E14 COVID19 with Neil Parry And Morad Hameed

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Hi, everyone. This is a special episode of Cold Steel recorded on COVID and the impact it’s had on surgeons across the country. We were lucky enough to be joined by two trauma surgeons and intensivists, who are actually repeat guests on the show. Dr. Morad Hameed is a trauma surgeon and intensivist at the Vancouver General Hospital. And Dr. Neil Perry is a trauma surgeon and intensivist at the London Health Sciences Center in London, Ontario. We went over how surgeons have been adopting to the COVID crisis and some basics of COVID management. We hope that you find this useful, and we hope that you all stay safe.

Chad Ball  01:33

Doctors Hameed and Parry, thank you again for joining us on such short notice. It’s exciting in the fact that you’re the first repeat guests we’ve had on Cold Steel. However, given the circumstances are tough, we thought you two in particular were in perfect position, given your critical care practice and your hospital leadership positions and also functioning as trauma surgeons to talk a little bit about how your hospitals and your healthcare systems are dealing with COVID. And maybe how your colleagues are dealing with COVID. And then I think we’ll get into some of the nuts and bolts of both the epidemiology as well as maybe some short cursory comments on ventilator management. So welcome. Thank you. I guess let’s start off really broad and just ask you guys, how have things changed at your hospital? You know, have you cancelled elective surgeries? How are you dealing with these issues at this crazy time, and maybe more of a concern, have you?

Morad Hameed  02:37

Well, we’ve had big pretty big transformations. And we’ve been approaching patients here. And I could never have imagined that it would disrupt the entire operations and organization so profoundly. Everything needs to be changed. And then general surgery trauma has had a big transformation. So, in order to create capacity, we instantly stopped doing elective surgery. And so, our OR activity reduced probably to about 40% of its baseline activity. And that actually gave us a little bit of breathing room to not only discharge patients and clarify sentences, but also to readjust our own car coverage to create a bit of surge capacity in an attending cost schedule. And also, to realign our residents. We’ve got all of our residents back from their community-based rotations, and it take them to the main COVID site in the city. So decreased activity gave us a little bit of capacity to react and then to create in trying to creating surge capacity. But that’s taken many hours of meetings and phone calls and text messages.

Neil Parry  04:03

And so, Chad or Morad, how many ORs are you guys running a day from what you would normally do? If you can give me like a digit?

Morad Hameed  04:16

Yeah, so normally we run at two sites: Vancouver General Hospital, and VGH runs about 19 units every day. And that’s gone down to about five a day. That changes almost from day to day, and we’ve been warned that the allocation to services could change in just a moment’s notice. Right now, general surgery has three units a week in our Vancouver General Hospital OR, and then three times a week at UBC which is more of an ambulatory hospital. But we still have slowed down limited episodes, but we can get scheduled surgery and everything.

Neil Parry  05:06

Yeah, so I think all the things you mentioned initially has been the same in London. Yeah, the landscape is, like everybody, it’s completely upside down and changed. And we, two weeks ago went down to running at about 40%. So, from 17 or 18 ORs at the Victoria hospital, and about 15 ORs at University Hospital, went down to about 40%. And then just this coming Monday, we’re going down to about a quarter, so probably going to run four rooms at each site. And then our more outpatient hospital will probably run about two or three rooms, so two emerge rooms, and then some scheduled urgent limb threatening cancer type surgery. So, it’s been a massive change clearly.

Morad Hameed  05:57

Has this reduction been in response to a surge of new cases? Or are you still sort of anticipating?

Neil Parry  06:02

It’s more of the latter. So it’s interesting. And I think it’s probably gonna be similar across the country, how one initially may think that, well, COVID, what’s the rule for surgery with COVID? And this huge pandemic. But I think it’s huge. One, obviously, from what we have to deliver, on an everyday basis, things are still going to occur. So, we have to be very mindful of that. But just from the leadership point of view. I can say that I think, again, I can’t be too subjective about this or objective about it. I mean, but you know, I can say that, in our system, I think the surgery leadership has been very good. And, quite honestly, has been several days ahead of the hospital administration, in decision making. So even for us, cutting back on ORs, we brought that to them. And so when it’s a group of surgeons that say, listen, we need to do this, because it’s the right thing to do to prepare for such a pandemic. that’s a big statement. I don’t think the hospital initially realized what a big statement that was.

Morad Hameed  07:21

I like that idea that I think when surgeons devise their own solutions and come forward with them. I think that works so well. People are waiting to hear what we say and how we respond. And one interesting thing, I think, with COVID is that as general surgeons and trauma surgeons in particular, I think we’re used to working in times of crisis. And so, we’re used to making decisions under conditions of uncertainty. And then defining those decisions as new information comes in. I think that mindset kind of helps in this situation. And even the concept of triaging severity is increasing. So in our division, pooling all of our cases, all of our scheduled cancer cases, for example, to try to figure out within our group, how do we triage someone when an OR does become available? I know Chad, you’ve thought a lot about this. Because you do such a high volume of cancer surgery.

Chad Ball  08:24

Yeah, it’s hard. I mean, as we’ve talked about, it’s hard to communicate with those patients that are at home with cancers that may or may not leave their separability window and some of our more aggressive tumors. Those are hard conversations. And they’re hard on the individual level and they’re hard on the system. And it certainly creates moments and days of frustration for sure. You know? And mostly for the patients of course. I can only imagine what they’re what they’re going through. But you’re right. It’s got to be done at some level. And I think the corollary for all three of us, of course, our love is trauma and injury care. And I’m curious how that’s going in both London in Vancouver. And the reason I ask is I just had come off of our trauma service here in Calgary on Friday morning, this past Friday morning. And it was probably the busiest week I’ve had here in over a decade. It represented really an inner-city American Center, with half a dozen gunshots. Every day, there was more than that. Stab wounds, there was tons of injured people. And I don’t know whether that was from just a sort of a “it’s a pandemic, let’s get crazy” point of view quite honestly. Or whether it’s because the social services that is marginalized on the fringe type patients that we may see have had the pullback as well, and they’re sort of left on their own. I don’t know. But it’s certainly something palpable and real had changed. Yeah.

Neil Parry  10:02

Yeah. One comment, just back to the cancer side, I think, you know, it has been exceedingly difficult. And I think, you know, sometimes the public may not understand, but I think it should be very clear that the physicians and the surgeons are still doing their best to advocate for this. Unfortunately, given the circumstances, surgery time will be delayed. But it’s not without the surgeons really advocating hard for this and trying to make time out of nothing. It’s very, very difficult.

Morad Hameed  10:39

Yeah, I agree, I think as surgeons, we probably have to take a longer view than our Emergency Operations centers, because they’re very focused on the immediate goal of creating capacity for COVID-19 patients. But I think we also know that once the pandemic passes, and it will pass, we’ll have this big rebound of cases that need to be done.

Neil Parry  11:04

Yeah, how are they going to find the capacity for this? Right? There are all sorts of different things to think of.

Morad Hameed  11:09

Exactly. And so, I think that means that while we prepare for the current crisis, we also have to have an eye on the horizon to see what it would look like, how are we going to handle that. That rebound in cases. And when we do get access to the OR, how will we prioritize our patients, bring them in, be efficient?

Neil Parry  11:31

As you mentioned, it has to be very dynamic too with the OR. It can change from day to day, from week to week. Today, it looks like things are fairly under control, blah, blah, blah, you know, we may be able to get a few more cases, and we’ll see how it goes up. And same goes the other way. Unfortunately, also.

Morad Hameed  11:49

Yeah. And that has to come from us. I don’t think that can come from a hospital administrator who doesn’t necessarily know what we do?

Neil Parry  11:56

Yeah.

Chad Ball  11:57

One of the things that, obviously, the group of us on this call has the privilege of doing is dealing with emergency general surgery cases, trauma cases and cancer cases. Those are obviously by definition the most urgent categories that we all deal with. But how, to speak to other types of surgeons, and I’m sure there’s orthopedic surgeons and plastic surgeons and other surgeons listening to this as well. How have you guys found those folks that maybe don’t do trauma, orthopedics or don’t do, you know, emergency work? How have they been dealing with it at your hospital? Because that’s a really tough position too.

Neil Parry  12:38

I think, all in all, the division chiefs that I’ve spoken with been outstanding, to be honest. You know, the arthroplasty group, you know, that would operate 24/7, if they could have said, listen, we can’t do this right now. And they stopped. And it’s incredible. And I think that thinking speaks just, for we understand the magnitude of that statement, but I don’t think really anybody else, who’s not a surgeon that really can understand that. But they’ve all come forward with this as well.

Ameer Farooq  13:16

One thing I’ve kind of felt like watching all of this is that, you know, our personalities as surgeons isn’t the type that can just sit on the bench, right? Like, I don’t think any of us growing up, playing on sports ever like being those people on the bench. But yet, I think part of our leadership, as all of you have said is actually being able to say, yeah, this one, our role, maybe right now is just to sit on the bench. And that’s very hard I think, as surgeons to do, and I think that shows a lot of leadership. That everyone across the country has been able to do that.

Chad Ball  13:53

Let’s transition into a little bit of specifics about COVID if it’s okay with you guys. Morad, are you treating your trauma and emergency general surgery patients like they may have COVID across the board? Or how are you nuancing that?

Morad Hameed  14:08

This has been a really big journey, Chad. When it first came down the pipeline, information about COVID was suggesting that we screen patients that are symptomatic or have some type of travel history or infectious contact. And that’s fine. But then it came to light that there’s a median 5.1 day incubation period when patients do have a very high viral load but are not yet symptomatic. So, they run presymptomatic phase. And I think that pre-symptomatic phase is one of the reasons why the pandemic has been so hard to control. Because people are infecting each other without knowing that they have symptoms. I saw one model where they thought that about 12% of transmissions were from pre-symptomatic or asymptomatic individuals. And I know that in nursing homes and in other health care facilities, that’s one of the reasons why they qualify. Because people have limited their screening to symptomatic individuals. So, we’ve taken the position as we are now, that we’re assuming that general surgery and trauma patients are COVID positive, until proven otherwise. And we’re advocating for PCR testing. PCR testing has been hard to get sometimes, and the turnaround times are getting better. But it had not been perfect. And we’ve also learned that PCR testing is not 100% sensitive. In fact, it’s about 70%, sensitive or insensitive, but then when we try to mitigate that, the focus activity is combined with it with a CT scan of the chest. And we have seen that the pneumonitis can sometimes appear on the CT before the PCR turns positive. So that’s been my strategy. I don’t know if that’s what you do. But the idea is to advocate for PCR testing, everybody is going to the OR. And if they haven’t had a CT test, try to get the CT test as well. And that gives you some confidence.

Chad Ball  16:21

Yeah, that’s an interesting comment. We have a post-whipple patient on our service now, who without the clinical concern for COVID, the chest x-rays and subsequent CT scan is classic straight out of the Lancet. And the test was negative, the initial test was negative. Subsequently, it’s been positive. That’s a real world concern for sure.

Morad Hameed  16:42

They keep getting infected? I heard there was a team at Columbia, the transplant team that got exposed and some people that transmitted but I haven’t confirmed that.

Neil Parry  17:06

I heard that as well. But haven’t heard of any up in Canada yet. From surgeons. So far, so good, I think. We do a similar thing with regards to our acute care, our emergencies, general surgery patients. They’re all treated as if they’re potential or positive, whether they pass or fail on their screen. And I guess we’ll probably lead into this as to what we do up in the operating room. So, you know, if they’re on the ward, and they’re coming up to the OR, we’re not doing any aerosol generating medical procedures, then we can all wear our enhanced droplet precautions. And this will be interesting to find out what you guys do as well in your ORs. You know, we’ve gone from the gamut as Morad was saying. Initially, we would, you know, before we really knew about the big lag time that they can have all the recent time, we would treat our patients that screen negative, we would in the OR, we would just do our enhanced drop to precautions. And now we’ve switched to our enhanced aerosol precautions. So N95s for everybody. So, any OR that we’re running now, we do a little huddle ahead of time with the anesthesia, nursing, surgery. No OR aids, ok as necessary. Up front, everybody should dominate the rules, see who’s going to be in the OR. Limit personnel, limit people getting in and out of the OR, and then proceed on with surgery. And everybody with their N95s, we try to intubate the patient in our rooms. We have anesthesia and minimal personnel, usually surgery waits outside and comes in once after talking with our microbiology, infectious disease and facilities after 10 minutes and come into the OR, proceed on. We’re still treating surgery as possibly aerosol generating so that’s why everybody in the room is wearing their N95s. We do not have any negative pressure ORs. From what we’ve been told, and I’d like to get your opinions on this as well. But we’ve been told from our local experts with the positive pressure OR that we use, where the air cycles between 20 to, up to 30 times within the hour. That it’s actually given that this is mainly a droplet precaution type of disease, although with the AGNPs, it can obviously be aerosolized and that’s sufficient enough. I don’t know what your thoughts are, what you guys do it in your ORs?

Morad Hameed  19:52

Yeah, that’s exactly right. I’m so happy to hear that. Like, how you’re approaching it. I think for all of us, the safety of our teams, and particularly our residents, it’s something that keeps us up at night. And so just erring on the side of enhanced airborne precautions for potential estrogenic entities uses it. I think it’s a great principle for now. And we follow pretty much exactly what you say. Kind of a two-tier approach, I think, first of all, kind of incorporating social distancing, or clinical distancing. And in our case, keeping surgeons and residents out of the hospital, as much as possible. Cycling in when needed. Reducing the size of our teams that are testing patients and reducing the size of our teams that are coming into the operating room. So that’s the social distancing side, and then on the personal protective equipment. Yeah, absolutely. We do the same thing as you guys. We try to do that. We did get a little bit of question about like, is laparoscopy aerosol generating and creating chest tubes or getting a laparotomy? I’d love to know your position on that. My position is that we shouldn’t assume it is until we have data proving it right?

Neil Parry  21:12

Yeah, I think we’ve gone along that road as well. I think, again, I mean, our local experts in microbiology and infectious disease are fantastic. Again, I’m not sure but they totally understand the OR culture scenario. Break what we exactly do all the time. And it can easily go from one non aerosol generating medical procedure to being aerosol generating in certain circumstances and like a test tube and that type of thing. So, we would do the same thing. I think the issue with laparoscopy also is, you know, not me, but this is the current generation of resins that have just coming out or you know, they’ve done everything laparoscopically. If they can do this quickly, then I think here time is really of the essence because our access to the OR is severely limited now. So, if you’re going to take a long time to do a subtotal collecting and you want to do it laparoscopically, rather than doing it open, we could potentially. Certainly at least at my end it’s gonna be faster open. But it all depends, right. So, I think that’s another aspect to think about with laparoscopy. And this small generating thing.

Chad Ball  22:21

Let me take that one step further. Now, open versus laparoscopic, for some procedures, as you point out is a real-world question right now, in the here and now. But the American College sort of dropped a recommendation and then backed out of it shortly after, talking about essentially indications. So, treating appendicitis with antibiotics only. Same thing with [inaudible]. What are you guys doing at your institutions? Have you changed your indications at all? Are you going to have days of doing that?

Neil Parry  22:52

No. I think that if you can get someone in and out of hospital within 24 hours, that’s the way it should be. Rather than sticking a drain in something, having people come and check the drain, there goes your social isolation that needs to be done. Putting someone an IV antibiotics, you need a nurse to come in. You know, I’m sure we could get into the behind the scenes of all of this. But, you know, the fact that they came out with a change so quickly. I think it’s safe to say people were in uproar about it.

Morad Hameed  23:26

Yeah, that was a big 180. One of our residents sent me the first version and I was pretty surprised. And then within a day, sent me the second version. I feel like maybe the AGS was trying to anticipate the worst-case scenario where we have access to the operating room. And I think the reality is that most places do have somewhat limited access and can triage cases in there. And so, I think then they came up with a more nuanced document to say yes, you can do MRS procedures and you can do appies in addition to [inaudible] and you can even do procedures that if you do them, you can keep patients out of hospital better. So, I think the second document is probably more common sense and it probably reflects the reality that we do have some access to the OR and Chad, to your point earlier about some services, and Ameer mentioned that some services are now kind of getting going on the bench you know, and patiently waiting for the pandemic to subside. With trauma general surgery, our access has been preserved. So, I think that’s an acknowledgement of the fact that we do a lot of emergency stuff. And so hopefully, that access is preserved. We can get some new patients.

Neil Parry  24:53

For sure but still decreased overall.

Morad Hameed  24:56

Yeah.

Ameer Farooq  24:57

I think one of the big challenges that’s been hard to deal with for everyone is that we’re having to deal with very limited information and have to make really big decisions like, you know, shutting down the electrical wires when we don’t really know how long or how hard this is going to go for. And then, you know this laparoscopy is a good example treating appendicitis and cholecystitis with antibiotics is another good example where, you know, for better or worse, we have to make these decisions with very limited information. And on an even broader front, like you can see the things that are getting published in the New England Journal, etc., with very small patient populations, very small RCTs are finding their ways into very big journals. So, I’m curious how, you know, all three of your academic kind of heavyweights as well as in administration. How are you guys dealing with, you know, the lack of information, but still having to make decisions to protect healthcare workers and the general public?

Chad Ball  26:05

Well, I think that’s a good question Ameer. Part of it, as reflected on what Morad said. It’s also part of how we’re trained as general surgeons, and I think it’s how, you know, you’re being trained as a general surgeon. Almost as conclusion now. You’re trained to think in an adaptive way, in less than optimal, or essentially sub-optimal conditions. And I think that’s not just trying to do, you know, a tough trauma operation when things are going sideways and patients trying to bleed. I think that applies to this sort of scenario as well. You’re essentially a high-level problem solver, aimed at just the problems of different from day to day. And this is a classic example that, you know.

Ameer Farooq  26:51

Ameer, you’re right. I just feel like it’s a tidal wave of studies and anecdotal information and podcasts and collect that and you’re trying to process all this information. But the one thing that you can cling to, that life raft that we have, is a lot of this is very just basic common sense, decision making. And even how you organize your system. We know how to do that from our experience with developing surgical systems and developing trauma systems. But even at the bedside, sifting through all the data, it can really refine 5% of your management. But the other 95% is what we’ve known to do all along with it, going back to the ABCs, and basic protective ventilation and protecting our staff. So, a lot like other things in surgery, the first principles really are most of the biggest part of the approach.

Neil Parry  27:58

That’s great. I couldn’t say it any better than that. I would just say, you know, we all try to work with best evidence possible, we try to change our practice that way. You know, we’re now in the realm of Twitter based medicine, it’s not really all evidence based, is it? The amount of information we get is staggering. And this gets changed to that? I don’t know how much of the telephone game gets published, you know, as you mentioned. Here’s an RCT of six, and it’s published in some journal. I don’t know what to make of that. And if we step back, I would never change my practice based on that. But people are doing that now. And so, I think we have to be very mindful of that, again, just take a step back to say, really? Hmm, how about that HM? I think that’s what we still need to do. And again, it’s evolving because we don’t really know how this bug works on a lot of senses. So, it will evolve, but we have to take a look at it still and have a critical eye with things.

Chad Ball  29:08

Yeah, it’s going to be interesting a year from now to look back at all this and see what was accurate and what was inaccurate. If I switch up the gears a little bit on you guys, and just, you know, point out to our listeners, Ameer is in his final year of residency and was supposed to do the Royal College exam this May and June, and then of course, you Neil are on that board and then Morad, the previous program director and as a section head in UBC. I’d say that first of all, it’s incredibly stressful for our fifth years and just wonder if you guys had any comments on that or any thoughts moving forward?

Neil Parry  29:47

I’d like to hear Ameer’s thoughts on it personally. How you Ameer, and your cohort but you know, I know you guys are in touch with everybody across the country from PGY1 to whatever. What’s the sort of? What are people thinking? What’s the morale like?

Ameer Farooq  30:06

Well, it obviously was very hard to get that news because I think everyone was sort of hitting their peak. In fact, I think next week was our last week that we were really going to be clinically busy. And then after that it was, you know, dedicated clinic or study block time. So, this was very hard for rural college residents, or finally residents across the country, not just in general surgery, but in emergency and anesthesia. And anybody who had to take their final exams. I think, like all of us are 100%, dedicated to being on the front lines and being there to help out. And I think we all recognize that we bring a lot to the table. Like, I don’t think anybody knows how to get stuff done in the hospital better than I do. Like, I know exactly who to talk to, or who’s the best at doing what. And I think that we bring a lot of value to the whole system. I think the frustrating part was, we wanted to do that. But there’s just so much uncertainty. And, you know, there was a bit of back and forth as to you know, it seemed like it was postponed, then it was going to be back on and it was postponed again, and so that I think added to the frustration a bit. I think most of us are kind of resigned at this point to just roll with it. I think probably most of us felt that, you know, this might have been the time to try some new things like, try a written exam or like online or try some other new things, given the circumstances. But I think the bottom line is that all of us are a bit resigned to it now. Or focused on how can we best prepare and best help both the hospital and our colleagues in this time period. And I’ve talked to a few residents from across the country. And I think we’re all kind of on that page.

Morad Hameed  32:03

That’s a great point to make. I know that is devastating to have this happen. I’m sure there are opportunities in it, though, and I know that everything’s gonna work out great for your class. But that’s a really interesting point Ameer. This would be the year, out of this crisis, would be the opportunity to really like move into the 21st century with the way that exam is delivered.

Neil Parry  32:34

Yeah, you know, they’re so close to doing that. Just not close enough. And that’s the really tough, tough part for the fifth years. Because that is completely in the plan, but it’s just been a little slow. And it’s a real shame.

Chad Ball  32:53

But let’s use that concept, maybe as a transition into another macro topic. Maybe to discuss, which is, clearly at least I hope the world’s gonna change, really, in all aspects. Some hopefully for the good and I’m sure some for the bad, whether it’s the economy or so on. Everyone’s struggling, there’s no doubt. But how do you guys see, on the positive side, this pandemic crisis potentially changing the way that we do business or do care or look after people or interact? Again, at a macro level on our healthcare systems going forward? If we look a year or two or three out?

Morad Hameed  33:34

I think Chad, from my perspective, I think this crisis has really made us aware of two things. It’s made us aware of the constraints of our healthcare system. And the real need to make this a value-based system that’s very aware of both quality and cost. But it’s also made us very aware of our synergy. You related to this earlier, Ameer. But it’s been a pleasure to work across disciplines to solve problems. I don’t know. I’ve never seen our faculty and residents across all specialties so engaged, and so involved in trying to work out the missing pieces together. And even within their our own division of general surgery, which sometimes has its own subspecialty agendas, people have really come together to try to figure out what’s best for patient care. And across the province, I’ve noticed the incredible communication between hospitals and we have a big province and many hospitals and we have an online platform where everybody is contributing online, communicating, exchanging ideas. So yes, it is a crisis and we know that our healthcare system is in perpetual crisis. When that kind of goes into sharper focus. But they’ve also shown that we can get together and solve problems and share ideas and scale ideas. Get out good ideas really well, because we have the technology. And we didn’t mention this, and I would love to know what you guys are doing. But we started to use Zoom for all of our meetings and rounds. And we’re doing a morning report via Zoom. And it’s paradoxus in that it increased the engagement and communication in using virtual meetings and virtual care. It’s certainly given us new opportunities to communicate.

Chad Ball  35:46

There’s no doubt, eh? I guess we all should have bought Zoom stock before the crisis. But you know, just as one minute example, we just conducted our HPB fellowship interviews with 12 candidates. We did them all by Zoom with half a day. And it was a remarkable, really interesting experience. The mechanics were different, the interview was different. The timeframe of the interview was different. I wouldn’t say good or bad, just truly different. And I think will certainly inform different options and different ways of doing things, even on that small level moving forward.

Neil Parry  36:30

Yeah, there’s so many things. It’s hard right now to look at this as a glass half full type issue. But I think what Morad has mentioned also about the relationships. Yeah, we can make things happen. You know, I’ve personally learned so much from other people during all of this and how to do things and to do things better. And this remote access for not only that, but for our patient care. Do we need to have somebody drive 200 kilometers? It doesn’t make any sense just to say, hey, how you doing? Look at this, look at your week. You know, we can do things. If there’s an issue, clearly different, but there’s so much that can change from that.

Morad Hameed  37:11

And suddenly, in one week, the healthcare system transitioned to seeing those patients 200 times a day.

Neil Parry  37:17

Yeah, yeah. Yeah, we can. So as you said before, even just on the academic side that the use of the remote access has improved the uptake, while this may improve access, like actual access to medicine, to surgery, by having these remote things from remote communities, maybe we’ll buy back into this again. Where it’s been all a lot of talk about remote telehealth and whatnot. And yes, it has been utilized, but still nothing close to its potential.

Chad Ball  37:47

But I mean, that’s just it. You know, Andy Kirkpatrick and I talked on Cold Steel about exactly that. And we felt a little bit guilty about not driving that to a greater extent, especially when you see the Australians leading the way and you have, you know, the trauma surgeon in Brisbane, helping remote guide them under real time video guidance up in Darwin to do a whole bunch of things, including big run of the mill trauma resuscitations from crashes. And in Calgary, we tried to do that with…we did that for a while, between the Foothills and Banff, and that sort of fell away when, you know, the technology wasn’t quite perfect. And there was no billing code to be able to do that. And Alberta still really isn’t. Some provinces have it, some it doesn’t. But there was enough issues where it sort of faded away. But the opportunity, the reinvigoration of that should happen now, for sure.

Neil Parry  38:43

Yeah, you bring up one word there: billing. And I don’t want to get into all of that now. But not that it’s hit in North America, where physicians are more so on a fee for service type of billing, whereas certainly in Europe, and further east, it’s more salary based. This will create a whole new complexity to this crisis.

Chad Ball  39:09

Yeah, no doubt. Well, in Canada specifically, right? I mean, the vast majority of the US physicians are still salaried. But it’s an interesting time for Canadians as well. No doubt. Let’s transition maybe into some nuts and bolts of COVID specifically. So, using the critical care backgrounds, guys, what are your recommendations in terms of…besides assuming emergency patients all have it, and precautions and PPD and so on. What are your comments about basic management, whether that’s, you know, anti-microbials steroids, hydrochloric, ventilator thoughts and so on?

Neil Parry  39:53

So I would just say from seeing the patients, I haven’t seen any. I haven’t had to look after any COVID-positive patients yet in the ICU and I’ll be there a couple weeks. But it’s the basic tenements we would have – this is hypoxia that they have. So, it’s not a ventilatory issue. Initially, these patients will come in, quite profoundly hypoxic, but yet their lungs are still quite pliable. They’re not stiff yet. So, it’s all about oxygenation, ensuring they’ve got adequate ventilation as they are. Keeping them as comfortable as possible. And depending on what mode of support that we want to use for that, there’s been a lot of talk about high flow nasal cannula or bipap, C-PAP, pros, cons. You seem to know what you guys are doing with either of those. We are using the high flow nasal oxygen, if they can be isolated. And if they can be in negative pressure rooms. And we’re actually pulling those people, you know, the physiology of it makes sense. We do it with bad ADRDs but why not do it when they’re still breathing spontaneously? And it works. Their oxygenation improves. Currently, right now, our infectious disease given that, you know, we don’t have a lot of cases right now, so three in our ICU. They have been managing thus far, with basically a protocolized approach to any type of medication for it. And really, certainly from what I read, there’s not a whole lot that really works in supportive care.

Ameer Farooq  41:34

What about Azithro or Chloroquine?

Neil Parry  41:39

Not to talk about it. I don’t know. Honestly, it’s not certain. I don’t know. I defer that to our ID group. They have instituted that in a couple of other retroviral in their algorithm. But I’m not going to debate them about it.

Morad Hameed  41:56

I couldn’t agree more. I think that’s a very great common-sense overview of management of this. And it depends on what you mean by that, like the way we look at this COVID-19. The pathogenesis of it is that there’s an initial viral stage where the virus attacks the Type 2 [inaudible] and the H2 receptors and causes direct viral induced lung damage. And so, patients start off with upper respiratory and then progress to lower respiratory symptoms. And they are shedding virus during that time. And then after a while, there’s a sort of a hyper inflammatory state, when the bodies start fighting off the virus, and then we get a secondary, type of delayed illness, that’s more of an ARDS, multi organ failure type of pattern. And so patients can look like they’re getting better, but then suddenly go into renewed respiratory failure and multiple organ failure. So that’s, that’s interesting, because, like you mentioned, at the beginning, when patients are in the viral phase of development, there’s no real specific antiviral therapy for it. So, the idea is to treat them initially prophylactically for community acquired pneumonia, support their respiratory status, use high flow, nasal canula. When we first saw these patients, when we were first receiving them, and we were worried that they’d be very difficult to oxygenate and recruit. But just like you said, once they’re intubated, the lungs are not that stiff. You can actually recruit them with a bit of heat. And you can oxygenate them. And then initially we were nervous that we shouldn’t wake them up too early because of the risk of the secondary inflammatory response. But now we’re realizing that we should probably just treat them again and everything and try to wake them up and localize them and get them going again. And then if they do develop that hyper inflammatory state, then at that point, we think of doubling down and doing more aggressive support. But then it’s still just the basic principles of multi origin support. And nothing that new or novel. I think antivirals have not been shown to work. There are other antivirals that have not panned out in clinical trials. Hydroxychloroquine is good at fixing in vitro activity but only very small clinical experience with that. And steroids are a big topic too. I think maybe in that hyper inflammatory state, we could make an argument that steroids may be useful but I think most people are just using steroids as another indication for their use.

Neil Parry  45:07

I think that’s the other thing to remember too, that you know, if they come in, and when they’re initially COVID suspect, still all the other regular pathology happens. So, we would treat that. So having said that, just as you would you know, community acquired pneumonia for your COPD exacerbations, and whatever other type of pneumonia they may have. Those things still need to be treated. And they can get acquired infections as well or supe infections on top of what they had. So yeah, exactly right. Do you guys have a set protocol as far as what you have for treatment wise for your COVID positive patients Morad? Not that I want to know what it is. But is there somebody that does that? Or it depends on who’s around or who’s on?

Morad Hameed  45:58

Totally. And in fact, it’s really interesting. We had two committees that were struck like almost overnight. One was the therapeutics committee, who started to review all of the studies that Ameer was mentioning. Should we adopt them into our management? And mostly, the answer is no to everything. And then we also developed a committee, which was kind of like a social media committee that looked at all of the information coming through different types of networks and emerging studies from the literature. And every day we get a report about, you know, what’s new, and what to consider, like a one page report that comes at the end of the day from that committee. But it needs adaptation. So, I feel like we’re getting the latest information. But like you guys are saying it doesn’t really change practice. A huge amount, it still always comes back to the basics.

Neil Parry  46:57

And we’re really still early on in this. Further than you guys are in BC, as far as the numbers and in your hospital. And just the amount of preparation, the stress is palpable. I mean, honestly, throughout most of the hospital. And really, that almost all boils around PPE, and the potential or the lack thereof, and how to deal with these patients. And we’re not even in the thick of it yet. I think that’s, you know, it’s to try to keep this communication going and to keep the morale as strong as possible is really challenging.

Chad Ball  47:40

Yeah, there’s no doubt Neil. I think that’s true of the whole country, and probably the whole world right now. There’s no doubt. Let me ask you guys one more question, which is that, you know, we have a fair number of community surgery partners and listeners. So, what would you recommend? Either formally or informally, if there is formal agreements or transfer thoughts in your regions? If you know, outside of a true emergency emergent surgery that needs to happen? Would you recommend that the general surgeon in you know, wherever, Timmins, or Medicine Hat, or you know. What it’s like to encounter in particular, some of these patients?

Neil Parry  48:30

I think it depends on the patient’s physiology. If they need the emergent operation, they need the emergent operation. And to treat them as COVID positive, I think, each institution, no matter how big or small, has been preparing for this. And so hopefully, within the OR, there’s some sort of standard operating procedure or something that’s set up to have a dedicated OR team that would be able to go through things. I still think you know, and this may be a bit controversial, but I think that certainly if we can test, which again has been a big issue, but if we can test perioperatively, then we can find out that they’re negative, again, knowing the false negative rates and everything there. But if they screen negative, or are negative, then if anything that takes down the stress level of people, I think that’s super important. We shouldn’t treat them any differently. Treat them the same way. But that inherently takes the stress down somehow.

Morad Hameed  49:34

Yeah, I agree. And I think one thing, I’m sure it’s like this in the rest of Canada too, but we have different ways of emergency operation command. We have hospital level, regional level and provincial. And we are coordinating multiple meeting today. And in our surgical response to our COVID positive and emergency surgical conditions could follow a similar type of organization network. And like in UBC, I mentioned we have a new web-based platform for interaction between services, kind of like a Twitter. And so that group has really started to…that platform has really become active as people start to trade ideas. And we’re hoping to use that platform to coordinate surgical care between recognizing that some of the COVID hospitals will get overwhelmed and may not be able to do urgent surgery. That might be a pathway to distribute the work a bit better.

Ameer Farooq  50:45

Is your platform – is that “Reticulum” that you’re talking about?

Morad Hameed  50:49

Yeah, yeah, that.

Ameer Farooq  50:50

That is super. Even before COVID, I think that was a really neat platform. And I think that the discussions on Reticulum have been really super high level and super useful. Sort of related to this sort of redeployment, managing resources, has there been any discussion at all about redeploying, let’s say residents, for example? Or surgeons into ICUs or kind of becoming, you know, undifferentiated physicians to kind of help, should that need arise? I don’t think we’re there yet. But has there been any discussion about that?

Neil Parry  51:30

Within our department, we’ve had that in the Department of Surgery. We felt that we should try to redeploy amongst the division within the department first. So, there are divisions that are bigger than others. And some of the smaller divisions in our group would say, like vascular surgery, plastic surgery, you know, if there’s one or two people get quarantined, that’s a big problem. And so, we thought that we would try to deploy within the department first. And then of course, you know, to be more of an undifferentiated physician as it were, to help out in other areas. It’s, you know, I don’t think we’re yet to dare to say that surgeons have to become intensivists. And there’s a fear that may become. Those people that have some background within it. Of course, they’re going to get ramped up in other ways. The way our system is, and certainly, anesthesiologists are much more comfortable with the ventilator than anybody else, apart from the ICU and some emerge groups. So that’s what we’ve decided to do thus far.

Morad Hameed  52:37

We do the same thing. We worked really closely with our residency program. Got our reference back to some of the big hospitals and the residents came up with a very innovative call schedule that actually made sure that some of them were rested and off. And then we cycle in every week and refresh the workforce. And so that also gives us the ability to support the ICU, so some of our residents have been sent to the ICU. And some of the some of the changes have asked about how to support the ICU. And there are online resources for that which we could give a link to, if anybody wanted a quick crash course in how to support ICU system. The pandemic really does escalate it.

Neil Parry  53:27

And from a resident point of view, it sort of pulled residents back away from community rotations back home, as it were, but we’ve not pulled our general surgery residents off their other services yet, or anything like that.

Morad Hameed  53:46

Yeah, the blocks have disappeared now and everybody’s just on standard general surgery services.

Chad Ball  53:55

That’s fantastic, guys. Any other comments before we wrap this up?

Neil Parry  54:00

I just had a question about negative pressure ORs, because it still comes up a lot. We’ve sort of put that behind us, of course as data is suggesting that we still should or shouldn’t, I don’t know. But what do you use at your hospital, Morad and Chad, for the COVID positive patient?

Morad Hameed  54:20

We have two negative pressure ORs, we’re trying to make those the COVID positive rooms. And then in the south of our emergency department, we try to do some new resuscitations in two negative pressure moving departments. It was technically very difficult to do so. Actually, we’re converting our trauma bays to negative pressure at the moment.

Chad Ball  54:48

Our experience was very similar. We tried to this past week do a gunshot and a stab in the isolation rooms and it was not physically possible to do that. The patient did fine, but it was challenging. So, we’ve converted one of our four trauma bays, similarly. We’ve certainly operating on a number of suspected COVID patients on the emergency side of things. Just over the past 10 days. And we have not been in our negative pressure rooms at all, so that debate does continue locally in Calgary.

Neil Parry  55:25

So you do have negative pressure ORs, though?

Chad Ball  55:28

It is possible, yeah.

Neil Parry  55:30

We don’t. I think most, at least when I talked to most groups across Ontario, you don’t really have negative pressure ORs per se. They’re relatively negative in that the core is slightly higher pressure than the OR itself. But all the ORs within the OR is positive pressure, as we’ve mentioned earlier. Interesting.

Chad Ball  55:50

Well to your point, Neil, and you describe that quite well. I think that’s really the message that’s been going across the country in most of ours and most systems is that the positive pressure that you run with the circular scrubbing of the area, in and out over the course of the hour should be okay. And I think that’s probably true. Although there’s certainly some strong opinions otherwise.

Morad Hameed  56:21

Chad and Ameer, I don’t know where this would go in. But going back to a note about the resuscitation of patients, I think it’s important to remember not to over fully resuscitate them. We are going to be involved with the resuscitation of patients in different contexts. And what we know about this COVID-19, is that they don’t need a lot of fluid. And if they develop a secondary sepsis, as Neil talks about, you can judiciously resuscitate them. But the idea would be always to do so very judiciously. Use ultrasound guidance, to assess going fast and just try to keep them on the dry side. Doing a bit of pressure. The idea is to try not to exacerbate the environment and gas exchange issues, but also create [inaudible]. And in some cases, get this myocarditis which could predispose you to [inaudible].

Chad Ball  57:31

I think that’s a great point Morad. The other corollary issue is who to intubate and who not to, and when to do that. And I think we’ve certainly seen a bunch of over intubations with a bunch of wet patients. Not to blame any particular subspecialty, but just to point out that our critical care colleagues, and many of our general surgeons that have critical care training, should probably be involved in a collegial way a lot earlier, or certainly very early to help make those decisions. So, no particular frontline physician or nurse or anybody feels like you’re on an island. Not sure as to what to do, I think we’re all available and ready to help.

Morad Hameed  58:18

Yeah, like we are so worried about these patients because some of them present with silent hypoxemia, so they look okay, but they’re [inaudible]. And then you put action on them, and they don’t come up right away. And then they also have been known to sort of deteriorate quickly. And then if you have to crash intubate somebody who’s on airborne precautions, it’s becomes a technical issue. So, I think people really focused on early intubation with these patients to try to avoid that quick drop off and [inaudible] to avoid options and also to avoid uncontrolled intubation. And I think that in principle, it is good to think about early intubation, but I think we’re moving towards a more nuanced approach, which is, if you can proceed with high flow nasal cannula, and continue back to saturation monitoring, we might be able to get some of these patients to develop incubating and in creating all the downstream antigenic problems that Chad mentioned, like fluid overload.

Ameer Farooq  59:25

I think it’s hard to fit everything on a podcast about what you might want to know in terms of a ventilator. I’m just going out on a limb here. But where would you guys recommend going for resources and staying up to date for let’s say the community surgeon who may you know, theoretically be called upon to at least sit and watch a ventilator if not be actively managing COVID-19 patients in the ICU?

Morad Hameed  59:59

I think when we start to double and triple ICU capacity and start putting ventilator patients on the wards, it is possible that non-intensivists and non-anesthesiologists will have to run these teams. And it’s happening in Italy. And even in Australia, I heard that surgeons are volunteering to help. And so I think general surgeons and surgeons in general, would be great at this. I think most of the patients will probably be on [inaudible]. Certainly, beyond invasive mechanical ventilation. And there are some online notes on that. I just was noticing this morning that the SCCM has a crash course assigned, where there’s critical care for non-intensive care physicians. And so, Chad you said we could provide a link to that.

Chad Ball  1:00:52

Yeah you bet. Ameer has kindly put up resources as the show notes, for all the listeners in the podcast links. And so he’ll do that again for all of you.

Neil Parry  1:01:05

I agree with Morad, there’s some great podcasts that break it down and make it very easy. Human resources will be taxed. You know, a person who’s not too familiar or comfortable with events, best human resources are the respiratory therapist. So even just hanging out with a respiratory therapist now, just to say, what’s that button? What do I need to do? What’s this? That’s probably going to be worth your salt as well, just to do that now, before the resources, both the human and physical gets stretched.

Morad Hameed  1:01:43

And I think in the long run, nobody will be really left. I think teams will have sort of a hierarchical structure. With the physiologists and then your surgeons and they’re all kind of working together, you know, they’re sort of distributed. So, I think within our teams, there’s so much depth, that we’ll be able to support each other. And again, that’s another benefit of this crisis is relearning how to incorporate the expertise of other specialties into our work. I think we all have a lot to bring to the table. If the pandemic extends further, I think we’ll be able to benefit a lot from the wisdom of all our colleagues.

Chad Ball  1:02:23

Fantastic. You guys, thank you very much for doing this. It’s been a pleasure. And it’s always amazing to see what Canadian surgeons of all different subspecialties can do and in times of need. It’s a great group to be part of.

Ameer Farooq  1:02:51

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.