. https://doi. org/10.1111/ans0.16174  Back to cited text no. 3


  [Figure 1], [Figure 2]

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