Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting

Background Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia. Methods A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated. Results During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients. Conclusion Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

Modified operations to permit safe and timely delivery of essential surgical care for high-risk skin cancer during a pandemic.

e21565 Background: Many surgical practices closed at the onset of the COVID-19 pandemic raising concerns that delayed cancer care might impact patient outcomes. We implemented operational changes to safely remain open and treat tumors with potential to threaten life or function. We studied the impact of these changes on safety, access, and treatment. Methods: A single-center retrospective study was conducted in an academic office-based dermatologic surgery practice. All patients consented to research. “Pre-pandemic” (Nov. 2019 – March 21, 2020) consultations served as controls. Consultations during the “pause” (March 22 - June 8, 2020) and “reopening” (June 9 – Sept. 30, 2020) were evaluated for time to treatment, tumor area, and upstaging. One-way ANOVA or Fisher Exact analyses were performed with P < 0.05 significant. Operational changes included (1) modified scheduling, staffing, and rooming; (2) COVID-19 symptom screening; (3) N95 masks and shields for patient contact; (4) triage by tumor acuity; (5) same day or video consultation; and (6) increased utilization of same day biopsy and surgery for suspicious lesions. Results: Data from 698 patients (23-103 yrs of age, avg 71 yrs) yielded 876 tumors treated by Mohs surgery (n = 776), standard excision (n = 73), staged excision (n = 14) or electrodessication and curettage (n = 13). The average time from biopsy or consultation to treatment was faster during the pause and reopening relative to pre-pandemic (Table). More frozen section diagnostic biopsies were performed in the pause (n = 6) and reopening (n = 4) compared to pre-pandemic (n = 0). Post-operative defects were similar to pre-pandemic sizes (3.2 cm2) during the pause (3.9 cm2) and reopening (3.2 cm2) (p = 0.72). A reduction in treatment of basal cell carcinoma (BCC, Χ2= 0.04) and shift toward treatment of higher risk tumors such as cutaneous squamous cell carcinoma (SCC, 49% of tumors during pause vs 37% pre-pandemic) and melanoma (11% pause vs 4.7% pre-pandemic) was noted. The percentage of SCC upstaged after treatment increased during the pause (42%, Χ2= 0.02) vs pre-pandemic (18.5%) or reopening (17.4%). Conclusions: Time to treatment, tumor size, and SCC upstaging pre-pandemic and during the reopening fail to identify any significant access interruptions. This likely reflects practice modifications of increased same day surgery, frozen section diagnostic biopsy, and tumor triage. Lack of COVID-19 transmission attributable to maintained operations suggests that essential surgical care can be delivered safely to patients with high-risk skin cancers during a pandemic.[Table: see text]

Summary of the Eighth World Health Organization Global Initiative for Emergency and Essential Surgical Care Biennial Meeting

A summary of the eighth World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) Biennial Meeting, which was held in conjunction with the Royal Australian College of Surgeons (RACS) eighty-eighth Annual Scientific Congress in Bangkok, Thailand.

Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste’s national referral hospital

ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures.SettingThe study was conducted at Timor Leste’s national referral hospital in Dili, the country’s capital.ParticipantsAll patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded.Primary and secondary outcome measuresData pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework.ResultsFifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05).ConclusionsSubstantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.