SURGICAL PERSPECTIVE
Improvise, Adapt, and Overcome
David P. Bray, MD,Y Nelson M. Oyesiku, MD, PhD, and Brian M. Howard, MD
Keywords: Covid-19, healthcare systems, surgery
(Ann Surg 2021;273:e5–e6)
Downloaded from https://journals.lww.com/annalsofsurgery by 01UGrXh3ipqzR4DKqW7bOJtSxsRVOheLV9OzOeHq2POX2t1GrKUD6m1aBQdlm0lX7bZxxCFBpuxAM3exuxdXARVaPXROhrEIELxLuiE5dAoxEXL1EbBXOmtN5qOe2K0cRH9XYihoqJLhl/QMQTWBWg== on 03/16/2021
N ovel coronavirus 2019 (Covid-19), has dramatically altered
medical care across the world. During the initial outbreak, to
conserve resources and reduce unnecessary exposure to the virus,
many hospitals halted elective surgical procedures.1 The global
medical community appropriately mobilized physician specialists
in infectious disease, immunology, critical care, and emergency
medicine. Indeed, these physicians have labored with unflagging
zeal to treat the deluge of Covid-19 patients.
Meanwhile, with elective surgeries suspended, surgeons may
have felt that they have diminished importance in the larger health-
care ecosystem. In an essay published in the New England Journal of
Medicine in mid-September, vascular surgeon Dr. Tambyraja elo-
quently describes this view during the Covid-19 pandemic.2 The
surgeon in Dr. Tambyraja’s piece is reposed in awe of his fellow
medical colleagues fighting the virus on the ‘‘frontlines,’’ while
simultaneously embroiled in existential crisis about a diminished
role in the ‘‘new order’’ of medical care.
What are we surgeons to do? Are we ‘‘impotent?’’ Do
surgeons need to move to the ‘‘back seat’’ and accept that our work
is ‘‘obsolete,’’ as Dr. Tambyraja posits?2 Resoundingly not! How-
ever, if surgeons do not define our role in the healthcare ecosystem
during this lingering global health crisis, we will fall victim to the
roles foisted upon us by hospital administrators and governing
bodies. Surgeons must continue to manage critically-ill surgical
patients, respond to increased surgical demand due to the pandemic,
discover new opportunities to provide assistance to our nonsurgical
colleagues, and educate the next generation of surgeons. We will
describe our experience as neurosurgeons at a high-volume, aca-
demic, tertiary care center to illustrate our points.
Despite the Covid-19 pandemic, surgical emergencies demand
surgical solutions. In hospitals bursting with patients and resources
stretched during the pandemic, surgeons manifest their value by
adjudication and triage, while efficiently delivering care. In
March 2020, during the initial Covid-19-related ‘‘shut-down’’ in
the United States, our neurosurgical resident and attending cohort
divided into 2 teams to cover our multiple hospital neurosurgical call
responsibilities with fewer people. With a tightened ship, we pro-
vided needed neurosurgical care while reducing risk of exposure for
our neurosurgeons, hospital staff, and patients.3 During a global
health crisis, surgeons prove their worth by doing more with less.
In addition, surgeons must remain vigilant and flexible to meet
the demand of increased Covid-19-associated surgical complications
From the Department of Neurosurgery, Emory University School of Medicine,
Atlanta, Georgia.
dbray3@emory.edu.
Dr. David P. Bray is partially supported by the Nell W. and William S. Elkin
Research Fellowship in Oncology, Winship Cancer Institute, Emory University
Hospital, Atlanta, GA.
The authors report no conflicts of interest.
Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/20/27301-00e5
DOI: 10.1097/SLA.0000000000004580
Annals of Surgery  Volume 273, Number 1, January 2021
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
and stress on the existing inter-hospital triage networks. The New
England Journal of Medicine published a report of increased fre-
quency of intracranial large vessel occlusions associated with Covid-
19. Oxley et al proffered that Covid-19 could be associated with a
prothrombotic coagulopathy and an increased risk of stroke.4 Stroke
is a neurosurgical emergency; 4 of 5 patients featured in the case
series necessitated emergent endovascular thrombectomy upon
admission to the hospital.
Subarachnoid hemorrhage (SAH) is a life-threatening neuro-
surgical disease. Patients with SAH may require surgical and/or
endovascular procedures, and are typically managed at high-volume
referral centers. The burden of Covid-19 has intensified the strain on
those systems of care. For instance, 42 patients were transferred to
our center for SAH during April and May 2020 – the initial surge of
COVID-19 in the southern United States. This represents a 120%
increase above the mean number of SAH patients transferred over the
same months in 2017 to 2019. Certainly, surgeons must remain at the
ready during the Covid-19 pandemic.
Surgeons can provide value to the healthcare ecosystem
during the pandemic by assisting nonsurgical colleagues with patient
care. We need not sit with ‘‘idle hands’’ while our medical partners
grapple with the influx of critically-ill patients.2 When elective cases
were canceled to increase ICU capacity at our hospitals, neurosur-
gery attendings and residents volunteered to redeploy to care for
patients in the neurological ICU and Covid-19 units.3 Surgeons are
well-trained and well-equipped to provide relief and aid to our
nonsurgical colleagues by caring for critically-ill patients during
the Covid-19 pandemic.
The Covid-19 pandemic has maintained a protracted hold on the
healthcare system, and if and when normalcy will return is unclear. As
the pandemic lingers, we are obligated to continue to educate the next
generation of surgeons. We must develop innovative methods to train
surgical residents and fellows whilst quarantining and social-distanc-
ing. Our neurosurgical residency training program – like many others
– pivoted to a remote-learning curriculum, which we continue to use.3
Surgeons need to create new opportunities to educate the next genera-
tion of surgeons for this and potential future pandemics.
The ‘‘new order’’ created by the Covid-19 pandemic has tested
and strained the global healthcare ecosystem.2 Surgeons may begin
to despair and ‘‘contemplate their purpose’’ in their hospitals with
elective surgeries canceled and increased demand on nonsurgical
physicians. Surgery had famously been described as the ‘‘neglected
stepchild of global health,’’5 but the Lancet Commission on Global
Surgery upended this posture and has energized a new priority for
surgical care.6 At the opening of the Commission, Jim Yong Kim,
then President of the World Bank, stated that ‘‘surgery is an indivisi-
ble, indispensable part of health care.’’7 On the heels of the Lancet
Commission, in 2015, the WHO launched the WHO Emergency and
Essential Surgical Care Program dedicated to strengthening health
systems by improving access to safe, timely and affordable surgical
care, to optimize health outcomes.
The Covid-19 pandemic does not represent the ominous, tolling
bell for surgeons worldwide, it is rather a call to arms. Surgical staff is
‘‘decisive,’’ broadly-trained, and keen to help during this global health
crisis. We can ‘‘improvise, adapt, and overcome’’ with our nonsurgical
colleagues as we meet the Covid-19 pandemic head-on; together.
www.annalsofsurgery.com | e5
Bray et al
Surgeons can deliver care more efficiently, treat new surgical patholo-
gies created by the pandemic, assist our nonsurgical colleagues, and
continue to educate the next generation of surgeons. If we surgeons fail
to respond to the increased demands placed on the health ecosystem,
we will manifest our own obsolescence.
REFERENCES
1. Iacobucci G. Covid-19: all non-urgent elective surgery is suspended for at least
three months in England. BMJ. 2020;368:m1106.
2. Tambyraja AL. New order, new hope. N Engl J Med. 2020. Epub ahead of print
September 9, DOI: 10.1056/NEJMp2016142.
e6 | www.annalsofsurgery.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 273, Number 1, January 2021
3. Bray DP, Stricsek GP, Malcolm J, et al. Letter: maintaining neurosurgical
resident education and safety during the COVID-19 pandemic. Neurosurgery.
2020;87:E189–E191.
4. Oxley TJ, Mocco J, Majidi S, et al. Large-vessel stroke as a presenting feature of
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7. WHO j Emergency and essential surgical care Available at: https://
www.who.int/surgery/en/. Accessed September 28, 2020
ß 2020 Wolters Kluwer Health, Inc. All rights reserved.