Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 107-112

Reign and domain of the nimbus


Chief Editor, Director – JIVAS, Bengaluru, Karnataka, India

Date of Submission20-May-2020
Date of Acceptance20-May-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Kalkunte R Suresh
Chief Editor, Director – JIVAS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_64_20

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How to cite this article:
Suresh KR. Reign and domain of the nimbus. Indian J Vasc Endovasc Surg 2020;7:107-12

How to cite this URL:
Suresh KR. Reign and domain of the nimbus. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 23];7:107-12. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/107/286910




  Impact of Covid-19 Top























We, the people of the world, would have expected the current leap year of the Gregorian Calendar to bring us a clearer vision of the present, and the future, as the numerical indicates – 2020! This year has been designated by the WHO as “The Year of The Nurse” and UN has declared it “The Year of (Plant) Health.” Little did they comprehend that the integrity and commitment of our comrades in arms, The Nurses, would be so severely tested – and the Health of Humanity will be compromised like never before! This also is the “Chinese Year of the Rat” – seen as a sign of wealth and surplus, and giver of new life! The creed of these “signs” has been decimated! But a silver lining – 2020 is also the 50th year of the launch of EARTH DAY, which was supposed to be celebrated on April 22, ironically the day when the entire humankind was under lockdown. But the replenished Nature, free from incongruous human interference in decades, resurfaced in its splendorous colors as seen on multitude of videos when all the species, except the Homo sapiens, were free to roam the earth.

The year 2020 will be reminisced, likely in the rest of the History of Humankind, as the year that the Nimbus (aka Corona) which unleashed its fury on humankind and reigned supreme on the entire domain of the humans! Its destructive impact has singed all humans, irrespective of color, creed, status, profession, race, or religion. But the path of humanity is always forward toward a better future not one of despair! Hence, as the ancient Persian adage declares, “This too shall pass …,” reflecting the ephemerality of this Nimbus!

Switching from esoteric to mundane, the Vascular Surgeons and the patients they care for have been significantly impacted by COVID-19 and the extended lockdowns. Number of vascular departments across India has shared their tribulations, which is reproduced in the latter part of this Editorial. Some issues, which were unthinkable about 3 months back, are listed below:

1. Single use devices (SUDs)/single patient devices

  • Reusable face masks – heard on news that washable, reusable masks are being manufactured in a country! If this is true, a “perishable mask” would it mean that many SUDs, like guidewires, etc., can also be re-sterilized and used? Also, the severe global economic downturn might force us rethink about SUDs and IFU guidelines
  • Single ventilator use on multiple patients – may not become the norm, but serious thoughts will be given to these modes of medical equipment use in the future
  • Severe shortage of above was felt even in the countries with excellent healthcare systems. Granted, healthcare systems have been overwhelmed by this unprecedented pandemic, but country like India will need to decrease the dependency on others.


Patients with vascular diseases are likely to be affected severely during lockdown, probably more than many other specialties:

  1. Even prior to COVID-19, the awareness even among medical profession was inadequate. It is more than likely that advance vascular problems were not recognized, if not ignored
  2. Vascular surgeons and vascular departments are sparse in India, and most of the departments draw patients from several surrounding states. With prohibition of interstate travel, most of these patients do not have access to care, unlike most of the other specialties could be available in their neighborhoods
  3. Even within a state interdistrict travel was not available and in department like ours (JIVAS, Bengaluru), over 50% of patients are from outside our city, which is true of most of the centers
  4. Most of the patients are “frightened” to travel even if they can, but most of vascular departments have not turned patients away
  5. Delayed presentation has become the norm and we have performed more amputation for CLTI than ever before
  6. Number of vascular patients visiting all our departments has drastically decreased – we at JIVAS are at 30% of our usual numbers
  7. Increased costs for PPEs and others have significantly increased the costs. India has amazingly increased production of PPEs from zero to several hundred thousand at a fraction of cost in “developed” countries. This is also true of COVID-95 masks. Even this might be unaffordable for already impoverished population and now with more economic strain on the “affordable” patients
  8. One cannot but wonder about the fate of the critical patients all of us cared for – from the following reports from across India, it is evident that a huge number of patients are “lost,” whichever way you want interpret the word
  9. Elective surgeries have come to a virtual standstill
  10. Unforeseen complications might need vascular surgeons' care, as the thrombotic disorders seem to the major pathology in COVID-19-infected patients
  11. Significant decrease in income of vascular surgeons, especially those who have just started to find their footings in their communities where they practice. Since we cannot see the end of this impact just yet, it might be a while (a nondescript word) before these younger colleagues are back on track. But they will!
  12. Training of our fellows, both didactic and hand-on, has been curtailed; but thanks to technology and innovation, envisaged by Dr. Tapish Sahu and few others, the online education continues. In fact, I find it a pleasure to interact with 40 + trainees and young colleagues, which we never did before. Here is a brief provided by Dr. Tapish:


  • Online platform
  • Ongoing since the last year – every working weekday evenings – initially was offered to the postgraduate student who would be appearing for the final examination. This consisted of case presentations and mock examinations
  • Since February 2020 – open to all vascular postgraduate students daily; case presentations and discussions with a senior consultant from different institutions; about 60–70 participate
  • Now, a new addition – basic surgical and endovascular skills video presentation; also, live cases beamed for students to see and learn


Below is the presentation from various vascular departments across India, unedited and not peer-reviewed:

1. Department of Vascular and Endovascular Surgery and Vascular IR, Care Hospitals, Banjara Hills, Hyderabad

Prem Chand Gupta, Rahul Agarwal, Viswanath Atreyapurapu, Gnaneswar Atturu


  Impact of Covid-19 Pandemic and Lockdown on Vascular Surgery Practice: the Good and the Bad Top


The coronavirus pandemic has hit the globe like nothing before. Homo sapiens has been literally brought down to its knees by this little but seemingly deadly microbe. The response of various governments has been unprecedented with major lockdown of populations, grounding of most transportation and really no clarity on how to proceed further. Livelihood of millions has been taken away with a huge number coming below poverty lines and most economies have taken a major hit. A large number of publications have appeared rapidly trying to shed light on the virus, pathophysiology, management and outcomes. The volume of publications and the contradictions have served to create a fair bit of confusion. At one point, the lockdown was supposed to contain the disease and stop community spread and also prevent health services from getting overwhelmed. We can see that the containment has not really happened though the latter aim seems to have been fulfilled for now.

A layperson is confused: should he/she continue to take extreme steps to protect self and family or accept that the virus is here to stay and that there is no escaping it unless a vaccine comes up in the near future and that too is rather unclear.

In the mid of this uncertainty, one thing is clear: a large number of patients suffering from various other diseases have not been able to access adequate medical care. Many healthcare professionals have been scared to work and patients have been equally scared to visit hospitals. We, in our unit at care hospitals, realized that the virus is not going away anytime soon and we have to learn to live and work in the new normal. We looked at the impact of lockdown 1.0 ending on May 3, 2020 (5 weeks), on our outpatient and surgical services along with research and teaching. We compared the current data with data from the same period of 2019. The experience has been an eye opener in many ways:

Clinical

  1. Doctors and other healthcare staff were apprehensive but not scared. They decided to continue to work for patient care. Everyone learned to wear masks in outpatient, clean hands and various surfaces. What should have been the norm for us was finally forced on us by the pandemic. Patients too learned to use masks and maintain distance from each other
  2. Hospital management rose to the occasion, provided required safety gear, made isolation areas and sensible protocols for dealing with suspected/confirmed coronavirus patients. Salaried staff have not faced a cut as yet
  3. The anesthesia team stood with us and did not shirk from serving any patient
  4. Doctors and staff were given time off in rotation so that exposure to coronavirus patient would not paralyze services due to required quarantine
  5. Closure of state borders and difficulty of traveling even within the state was clearly seen with our overall outpatient footfall falling to less than 20% (2037 to 369). However, we fared much better with new patients: 45% (548 vs. 247) as compared to the last year
  6. Surgical and interventional procedures fared better: 67% compared to the previous year (fall from 271 to 181). The decrease was not as bad as overall outpatient deficit. This can possibly be explained by the fact that we saw a reasonable number of new patients and most needed procedures. A large number of hospitals were not providing services and that seems to have helped us
  7. There was not much difference in surgeries for aneurysms and we operated more than twice the number of acute limb ischemia. However, none of them had COVID-19 infection
  8. Surgeries and interventions for CLTI and carotid stenosis fell to less than 50% (23–10). We fear that we may see many more patients with irreversible ischemia and nonsalvageable feet when the borders and transport open up and fear of visiting hospitals comes down. It also makes a very strong case for the presence of vascular services in tier II cities
  9. We decided to treat vascular access creation for hemodialysis as semi-emergencies and did two-third the number compared to the last year in the same period (143 vs. 92). We did nearly the same number of procedures for vascular access complications as in 2019 (42 in 2019 and 39 this year)
  10. Vascular access creation and salvage seemed to become the most essential procedures during this period and highlight the importance of learning all open and endovascular techniques for vascular surgeons. We define these as the new vascular emergencies/semi-emergencies
  11. Finally, we joined the bandwagon of video consultations. It has been reasonable to follow-up an occasional patient and we did earlier too, over phone and getting pictures or videos over email or WhatsApp. We realize that new patients are practically impossible to assess over videos. We need to physically examine most of them and scan with ultrasound. For this reason, we also cannot create a barrier with plastic sheets or make Lakshman-Rekha to keep distance from them.


Economic

1. Operating during these times has been a financial tight rope walking: hospital finances have suffered hugely with 20% bed occupancy, use of protective gear where needed increased procedure costs, paying capacity of patients has come down for obvious reasons. It was, however, not the time to refuse any procedure and the management has been very supportive.

Teaching

As everyone started working without fear, the atmosphere turned positive. Lesser clinical work meant more time for academics and a more relaxed lifestyle. DNB residents got more opportunities to operate since we had more time to teach and assist operative procedures. We also saw suspension of Hyderabad DNB classes and initiation of web-based teaching nationally.

Research

The pandemic and lockdown had both negative and positive impacts. We presented nearly 50 papers national and international meetings last year. However, with suspension of most meetings, this activity has taken a backseat. On a positive note, we are in the process of writing papers and designing new trials for research.

2. Department of Vascular and Endovascular Surgery, Ruby Hall Hospital, Pune, Maharashtra

Dhanesh Kamerkar

Since lockdown March 24, we have stopped elective surgeries thinking that there may be avalanches of cases where there may be shortage of PPE kits, gradually footfall in hospital dropped drastically, so closed OPD, patients were asked to contact us directly if any urgency or emergency. Emergency work continues but far and few in between. We did two thrombectomies, one hybrid femoral endarterectomy with upstream and downstream stenting and couple of AV fistula. Lots of protocols, which keep changing, all HCWS have anxieties what if patient turns positive in postoperative period. Operating in PPE kits with surgical loupes on, especially for long cases, is nightmare to say the least. Certainly, income has gone down, but I can shudder to think about young surgeons who may have taken loans for hospital, high-end instruments, etc., can be nightmarish. I think it will take another 1–2 months for patients to develop confidence to attend hospital for OPDs, elective surgeries. On personal front, learning some cooking, odd painting, WhatsApp talks with family and relatives, good time to catch up in virtual person. Have been going to hospital 3/4 days a week, hoping that not carrying the virus back home, especially when one has elderly parent at home. More than ever you start appreciating life, nature, relationships, everything comes back in circle. Will share some photographs in PPE kit.

PS: Also, DNB students are losing precious time of training but getting more time to read, write, Zoom meets for intrahospital teaching

3. Institute of Vascular and Endovascular Surgery, Sir Gangaram Hospital, New Delhi

VS Bedi, Senior Consultant and Chairman; Sandeep Agarwal, Senior Consultant and Vice Chairman; Ajay Yadav, Senior Consultant and Vice Chairman; Ambarish Satwik; Consultant and Director Hybrid Cath Lab; Dhruv Agarwal, Consultant; Apurva Srivastava, Consultant; Nikhil Sharma, Clinical Assistant, IVES

The global spread of the 2019 novel coronavirus (COVID-19) has profoundly affected the way we conduct our health care practices. Since the nationwide lockdown was implemented as a measure to fight against the spread of COVID-19, there was a significant fall in the outpatient and inpatient services provided in our Institute of Vascular and Endovascular Sciences, Sir Ganga Ram Hospital, New Delhi. On comparing the OPD and IPD data between January 2020 and April 2020, the outpatient services including consultation and dressings have seen an 88% drop and outpatient diagnostic procedures including Doppler study, ABI and TcPO2 measurement have seen a drop by 90%. The total admitted patients were reduced by 71% and the interventions including both endovascular and open surgical procedures dropped by 63%. However, the inpatient interdepartmental references and subsequent vascular interventions saw a raise of 23% in the same time period.

Among the procedures, no major aortic intervention was performed in April 2020 compared to 3 EVAR/TEVAR performed in January 2020. Peripheral angioplasties including Iliac, SFA and BTK angioplasties/hybrid procedures for CLTI patients were consistently performed throughout the lockdown period and showing only a fall of 13%. Surprisingly, no emergency embolectomy procedure for ALI was performed in April.

On comparing venous procedures, no varicose vein interventions including ablation and sclerotherapy were performed. In the same time period, there was 75% reduction in iliac venoplasty cases. No elective interventions were performed for AVM/VM during the period.

On comparing open surgical procedures, there was a 100% drop in carotid endarterectomies and angioplasty. Peripheral bypass procedures and embolization procedures including uterine artery embolization had also seen a 100% drop.

On comparing dialysis access-related interventions, AV access procedures including fistula creation, fistula re-intervention procedures (fistula angioplasty and fistula thrombectomy) and Permacath were reduced by 53%. Whereas short-term dialysis access interventions including dialysis catheter insertion and repositioning of catheters increased by 17%.

While analyzing the data, it becomes evident that there was a reasonable increase in number of major amputations performed for ischemic extremities (below knee and above knee amputations) performed in April (ten vs. eight). Also, there was no significant change in wound debridements including toe amputation and forefoot amputation during this period.

We adopted the appropriate protective gears as per the guidelines and followed a split-team policy and encouraged complete team segregation including Cath Lab technician, nurses and ward boys to reduce the risk of intradepartmental cross-contamination. All patients posted were tested for COVID-19 prior to admission and taken up for intervention after a negative report.

4. Christian Medical College and Hospital, Ludhiana, Punjab

Pranay Pawar, Amit Mahajan, Anil Luther

Since the declaration of the lockdown on March 24, we have done 47 cases till May 11, 2020.

We average nearly 80 cases a month including renal access work and debridements. So its nearly a 50% decrease. A majority of the work that we see nowadays is renal access work × 25 cases, that too a lot of referrals as other hospitals are not doing any elective surgeries, trauma cases × 6; acute limb ischemia × 6, diabetic foot angioplasties × 6, and debridement × 4.

We have kept our elective surgery theater running from April 7 as we observed an emergency only protocol from March 24 till April 7. All the patients get screened by a questionnaire, vital signs monitoring, chest X-ray and a blood gas prior to any surgery. We are not getting a PCR test unless advised by our infectious disease consultants.

The routine vascular patients like varicose veins, claudicants, postoperatives, etc., are advised to consult on telemedicine for the time being and are given later dates for intervention.

We screen all patients at the hospital entrance based on a COVID form that the infectious disease specialty has developed along with ABG and chest X-ray. Depending on the stratification the patients are sent to the COVID or non-COVID side.

For surgical ward we keep a space of two beds in between patients and prefer them to be in individual private rooms if they are affordable.

We have two dedicated theaters running, while the rest of the 8 are nonfunctional. We use spinal or regional blocks as far as possible and avoid intubations. Only three people that is the surgeon, one assistant and one scrub nurse are involved in the case and in case of Endo only two. We use an N95 mask and an HIV surgical kit which is two layered and water proofed, part from this normal surgical practice.

5. Christian Medical College, Vellore

Dheepak Selvaraj

The lockdown has been rather unprecedented and disrupted our routines in ways we cannot fathom. We are a busy vascular unit and had to scale down our work from 4 theater days of one table each to 2 theater days of one table each. As a department, we split our self into two units vertically and worked on alternate weeks. We have done around 75 surgical procedures during the lockdown period of 5 weeks which is half of what we would have done over the same period. However the pattern of cases was different. Our venous work which was in abundance earlier almost stopped except for a couple of patients. This was probably a result of the nonurgent nature of this disorder and the possibility of addressing this problem at a later date. However, we also noticed that the number of arterial surgeries which included bypass procedures and endovascular procedures had increased as also the number of access procedures for end-stage renal disorders. I would also like to note that the number of outpatients we were seeing as a department had decreased by 1/5th (around 50 a day). So in effect the lockdown had resulted in filtering the nonessential vascular out patients as well. We have also started once a week teleconsultation where we see around 5 patients a week. However I understand CMC cannot be representative of the situation in the country as a whole due to various reasons.

6. Department of Vascular Surgery, TMCH, Thanjavur, Tamil Nadu

S Maruthu Thurai



The hospital had become COVID-19-designated treatment center in the region. We ran OPD with poor footfall because many of our patients were not able to reach from nearby places due to travel restrictions. The trauma which usually keeps us busy saw a significant fall in numbers and the couple of vascular injury were due to agricultural work-related injuries. We also noticed more number of delayed presentations of embolism due to lockdown – delay in diagnosis and delay in reaching tertiary center for treatment.

Epilog

The impact reported by the institutions above is likely to be true of all vascular departments across India. Vascular surgeons have done well to weather the storm and have shown adaptability to continue to care for these patients, albeit with more restrictions imposed by the pandemic and unfortunately likely at a higher cost to the patients.






 

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