The COVID pandemic continues to have a dreadful human impact, both through direct morbidity and mortality but also due to increasing economic strain. A growing concern is how we re-start ‘normal’ healthcare delivery as we regain control; and what will new normal surgical workflows look like? For a while, we were on a war footing – with only the most urgent and life-threatening cases performed. We quickly re-incorporated urgent cancer surgery, and then surgery for some benign disease (that if left would result in harm). But what of more elective work?
We are going to be reminded of the natural history of some diseases processes, as our capacity to intervene is restricted. The CovidSurg study is shining a light on the peri-operative risks of surgery and it makes for startling reading. A 24% mortality for those who contract COVID in the peri-operative period is a frightening material risk. Mid pandemic, the message is clear: the only operative if absolutely necessary. However, as community and in-hospital cases reduce, and the health system comes under less strain, the situation will become more nuanced.
There is now an extra dimension to consent. As well as the operation and anaesthetic-specific risks, there is COVID. For elderly and comorbid men, in particular, the peri-operative risk if one contracts COVID is desperately high (35% for an elective major operation). But what is the risk of peri-operative COVID exposure? And what of the patient who is suffering badly with pain for which an operation offers the only real hope of significant improvement? These cases will wait until the probability of community and hospital infection is low enough (and the testing comprehensive enough) that the risk is mitigated. The process will be gradual.
As with all decisions to operate on people with capacity, it is a joint process based on an assessment of risk and potential benefit. A degree of uncertainty is inherent at the best of times. However, we now exist in a grey(er) zone where COVID-related risks are dynamic and very difficult to quantify. What is the regional R value? How many people in your hospital have COVID? Are all staff being regularly screened? Has the patient shielded for two weeks pre-operatively? This uncertain situation is a useful moment to solidify the principles enshrined by Montgomery. As ever, high-quality communication with a detailed explanation of risks (and the inherent uncertainty of this situation) together with diligent record-keeping is crucial. It is almost certain that medicolegal cases are already in the offing. In due course, COVID testing may become just another part of the pre-op work-up, but for now, we must navigate uncertain waters.
Consultant neurosurgeon, Edinburgh