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Director of the Faculty of Surgical Trainers, David O'Regan - Training in the infected era


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19 May 2020

Recent programmes on radio are talking about surgeons on the frontline. They are saying things about COVID-19 changing the way we conduct surgery for a long time to avoid transmission of the virus to patients and surgical staff. Procedures are being restricted in many disciplines to emergencies only and some procedures are being avoided. What will this mean for the future? Is this new normal? Are we going to forsake tried tested and evidenced based procedures that have clear long term and quality benefits?

At the turn of the time change 19 century, it was acknowledged that five percent of the medical school intake would probably die from tuberculosis. I am not sure if this was communicated to the trainee or if this was taken as the ‘sacrifice’, the quietly acknowledged martyrdom of an altruistic calling. There is the notorious tale of a three hundred present operative mortality – the patient, assistant and surgeon who succumbed to a perilous infection, an ignominious tale consequent of microbiological ignorance.

We are all aware of the prejudice and scaremongering heralded by the advent of the HIV infection – much of which was dispelled by the generous and benevolent action of Princess Diana. A surgical needle stick injury is ‘safer’ than that from a hypodermic needle as the inoculate is less and we wear surgical gloves. But double gloving dampens the necessary proprioception and lightness of touch that enables the ‘caressing of tissues - Lord Moynihan’ as opposed to being ‘a hewer of flesh – Lord Moynihan’: I recall the trainee who ignored my advice and slashed through the radial artery of a hepatitis C patient spraying all with blood. Surgeons have always been cognisant of the risk of blood transmission. I recall a trainee colleague acquiring hepatitis C after a needle stick injury and being forced to continue his illustrious career in the Middle East – an unwarranted sacrifice for an occupational hazard. What constitutes an occupational hazard, is the compensation adequate and how much are we as surgeons prepared to sacrifice?

We now have a new ‘enemy’ to add to the lexicon of military metaphors - ‘our troops are being sent over the front line not properly prepared or protected’. How noble and how brave…. is this romantic altruist heroism juxtaposed to the rational, pragmatic and pedagogic world of a Cartesian culture? What does this mean for trainers and trainees and how will surgical training involve? The ‘scary’ thing is that it is ‘everywhere and nowhere’ - we are not sure. There is no pain from a needle stick or visible splatter of blood to prompt our response. The media have played the classic high unknown and high dread ‘fright’ factor and emotions are high and perhaps negating rational thought?

Surgery is evidenced as safe and effective and cannot not be substituted with new technologies – look at TAVI and Stents and Cardiac Surgery and many publications reinforcing the effectiveness of coronary artery bypass grafts over last twelve months. Are we going to sacrifice known cures and better outcomes because we have a new hazard? There is a theoretical risk that every operation is a potential hazard for the surgeon and the team; all patients should be assumed to be infected.
This is the future and it has always been so. We should therefore learn and adapt. What can we learn from the military and others who have worked in Ebola environments? We need to look at how we work as teams and how we manage our work environments to mitigate the risks.

I know from my own perspective dealing with patients with endocarditis who have acquired infection on heart valves due to drug abuse are often carriers of hepatitis B C, E and HIV. As the senior surgeon, I have often taken upon myself to do the operation to mitigate the risks for the trainee and the reduce duration of the procedure. I now reflect that this is not right. The new normal mandates that we must train the trainee to be able to work in this new future. We must ensure they are professionally trained, prepared and protected. No ifs…No buts… No compromise… the safety of the trainee and the patient now and in the future depends on us as trainers – safe, effective, evidence-based surgery with no compromises.

We all need to look carefully at all aspects of our care, and we must be prepared to for difficult risk-benefit decisions and share our decision processes with the trainee and patient. I note a trainee was recently reprimanded for removing his fogged-up visor during a uniport lobectomy of the lung. He had to explain he could not see anything! Do we need take a pause and ask ourselves if we cannot see the wood for the trees?

 

If you have any comments, insights or more regarding this story, please contact us at covid19comms@rcsed.ac.uk.


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