COVID-19 has changed our world and surgical practices as vascular surgeons. We have been faced with unforeseen challenges, and the professional impact has been global. Elective procedures, the staple of our practice, have been indefinitely canceled and delayed. Clinics have been replaced by virtual encounters, and patients are only seeking hospital care when their vascular disease is severe and/or life threatening. The pandemic is taking healthcare providers far outside their comfort zones, and physicians and surgeons are being transitioned or deployed into unfamiliar or novel clinical roles. Physicians are being asked to work in unsafe conditions, where shortages in personal protective equipment (PPE) put the providers and their patients equally at risk for contracting the viral infection.
The following narratives provide witness and lay bare the stories of the earliest communal responses to COVID-19 from the point of view of vascular surgeons practicing amidst the crisis. The stories start with the experiences of vascular surgeons in Lombardy, Italy, the first place, outside of Wuhan, China, to be affected by COVID-19. We then journey to South Korea, followed by Japan, Abu Dhabi, Chile, Austria, Canada and the United Kingdom. A collection of COVID-19 vascular surgeon narratives from across the U.S. is available here, with the stories starting in Seattle, the first described U.S. COVID-19 touchpoint, then moving on to New York and other states thereafter.
ITALY: Into the eye of the storm
The first two confirmed cases of COVID-19 in Italy occurred at Spallanzani Institute on Jan. 30. The patients were from China, and were visiting Italy on holiday. They were hospitalized and isolated on Jan. 29, then successfully discharged Feb. 26. The first case of the disease resulting from secondary transmission occurred on Feb. 18 in Codogno, a municipality of Lombardy in the province of Lodi.
I am an Italian vascular surgeon, born in the Lombardy municipality, but work in a hospital in Treviso in northern Italy, about 300km from Lodi. It was unfathomable to me that a COVID-19 outbreak could occur in my hospital. This is an account of my experiences during the first month of COVID-19. First week: I did my work without fear, not fully aware of the potential risks and severity of this infection.
Second week: A case of COVID-19 on our vascular surgical service was reported. The patient was admitted for critical limb ischemia. On hospital day two, he displayed symptoms of respiratory distress. A chest x-ray demonstrated findings suggestive of pneumonia; a nasopharyngeal swab was positive for COVID-19. I started to worry. Third week: My hospital reduced elective operations and focused on increasing capacity in intensive care. Our hospital created new intensive care units (ICUs) in the operating room (OR). I was now experiencing dread, worry and loneliness.
I chose to physically isolate from my family, not wanting to put them at risk, and knowing that I chose this work and profession. Despite the risk of working with COVID-19 patients, I remained passionate about my profession but found that I was constantly trying to mitigate my anxiety, uncertainty, and fear of contracting the disease.
Fourth week: I performed a popliteal artery and tibial thromboembolectomy in an infected man, aged in his 60s, for acute limb ischemia. Post-operatively, he was initiated on unfractionated heparin. Despite this, two days later he redeveloped ipsilateral acute limb ischemia and worsening COVID-19 pneumonia. He was transferred to the ICU after I took him to the OR for re-do popliteal and tibial thromboembolectomy.
Unfortunately, eight hours post-operatively he again redeveloped acute ischemia. Thinking the recurrent thrombosis was due to pedal microvasculature thrombosis, I performed popliteal and tibial thromboembolectomy (for the third time) and plantar artery thromboembolectomy with concomitant arteriovenous fistula (AVF) creation to the tibial vein. Anticoagulation with heparin was continued. At 23 days, the patient is in the ICU with a tracheotomy and salvaged foot. He has triphasic Doppler signals and a patent AVF.—Laura Nicolai, MD, vascular surgery unit, Cà Foncello Hospital
SOUTH KOREA: Land of the Morning Calm
South Korea was one of the first countries outside of China hit hard by the COVID-19 outbreak. Our first case occurred on Jan. 20. A steep rise in patients was seen from Feb. 19 onwards and continued throughout the month of March. By the beginning of April, our daily incidence of new COVID-19 cases finally stabilized, but now we are facing a resurgence in newly diagnosed cases as Korean citizens living abroad return.
As a vascular surgeon working around Seoul, I did not have to change any of my daily practices during this period primarily as many cases (more than 80%) in Korea centered around Daegu and Gyeongbuk province. As in the case of Wuhan, our country managed to contain the outbreak, thus preventing a nationwide spread.
This experience has allowed the Korean people to remain relatively calm and unaffected by the outbreak, especially since Koreans have no objection to wearing masks and social distancing. The rapid development of a diagnostic tool for COVID-19, and the large number of diagnostic tests performed, has allowed for appropriate self-isolation of potential candidates. Additionally, an effective quarantine system and rapid assessment of potential close contacts has limited the spread of the virus.
In the city of Daegu and Gyeongbuk province, where the newly diagnosed patients outnumbered the hospital facilities, several hospitals were designated as COVID-19 inpatient hospitals, allowing for all symptomatic patients to be admitted to these facilities. At our hospital preventive measures were taken from the start.
By the end of the first week, all conferences were canceled for an indefinite period. Medical personnel were advised not to engage in activities involving a crowd, including dining events. All travel abroad was prohibited, and personnel with recent travel to either China or any other country with COVID-19 were evaluated for symptoms. All outpatients were screened for respiratory symptoms and fever, and, if positive, were guided to a separate outpatient facility for isolation from other patients.
By the fifth week, the period with the greatest rise in cases, a ward was specially designated for suspicious COVID-19 patients. Based on these preventive and isolation measures, the hospital maintained its usual function, and, as such, our daily practice was not affected. During the period of the COVID-19 outbreak, our outpatient numbers only decreased by 20–30%, and hospital admissions and operative cases remained relatively constant.
Despite the relatively larger number of COVID-19 patients, vascular surgeons in the region continued practice as usual. Cases that could be delayed, without causing harm to the patient, were postponed indefinitely, while other elective cases that required a postoperative ICU stay were delayed. Urgent cases not requiring an ICU stay were performed as usual.
Since mid-April, we have had less than 20 cases per day nationwide, and the government is now considering loosening up on the strict measures implemented to achieve social distancing.—Hyung Sub Park, MD, assistant professor of surgery, vascular, Seoul National University Bundang Hospital
JAPAN: Beyond the East Sea
The East Sea separates Japan from China. The first COVID-19 patient in Japan was confirmed on Jan. 16. The patient had recently traveled to Wuhan, China. On April 7, there were 4,100 COVID-19 patients, 79 in intensive care, and 97 total deaths. In my hometown of Nagoya, 148 patients have been confirmed, with only two inpatients in Nagoya University Hospital.
\In my hospital, vascular surgeons are working as usual and performing elective operations. Our other medical colleagues have not yet encountered COVID-19 patients. In the three months since the first reported patient in Japan, the outbreak has only affected our capital of Tokyo.
A state of emergency—without a lockdown—was declared on April 7, covering a total of five cities, including Tokyo and Osaka. Nagoya was excluded from the list. As the situation in Tokyo worsened, our perspective changed, and we prepared for the worst.—Hiroshi Banno, MD, assistant professor, division of vascular surgery, Nagoya University Graduate School of Medicine
ABU DHABI: At the heart of the UAE
The early Cleveland Clinic Abu Dhabi (CCAD) experience with the COVID-19 pandemic has been characterized by a rapid response calibrated to incoming data. Since its inception, there has been a cultivation of a culture characterized by community.
There are daily meetings called “huddles” directed at the department or institutional level, followed by a daily hospital wide huddle. Since the first cases in Abu Dhabi in February, there has been a weekly virtual town hall and a central website to collect directives, training videos and news.
A daily huddle of specialists, focused around action plans for the pandemic, results in email transmission of directives hospital-wide. These remarkably clear directives provide caregivers with the ability to rapidly react to the exigencies of the pandemic.
The early and broad availability of testing has benefited the Emirate of Abu Dhabi, and has been critical in saving lives and keeping the hospitals from being overcome by a surge. As a vascular department— composed of three surgeons, one cardiologist, one podiatrist, two vascular technologists, one clinical nurse coordinator and several clinic nurses and staff—our mission has shifted from frantically managing the crisis to “winning the war.”
This involved adopting guidance from the Society for Vascular Surgery (SVS) and reducing our elective cases. Rapid employment by the CCAD department of information technology allowed our clinic to be safely conducted by telephone and video conference visits via virtual telemedicine.
Additionally, based on individual skills, all physicians have been assigned a secondary function in the case of a case surge. Workflows have also been modified to minimize contact with other caregivers.
This entire experience has made us reflect and profoundly rethink our practice strategy: vascular surgery as vascular hospitalism. This is how we train our residents and fellows, and the term informs us on the concept of the hospital as a critical, evolved and mighty community for curing patients. In a post-pandemic world, I see the need to reprioritize our values with the collected experience of this tragedy.—Michael Park, MD, chief of vascular surgery, Cleveland Clinic Abu Dhabi
AUSTRIA: Bordering northern Italy
The southern border of Austria faces northeastern Italy. The first case in Austria was Feb. 25. This patient had recently returned from Italy. On March 10, Austria imposed travel restrictions from travelers returning from China, Iran and Italy.
Not long after, on March 12, we had our first reported COVID-19 death. On March 16, we had a national shutdown. Travel was only allowed for the purchase of food or medications and to provide help for others in need. Walking outdoors within 1 km from your home address was allowed.
Our department of vascular surgery at Graz Medical University here in Graz includes 10 attendings, four residents, and two general practitioners. Between Feb. 25 and March 7, there was not much change to our work schedules, nor caseload. However, in early March, we began to develop a COVID-19 strategy. This included isolation in-hospital, clearing wards and ICU beds to make way for a surge, training all the staff on the use of PPE, and canceling all elective cases and pre- admissions.
On March 15, we had three attendings and one resident start self-isolation (14 days) after all returned from a high exposure area while skiing in Tyrol, Italy. The call schedules were subsequently adapted, outpatient clinics were canceled, and only emergency operations were performed. Unfortunately, during this period PPE was not available at the hospital for all personnel, including staff in the emergency department. COVID-19 testing was restricted to patients with fever, coughs and positive travel histories or recent exposure.
This has certainly been a trying time, and we have encountered several challenges. First, COVID-19 testing is not widely available and reporting takes 12–14 hours. Second, we have been overwhelmed by calls from anxious patients concerned about their health—not understanding that their condition is not an emergency. Finally, staff wellbeing and mental health have been negatively affected. The professional and personal impact of this pandemic cannot be understated; efforts to address these issues need to be a priority.—Tina Cohnert, MD, department of vascular surgery, Graz Medical University
CHILE: Along the South Pacific
My first month’s experience as a vascular surgeon working through the pandemic in the Chilean capital, Santiago, was to ensure that coverage was available should the outbreak overwhelm our hospital’s capacity, as well as that of our country.
We are currently on day 34 after the first case and have a total of 4,815 cases and 37 deaths. The estimated number of recovered patients is 724. The government has worked tirelessly to keep its citizens safe and healthy by selectively quarantining different areas of the country, flattening the curve.
We are about two to three weeks behind the northern hemisphere. Only time will tell if this trend continues in the following weeks. We work in a university-affiliated private hospital with five vascular surgeons who cover two hospitals. We are currently working in call teams of one fellow and one staff, with one surgeon as backup on week rotations. This leaves three staff at home.
The staff on call rotates every five weeks, the fellows every three. We have not had any of our vascular colleagues become infected. We had a very significant reduction in our elective cases, with the only operations we are conducting being placement of perma-caths (for oncologic patients needing chemotherapy and patients needing dialysis), symptomatic and/or ruptured abdominal aortic aneurysms (AAAs), and symptomatic carotid disease.
Our outpatient clinic volume has dramatically declined to a minimum and we have started implementing telemedicine this past week. This has been a remarkably interesting experience since we have had to fight against the opinions of some of our senior members who do not approve of doing medicine without a physical exam.
I believe there are benefits and pitfalls to telemedicine, but it is a tool that all specialties can use. Telemedicine will likely prove to be an excellent alternative to provide counseling, guidance and follow-up for a great number of our patients in the current setting by avoiding the risk of acquiring COVID-19.—Francisco Vargas, MD, assistant professor, department of vascular and endovascular surgery, Pontificia Universidad Católica de Chile
CANADA: Across the northern frontier
Canada saw its first COVID-19 related death on March 9 when an elderly resident in a long-term care facility in British Columbia passed away. Early on, the vast majority (89.7%) occurred in the two most populous provinces, Quebec and Ontario, with 805 and 513 reported fatalities, respectively.
During the months of March and April, the strategies in our hospitals and vascular surgery services were to mitigate what was expected to be an exponential spike in cases that would threaten to overrun our acute care services. Preservation of PPE, healthcare personnel and maximizing ICU capacity were the priorities. Elective surgical activity was immediately limited to patients who would suffer significant harm if they waited beyond a week or two.
Other than emergencies, at most hospitals vascular surgery cases were limited to exceptionally large aneurysms, symptomatic carotid stenoses and severe chronic limb threatening ischemia. In Ontario, this resulted in a greater than 70% reduction of vascular surgery activity compared to the same time period last year, and a projected backlog of vascular cases exceeding 2,000 patients.
At our academic institutions, our residents and fellows were organized into teams so there were “on” and “off” teams to minimize exposure. Surgeons adopted similar schedules. In tandem, there have been some potential advances in medical care, specifically the adoption of telemedicine.
It is ironic it took a pandemic to prompt us to adopt existing technology. As the spring turns into summer, it’s becoming apparent that instead of an overwhelming short-term spike, most Canadian jurisdictions are facing a longer- term situation where there will be a certain level of COVID-19 activity in our communities and hospitals for the foreseeable future until a vaccine is available.
Attention is presently being paid to Canadian long-term care facilities, which comprise almost half of COVID-19 deaths, and to de-escalate the original reductions in non-coronavirus activity. Various systems have been proposed to do this, but one that allows for this necessary flexibility is the Vascular Surgery Activity Condition (VASCCON), which is modeled after the Defense Readiness Condition (DEFCON) used by the U.S. military to describe the various stages of readiness in response to an external threat.
Similarly, this coronavirus pandemic is an external threat to the normal practice of vascular surgery, and in response to various degrees of COVID-19 activity and the availability of PPE and ICU resources, VASCCON describes five graduated levels of surgical activity ranging from 5 (normal practice) to 1 (no surgical activity). Levels 4 and 3 represent increasingly strict reductions in elective surgical activity while level 2 represents only truly emergency procedures. Level 1 is the untenable situation where all surgical activity ceases and even emergent patients are palliated.
This system is relevant to all surgical services and offers a step-wise escalation and de-escalation of surgical restriction with an eventual return to normal activity.—Thomas Forbes, MD, professor and chair, division of vascular surgery, University of Toronto
CANADA: Trainee perspective
On March 14, after several weeks of being on study leave for my specialty exam in vascular surgery, I received an email saying our licensing exam was postponed to an indefinite date. My heart immediately sank. I was in my own world for several weeks, reviewing SVS guidelines, personal notes and practicing oral exams.
I heard of rumblings of a virus that may be heading to our shores and, even after the World Health Organization proclaimed that we would be facing a pandemic, I would be the first to attest that I wasn’t present to the idea that we would be living today in a society of social distancing and closed international borders. I immediately returned to clinical activities to help where needed.
My first week back, we were operating as usual—but this quickly transitioned to only emergent and urgent cases. We went from operating every day to, if we were lucky, operating once a week. So, with no licensing exam, and a huge decrease in surgical volume as a chief resident, I felt my skills slowly spiraling down a rabbit hole.
I was staring into a void with anxiety; my exam date, my ability to pursue a fellowship in Europe. To maintain my competencies for practice. And to see my family. The more I pondered these existential questions, the more I descended into the abyss.
We have not reached the so-called peak in Montreal and my home province of Quebec, and with rising numbers of COVID-19 cases and deaths daily, it is hard to see how we will ever return to normal any time soon.—Laura Marie Drudi, MD, vascular surgery resident, McGill University
UNITED KINGDOM: Braced for impact
In the early stages, the ultimate course and impact of this pandemic and the resumption of normal vascular practice remain unknown. In the U.K, the first index case was announced Jan. 31. The first confirmed positive admission to my hospital at my hospital in Norwich, England, occurred March 14.
In response to the pandemic, we modified our practice in accordance with guidance from the Vascular Society of Great Britain and Ireland and the Royal College of Surgeons. We adopted a traffic light system to prioritize vascular conditions that require interventions.
Following the first admission at our hospital, we called for an urgent business meeting to make plans for service provision during the pandemic. From March 14–22, the first week, we continued to practice within the green zone (normal practice). During week two, we moved to the yellow zone (urgent and emergency cases) and moved to the orange zone (emergency cases only) in the third week.
All outpatient appointments were triaged into three categories: deferred, telephone consultation and outpatient attendance. We deferred all non- urgent appointments by sending a standard letter to patients and their general practitioners. We triaged all urgent appointments into those suitable for telephone consultations and those who needed to be seen in the hospital.
We continued to offer three emergency clinics per week for this purpose. We modified our call schedule to accommodate the need to cover only urgent and emergency cases. After the first week, one of our vascular surgeons was advised to self-isolate until the end of pandemic due to identified individual risks. From week four, all clinicians in the hospital would be combined in teams providing ward-based services.
In this way, vascular surgeons, thoracic surgeons and urologists combine into one team to round on all patients on the two wards that they normally cover and provide care for patients regardless of their clinical presentations. Hospital-based educational events are continuing virtually with an emphasis on COVID-19 publications.
We continue to retain vascular trainees, who are encouraged to read for exams, write up any research projects and train via simulation. The main challenges we continue to face are ensuring the continued supply of essential resources and PPE for those in need, and a high attrition rate among ancillary staff, resulting in reduced operating room capacity. We anticipate that we will face a long waiting list after the outbreak as our monthly open and endovascular arterial procedures equate to an average of 180–200 cases.— Wissam Al-Jundi, MD, consultant vascular and endovascular surgeon, Norfolk and Norwich
University Hospital
