Global vascular community addresses geographic disparity in pandemic impact and response, rescheduling electives, and making difficult decisions during COVID-19

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Last week, the Charing Cross (CX) Symposium 2020 would have taken place in London, UK. To mark the occasion virtually, experts from across the globe took part in a wide-ranging informal chat to share the impacts of the COVID-19 pandemic on the vascular community. Chaired by Roger Greenhalgh (London, UK), Enrico Ascher (New York, USA), Michel Makaroun (Pittsburgh, USA), Roberto Chiesa (Milan, Italy), Jürg Schmidli (Bern, Switzerland), Gunnar Tepe (Rosenheim, Germany), and Rebeca Reachi (San Luis Potosí, Mexico) discussed the effect of the virus on their daily practice, compared the differing readiness with which the threat was met by governments across Europe and North America, and deliberated on what healthcare will look like in the aftermath of the deadliest pandemic in living memory.

A key take-home message is that not all healthcare systems have been impacted equally. Those hit first by the virus had the least time to prepare, and are consequently seeing a greater loss of life. Anecdotally, poorer neighbourhoods and countries (such as Brooklyn in the USA and Mexico City, Mexico) also seem to be the most overwhelmed. On a positive note, governments and local authorities exposed to the virus later, such as those in Switzerland and Pittsburgh, USA, seem to have been able to prepare for the pandemic, having learned from those hit first. Schmidli and Makaroun were able to recount how their regions were able to effectively mobilise against the virus early, closing borders to reduce footfall and slowing the spread. This was possible, they related, due to a delay in the virus reaching their communities, providing a window of opportunity to witness the response from medical communities already exposed.

As an additional consequence of the COVID-19 pandemic, the webinar participants reported that the necessary cancellation of elective procedures has resulted in a backlog of surgeries, meaning the current crisis will potentially have ramifications for healthcare for years to come. Indeed, when considering life after the pandemic, the discussants agree that while virtual meetings are no match for face-to-face interaction, they have been an essential part of healthcare provision during government-enforced lockdowns. Chiesa proposed that a return to normality is possible, providing healthcare professionals work together in unity.

The effects of COVID-19 on physician environment and practice

Later hit countries benefit from early preparation

A key takeaway from the webinar is that there is a large geographic disparity in the severity of the virus’ impact. Timing is also crucial. Those vascular specialists practicing in countries or regions with a “head start” on the virus repeatedly reported being able to mobilise earlier and to prepare their wards for the coming influx of coronavirus patients. For those first impacted by COVID-19, this was not the case. Speaking from Milan, Italy, Chiesa relates the difficulties with being amongst the first hit with the COVID-19 pandemic in Europe. “The problem in Italy is that we are the first country to be infected with COVID-19, so other countries have had a one, two, or three-week delay. It was easier for the other countries. For example, for Switzerland, it was easier, after observing what has happened in Italy, to stop everything immediately, to close down everything.”

Schmidli concurred. “We were quite lucky in Switzerland,” he told webinar listeners. “We knew what happened in Italy, and our authorities shut down the country quite fast. Most of the hospitals had about two weeks to prepare for COVID-19 patients,” he relayed.

Providing a US perspective, Ascher said: “Unfortunately, we were hit with this horrible pandemic, and in particular in New York state we have been hit very hard.” Providing some statistics, Ascher shared that, to date, there were more than 130,000 confirmed cases of COVID-19 in the state, with over 35,000 hospitalisations, and more than 9,000 deaths from the virus. “Just in Brooklyn, which is a very endemic area, we had close to 35,000 diagnosed patients. This is double what you have in Manhattan. We have been particularly hit; although we do not have as many institutions in Brooklyn as in Manhattan, we have double the number of cases. Not only have we been doing what we know how to do within our specialty, but [we have] also been expanding our services to particular needs within the hospital.”

Ascher claims that there is a “poverty factor” associated with the differing proliferation of COVID-19 within New York state; when asked directly about why he believes the discrepancy exists between case numbers in Brooklyn and Manhattan, he replied: “I think it is because the average person in Brooklyn is poorer than in Manhattan.”

In neighbouring Pittsburgh, a city in Pennsylvania, USA, Makaroun reported that there have been very few COVID-19 cases. “We have been lucky in Pittsburgh,” he disclosed. “We have had very few cases, and certainly the system has not been overwhelmed.

Relating her experience of COVID-19 in Mexico, Reachi told the other panellists: “The government are not testing everybody. The number of [confirmed] cases right now is only 8,000, but it is estimated that there are over 50,000. […] The main problem for me is there is not enough testing of patients.

“We do not have anything. We do not have N95 masks. I bought one for myself because some public institutions do not have enough equipment. I am in fear of going to work. We do not know if the patient [we are treating] is infected or not because they are not being tested. We have to take our own protection, not to get infected, so that is a problem here.”

Footfall favours viral spread

Chiesa noted that a football game at the San Siro stadium near Milan in February has been attributed to the initial spike in COVID-19 patients in the region. Similarly, although Tepe described Germany as not being too inundated with COVID-19 patients, he acceded that “Bavaria is quite different”, elaborating: “Rosenheim is the number one spot for COVID-19 within Germany. This is because we are close to Italy and Austria, and quite a lot of people have travelled through who had been in ski resorts in the Alps. About 10% of the population of Rosenheim are affected. Our hospital has 600 beds, and 200 of those are COVID-19. So, we are quite heavily affected.”

Closing borders helped to stop the spread

Makaroun noted: “Pennsylvania borders New York, and when the number of cases started increasing, they put a lockdown on all of Pennsylvania. We are a six-hour drive away, so our region was locked down before the big increase in cases.” Greenhalgh noted Makaroun was the first vascular surgeon he had heard report being ready for the COVID-19 crisis. Most healthcare centres around the world were overwhelmed by the virus.

Schmidli concurred: “Only cities close to the border (such as Geneva, Lausanne, or Lugano, which is quite close to Italy) had a lot of novel coronavirus patients from the beginning. But in the Swiss-German part [of the country], we had very few patients.”

Effect of COVID-19 on surgical practice and emergencies: Increase in number of endovascular procedures performed as physicians aim to keep patients out of hospital

Many elective procedures have been delayed or postponed around the world in response to the COVID-19 pandemic. What is elucidated in the CX COVID-19 webinar is that as well as impacting the number of surgeries taking place globally, the virus has also influenced the type of surgery being performed. Chiesa reported seeing more endovascular procedures than normal, citing the lack of beds in the intensive care unit of his hospital as one explanation: “It is very difficult to do open surgery without intensive care on our ward.”

Making incisions brings greater risk of infection. Several vascular surgeons speaking testified to seeing fewer transplants and fewer cancer referrals because of this increased risk. “In our hospital and throughout Germany, emergencies like patients who present with stroke or heart attack have gone down by 50%,” Tepe stated.

“We have got to assume that heart attacks and stroke are still taking place,” Greenhalgh replied. “So, are we making the assumption that this means patients are not coming into the hospital, but they are in trouble somewhere in the community?” Both Tepe and Schmidli agreed, with the latter adding: “We have seen the same thing—we did not have one ruptured aneurysm [in the last few weeks], which is completely unusual.”

Ascher noted that the same story was true in New York: “We have fewer emergencies, much fewer heart attacks coming to the hospital, and the reason I believe this is happening is because patients are afraid of coming to the hospital. They are saying they might as well take an aspirin at home and take a telemedicine. So, I think we have seen fewer of all these patients.” He declared his concern that several of these patients may need more intensive treatment in the future, once the pandemic-induced panic has passed.

Contrary to the other speakers’ experiences, Makaroun shared that his institution has treated six ruptured aneurysms in the last two weeks, and that, although the number of trauma cases were down (which he attributed to fewer cars being on the road meaning fewer traffic accidents), the number of cancer surgeries “has not really stopped”. He expanded: “Elective work, as you have mentioned, is down to almost none, but in general the emergencies have stayed to about the same as where they were before, but we may be privileged in a way in terms of where we were before, not being overwhelmed with COVID-19, and the hospital actually has around 20% empty beds.”

Backlog of elective cases: Catch-up will vary by geography

The necessary deferral of elective procedures has resulted in a backlog of cases across healthcare systems worldwide. During the webinar a geographical disparity in readiness to restart procedures became clear.

Makaroun predicted some logistical problems in starting the catch-up. “How many operating rooms can you reopen? How many nurses are sick and cannot show up?” he asked. Putting the scale of the situation at his centre in perspective, Makaroun detailed: “Normally on our system there are over 2,800 procedures a day, so you can imagine the backlog after about five weeks of doing very little elective work.”

In general, however, Makaroun noted that his hospital still has “a lot of capacity”, so they are now trying to work out how to prioritise patients and provide a framework for the cases to restart with minimal risk. Schmidli anticipated this to be the case in Switzerland as well: “restarting cases will not be a big issue,” he disclosed, as the number of infections has been lower than expected.

In contrast, Reachi outlined that in Mexico, they will not be starting elective cases again any time soon. “I know that we are very far from where we have to be. We are trying to flatten the curve and we are trying to stay at home. The government says this will be the case until the end of May.”

Medical education during the time of COVID-19: Virtual meetings no match for face-to-face interaction

The discussion then moved towards medical education during an era of unprecedented social distancing. Greenhalgh noted that the CX Symposium had been ready to showcase numerous first-to-podium presentations, covering “a lot of new data which is important to communicate”.

The panel agreed that while virtual meetings have enabled communication whilst face-to-face meetings are not an option, they are no match for a live conference.

Makaroun commented on both the necessity and ubiquity of the online meeting at the present time: “I think virtual is something that we have to do. Most of our meetings are now virtual and I am spending more time in front of my computer than I ever did in my entire life.”

Ascher then emphasised the benefits of interacting in person, stating that “nothing will ever replace the live presence of your colleagues at a meeting”. However, he acknowledged that “right now, we are in a situation where we have no other option but to go online.”

Return to status quo desirable, but timeline remains unclear

It was made clear during the conversation that a return to the status quo ante is desired, however the rate at which this can happen will vary by geography.

While Makaroun is hopeful that things will go back to normal, he stressed that it would take time. “Until the science catches up with this virus, I am not sure that we will ever know how we are going to return to normal. I think we have to learn to live with it for the foreseeable future and it may be a year or two, but I hope we will all go back to where we used to be.”

Schmidli believes that until there is a vaccine, things cannot go back to normal. “In the meantime,” he said, “we hope that the second wave does not hit us too hard.”

There was universal consensus about the need to return to normality as soon as responsibly and feasibly possible.

Profession faces specific COVID-19 danger

On the specific risks faced by the medical profession, Tepe pointed out the importance of testing and how his centre is addressing this: “We have to know who is positive and who is negative. Here at our institution we are doing a lot of CT scans. It is quite sensitive and is faster than a test.”

On a personal note, Ascher raised the point of responsibility towards the families of physicians. “I do not think we should overlook the influence on the family of the surgeon or the provider. It is a big deal because you go and spend 12 hours working and when you get home you have small children, you have a wife, you have grandparents. It is a big problem, and this is affecting a lot of us.”

Role of medical students varies widely across the globe

On the topic of responsibility, the conversation then considered whether medical students were prematurely functioning as doctors in order to meet the needs of the COVID-19 pandemic, with answers once again revealing geographical imbalance.

“In Mexico, all the medical students are at home,” Reachi began. “They are not allowed to go to the hospital because they are not prepared and there is not enough equipment to protect them.”

Ascher outlined a contrasting situation in New York: “At NYU [New York University], 50% of our senior class graduated already. Many of them were given jobs as residents and those who were not were hired to help in other ways and paid as residents.”

In Pittsburgh, however, medical students are not required in the hospitals and have instead been providing childcare for healthcare workers who cannot be at home, and volunteering at clinics in disadvantaged areas of the city. “They are stepping up and helping but not necessarily as physicians,” Makaroun commented.

“If only I knew…”: Vascular community reflects on what they would have done differently

Tepe cited testing as a “major issue” at the beginning of the crisis and something he would like to have been better prepared for.

The conversation then turned to equipment, with Ascher commenting: “I would have called the governor and asked him to expedite an order of ventilators”. One a similar note, Reachi stated that she would have bought more equipment for her college. “It is gone. There is no more.”

In Switzerland, “we would not shut down the whole system completely,” said Schmidli, noting that they had overestimated the impact of the virus in their country.

Chiesa ended this part of the discussion by commenting that in Italy the onset was so sudden that “it would have been impossible to do something differently”.

With more forewarning, Chiesa would have implemented a different organisation of the healthcare system in order to better prepare for the crisis. He outlined that he would have created a hub for every type of specialty “as soon as possible”, stressing that this was “very important, because it would allow you to do all emergency or other important cases in one major hospital in the region and use all other hospitals to cure COVID-19 patients”.

Difficult decisions during the COVID-19 crisis

As the conversation came to an end, the panel revealed the most difficult decision they have had to make so far during the COVID-19 crisis.

Chiesa, Schmidli, and Tepe agreed that choosing not to operate on certain patients was their most difficult decision. Chiesa noted, for example, that he was not able to operate on patients with thoracoabdominal aneurysms of up to 10cm.

One of the most difficult decisions for Makaroun related to his responsibility towards his employees. “I had to make sure that most of our employees and personnel are protected by sending them home and making sure their jobs are protected.”

Ascher addressed the decision between loyalties to family on the one hand and to patients on the other, questioning “whether at my age I should put myself in the situation of being on call 24 days a month.”

Reachi also felt that her loyalties were split between her hospital duties and family ties. She cited her most difficult decision as simply going to the hospital, likening it to gambling in its risk and recalled feeling “petrified” when entering her institution, due to the unknown prevalence of the virus and the lack of PPE.

COVID-19 has illuminated stark differences in healthcare systems across the world. Responses to the pandemic have been reflective of the extent and timing of exposure to the virus, and the resultant impact on the vascular community is markedly variable. At the same time, COVID-19 has brought the medical profession together. While the CX Symposium would have assembled vascular specialists from nearly 80 countries this week, this conversation has revealed commonalities within the community during a crisis. The degree of testing, PPE provision, and the timing and suddenness of onset have determined the severity of the impact on healthcare systems. Speaking from one of the hardest-hit countries in the world, Reachi expressed that her enduring dilemma was between her professional and personal duties, something at the forefront of every physician’s mind today.


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