|Year : 2021 | Volume
| Issue : 2 | Page : 141-142
COVID-19 and its impact on surgery in kwazulu-natal, South Africa: A wholistic overview
Timothy Craig Hardcastle
Department of Surgery, University of KwaZulu-Natal, NRMSM, Congella; Trauma Service, Inkosi Albert Luthuli Central Hospital, Mayville; Durban University of Technology, Durban, South Africa
|Date of Submission||10-Feb-2021|
|Date of Acceptance||15-Feb-2021|
|Date of Web Publication||31-Mar-2021|
Timothy Craig Hardcastle
Department of Surgery, University of KwaZulu-Natal, NRMSM, Congella; Inkosi Albert Luthuli Central Hospital, Mayville; Durban University of Technology, Durban
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hardcastle TC. COVID-19 and its impact on surgery in kwazulu-natal, South Africa: A wholistic overview. Adv Hum Biol 2021;11:141-2
COVID-19, the clinical pandemic caused by the SARS-CoV2 virus, or its variants, is a current global disaster of social, economic, and emotional proportions. COVID-19 hits the South African shores in February 2020, and by the end of March 2020, the country was facing a major lockdown, with curfew hours and restricted work categories allowed to continue normal business, with most people staying home and some working from home.
The impact on the health sector was no less drastic, with most health facilities reorganising the layout and flow of services to cope with the expected major rush of infected patients. The resulting restructuring of intensive care unit (ICU) facilities led to restrictions of the number of general ICU beds for non-COVID patients and closure or severe reduction in outpatient services, both for medical and surgical units.
Staff from the clinical disciplines who had any experience in ICU (including surgical disciplines and anaesthesiology) were relocated to the designated COVID units and prepared for treating these patients. This resulted in a severe reduction in planned surgical services and the closure thereof at many facilities. This all led to a reduction in access to ICU facilities for patients with other ICU-requiring conditions, such as trauma, sepsis and cancer surgery.
To counter this threat, the hospital management established joint operating committees (JOC) to manage the hospital to ensure that there was no undue increase in collateral damage in the form of deaths due to delays in surgery. Nationally, a COVID surgical screening tool was developed by the NSOAP group and accepted by the Ministerial Advisory Committee in August 2020.
The decision of the JOC at this author's facility was that the trauma-specific ICU would act as the general ICU and the beds were expanded to cope with the influx. The decision further was that all planned surgical patients would be tested for COVID with a polymerase chain reaction (PCR) before planned surgery, while surgery for life and limb compromising pathology should proceed pending the test result, and if positive, the patient would transfer to the COVID unit. This enabled the surgical services to provide care to trauma, sepsis (not COVID related), cancer surgery and limb-threatening vascular surgery (ischemic and aneurysmal).
Obviously with the reduction in operation slates, the necessity also arose to provide surgical cover for patients with COVID who had a surgical pathology or complication. A designated ICU and ward to operation room pathway was designed and a designated room identified. This was in proximity to the COVID ICU for reducing the risk of contamination.
All this planning has paid off. The trauma ICU, an 8-bedded unit, had an additional eight high-care beds added, and over the period from “lock down” announced on the 23rd of March 2020 till the end of January, the unit treated 398 patients in total, of whom 123 were “non-trauma” cases including tumour surgery for brain tumours, various cancers and also major vascular or liver surgery. Lots of ENT/plastics cases were also admitted for airway support.
Of this total, we only identified 19 “unexpected” COVID-positive cases (4.8%), of whom 11 were in emergency trauma admissions and the other eight were non-trauma cases, suggesting that our screening of everyone with a test was working. The eight non-trauma-positive cases resulted in a policy change such that planned cancer or other urgent non-trauma surgery would only be allowed to proceed after being proven COVID-negative on PCR test. This was in light of the COVIDSurg study findings showing worse outcomes for planned surgery in COVID-positive cases. There was a clear association with spikes of positive cases during both the first and second “wave” of infections in South Africa. During the entire time under review the mortality rate for the ICU stood at 15% (13% for trauma and 16% for the non-trauma cases) for the non-COVID patients.
It must be highlighted that the trauma burden did not really reduce overall, apart from briefly during the alcohol ban for part of the first wave. Severe trauma did not really change, and gender-based violence probably increased. Thereafter, trauma numbers increased again, but trauma did reduce over Christmas and New Year during the second alcohol ban in a remarkable fashion with major trauma facilities around the country reporting their quietest period in many decades. This was evidenced by a number of recent publications highlighting this fact from around South Africa.,,,
The preceding discussion applies mainly to the South African public sector. The private sector, catering to the 16% of the population with private medical insurance, mostly followed a similar pattern; however, there were isolated facilities that elected not to admit any COVID-positive patients and continued with their normal surgical cases.
Overall, the postponement of purely planned elective surgery, such as joint replacements, hernia repairs (if asymptomatic) and similar surgical procedures, in the public and private sectors has resulted in a huge backlog of such cases, worsening the already long delays for these cases in the public sector.
In terms of trauma care and emergency surgery, there were still some undue delays resulting from a prolonged pre-hospital time due to the shortages of emergency medical services. This was from shortages of personnel (COVID infected or exposed and the need to self-isolate), vehicles (since they were so busy transporting COVID-positive cases) and restrictions around access during certain hours of the night. This led to worsening of the already long waiting times for inter-facility transfers. KwaZulu-Natal, a largely rural province, suffers from the devil of distance, covering over 94,000 km2 and with many mountains and hills, making straight-line transfer impossible. With limited aeromedical services, only day-time operational, night transfers became more difficult than usual.
In terms of the trauma patterns over the lock down period, we noticed an increase in inter-personal and gun violence and an expected reduction of the motor vehicle-related trauma with a penetrating trauma ratio that changed from one with over 65% blunt trauma at the specialised unit to a more “South African” rate of over 40% penetrating trauma and 55% intentional trauma.
Overall, the COVID pandemic has placed much strain on the personnel, particularly since the vaccine is not yet available for use in South Africa, and the recent information suggests that it may be ineffective against the recently described “South African” variant of the virus.,
In conclusion, we can only hope that the people of the country respect the request to mask up and abide by the various restrictions, while we as surgeons aim to address what we can during this difficult time.
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