key: cord-340646-dj1gqzzt authors: Molina, Gabriel A.; Rojas, Christian L.; Aguayo, William G.; Moyon C., Miguel A.; Moyon, Fernando X.; Herrera, Juan M.; Jiménez, Galo Enrique; Ayala, Andres Vinicio; Fuentes, Germanico; Endara, Santiago A. title: COVID-19 in Ecuador, how the pandemic strained the surgical healthcare systems over the edge date: 2020-09-02 journal: nan DOI: 10.1016/j.ijso.2020.08.012 sha: doc_id: 340646 cord_uid: dj1gqzzt nan Ecuador's response to the COVID-19 pandemic started on February 26, 2020, when the first case was detected in Guayaquil. (1, 2) Several mitigation measures were implemented at that time, including temperature monitoring, and checking for other COVID-19 related symptoms in travelers returning from high-risk countries. ( 3) Yet, as the cases continued to rise, several policies were implemented to reduce the number of infections, following the example of other countries including Spain, Italy, France, and China. Activities deemed non-essential were suspended, school and universities were closed, and virtual platforms were encouraged to sustain academic activities, jobs, and medical care. (1, 4) Ecuador closed its land, air, and sea borders and several restrictions to vehicular and pedestrian traffic were implemented as part of a national lockdown. (1) Nonetheless and despite these measures, the number of cases overrun the national health services. One ominous sign of this surge in infections was the eightfold increment in expected fatalities during the first two weeks of April. (4) Health care systems like our own and all over the world were not prepared for this disease, as we witnessed the human toll COVID-19 took in New York City, Madrid, and northern Italy. (5) Due to our scarce resources and the high demand for medical attention in an already strained medical service, healthcare providers such as surgeons, anesthesiologists, urologists, and gynecologists had to assume the role of clinicians. Most of the surgical workforce was transferred and are still in COVID-19 care. Four months after the start of the COVID-19 epidemic in Ecuador, we surgeons continue to work with resilience, adapting to the changes in our new role and enduring under these adverse circumstances. We have seen how many treatments including Remdesivir, hydroxychloroquine, and different antibiotic and antiviral therapies have failed to adequately treat the infection. (6) Different ventilation regimes have also proved insufficient to improve the survivability of our patients. As the number of occupied hospital beds increased, it became clear that our planning and training were inadequate to address the magnitude of COVID-19. The surgical activity has been limited, and we continue to operate in emergency cases only. All elective procedures have been canceled or delayed and outpatient attention has also been canceled. (7, 8) A worrisome side effect of the COVID-19 pandemic is the delay in surgical treatment for seriously ill patients. We have seen an increase in surgical complications due to delayed care, lack of access to the healthcare system and a hesitancy of patients to seek care due to fear of the virus. Ecuador and Latin America in general face limitations in intensive care unit beds, operating rooms and surgical equipment availability, even in the absence of a pandemic. (8) This reality is likely to worsen in the upcoming months. Finally, a longer patient waiting list for elective surgeries is expected, further delaying care. Nonetheless, the complete ramifications of this disease are yet to be seen, as surgical patients require close follow up to avoid complications and to provide necessary treatment when they arise. As hospitals continue to cope with the presence of COVID-19, we wonder what happened to our patients who didn't have access to adequate attention and how many complications did we miss. How many patients could have been saved had we been able to provide life-saving procedures? And, most importantly, how much have we failed to our patients? This feeling of self-reproach, taken together with chronic stress, emotional and moral distress, and increased personal and family risk in healthcare personnel may lead surgeons to question their role in this critical scenario, especially those of us who are still in contingency. Although COVID-19 is a nonsurgical disease, there remains much to be learned about its proper prevention and treatment. We are still in the early phases of the pandemic, where no treatment or vaccines are currently available or likely to become available in the near future. Nonetheless, due to the economic burden, many human mobility restrictions are being lifted and a surge in new cases is expected. Many countries are beginning to accommodate elective surgeries in this "new normal", yet we believe that for the moment in our conditions, elective surgeries should remain canceled, it is better to be safe than sorry. (9, 10) Developing countries like Ecuador, where health services were already limited, will have to prepare for the next wave of infections and provide the best possible care in this difficult situation. Surgical departments will always be an essential part of any hospital, and while the COVID-19 pandemic is a nonsurgical emergency, the lessons learned may allow medical systems and surgical departments to become stronger to face future challenges. These conversations must take place soon to implement changes in local governments and healthcare services. Failing to adapt to these circumstances will worsen our prospects and hinder our capacity to react to these types of emergencies, to the detriment of the patients above all. A coordinated action is required, especially in developing countries, to minimize the aftermath of the COVID-19 pandemic. This would allow us to keep faith in the resurgence of surgical services to provide the same high-quality attention we once offered. WHO Director-General's opening remarks at the media briefing on COVID-19 -17 Presidente declara emergencia sanitaria en el Ecuador por el coronavirus covid-19 Toque de queda entre 19:00 y 05:00 a partir del sábado 21 de marzo del 2020 por covid-19 en Ecuador Más de 14 000 muertos en la provincia del Guayas en 106 días Covid-19: Supporting nurses' psychological and mental health Treatment of COVID-19: old tricks for new challenges Out Of Darkness. Annals of Surgery, Publish Ahead of Print To a New Normal COVID-19 -Implications on and of Surgical Practices. Annals of Surgery, Publish Ahead of Print Acute Care Surgeons' Response to the COVID-19 Pandemic Author contribution Please specify the contribution of each author to the paper, e.g. study concept or design, data collection Herrera ; Data curation Galo Enrique Jiménez; Formal Analysis Andres Vinicio Ayala; Data curation Germanico Fuentes: Data curation Santiago A The authors declares that there is no conflict of interest regarding the publication of this article Please state any sources of funding for your research All sources of funding should be declared as an acknowledgement at the end of the text. Authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. 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