Earlier this year, when a 65-year-old HIV-positive woman admitted to a hospital in Nagothane suffered a sudden heart block, she was rushed to Fortis Hospital in Vashi for emergency intervention. Her heart rate had dropped to 30, well below the normal range of 60 to 100. Doctors took her to the catheterization lab on the fifth floor of the hospital to implant a pacemaker, a small device that sends out blood pressure. electrical impulses to the heart muscle. But surgery on a patient with an active Covid-19 infection would also mean risking medical staff with the infection. To minimize the risk, the medical team decided to limit the use of cauterization – an electrosurgical machine commonly used to burn and seal a bleeding blood vessel, which produces smoke during the process. This surgical smoke could potentially carry the virus and thus pose a huge threat to medical personnel in a closed operating room.
“To insert the pacemaker into the chest wall, we needed an incision about the width of four fingers,” said interventional cardiologist Dr Brajesh Kanwar. “We switched to other techniques like squeezing the bleeding with gauze and using mosquito forceps, a type of forceps used to control bleeding. But ultimately we had to give in to the cauterization machine to burn off a hemorrhage that wouldn’t stop easily, ”he said.
As the pandemic unfolded in March 2020, surgeries came to a complete halt, except for emergencies like the case of this 65-year-old woman. When the doctors started to operate on such special cases, they made some adjustments and changes to the operating table to reduce the risk of infection inside the operating room. While surgical work has now resumed to a large extent, doctors have stuck to these techniques as a precaution amid fear of breakthrough infections and re-infections.
“Every patient can be infectious at some point,” Kanwar said. “Infection control standards and personal protection standards are here to stay for a long time. Some operating room time-saving shortcuts will also be widely used. For example, a surgeon may choose to use a stapler instead of a suture to save time and limit exposure in the theater, especially if the patient has an active infection. Instead of cutting the tissue, doctors may opt for the dissection using closed forceps. This reduces bleeding and, in turn, reduces the use of a smoke-producing cautery device. These decisions need to be weighed against the type of case to be treated, ”said Kanwar who has performed nearly 20 pacemaker implantations and more than 150 angioplasties in active Covid patients since last year.
Doctors choose to delay invasive procedures for at least two weeks if patients have active Covid infection and surgery can wait. “But in some cases, waiting is not an option at all,” said Dr. Manmohan Kamat, chief of general and minimally invasive surgery at Nanavati Max Super Specialty Hospital. He cited the example of a 64-year-old HIV-positive woman who was transferred from a nursing home with severe abdominal pain. Investigations revealed that she was suffering from intestinal gangrene which required surgery immediately before the infection spread. However, such surgery would involve a large spill of digestive chyme – the partially digested food and secretions from the gastrointestinal tract – which can be highly contagious.
“The procedure involved making an incision on the abdomen and removing at least five feet of the small intestine,” said Kamat who has operated on nearly 15 patients with active Covid infection. “We were able to minimize spills by using a stapler cutting method, instead of a clamp and cut method,” he said, adding that he preferred to perform open surgeries on these patients rather. than laparoscopic procedures.
Among surgical emergencies, gynecologists may have been the first to jump into operating rooms amid the raging pandemic to perform normal deliveries and Caesarean sections of women with Covid-positive. The Lokmanya Tilak municipal general hospital in Sion has carried out nearly 500 deliveries to women with HIV, more than half of which are cesarean sections. In the process, the gynecology department adopted several protocols, including using a knife to cut open the lower abdomen instead of using the cutting probe in the cautery machine, which cuts and helps reduce bleeding, but produces excessive smoke. “To control the bleeding, we opted for ligation of the blood vessel by suture,” said Dr Arun Nayak, head of the gynecology department. “The ligature process takes longer, but we stuck to it. In cases where the use of cauterization was unavoidable, we used a suction machine to trap the smoke, ”he said.
According to Nayak, they also started using an acrylic box when intubating a patient and administering anesthesia. “The acrylic box creates a transparent barrier between the patient and the anesthesiologist and reduces the direct flow of aerosols from the patient’s breath or the doctor’s cough,” he said.
Protocols outside the operating room include micro-coordination in terms of cleaning up the track of Covid patients when they are brought to the hospital and moved from one department to another within the premises for investigation. Interventional cardiologist Kanwar said Fortis Hospital in Vashi has a microphone system that announces movement of Covid patients so staff can quickly follow the trail and spray the area with disinfectant as a precaution.