key: cord-347185-ttf8oigk
authors: Hart, Andrew
title: Editorial - Covid-19
date: 2020-05-20
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.04.002
sha: 
doc_id: 347185
cord_uid: ttf8oigk

nan

JPRAS is a global journal, and that world changed on 9th January 2020 when the causative agent for a cluster of pneumonia cases of unknown origin in Wuhan, Hubei Province, China was characterised as novel coronavirus disease 2019 (COVID-19). Recent weeks have seen COVID-19 finally transform from a devastating regional epidemic into a true global pandemic. While 80% of cases are self-limiting, 14% merit inpatient care and ∼6% require intensive care. 1 At the time of writing, 3,664,143 individuals had become infected across 187 countries, and 257,303 were known to have succumbed; 2 this figure preceded its inevitable impact in the majority of low middle income countries and conflict/refugee zones across the globe. 3 With no signs or symptoms by which to unequivocally diagnose infective carriers, and without a universally available rapid diagnostic test, meaningful pharmacotherapy, or immunisation, 1 disease management falls to supportive care and public health measures. Supportive care needs exceed any previous healthcare challenge, while public health measures are reliant on the blunt tools of isolation and travel restriction which have an economic impact on a scale not contemplated for generations (e.g. predicted 35% fall in U.K. GDPunemployment reaching 10%; 4 10% contraction in the Eurozone economy, 42% fall in global oil price, 44% contraction in air & travel). 5 Supply chains and whole sectors of industry will be disrupted, some never to re-establish themselves. Food harvest or delivery may fail at a national scale. Large scale civil unrest, collective violence, 6 mass migration, and loss of governance are real threats in both developed and developing countries if political leadership falters. Governments have enforced robust but draconian restrictions on personal and societal freedoms to limit the rate of infection, softening the effect with financial support for support individuals, business sectors, and whole economies on a scale unmatched in history. Resulting levels of government debt (e.g. U.K. 95% of GDP in 2020-21) 4 will burden a generation, and global recession will surely ensue. The insurance industries and taxable bases that support healthcare and bioscience research will inevitably contract, threatening longterm healthcare delivery, screening and preventive care systems, and the development of new therapies for the core conditions that Plastic Reconstructive & Aesthetic Surgeons treat.

Following utilitarian ethical principles, and facing massive deficits in acute care resources (such as inpatient beds, ventilators, intensive care provision, the staffing and consumables needed to run them, even oxygen) and protective equipment, hospital services around the world have had to stop the overwhelming majority of surgical care. No healthcare model has been robust enough to entirely avoid this, but socially funded models of equitable population care have arguably proved more robust and better supported by whole populations. The Canniesburn Unit reduced elective activity from six general anaesthetic theatres a day, to one list per week shared across all surgical specialties; this is typical for NHS services. All except the most immediately necessary and predictably beneficial cancer and elective surgery has stopped -a radical utilitarian rationing of healthcare resource that politicians had shied away from for generations was normalised inside a week. Health and social care budgets, equally hot political potatoes, were also rationalised and the largest single injection of government funding in history was delivered within days. Within a small number of days temporary 500-4000 bed COVID-19 care "Nightingale" hospitals were setup in sports stadia and national conference facilities across the U.K., and an army of staff recruited back into healthcare from career changes and early retirement. Similar seismic changes have occurred around Europe and the World, almost without comment. No longer can governments claim that healthcare is a private matter, or that fiscal prioritisation cannot rapidly support clinical priorities.

COVID-19 is not a surgical disease, but its impact upon surgical services has already been profound. In the short term, utilitarianism within the setting of nationally and globally limited resources, and the politics of a pandemic, meant a broad swathe of the care we delivered had to stop. Ventilators, anaesthetic/sedative drugs, adrenaline, anaesthetists and nurses, ICU beds, even things as simple as inpatient beds, masks and gowns, or oxygen, cannot be justifiably consumed when COVID-19 patients might die within hours or colleagues become infected for the lack of them.

We must recognise the workload pressure and psychological impact of this epidemic upon our colleagues in other specialties, and upon our nurses, allied healthcare professionals, and junior doctors. Support for them must not only be in words and gestures, but by our limiting other workloads that may otherwise fall to them. That not only implies restricting who and what we treat but also how we treat those who cannot wait, in order to minimise operative duration, hospital stay, and risk of complications that could place critical additional stress onto other services. If the normal surgical care of cancers, trauma, and significantly painful or functionally restricting conditions must ethically pause, then surely aesthetic surgery cannot be justified. When healthcare colleagues are being placed at risk of severe disease or death through patient contact (particularly in the face of limited protective equipment or training), we must all support social measures to minimise case numbers -virtual clinical care systems should be used to enable patients not to travel.

It's important that within the overall medical, and plastic surgical, community we hold to agreed common values, deferring to more acutely pressed colleagues, and build shared experience of the impact of the outbreak upon us. In the early phases of the outbreak that is simpler, as time passes it becomes harder to maintain and the risk of severe moral injury 7 , 8 becomes high if fault lines develop between specialties or individuals, and perceptions arise of winners and losers; those who fought vs. those who evaded the risk. The defining question of our generation must not become " and what did you lose during the COVID outbreak?"; loss and risk should be shared as equally as possible. Perception will count for as much, or more, than reality. If critical moral injury is sustained, then evidence from genocide, sectarian and military conflict indicates that hard-to-reconcile divisions will result, and those on both sides of the moral divide will suffer significant lasting harm. Multidisciplinary working could not endure such division.

As a profession we have become unused to placing ourselves at unrelenting risk of major harm due to the simple act of delivering patient care, yet data indicates that healthcare workers have greater than community average rates of infection, and are at significant risk of more severe disease. Since the death of the first Chinese doctor in Wuhan, COVID-19 has claimed the lives of a growing number of colleagues (those in the U.K. are currently remembered at https://www.bbc.co.uk/news/health-52242856 ). It is clear that certain specialties, procedures, and circumstances bring particular risk. Staff with co-morbidities that place them at excessive risk if they were to contract COVID-19 9 should be identified and shielded from frontline exposure, then enabled to support colleagues by delivering critically important supportive and managerial roles. Patient flow and care pathways should be adjusted to minimise exposure risk (for staff benefit and to minimise crossinfection between patients), with increased utilisation of local anaesthesia, more conservative treatment options, and virtual clinics. Risk of infection relates to contact proximity (logically this rises exponentially ∼2 metres distance until actual aerodigestive tract contact), duration of that proximity (particularly beyond 15 minutes), and the type of infective agent exposure -close prolonged contact with aerosolised aerodigestive tract secretions seems to carry highest risk. Aerosol generation requires airflow across infected secretions -the higher the rate of flow and the more active the infection, the greater the viral load. High viral load seems to induce more severe disease, hence the tragic deaths of ENT, emergency, and anaesthetic colleagues. Plastic Surgeons are therefore at greatest risk during functional / oncological oropharyngeal surgery, and tracheostomy, but logic dictates that any facial surgery places the operator at high risk of greater infective load.

Yet healthcare staff need not contract COVID-19, and need not suffer severe disease or death, if they are simply enabled to work safely through organisation and institutional supply chain management. Personal Protective Equipment (PPE) provision, and guidance on its use must recognise this. PPE needs should be appropriately risk stratifiedjust as we should not needlessly use this precious resource while colleagues in higher risk circumstances have failing supplies, there is a fundamental moral obligation upon governments and health agencies to deliver the right PPE, to the right staff, at the right time, in sufficient volume. Professional bodies must accept their moral imperative to provide guidance on PPE that is evidence based, not supply based, and where evidence is not absolute they should err toward greater safety. BAPRAS has recently issued professional guidance to aid specialty specific interpretation of Government body and Royal College guidelines on PPE use. 10 Similarly, there is an onus upon us to minimise risk exposure for supporting staff, including minimising dressing clinic visits and operative durations -theatres should run with minimum staffing and training cases should not be undertaken. Instead the most efficient available operator should accept the need to operate in person; juniors should not be left to field cases.

The impact upon training and career progression will be workable in the short term, but if COVID-19 related practice restrictions become protracted, then Professional bodies will need to turn to web-based platforms to maintain education and training progression. This has begun, for example by the BSSH, but broader scope arrangements will be needed and trainees pushed to use external resources rather than hands on training. This may lead to more efficient educational delivery in the longterm, if innovative virtual platform learning becomes normalised, and future courses and meeting cease their reliance on physical attendance. JPRAS strongly supports this direction, through promoting change from physical print copy to online access, soon through provision of journal clubs online, and through scoping novel platform use. A larger shift in technology will be needed to fully optimise remote learning, through immersive reality approaches.

The short term clinical challenge is difficult, but the medium term will most probably be more so, and the long term may present existential threats to aspects of our specialty. Unless the COVID-19 peak, and its restrictions on practice, is of very short duration, fiscal compromise is inevitable and a sizeable waiting list of untreated or undiagnosed but urgent cases will amass. More advanced pathology may then need more complex care, and a growing number of cases (particularly hand trauma) will merit secondary reconstruction having been unable to access usual primary surgery. Resource needs will be high. Considerable logistical challenges will arise if services are to treat such cases timeously and avoid a prolonged hangover effect by failing to synchronously restore normal treatment times for the new cases that will still arise. The longterm will surely see a spike in all cause mortality as pathologies that went undiagnosed, or missed windows for early definitive treatment, run their course. That will likely be due not just to the malignancies we treat, but also to more subtle impacts upon overall health and fitness (e.g. fitness for prolonged general anaesthesia). If recession bites and unemployment rises as predicted, then socioeconomic deprivation will rise and safety standards in homes and workplaces become compromised, inevitably increasing the incidence and severity of pathologies that we treat, from burn injury and trauma, to malignancy. Individuals may place less emphasis on appearance, constraining aesthetic surgery markets. We may see a retrenchment of healthcare funding away from the trauma and oncological care (including complex reconstruction) that benefits the individual, towards population level interventions in public health and infectious diseases. Healthcare funders have long challenged, or misunderstood, the welfare benefits of plastic surgical interventions (such as breast reconstruction and limb salvage), they may seize the opportunity to stop whole sectors of activity, twisting priorities in the face of reduced healthcare spend secondary to economic contraction.

Both the public and the charitable sectors are likely to have reduced funding. There is likely to be particular constriction in research funding for functional and appearancerelated treatments, perhaps even for cancer care, as funding bodies first seek the treatment solutions for COVID-19 then fund retrospective research into the pandemic, and as virology, immunology, and public health justifiably seek research funding prioritisation. Plastic Surgery has long been portrayed as a cinderella specialty, easily trivialised; it is imperative that as individuals and professional bodies we now prepare to robustly advocate for our patient groups, in terms of quality outcome measures and overall healthcare cost savings. Research and audit activity should now focus even more onto outcome studies with robust objective measures and trial designs that cannot easily be deflected by competitors. As a specialty we need epidemiological and healthcare economic expertise as never before, and to invest in public relations to ensure we maintain broad public support. Reconstruction should continue to restore socioeconomic productivity at a time when economic output will be challenged.

Many have analogised this pandemic to a battle, with frontline heroes fighting a lethal foe. Although understandable, this battle analogy is an insidious misinterpretation.

Resolution will more likely come through longterm resilience, methodical organisation, and the rigorous repetition of simple measures than to acts of individual heroism. It will take common action by whole populations, enduring rather than fighting, and maintaining values and cohesion in a way that has become unfamiliar, in the West at least. The virus can be imagined everywhere in our communities but cannot be seen and directly targeted, in the military sense. If there is a better military analogy it is presumably political insurrection where the enemy blends unseen within a population, fear commonly outweighs the reality of risk, glorious victory is unlikely, and a conclusion typically comes through political compromise, plus societal and fiscal change. Amongst the most likely changes will be the end of the West's hegemony over healthcare advances and its insistence that individual liberties override public health, several Asian countries having just cause to claim better management of this disease. Demographic change is inevitable, given the age-related increase in mortality from COVID-19 (particularly where rationing of access to ICU has had to occur), society being forced into the realisation that death is a natural part of life. This, or fiscal tightening of care budgets, may bring a changed emphasis upon end of life care, and whether healthcare is directed more toward quality of life and functional independence rather than upon prolonging life per se . Depending upon the final public perception of how healthcare services have served their population, we may either see enhanced engagement in vaccination programmes and preventive care, or mistrust in medicine with a negative impact on early presentation, preventive healthcare and screening services. Greater experience of virtual clinics may enhance remote healthcare delivery, and enable a change in referral pathways with, for example, plastic surgery services taking greater roles in early skin lesion triage and streamlining access to surgery. It is highly likely that travel will reduce, and the format of departmental / MDT activities, training and education, and major meetings will then need to change. Virtual technologies, smaller targeted meetings, and increased use of online platforms will need to be embraced by bodies such as BAPRAS EURAPS, ES-PRAS, ICOPLAST, and the WSRM if they are to retain their roles.

These are massively challenging times, during which many of us will lose loved ones and colleagues, develop altered workforce roles, and have to look to define new practice and professional structures for the longterm. JPRAS supports global equity, internationalisation, and building a stronger community of plastic surgeons -we should not fall victim to short term pressures, but rather retrench to our core specialty strengths of innovation, excellence, and adaptability. We must advocate for a return to the delivery of high quality plastic surgical care, giving primacy to patient care approaches that are to the clear benefit of societies and economies, and not allow our specialty to be portrayed as defending vanity or individual greed. Economies, societies, politics, and the demographics of whole continents are changing; healthcare and research funding priorities will follow. Plastic surgery must continue to innovate and adapt, but now more than ever look to generate and disseminate high quality evidence of its positive impact on welfare, quality of life, overall healthcare efficiency, and population level capacity for productive independent living.

Covid-19 briefing notes

Moral Injury: An Integrative Review

Guidance on at risk groups and social distancing