Coronavirus Impact

[TraumaLlamaMD]

I’ve seen similar threads in other forums, but wanted to get a sense of how other surgical residents are impacted by, or preparing for, the coronavirus invasion. Are your programs having conversations yet about backup plans for coverage if multiple residents are quarantined? Any change in your vacation policy? Have any of your hospitals shut down elective cases yet?

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[Dr.LeoSpaceman]

I’ve seen similar threads in other forums, but wanted to get a sense of how other surgical residents are impacted by, or preparing for, the coronavirus invasion. Are your programs having conversations yet about backup plans for coverage if multiple residents are quarantined? Any change in your vacation policy? Have any of your hospitals shut down elective cases yet?

Other than getting a million emails and having the majority of conferences/lectures canceled, no. I know there are plans in place, but we haven't been told what's going to happen if things get ugly. We have discussed as a family what our plan will be if it shows up in our hospitals. I doubt I'm going to be kept home and my exposure will be all but certain. So it might make sense to have my family go stay with other family in town so I don't expose them. But at this point, the impact of actual illness may be secondary. They just shutdown all schools/daycares in our state for the next two weeks (at least). This is going to undoubtedly cause a ripple effect in families where both parents work, especially two resident/physician families. It's not just going to be people who have to quarantine, but potentially those that don't have a childcare option.

No word on elective cases yet, but I assume it will happen if the ICUs get full and they start having to use PACUs as overflow. But again, what I've heard is that it may not even be handling the sick that gets us, but the supply chain disruption. If we start saying we don't have certain types of equipment (e.g. staplers or whatnot), I suspect staff will start canceling cases on their own.

 

[deleted50541]

There doesn't seem to be any major disruption of education for our residents/fellows. However, medical students are not allowed to scrub cases anymore and it's unclear what will happen with their upcoming clinical rotations.

We've had a similar discussion about elective cases. Just the other day, I had to secure an ICU bed the day before a case because ICU managers said they could no longer guarantee having a bed the day of surgery if we didn't check in advance. There's also been talk of turning one of our surgical floors into an overflow unit for coronavirus patients if needed.

Disruption of the supply chain is definitely on folks' minds here too. So far, my hospital isn't having any issues and we haven't been told to curtail elective cases. But total cases do seem to be down for the week and the hospital is feeling more like a ghost town with visitor restrictions in place.

 

[armybound]

They have changed resident allocation. Residents have been pulled from their off campus rotations. The residents now work in certain squads and rotate so they're not all on at the same time.

The VA has asked us not to do elective cases because we had a shortage of gowns. They are also asking us to minimize who does scrub in, specifically asking for no med students or interns unless absolutely necessary. The University has not asked us to stop elective cases, though just today we had some emails going around so we could agree what is elective and what isn't, since we expect to lose elective cases. We have also been asked to screen our clinics for patients who can be handled over the phone or postponed to decrease traffic.

 

[anonperson]

I’ve seen similar threads in other forums, but wanted to get a sense of how other surgical residents are impacted by, or preparing for, the coronavirus invasion. Are your programs having conversations yet about backup plans for coverage if multiple residents are quarantined? Any change in your vacation policy? Have any of your hospitals shut down elective cases yet?

Elective cases officially stopped at my community hospital (CA). The ACS recommendation helped push leadership in that direction, which I agree with.

 

[armybound]

 

[sinombre]

We basically changed to a skeleton crew with minimal resident coverage. When not in-house we are supposed to be “available” in case other people get sick/quarantined so we can switch out

 

[DoctwoB]

My main shop Is leaving it up to individual docs to cancel cases (RVU based compensation) and most seem to be going full steam ahead. Resident coverage unchanged. The lack of leadership is appalling. CMS should stop paying for clearly elective cases if they want the recs to have teeth. Have a system where you can plead your case that your elective case really wasn’t elective for x y or z reasons.

Even worse is the data that there are a lot of minimally or asymptomatic carriers and that intubation basically makes the virus airborn for a period of time. A lot of healthcare workers could be infected not using n95/airborne precautions in elective surgeries until we can screen patients for covid preop.

 

[DoctwoB]

They have changed resident allocation. Residents have been pulled from their off campus rotations. The residents now work in certain squads and rotate so they're not all on at the same time.

The VA has asked us not to do elective cases because we had a shortage of gowns. They are also asking us to minimize who does scrub in, specifically asking for no med students or interns unless absolutely necessary. The University has not asked us to stop elective cases, though just today we had some emails going around so we could agree what is elective and what isn't, since we expect to lose elective cases. We have also been asked to screen our clinics for patients who can be handled over the phone or postponed to decrease traffic.

Our VA is doing the same. Where are you drawing the line on elective so far?

Obviously IPPs, BPH surgery, hydro/varicoceles, infertility and basically all of female are elective, but there are tougher calls.

High risk prostate ca? (yes for us, no low or intermediate)
Restaging TURBT? (No for us)
Kidney cancer surgery? We’re generally still doing masses >4 cm or bad enough to need radical nx, delaying others.
Cystectomy? (Yes for us, but we are definitely less aggressive in pushing cystectomy for the bad or recurrent HGT1s then before).

 

[deleted50541]

All elective cases have been put on hold as of Monday. From my end, we're allowed to do cases that fall under "urgent oncologic consultations" or anybody in house who wouldn't be able to leave without a surgery. I did two cancer cases this week for patients needing adjuvant chemotherapy. I did have to justify to the higher ups why I was doing them, but didn't get any push back thankfully.

Overall cases are down probably 50-60% and everyone seems to be complying. Our group has set up a "surgeon of the day" so that only one of us is in hospital at any given time. That person is on call and rounds on the whole service. We've rearranged our clinic schedules too to accommodate the change.

I'm sure like many others, we've been given no timetable for how long this will last and policy seems to change every 24 hours.

 

[Smurfette]

Anything time-sensitive is able to go (i.e. cancers, biopsies, inpatients, etc.), otherwise we consider it elective and will have to wait until things improve. I have some breast cancers I am trying to move up and get done ASAP before we are unable to do anything outpatient due to volume or converting ORs to ICU beds. And I want to get them done before I end up sick/exposed and am off for a while...

 

[Thanatos]

We got orders from the high command to do as little surgery as necessary so we can start to make room in the ICUs for a possible tidal wave of COVID patients. We are pushing all truly elective cases out 2 months....honestly though very little of what I do is truly elective. I've been operating all week on inpatient endocarditis and NSTEMIs and have several CABG/valve cases booked next week. Every case I book I have to justify as to why it can't wait although I'm getting no pushback really....I think everyone knows we're trying to do the right thing by getting the inpatients out and make room in the hospital...but some guy who comes in with 3v disease after an NSTEMI loaded on heparin and nitro isn't going anywhere until we revascularize him lol!!

On the transplant side most of us are a little leery about accepting organs right now....I have two patients on ECMO awaiting lungs so of course I'll take something for them and just hope it doesn't come back in the cooler with a nice dose of coronavirus. Have to admit I'm not too excited about calling in a relatively stable status 4 patient chillin at home for a heart though....

We've converted an entire stepdown floor to a COVID ICU and now admitting people....I had our techs go to the warehouse and blow the dust off some equipment and have 10 ECMO circuits ready to go for the pandemic. Fortunately when we soon run out of N95s the CDC has given us some sage advice on using bandanas instead.....I'm trying to picture myself cannulating people with a deadly virus while wearing an OG bandana like a California gang member robbing a bank.....

 

[LucidSplash]

Elective-non-urgent surgeries cancelled, elective-urgent on a case by case basis. I’m hospital-employed and department put out guidelines by service line for what should be delayed and what should be done. Obviously all urgent/emergent cases still going. It is pretty reasonable list for vascular. I ran through the other specialties and seems to strike a reasonable balance.

 

[WinslowPringle]

All elective cases cancelled.
No more med students.
Conferences cancelled.
All non-quarantined residents are still showing up to the hospitals daily for inpatient duties, no significant rearrangement to expected services.
Restricted out of state travel.
Recommended we carry our licenses with us at all times in face of an expected lock down.

And.....they took away our coffee pots.

 

[ThoracicGuy]

Elective-non-urgent surgeries cancelled, elective-urgent on a case by case basis. I’m hospital-employed and department put out guidelines by service line for what should be delayed and what should be done. Obviously all urgent/emergent cases still going. It is pretty reasonable list for vascular. I ran through the other specialties and seems to strike a reasonable balance.

That list is pretty similar to some of the lists circulating from our local hospitals.

 

[sinombre]

And.....they took away our coffee pots.

I can understand not having enough PPE for us to use, but this... I would literally quit on the spot.

 

[deleted50541]

I can understand not having enough PPE for us to use, but this... I would literally quit on the spot.

The coffee is still flowing in our doctors' lounge. I'm pretty sure there'd be a riot if it was gone.

 

[LucidSplash]

I can understand not having enough PPE for us to use, but this... I would literally quit on the spot.

I don’t even drink coffee daily anymore but can see this would be a huge problem. Our doctors lounge has moved to grab and go only food (no hot food). Luckily the coffee comes from one of those fancy machines that dispenses it one cup at a time rather than a traditional pot. Easier to sterilize the button probably than a regular coffee pot.

 

[armybound]

Our VA is doing the same. Where are you drawing the line on elective so far?

Obviously IPPs, BPH surgery, hydro/varicoceles, infertility and basically all of female are elective, but there are tougher calls.

High risk prostate ca? (yes for us, no low or intermediate)
Restaging TURBT? (No for us)
Kidney cancer surgery? We’re generally still doing masses >4 cm or bad enough to need radical nx, delaying others.
Cystectomy? (Yes for us, but we are definitely less aggressive in pushing cystectomy for the bad or recurrent HGT1s then before).

Very similar to yours. If it's cancer, it's getting done. We use IR a ton for small renal masses, so we wouldn't be doing those anyway. We actually don't get a lot of kidneys here for some reason.

Any bladder cancer is on. TURBT, high risk surveillance, etc are all going forward. Cystectomy, RALP moving forward.

Practically everything else is delayed. Microhematuria workups are being pushed back, as you/we know we're very unlikely to find anything significant. Gross hematuria evals are up to our discretion based on perceived risk (smoking status, etc). TRUS biopsies postponed. I think the chief resident snuck in an AUS eval/explant, but we're concerned for erosion so I think that's a reasonable case to do.

We do a ton of elective stones normally, but those are being delayed depending on how long the stent has been in, if there is a stent.

 

[WinslowPringle]

I don’t even drink coffee daily anymore but can see this would be a huge problem. Our doctors lounge has moved to grab and go only food (no hot food). Luckily the coffee comes from one of those fancy machines that dispenses it one cup at a time rather than a traditional pot. Easier to sterilize the button probably than a regular coffee pot.

They claim it's to stop spread from people using reusable cups under the spigot....? Who knows what the administrators think: somehow bandanas are enough to stop the spread, but the coffee machines will kill us all.

 

[TypeADissection]

As many of the programs above, we have cancelled all elective cases until mid-May at the earliest. So our current guidelines are AAA >6cm, acute mesenteric ischemia, symptomatic carotids and CLTI with tissue loss/gangrene. This is all subject to change on how badly our hospital gets hit and resources become more scarce. Stay safe everyone. Remember that there is no such thing as an emergency during a pandemic that is more important than your safety first. I don't care if the patient with COVID-19 is coding, make sure you use proper PPE. We are in the trenches on the frontline and are force multipliers that are not easily replaced. So do your due diligence and take care of yourselves first and foremost. Cheers.

 

[sinombre]

As many of the programs above, we have cancelled all elective cases until mid-May at the earliest. So our current guidelines are AAA >6cm, acute mesenteric ischemia, symptomatic carotids and CLTI with tissue loss/gangrene. This is all subject to change on how badly our hospital gets hit and resources become more scarce. Stay safe everyone. Remember that there is no such thing as an emergency during a pandemic that is more important than your safety first. I don't care if the patient with COVID-19 is coding, make sure you use proper PPE. We are in the trenches on the frontline and are force multipliers that are not easily replaced. So do your due diligence and take care of yourselves first and foremost. Cheers.

What about clotted AV fistulas?

 

[ThoracicGuy]

What about clotted AV fistulas?

If you can get to it within 24-48 hours, you might be able to open it and have it stay open... Maybe.

 

[sinombre]

If you can get to it within 24-48 hours, you might be able to open it and have it stay open... Maybe.

But this has to be attempted right? Otherwise they all just get permacaths to use until the apocalypse is over?

 

[LucidSplash]

But this has to be attempted right? Otherwise they all just get permacaths to use until the apocalypse is over?

I’m still declotting grafts, doing fistulograms for low flow, high venous pressures, prolonged bleeding. Revisions for ulcerations, etc. Not doing new access for those with working catheter or aneurysmorrhaphy.

 

[TypeADissection]

What about clotted AV fistulas?

Meh. If the fistula is occluded then it’s done. Place a catheter, discharge them and move on. If it’s a graft, I’d maybe try an attempt at declot +\- place a catheter, discharge them, and move on. No need getting crazy over dialysis access if you’re staring down the barrel of a resource shortage.

My institution has basically said nothing heroic for dialysis cases at the moment. This is to preserve PPEs.