The Uneven Price: A Neurosurgical Experience Out of the Line of Fire
Ospedali Riuniti di Livorno, Italy
I was on call the night the first case of COVID-19 was confirmed in the hospital where I work. I went to the ER to evaluate a suspected cauda equina patient. I remember the puzzled looks, everybody unsure about how to manage the spaces, the patient, and the family themselves. The pretriage tent outside was already set and running for a couple of days, but the first case came anyway as a surprise - the sudden deterioration we now know all too well, nothing by the book. On that day Lombardy had already had more than a thousand of cases and several hundreds of deaths.1 Three days later elective surgery stopped in the whole Region; one week later, on March 11th, the World Health Organization (WHO) declared the pandemia - by then, there were more than three hundred cases of COVID-19 in Tuscany.
Because our surge occurred a fortnight after Lombardy, our Region had time to brace for the impact and implement preparedness. Although with some important intra-regional geographical differences in figures, the healthcare system rose to the occasion.
We watched in awe and terror our General Practitioner, Emergency Medicine, Pneumonologists, Intensive Care Unit (ICU) colleagues outdoing themselves while working through scarce protecive personal equipment (PPE) resources, continuosly updated protocols, space and time constraints. On call times became strangely quiet for us. Our almost-empty department wing started to host other specialties while an increasing number of hospital spaces were recruited for COVID-19 patients. We started to work in smaller teams to limit exposure.
We surgeons were updated with basic concepts for task-sharing that, in the end, were scarcely necessary.2 While numbers were high, Tuscany never reached a full ICU-beds surge capacity. Trauma cases dropped and elective surgeries were halted, but all neurosurgical centers in our Region performed oncological cases during lockdown following strict safety protocols.
Now we are seeing a wave of patients with intracranial pathology presenting after several weeks of symptoms – they were too frightened to seek medical attention earlier. Collateral damage and morbidity from neglected pathologies are to be expected: Emergency Department admissions for myocardial infarction and stroke went down as much as 60%, while mortality for the same pathologies rose.3,4 Most of the 28 million surgeries cancelled are, hopefully, still there awaiting5 - studies like CovidSurg and its Cancer subsets are exploring issues related to the pandemia.6
While COVID is still fully raging in many countries, we are now appreciating a slow, cautious return to a new normalcy. I – for one – felt sincerely happy to scrub on an elective degenerative spine case… and that says lots.
What are we left with, besides pre-pandemic level of traumatic injuries, Zoom webinars, homebound kids, and a huge amount of COVID-19-related questions? Sleep troubles. Mourning for colleagues. General grief. Inability to debrief as usual with our teams, to make sense together of a world gone mad. Ethical concerns. Scared patients. Troubling, deep social concerns. Moral injuries need exploring to heal. Troubling, deep social issues. Training to be reinvented.
While writing down this I thought, however, of the many ongoing initiatives, of the way our neurosurgical community got together.
Will our deeper sense of community be able to turn 2020 from annus horribilis into annus mirabilis, a year of wonders?