key: cord-0747207-qmtch3nu
authors: Low, Peh Hueh; Mangat, Manvinder Singh; San Liew, Donald Ngian; Hieng Wong, Albert Sii
title: Neurosurgical services in the Northern Zone of Sarawak in Malaysia: The way forward amid COVID-19 pandemic
date: 2020-09-17
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.09.045
sha: 2dd64cc60e9292abe753f2772a2bd464fd65b432
doc_id: 747207
cord_uid: qmtch3nu

Background The novel coronavirus disease 2019 (COVID-19) pandemic has set a huge challenge to the delivery of neurosurgical services including the transfer of patients. We aimed to share our strategy in handling neurosurgical emergencies at a remote center in Borneo Island. Our objectives included discussing the logistic and geographical challenges faced during the COVID-19 pandemic. Methods Miri General Hospital (MGH) is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the healthcare workers involved was determined. Results During the initial six weeks of the Movement Control Order (MCO) in Malaysia, there were 50 urgent neurosurgical consultations. Twenty patients (40%) required emergency surgery or intervention. There were nine vascular (45%), five trauma (25%), four tumor (15%), and two infection cases (10%). Eighteen patients were operated at MGH, among whom 17 (94.4%) survived. Ninety percent of anticipated transfers were avoided. None of the medical staff acquired COVID-19. Conclusions This framework allowed timely intervention for neurosurgical emergencies (within a safe limit), minimized transfer, and enabled uninterrupted neurosurgical services at a remote center with difficult access to neurosurgical care during a pandemic.

The novel coronavirus disease 2019 (COVID-19) pandemic has set a huge challenge to the delivery of neurosurgical services including the transfer of patients. We aimed to share our strategy in handling neurosurgical emergencies at a remote center in Borneo Island. Our objectives included discussing the logistic and geographical challenges faced during the COVID-19 pandemic.

Miri General Hospital (MGH) is a remote center in Sarawak, Malaysia, serving a population with difficult access to neurosurgical services. Two neurosurgeons were stationed here on a rotational basis every fortnight during the pandemic to handle neurosurgical cases. Patients were triaged depending on their urgent needs for surgery or transfer to a neurosurgical center and managed accordingly. All patients were screened for potential risk of contracting COVID-19 prior to the surgery. Based on this, the level of personal protective equipment required for the healthcare workers involved was determined. Transport and communication remain a major challenge in the Northern region of Sarawak in Malaysia. The location is sparsely populated with a density of 12 persons/km 2 , and many of them have difficulties accessing Miri hospital-including those staying at regions where a boat is the only means of transportation. 3, 5 Hence, it is near impossible for patients with neurosurgical emergencies requiring immediate intervention to reach our neurosurgical center at Sarawak General Hospital (SGH), which is situated 798 km away in the Kuching city ( Figure 1 ). The emergence of the COVID-19 pandemic has imposed an even greater obstacle to an already difficult transfer process.

Most neurosurgical emergencies require a prompt consultation and occasional intervention for an optimal outcome. Time till neurosurgery and distance of transport to the center with appropriate neurosurgical care significantly predict mortality and outcomes. 6, 7, 8 Approximately 10 % of patients with a mean transfer time of just over 5 hours encounter a drop in Glasgow Coma Scale (GCS) during transfer. 9 Those who experience delays of 4-5 hours before their surgery, have a higher mortality rate compared to those who present to the neurosurgical service directly. Distance to the neurosurgical center is one of the main factors that causes delay in the treatment of neurosurgical emergencies. 10 Travelling by land from Miri to Kuching takes an average 12-15 hours because of the distance, coupled with poor road conditions. Air transfer shortens the duration but has its own inherent limitations. In Sarawak there are two modes of air transfer available, either the usual J o u r n a l P r e -p r o o f commercial flight or a more urgent transfer, the airborne medical evacuation service (MED-EVAC) by helicopter. Critically ill patients are transferred by MEDEVAC.

There are two helicopters chartered for all the emergency medical evacuations in Sarawak. However, this service is limited by the availability of helicopters when the need for transfer arises, in addition to the environmental and weather conditions for air travel. The state has an average rainfall of 3,300 mm to 4,600 mm per year. Approximately 30% of the days in a year are rainy days. 11,12 Furthermore, the mountainous topography at this part of the island with low clouds, strong winds, and occasional turbulence creates more obstacles for the medical team to travel safely in helicopters.

All the above mentioned challenges compromise patient care, and the healthcare system incurs significant costs. To mitigate these, two neurosurgeons from Sarawak General Hospital (SGH) were stationed at Miri General Hospital (MGH) on a fortnightly rotational basis. This was done to ensure in-house delivery of neurosurgical services, with an aim to minimize the time till neurosurgical intervention and optimize patient outcomes.

All neurosurgical patients who presented to MGH or were referred, during this pandemic were screened and evaluated. Those with life-threatening emergencies were operated immediately; while urgent cases were triaged based on the complexity of the case, availability of surgical instruments, and the ability of anesthetic team to support. Urgent cases that could be handled with the current set up were operated according to a semi-emergency list.

Patients were discharged as soon as possible post-operatively, to generate the capacity to cope with more cases.

All patients who required emergency surgeries were screened for potential risk of contracting COVID-19. Patients with no known exposure to COVID-19 cases and those J o u r n a l P r e -p r o o f without acute respiratory signs and symptoms with a normal chest radiograph were considered low-risk. Low-risk patients were operated by one neurosurgeon and one medical officer with an N95 mask and face shield in addition to the standard surgical gown and attire. Auxiliary staff in the same theatre put on a face shield on top of their three-ply surgical mask. We did not encounter any high-risk patients that necessitated the use of a higher level of personal protective equipment (PPE) during that short period of time. COVID-19 polymerase chain reaction (PCR) test was performed for patients requiring transfer and they were transferred after the test result became available to avoid the potential spread of this virus.

During the first 6 weeks of the Movement Control Order (MCO), 50 patients sought urgent consultations. Twenty patients (40%) required emergency surgery or intervention. There were nine vascular (45%), five trauma (25%), four tumor (15%), and two hydrocephalus cases (10%) ( Table 1) .

Of the eight patients with intracranial hemorrhage, there were six with basal ganglia bleed, one with lobar hemorrhage, and one with cerebellar hemorrhage and obstructive hydrocephalus. The three patients with severe head injury were diagnosed as having extradural hematoma in two and compound depressed skull fracture with underlying contusion in one.

As for those with mild head injury, one suffered from penetrating brain injury and another (Table 2 ). There was one death (5.6%) of a male patient with obstructive hydrocephalus secondary to cerebellar hemorrhage.

With this framework and strategy in place, ninety percent of the transfers were avoided during a pandemic, and none among the clinical staff involved in the care of the patient contracted COVID-19. 

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The COVID-19 pandemic has disrupted the delivery of care to neurosurgical patients globally. The set-up of this framework allowed timely intervention for neurosurgical emergencies, minimized transfer, and enabled continuity of neurosurgical care at a remote center with difficult access to neurosurgical services during a pandemic.J o u r n a l P r e -p r o o f