COVID-19 and Pakistan
Co-Chair, Neurotrauma Committee, World Federation of Neurosurgical Societies
Dean, Neurosurgery, College of Physicians and Surgeons of Pakistan
Professor & Head of Neurosurgery and Dean, Northwest School of Medicine
Pakistani people are socially very active and are into public large gatherings for everything from weddings to funerals. It is considered a great insult if you do not attend these events and do not embrace and shake hands with those present. When a patient is brought into hospital there are at least 5 to 6 relatives with each; the older the patient, the more people accompany them. Then the whole extended family and the village has to visit them in hospital.
The first and most difficult task faced was to convince people to agree to social distancing. Despite repeated efforts, by and large we have failed – although some success has been seen in funerals and prayer areas.
Being considered a COVID-19 suspect or diagnosed as a positive patient was considered a stigma and many people quarantined in centres escaped and had to be tracked with great difficulty. People are still reluctant to come forward for testing as they do not want be reported to the officials who would then enforce quarantine on the whole street.
In the initial stages everyone was in a state of denial regarding the seriousness of this disease. The hospital staff was not inclined to wear gloves, masks and other protective gear. This and the fact that there was no testing available resulted in large numbers of staff being exposed to COVID-19. These staff then would go home, or since many were working two jobs, they ended up infecting many more people, at home and in other hospitals.
Due to the lockdown, patients were having great difficulty in reaching tertiary care hospitals – people generally use public transport since it is cheaper than private transport. Due to the lockdown, public transport was closed and patients had no means to travel.
The one good thing was a big decrease in trauma. This was because everything was closed down, there was no one on the streets, schools were closed so no children were out, and industries were closed so there were no industrial accidents.
In most of the hospitals the outpatient departments were closed and routine surgeries were suspended, but not in all hospitals. There was great fear that hospitals would be inundated with sick COVID-19 patients. This worry started when the first case was diagnosed on February 26th. For some reason this did not happen and until the present it is the same – most patients have had mild symptoms and could be easily managed at home in self isolation.
For the hospitals that tried to continue as normal, a number of changes and adjustments had to made. I will give an account below of what protocols were adopted in this very new and dangerous situation in our institution (Northwest General Hospital and Research Centre).
The first step was a triage system to detect suspected COVID-19 patients - then referred to the designated hospital for testing and further management. Initially travel history carried the highest marks for suspecting COVID-19; this was followed by fever, cough, flu, and body aches. The interesting feature of loss of smell/taste, recently identified as a symptom in the United Kingdom (UK), was not a part of this triaging. The triaging form was the one approved and circulated by the World Health Organization (WHO). The importance of travel history was changed as most transmission cases were then from local spread. The triaging started from mid-March: in the first month (until mid-April) 13,985 patients were triaged, with 233 patients being referred for testing.
Once patients clear triaging they pass through a cubicle with an atomizer of chlorinated water (this was added a few weeks later). After this the temperature is checked with a thermal gun and any person registering a high temperature is again referred back to triage. The thermal gun in our setting was the first instrument used as a triaging tool. Once in the outpatient area, patients are asked to sit at a distance from each other. This again is a constant campaign to ensure that people comply with social distancing. Everyone entering the hospital, if not wearing a mask, is given one to wear. The consultants seeing patients are advised to wear gowns, masks and gloves while examining patients; strict compliance is ensured.
As you will see from our figures, we had in our initial days a number of hospital staff who tested positive for COVID-19. The reason initially was a lack of Standard Operating Procedures (SOPs); later non-adherence to the SOPs by the staff was a problem. Once the staff had repeated trainings, the number of positive cases dropped dramatically. Since mid-May we have had none of our staff become infected in hospital. The staff who tested positive were given the choice of self-isolation at home or in our hospital accommodations, where we had converted the 7th and 8th floors to isolation rooms for positive cases, and the 6th floor for contact cases. These contact cases are isolated for two weeks, then released if they have no symptoms and test negative.
Our biggest problem was seen in patients coming in for routine child deliveries who had to be converted to cesarean section. Two such patients were positive in our initial period, and as the staff had not taken precautions, we had to self-isolate the whole team until they were confirmed negative. Once the staff were repeatedly trained, there were no further mishaps. We did not stop routine procedures but rather followed strict SOPs, whereby the staff and other patients were not subjected to unnecessary risks. All routine patients were first tested and then admitted for their procedure.
In two months, 459 surgeries (both emergency and routine) were performed. Out of these, 52 cases were neurosurgical. This was 10 % of the number of cases performed in pre-COVID-19 times. The majority of cases were brain or spine tumors, but also some disc surgeries were performed. During this period no trans-sphenoidal surgeries were carried out. Trauma cases were much less frequent compared to previous months.
In late May the lockdown was eased – and since that time there has been a surge in the number of patients in the outpatient departments, resulting in great difficulty in social distancing and also a dramatic increase in the number of COVID-19 patients. In our hospital the 32-bed COVID-19 patient facility is running full all the time.
Our learning curve in the COVID-19 pandemic has been very steep – and continues as the pandemic evolves in Peshawar locally and Pakistan as a whole.