Global surgery in the time of COVID-19: A trainee perspective

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Abstract

To the Editor We read with great interest a number of recent articles by L Ferrario et al., 1 AN Martin & RT Petroze, 2 C Shao 3 and Chen et al. 4 ; we would like to thank the authors for sharing their perspectives. We echo the authors’ concern that the COVID-19 pandemic has presented unprecedented challenges to surgical training at all levels and support their desire to identify opportunities for trainees interested in surgery. Eager to continue the conversation, we provide suggestions for continuing education for trainees interested in global surgery (GS) during this pandemic (see Table 1 ). The acquisition and application of principles learned through GS, such as health economics, ethics, and health equity, are particularly pressing now for surgical trainees, as the recent health crisis exposed health disparities and resource scarcity in health systems worldwide. 2 , 3 As described by C Shao, “scarcity [on multiple fronts] has become a reality” for surgeons and doctors facing the COVID-19 crisis in the U.S. and abroad, which has forced physicians to make challenging healthcare decisions. 3 Additionally, the rise in COVID-19 cases in the U.S. unleashed an ugly tide of anti-Asian sentiment, seen both in healthcare and in society at large. 4 These phenomena further reinforce the importance and profound necessity of promoting GS principles to surgical trainees, so that they are equipped with the tools to address healthcare crises, both locally and globally. As North American medical students and residents passionate about GS, we offer these reflections on opportunities for continued and meaningful participation in GS for trainees during this time. Table 1 Various platforms for trainees to engage in global surgery during the COVID-19 pandemic. Table 1 Organization or platform Example of how involvement in global surgery has continued International Student Surgical Network (InciSioN): incisionetwork.org Hosted educational webinars on a variety of topics including trauma and critical care, medical education, etc. Global Surgery Student Alliance (GSSA): globalsurgerystudents.org/webinars Led ten free webinars on various medical and surgical specialties ReSurge Global Training Program (RGTP): facebook.com/ReSurge Developed a Facebook group to facilitate collaboration among surgeons in LMICs and experts from around the globe Harvard Program in Global Surgery and Social Change (PGSSC): pgssc.org Assembled a panel of experts to deliver an online discussion on surgical capacity-building in LMICs as pandemic readiness strategy InterSurgeon: intersurgeon.org Platform where members can create an offer either to provide or receive education, clinical assistance, or additional surgical training CovidSurg: globalsurg.org/covidsurg/ International collaborating group that strives to understand surgical outcomes of patients with COVID-19 Social Media (e.g. Twitter) Case studies, journal clubs, “tweetorials,” and hashtags (such as #COVID19, #Global Surgery, and #MedTwitter) can be used to engage a global audience Remote educational modules Online learning can promote sharing of educational materials among medical schools across the world Online opportunities and web-based learning in global surgery While the COVID-19 pandemic has significantly impacted medical trainees and GS, efforts have not come to a complete halt. As suggested by L Ferrario et al., video-conferencing and virtual lectures have been particularly important educational tools for students of GS during this time. 1 Numerous trainee-led organizations continue to remain active via web-based modules. For example, the International Student Surgical Network (InciSioN) has hosted webinars on various topics since the beginning of the pandemic. 3 InciSioN led a webinar with surgeons from the U.S., Germany, Italy, U.K., and the Netherlands regarding the impact of COVID-19 on surgical training. 3 Similarly, a more recent webinar in June 2020 discussed strategies for healthcare professionals in trauma and critical care to provide safe and effective care during this pandemic. 3 A recent panel of physicians from Germany, Kosovo, Croatia, and Iran discussed the impact on medical education during the pandemic. 3 In addition, since the beginning of this crisis, the Global Surgery Student Alliance (GSSA) has hosted ten free GS webinars on a variety of topics. 4 These topics include leadership in GS, anesthesiology, obstetrics and gynecology in a global arena, the importance of checklists in surgery, global neurosurgery, and capacity-building during short-term medical missions. 4 Although these webinars do not provide the same on-the-ground experiences as GS missions, they inform trainees about fundamental principles and skills needed to continue their training in GS. Social media also plays an important role in engaging trainees in GS, while practicing physical distancing. For instance, ReSurge Global Training Program (RGTP) launched a Facebook group to deliver weekly lectures and clinical case presentations. 5 This group enrolled 103 members from 14 different countries to educate trainees on global reconstructive surgery. 5 Additionally, Twitter has facilitated many discussions around GS. Physician-led case studies, journal clubs, or “tweetorials” allow trainees to join a global platform and interact with leaders in various areas of surgical interest. Specifically, the use of hashtags, such as #GlobalSurgery, #COVID19training, or #medtwitter reinforce a sense of virtual community. The role for collaboration With global health efforts focusing more on equity and bidirectional relationships, the transition to online learning during the COVID-19 crisis presents a novel chance for similar international collaboration. As U.S. medical schools have rapidly adopted remote learning modules, an opportunity exists to extend online learning to global partners. This avenue has been explored in a GS context, with simulations and curriculums created for U.S. medical students being disseminated via online web-based platforms. 6 Increased online learning during and after the current pandemic allows for the sharing of lecture materials between medical schools around the world, creating a “more global classroom.” 2 A basic international medical school curriculum could be considered, allowing movement toward basic common knowledge and skills for future physicians and surgeons worldwide. Conclusions While travel restrictions interfering with GS electives may persist indefinitely, trainees at all levels can continue to engage with GS and may even be able to enhance their participation through online platforms. With freely accessible online lectures through video-conferencing software and social media platforms, the COVID-19 pandemic presents an opportunity to amplify the involvement of medical trainees in GS worldwide. The increased use of online learning will likely allow for a greater number and diversity of trainees to participate in GS, facilitating more robust and meaningful bi-directional learning. Engaging with these resources will create better informed trainees and will equip them with the global perspective and GS education needed to be leaders in surgery. Uncited References 7; 8. Declaration of competing interest The authors received no financial support for the research, authorship, and/or publication of this letter. The authors have no competing interests to declare.

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Anti-Asian sentiment in the United States – COVID-19 and history

H. Chen, Jessica Trinh, George Yang (2020)

In 2020, the South Korean movie Parasite became the only foreign-language film to ever win an Oscar for Best Picture. This historic first mirrors a broader trend towards acceptance and integration of Asian culture in the United States. Yet, despite our innumerable contributions to society, there remains little representation of Asians at the highest levels of government, business, academia, and popular media. Asian Americans are often stereotyped as perpetual foreigners because they are seen as inherently different. 1 This has led to a sense of not fitting in, or “otherness”, as if our membership in America society were conditional. As COVID-19 sweeps the nation, this reality becomes painfully apparent. Asian healthcare workers on the front lines of the pandemic have been subjected to slurs and assaults. Nurses have been spat on, doctors have been told to “go back to f****** China”, and care by staff with “Asian appearances” has been refused. 2 While Chinese people are ostensibly the target, the affected individuals have included Koreans, Filipinos, and other Asian ethnicities. In the midst of the COVID-19 pandemic we see not only a rise in anti-Asian sentiment, but also a recapitulation of history. The earliest Asian immigrants to the United States were brought in during the second half of the 19th century as cheap labor for the mining, agricultural, and railroad industries. They were often forced to work in sub-human conditions, and were cast as scapegoats for multiple outbreaks of smallpox and bubonic plague. 2 The term “yellow peril” was coined in this era to describe the perceived threat of Asian migration to European culture. The West Coast was the epicenter of anti-Asian sentiment and on multiple occasions Asians were driven out of towns or lynched. This activity culminated in the passage of the 1882 Chinese Exclusion Act, the only American law denying immigration and naturalization rights for a single ethnicity, and the 1924 Immigration Act that effectively shuttered immigration from Asian countries. The start of World War II then precipitated one of the greatest injustices of American civil liberties. Americans of Japanese ancestry, the majority of whom were citizens or minors, were forced into concentration camps for most of the war because of their perceived allegiance to the Japanese empire. In the face of injustice, many patriotic Japanese Americans still volunteered for active military service. 3 Immigration reform in the mid-1960s would reopen American borders to Asians, who would become the fastest-growing racial group during the next millennium. 4 These reforms favored a highly-selected group of professionals, leading to an influx of engineers, scientists, and doctors from Asia. This skewed immigration pattern would give rise to the mythology of Asians as the model minority. Asian physicians wound up serving in many rural and underserved communities simply because these places were desperate enough for doctors that they could not discriminate. Despite the vast differences across Asian cultures, we often found ourselves viewed as a single group. This was highlighted by the murder of Vincent Chin in 1982. 5 He was beaten to death by American autoworkers who were upset by the potential loss of their jobs due to Japanese competition. He was targeted because of how he looked although he was of Chinese ancestry, not Japanese, and worked in the American auto industry. His assailants received probation and a small fine. This underscored how Asians of all ethnicities were seen as a single entity when it came to discrimination. In spite of the progress made towards racial justice and equality within the past decades, many Asian Americans have never felt fully accepted in American society and continue to be treated as perpetual foreigners. As anti-Asian sentiment and hate crimes rise in the wake of the COVID-19 pandemic, this perception has become reality. A recent analysis of Twitter and online image-message boards revealed a surge in the use of Sinophobic slurs beginning in late January 2020. 6 Compared to data from before the COVID-19 outbreak in the United States, the authors discovered a shift towards blaming Chinese people for the outbreak on Twitter, and an increasing emergence of novel Sinophobic terms on message boards. On both sites, the terms “virus” and “chink” now appear more frequently alongside the word “Chinese”. Both sites also showed substantial upticks in the use of Sinophobic slurs following references to COVID-19 as the “Chinese virus”. Since the outbreak, the FBI anticipated a rise in hate crimes across the United States citing examples such as the stabbing of an Asian American family, including children ages 2 and 6, whom the assailant believed were spreading COVID-196. Their prediction was confirmed by the Asian Pacific Policy & Planning Council, 7 who documented over 1,000 reports from Asian people of coronavirus discrimination and hate crimes from March 19th to April 1st. Common incidents included verbal harassment, shunning, and physical assault. One report reads: “My kids were at the park with their dad (who is white.) An older white man pushed my 7- year old daughter off of her bike and yelled at my husband to ‘take your hybrid kids home because they're making everyone sick.’” Others have reported strangers spraying them with disinfectant, or burning them with caustic substances. 2 These accounts, along with associations between “Chinese” and “virus”, suggest the emergence of a more sinister phenomenon—namely, the personification of COVID-19 as Asian people. This is especially tragic for Asian healthcare workers, who make up 17% of physicians in active practice and are the most represented ethnic group among foreign-born medical professionals. 2 , 8 The data show a pervasive spread of anti-Asian sentiment in the United States in the wake of the COVID-19 pandemic. History tells us that minority groups are often targeted during periods of global unrest and economic instability. The fear and uncertainty inherent to novel infectious disease, the presumptive origin of COVID-19, and the perpetual foreigner stereotype make Asian Americans especially vulnerable to racism and disease scapegoating. Lest we regress to our historical antecedents, leaders within our society have a responsibility to tamp down on rising xenophobia through thoughtful and humane representation of all people. Although COVID-19 has stoked racial tensions in the United States, it also presents us with an opportunity to rise above these circumstances. We have seen the remarkable resilience of Americans who endure self-isolation and social-distancing to protect the public health. We have also witnessed the awe-inspiring resolve of healthcare providers across specialties who compassionately care for those infected despite working on units staffed by skeleton crews. Each day that passes brings new innovations in medical education and patient care.9, 10, 11, 12 As it turns out, few things unify a population like an endeavor to protect a shared value against a common threat. If we can unite to overcome a pandemic of epic proportions, certainly we can also confront the socioracial issues made manifest by COVID-19. Finally, those driven to discrimination by fear also have something to learn from the virus: it doesn't care what race you are, only that you are human.

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Pedagogical foundations to online lectures in health professions education.

Amy E Seymour-Walsh, Anthony Weber, Andy S Bell (2020)

Professional and tertiary health professions education (HPE) has been markedly challenged by the current novel coronavirus (COVID-19). Mandates for training organisations to reduce social contact during the global pandemic, and make learning available online, provide an opportunity for regional, rural and remote clinicians and students to more easily access learning and professional development opportunities. Online lectures, while posing an opportunity for regional, rural and remote HPE, entail potential risks. Educators who are familiar with face-to-face pedagogies may find a transition to remote, digital interaction unfamiliar, disarming, and therefore they may not design maximally engaging lectures. The strategies used in a face-to-face lecture cannot be directly transferred into the online environment. This article proposes strategies to ensure the ongoing effectiveness, efficiency and engagement of lectures transitioning from face-to-face to online delivery. Cognitive learning theory, strategies to promote learner engagement and minimise distraction, and examples of software affordances to support active learning during the lecture are proposed. This enables lecturers to navigate the challenges of lecturing in an online environment and plan fruitful online lectures during this disruptive time. These suggestions will therefore enable HPE to better meet the existing and future needs of regional, rural and remote learners who may not be able to easily access face-to-face learning upon the relaxation of social distancing measures. Strategies to provide equitable HPE to learners who cannot access plentiful, fast internet are also discussed.

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The COVID trolley dilemma

Connie Shao (2020)

Due to the COVID-19 pandemic, hospital systems have had to drastically reduce the number of surgeries being performed, and in many cases eliminate certain procedures altogether. Restricting our current surgical volume is an attempt to decrease exposures for our patients and healthcare workers while preserving personal protective equipment. As the first wave of this pandemic subsides, hospital systems are faced with prioritizing which surgical services can resume while simultaneously minimizing the disruption of ongoing care for the remaining COVID-19 patients. This is all while ensuring our patient population at home is able to receive appropriate care. Surgical management of patients is seldom “elective”. The effects of general anesthesia, the trauma of undergoing an incision, is a physical breach unwanted by those who can avoid it. However, in the era of limited resources in a pandemic, this word has developed a new meaning. “Elective” – a normally one-dimensional word reflective of whether a surgery is an emergency or not now has an added dimension of temporality. How does one quantify an emergency? Will this patient survive one week, one month, one pandemic without undergoing surgery? In a medical structure now limited by resources, as well as patient and provider exposure, guidelines have been disseminated by multiple bodies. CMS created guidelines to guide surgical management stratified by local COVID-19 disease burden, resource availability, and patient disease severity. Hospitals now function with a new set of perioperative management to limit exposure of healthcare workers. 1 Guidelines on surgical management of oncologic care were previously established with years of literature to support and create the 10.13039/100013700 NCCN guidelines. Patients requiring oncologic surgery now face a “double jeopardy” of increased exposure to COVID-19 due to frequent interactions with medical facilities, but also worse outcomes associated with delaying surgery. ACS created a set of guidelines relying on anticipated phases of the pandemic: Setting Surgery restricted to patients likely to have survivorship compromised if surgery not performed within Acute phase I Semi urgent: few COVID-19 patients, hospital resources not exhausted, institution still has ICU vent capacity, COVID trajectory not in rapid escalation phase 3 months Acute phase II Urgent: Many COVID-19 patients, ICU and ventilator capacity limited, OR supplies limited or COVID trajectory within hospital in rapidly escalating phase Next few days Acute phase III Hospital resources are all routed to COVID 19 patients, no ventilator or ICU capacity, OR supplies exhausted Next few hours Early phase recovery Past the peak of COVID-19, with fewer new cases recorded each day. Resources are starting to become available, including hospital and ICU beds, ventilators, blood, healthy staff, PPE, and critical testing. ? Late phase recovery Well past the peak of new COVID-19 cases by at least 14 days. Resources are more readily available to near normal levels, including hospital and ICU beds, ventilators, blood, healthy staff, PPE, and readily available testing ? Guidelines have also been created on a federal and state-wide level. But who will enforce? At a time when hospitals are furloughing staff, reducing salaries for staff, and scrambling for PPE for their employees, it would be in the financial interest of keeping a hospital running to proceed with elective surgeries in an effort to help mend the expected deficits of hundreds of millions per hospital. But how will these tenuous months be remembered in history? As certain areas in the country have the resources to resume elective surgery, how will they be remembered in a time when other, heavily affected parts of the country struggle with unmet needs for goods and services? 2 How will public opinion change as institutions protect their financial interests over the wellbeing of their neighbors? As the federal government makes decisions to re-open the economy, how will each state be remembered for their own autonomous decisions to do what is best for their citizens based on the data they have? On the other hand, restricting surgical management to those who will perish along some unknown sliding scale of urgency has lasting consequences. More than 21 million surgeries were done in the United states in 2014, 3 with an estimate that over 90% of these surgeries are considered elective. 4 With an estimated three-month delay of elective cases, almost 5 million cases will be delayed, some for the entire three-month course, resulting in both immediate and repercussive effects. Delaying resection for clinical stage I non-small cell lung cancer by 8 weeks or greater after radiologic findings concerning for lung cancer is independently associated with increased rates of upstaging and decreased median survival. 5 Those who are anxious to come into a hospital setting with abdominal pain present days later with gangrenous, perforated appendicitis and cholecystitis. Patients with delayed elective aneurysm repairs wait at home with increasing risk of rupture. As the immediate wave of morbidity and mortality associated directly with the COVID-19 pandemic subsides, the effects of delaying both diagnosis and surgery will be revealed. • Inpatient populations, increasingly consistent of critically ill patients, will overwhelm nursing care facilities and home health nursing. • With furloughed clinic staff and patient populations unfamiliar with how to interact with telemedicine, many will present with preventable complications after months of no preventive medical attention. • Patients with chronic conditions will present with hypertensive strokes, COPD exacerbations, diabetic neuropathies with subsequent wounds/impaired healing. Many of these issues will be mitigated by the chemotherapy, medical management, telemedicine, and ePrescribing, but there will be those lost to a world without medical care for months. In a world currently controlled by scarcity, it seems an unfair decision to have to make – who will be seen, who will be treated, who will be sent home with hopes for a successful course of conservative management, who will perish. But with limited resources on multiple fronts – finances, staffing, hospital resources, critical care availability - scarcity is a reality. With multiple forces at play, it becomes increasing important to recognize why we became physicians. Our purpose is to heal, to do what is best for patients. The hospital exists as a locus for patient care, its bottom line is not the reason why we became physicians. There will be losses, but the greatest loss is that of life. Image 2 The patient Recently, a patient with plans for elective repair of his ventral hernia presented to the emergency department with incarcerated bowel in his hernia. His exquisite tenderness and skin changes required emergent repair. With penetrating fear in his eyes, he told his surgical team of his siblings who had both gotten sick and passed in the last year. His fear of becoming sick or dying was recognized and acknowledged – who wouldn't be afraid in his position; but he was safe now, in the care of physicians who knew exactly how to fix the cause of his pain. There was no better place for him to have his problem than in the hospital. Now he was here, and everything else was in our hands. His trembling grip and imploring gaze made clear his fear felt seen but was not mitigated. As a surgeon, bringing patients' anxiety and fear into quiescence is as close as one can come to a nonsurgical remedy, knowing that the true resolution of their fear happens under the blade of a knife and the curtain of sedation. He was emergently brought to the operating room and underwent induction of general anesthesia. The circulating nurse was painting his abdomen in betadine when his rhythm suddenly changed from normal sinus to ventricular tachycardia, then fibrillation. Compressions started. A crash cart appeared. The room populated within minutes. He became profoundly hypoxic. After half an hour of ACLS, he finally regained return of spontaneous circulation. His bedside EKG and echo showed antero-lateral infarction with a hypokinetic septal wall consistent with ischemia of his left anterior descending coronary artery – he had suffered a massive heart attack. His road toward recovery now led him to ECMO and the catheterization lab. Had his elective procedure continued with its normal timeline of pre-operative workup, a stress echo would have brought his underlying cardiac pathology to light and likely led to a pre-operative PCI or surgery. He would have had smoking cessation counseling, he would not have known a world in which he had chest compressions, cannulation for ECMO, or emergent catheterization to salvage a dying heart. For the determinists, perhaps a world without a pandemic would have still resulted in these events in some other way. But to extend one's hand to a patient in treacherous waters and watch a buoy become an anchor places the weight of unseen costs of this pandemic on a very personal set of shoulders. The dilemma How long should we continue to delay care to ensure we are doing what is best for all of our patients? This pandemic has proven itself to be a trolley problem incarnate. The trolley problem is a classic thought experiment introduced in 1905 – to watch a train go down the main track and kill five people, or to flip a switch for the trolley to go down a side track, killing only one, but then becoming directly responsible for that person's death. While typical variants include changing the number of people on each track or making one of the possible victims the switchman's family member, the current variant brings a tremendous number of considerations: • As the train moves forward, the number of people on both the main and side tracks increases, but the actual number at each track is unknown. The mortality and morbidity associated with being in the way of the trolley is also unknown. Some may survive only to be injured, others may survive with no sign of injury at all. • There are groups of people demanding that it is a violation of their rights to not be positioned on the main track. They are eventually on the main track and their occupation of resources puts additional people on the side track. • The governing body supplying funding for the trolley, reopens ticket sales for additional passengers, who find themselves on the main track in the path of the trolley. Investing in the trolley also lengthens the tracks, increasing the amount of time before the trolley hits and thus the number of people on either track. • The tracks do not target isolated groups of people; rather, there is an infinite number of options that will result in morbidity and mortality in both groups to varying degrees. • The number of subsequent groups of people on main and side tracks (i.e. second and third waves) are dictated by current decisions with an impact that can be anticipated but not predictable. The trolley dilemma engages the praxis of our intentions and hopes for our patients. What will come of loosened shelter-in-place orders as economies suffer? How long will our patients wait at home until their elective surgeries become urgent? How long can you treat a patient's cancer with chemotherapy before their cancer becomes unresectable? How will patients be affected by increasing length of stay by several days for follow up studies to avoid returning to clinic, or by decreasing length of stay for patients who are sent home from the hospital with monitoring devices and telehealth to decrease exposure? With data and guidelines changing continuously, it is important to maintain ongoing, transparent discussions of frameworks developed by different institutions to provide care for our patients. Mitigating spread To have some understanding of how the tracks of the trolley populate requires an understanding of pandemic modeling. Alabama has been fortunate enough to be trending somewhere between the early and late phase recovery of the ACS guidelines. The decision to start caring for patients who have been getting sicker at home is based on an incredibly complicated trolley dilemma in which the focus is on damage control, both actively and in anticipation. Though the current burden of the pandemic is different in every state, eventually each will need to determine whether it is an appropriate time to resume “elective” cases, as well as tier which cases are to be resumed at which time. As the ACS described, “understanding both the local facility capabilities (e.g., beds, testing, operating rooms [ORs]) as well as potential constraints (e.g., workforce, supply chain), while keeping an eye on potential subsequent waves of COVID-19 will continue to be important.” Due to strict measures, both institutionally and on a policy level, the spread of COVID in Alabama has maintained a steady state for two weeks, as seen by a Ro value consistently around 1. Ro reflects the infectivity of the virus – the general concept is simplified and described below: Image 1 For the increase in I to be 0, d I d t = 0 = i S I − r I , therefore ( i r ) ∗ S = 1 , which will be defined as Ro. If Ro < 1, then d I d t < 1 , which means that the number of infections is decreasing. At the beginning of the pandemic, it was said that each person infected 2–3 people (Ro = 2.2–2.7), with additional reports showing R0 values between 4.7 and 6.6, leading to the extremely rapid growth of the of 2019-nCoV outbreak as compared to the 2003 SARS epidemic where R0 was estimated to be between 2.2 to 3.6. 6 To make Ro < 1, ( i r ) ∗ S < 1 , one or more of the following are needed: • Decrease in i (daily rate of contacts per infective) • Decrease in S (number of susceptible, which decreases with herd immunity, vaccination) • Increase in r (shorten the number of days people are infectious, currently thought to be around 14 days) While herd immunity (sufficient decrease in S) is not attained and i increases again when stay-at-home policies are lifted, the rate of infection will again become exponential. Additionally, to attain herd immunity while in anticipation of a vaccine requires all to become afflicted with COVID-19, for which there is currently a mortality rate of 6%. 7 SARS and MERS were both contained by restricting i – however, while case fatality rates were higher, COVID-19 has proven to be more infectious, 5 resulting in a higher overall number of deaths, especially given the speculation of silent spread by asymptomatic carriers and the survival of those who are infected and capable of further spread. In addition, there is no clear evidence on permanent immunity against COVID-19. Until testing capabilities are able to select and isolate only those who are known to be infected with COVID-19 or the development of a vaccine can successfully reduce S, spread can only be minimized by decreasing i not only through containment of the symptomatic, but additionally by restricting interactions among the symptomatic and asymptomatic alike. Statewide changes When the state-wide shelter-in-place order was instituted in Alabama 4/4 at 5 p.m., the anticipated ICU bed needs went from 4382 on 4/4 to 400 on 4/6 based on IHME COVID-19 projections. The statewide shelter-in-place policy protects those in and out of the hospital, but mostly those who are not yet inpatient and who will need to come to the hospital. • On Mar 13, Governor Kay Ivey declared a State Public Health Emergency • On Mar 16, the Jefferson County Health Officer issued an order suspended certain public gatherings • On Mar 17, the State Health Officer issued a similar order for counties surrounding Jefferson County • On Mar 19, the State Health Officer issued a similar order for the state • On Mar 24, a city-wide shelter-in-place order for Birmingham was mandated by Mayor Randall Woodfin • On Apr 4, a state-wide shelter-in-place order was mandated by Governor Kay Ivey. It is scheduled to last until Apr 30. • On Apr 28, a “Safer at Home” order was instituted by Governor Kay Ivey, allowing retail businesses and beaches to reopen April 30 Consequently, new cases have been stabilizing. The estimated Ro value depicted in the graph above was calculated using Bayesian statistical analysis of the data provided from covidtracking.com and reported in the New York Times. 8 The rate of infectivity has dropped due to timely action on both a state and city level. Image 3 Next steps The pandemic is far from over – additional surges are expected to recur as states begin loosening shelter-in-place policies. The 1918 Spanish flu lasted two years, infected 500 million worldwide and killed 20–50 million. A significant number of mortalities occurred during the second wave, 9 thought to be caused by a mutated version of the virus. Mutations aside, the relaxation of shelter-in-place policies will result in an inevitable recurrence of exponential increase in infections. As we attempt to open our doors to take care of those trapped by the pandemic getting sick at home, it becomes increasingly important to invest in measures to reduce the burden of the pandemic until testing or a vaccine is widely available. As with all forms of prevention, the benefit of shelter-in-place orders can never truly be measured, only estimated in theory – an avoidance of devastation is just a normal day taken for granted. Guidelines, such as those created by ACS, for careful and precarious resumption of local “elective” surgeries are moot when conservation efforts are overrun by an uncontrolled Ro. At a time that we do not have herd immunity and a vaccine does not yet exist, government-mandated orders are necessary to protect our patients, ourselves, and those who will become our patients. As this pandemic continues to force us to question everything we thought was certain, including certainty itself, it is important now more than ever that we move forward in a concerted effort. The purpose of creating a trolley is to serve people, just as money was created as a tool to serve people. To become subjugated to a system that we created to serve us is to lose who we are to what we are. We exist as a precious microcosm of life in a vast, infinite nothingness – do we not exist purely for love, for family, for passion, for beauty? As this pandemic passes, will our woes not be counted by those that we have lost - a scar in our mortality, our roots, our identity? The cost of this pandemic is high in so many seen and unseen ways. May this fork in the tracks be short and merciful. Declaration of competing interest None.

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Sangrag Ganguli

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Journal ID (nlm-ta): Am J Surg

Journal ID (iso-abbrev): Am. J. Surg

Title: American Journal of Surgery

Publisher: Elsevier Inc.

ISSN (Print): 0002-9610

ISSN (Electronic): 1879-1883

Publication date PMC-release: 10 July 2020

Publication date (Electronic): 10 July 2020

Affiliations

[1]The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA

[2]University of Toronto, Department of Surgery, Canada

[3]University of Michigan, Department of Surgery, USA

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[∗ ]Corresponding author. sganguli@ 123456gwmail.gwu.edu

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Publisher ID: S0002-9610(20)30434-7

DOI: 10.1016/j.amjsurg.2020.07.005

PMC ID: 7351067

PubMed ID: 32684291

SO-VID: 9ee63bfc-f5c3-43f7-a7d0-dc415b12764c

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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Date received : 5 July 2020

Date revision received : 7 July 2020

Date accepted : 8 July 2020

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Global surgery in the time of COVID-19: A trainee perspective

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Anti-Asian sentiment in the United States – COVID-19 and history

Pedagogical foundations to online lectures in health professions education.

The COVID trolley dilemma

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