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| EDITORIAL |
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| Year : 2020 | Volume
: 68
| Issue : 5 | Page : 972-974 |
Neurosurgery in India during COVID Times
Basant K Misra
Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| Date of Web Publication | 27-Oct-2020 |
Correspondence Address:
Dr. Basant K Misra
Department of Neurosurgery and Gamma Knife Radiosurgery, P D Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.299142
How to cite this article:
Misra BK. Neurosurgery in India during COVID Times. Neurol India 2020;68:972-4 |
| » Covid-19 Global Pandemic | |  |
Since the discovery of the first case of COVID-19 in Wuhan, China, on November 17, 2019, in a 55-year-old gentleman, there have been unprecedented changes in the entire world in a matter of 6 months. The WHO declared COVID-19 as a pandemic on March 11, 2020. Since then, the COVID-19 pandemic has disrupted all aspects of society globally and neurosurgery is no exception. While many countries have managed to flatten the curve, India seems to be still struggling with a large number of active cases.
| » Covid-19 India | | |
The first case of COVID-19 was reported in India on January 30, 2020, and the count as of October 6, 2020, is 6,754,179 confirmed (still adding >70,000 cases every day) with 104,591 deaths and 5,741,253 recovered (www.covid19.india.org). The Government of India and various state governments have set up multiple centers for patients with mild symptoms in public schools, public halls, railway bogies (hotels and lodges were converted to an isolation facility), and facilities erected on open grounds, comprising 1000 beds with an expansion capacity to 5000 beds for COVID-19 admissions. Mobile testing units are used for mass screening. All health professionals, including neurosurgeons <55 years old, were urged to join COVID duties. Initially, the efforts to contain the spread of this virus in India by imposing an early lockdown were lauded across the globe. The goal was partially achieved as we could delay the community transmission to a certain extent. This provided us with the opportunity to prepare for the worst. Currently, the exponential increment in the new cases is the highest in India globally, and the total number of cases in India is probably much higher as testing is limited. However, it is significant to note that the case-fatality rates are much less compared to some European and U.S. cities. The healthcare services in India is overburdened by this pandemic with the healthcare workers taking a major hit with a high risk of contracting the disease themselves while caring for the affected patients. Major public and private medical facilities in India such as AIIMS, New Delhi; PGIMER, Chandigarh; SGPGIMS, Lucknow; NIMHANS, Bengaluru; SCTIMST, Trivandrum; CMC, Vellore; Medanta Hospital, Delhi; Hinduja Hospital, Mumbai; Manipal Hospital; and many other corporate tertiary care hospitals have adapted to this situation over time and thereby continue to provide quality care. Some of the many adaptations are detailed below.
| » Creation of a Separate Covid Facility | | |
“Necessity is the mother of invention,” and the same holds true for the current situation. This has led to the creation of an isolated facility within or in the vicinity of the premises of the main hospital, as per the available resources, designated exclusively for COVID-positive patients. This facility caters for the general and emergency care of the patients, including traumatic and nontrauma-related neurosurgical emergencies. This establishment has wards, intensive care units (ICUs), and operating rooms (ORs) well equipped to deal with all types of emergency surgery. A separate OR with separate air duct flow for managing COVID cases or whenever the test results are not available owing to the emergency surgery is planned. The operating theaters should have a negative pressure environment to reduce transmission of infection. A high frequency of air changes (25/h or more) is also effective to rapidly reduce the viral load. Each OR should have its ventilation system with an integrated high-efficiency particulate air filter. The same would apply to the intensive care facility along with maintaining the adequate spacing of beds. This facility is manned by healthcare staff including the doctors and nurses, borrowed from the main center in regular rotatory cycles.
| » Triaging Neurosurgical Emergencies | | |
A consensus statement from India published recently has set protocols regarding the COVID testing, a standard operating protocol for the creation of operation theaters along with donning and doffing of personal protective equipment (PPE) kit.[1] Mandatory testing for COVID status is recommended in all the patients, before admission and surgery. Three testing modalities are currently available, rapid antigen test, which is less sensitive (gives instant results), and nucleic acid tests, such as the CBNAAT/TrueNat (within 2–4 h) and the RT-PCR (up to 8 h). Hence, patients requiring intervention for immediate life-threatening situations (such as trauma/neuro-oncological emergencies with impending herniation/hydrocephalus/vascular pathologies with hemorrhage) are operated without awaiting the results of the COVID test or a rapid antigen test, using full protective gear. A high-resolution computed tomography (HRCT) chest in such situation helps in diagnosing COVID and risk stratification from general anaesthesia (GA). The patient may be managed following surgery, as per the results of COVID status, at respective centers. The semi-urgent cases may be subjected to the nucleic acid tests which are of equal efficacy compared with the RT-PCR.
| » Elective/semi-Elective Surgeries | | |
The elective neurosurgery procedures were significantly affected by the pandemic and in many institutions stopped, especially the initial 3 months of lockdown between March and May 2020. With the beginning of the unlock, the elective surgeries have resumed gradually and are currently at 50%–70% of the pre-COVID volume in various major hospitals with neuro-oncology taking up the major share. The main reasons for continuing low volume are:[2]
- Patients are scared to come for hospitalization, unless it is an emergency
- A significant drop in regional transport authority travel
- A significant decrease in out-of-town patients because of air and rail travel restrictions.
Epilepsy and functional neurosurgery, degenerative spinal disease, congenital spinal disorders, and unruptured arteriovenous malformations/aneurysm surgery have come to a halt awaiting the pandemic to ease off. The Indian Society of Neuro-Oncology recently published a position statement with the recommendations for neurosurgeons/radiation oncologists.[3] The guidelines once again emphasize on the optimal utilization of the available resources, especially where the benefit of the intervention is maximal. Delaying surgery for benign tumors without mass effect, considering cerebrospinal fluid diversion for obstructive hydrocephalus due to pineal/third ventricular tumors, thereby postponing the definitive surgery, advocating supportive care for patients of glioblastoma multiforme in patients older than 65 years and with comorbidities or poor quality of life, disseminated medulloblastoma/ependymomas, multiple brain metastases, rather than palliative radiation therapy have been recommended. Endoscopic pituitary surgeries or skull base lesions in the vicinity of pneumatized sinuses are among the highest risk neurosurgical procedures. These are grouped as aerosol-generating procedures owing to bone drilling; hence, whenever possible, delaying is advisable. Evidence suggests that there is an increased risk of morbidity and mortality (up to 20%) in COVID-positive patients undergoing surgery.[4] Mandatory testing before admission and 24–48 h before undergoing surgery is recommended and is followed uniformly in most of the major centers in India and abroad. Elective surgery in COVID-positive patients is postponed and rescheduled after 17–21 days if the patient remains asymptomatic. In spite of routine PCR testing, patients operated on negative PCR have occasionally turned out to be COVID-positive in the postoperative period. Hence, some centers also perform an HRCT before any intervention under GA as HRCT may pick up cases of COVID that were missed on a PCR test. It is the for the same reason that neurosurgeons in many centers have fully protected N95 mask, goggles/face shield, and appropriate PPE even when operating on COVID-negative patients and use simple modifications to reduce aerosol spread [Figure 1]. | Figure 1: Craniotomy being done under a transparent plastic sheet to reduce aerosol contamination, operation room personnel on full personal protective equipment and N95 masks while operating on a COVID‑negative patient
Click here to view |
| » Covid Patients and Neurosurgeon | | |
Neurosurgeons in most major centers in India have conducted emergency procedures on COVID-positive patients. Neurosurgery residents and exceptionally neurosurgery faculty in most centers in India are/were posted in the COVID facilities tending to nonneurosurgery patients. Many residents and some faculty have become infected with COVID. While some neurosurgeons have got infected after operating or tending to an infected patient, more neurosurgeons have been infected outside the theater and often from a colleague or other hospital personnel when their guard was down. One neurosurgeon in India, unfortunately, has succumbed to COVID-19.
| » Training and Teaching during Covid-19 | | |
Another major casualty of the COVID pandemic has been resident training. Clinical workload and surgical exposure have reduced dramatically. Another puzzling statistic is the reduction in emergency admissions and surgery that has been experienced across all specialties. While there is no good solution to increase surgical exposure and clinical case studies for trainees, there is a constant effort to continue academic activity and teaching. Periodic evaluations of residents and case presentations through a digital platform are being resorted to in many centers. There are also periodic webinars on a variety of subjects (complimentary registration to all) that have been very popular. This initiative is going to continue post-COVID.
| » Digital India and Made in India | | |
The digital revolution in India has also helped. Most major centers have resorted to virtual/tele-rounds without physically seeing patients admitted in the ICU/wards via various digital platforms available today. This has also made it possible for the virtual counseling and briefing of the patient's status to the caregivers. The outpatient services are being carried out digitally, which is accessed even from the remotest places in India, thanks to the widespread availability of the smartphones in India.[4]
The entrepreneurs and innovators in India have also risen to the occasion. While most PPEs, N95 masks, and ventilators were imported before the pandemic, most requirements are currently locally produced in our country. India is also not far behind in the efforts of producing a vaccine for COVID-19.
| » Final Thoughts | | |
None of us, nobody in the world, has seen a catastrophe of such magnitude in our lifetime. It is a humbling experience to realize how insignificant we are in the scheme of things. Has it taught us anything? It has taught me to treasure and value the time I have and thank God for the free air I breathe and marvel at the beauty of nature, which I did not have time to cherish!
I am optimistic that this will also pass and we will be back to 12-h day of neurosurgeons soon!
Acknowledgment
The author gratefully acknowledges inputs from Profs. V. Rajshekhar, Ashish Suri, Sunil Gupta, Sanjay Behari, Malla Bhaskar Rao, Ari Chacko, V. P. Singh, Girish Menon, and Ramesh Doddamani.
| » References | | |
| 1. | Gupta P, Muthukumar N, Rajshekhar V, Tripathi M, Thomas S, Gupta SK, et al. Neurosurgery and neurology practices during the novel COVID-19 pandemic: A consensus statement from India. Neurol India 2020;68:246-54.  [ PUBMED] [Full text] |
| 2. | |
| 3. | Gupta T, Singh VP, Balasubramian A, Menon H, Kurkure PA, Kumar S, et al. ISNO position statement on treatment guidance in neuro-oncology during pandemics. Neurol India 2020;68:769-73. [ PUBMED] [Full text] |
| 4. | Ganapathy K. Telemedicine and neurological practice in the COVID-19 era. Neurol India 2020;68:555-9. [ PUBMED] [Full text] |
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