COVID-19: patients, pregnancy and planning
16 Jun 2020
June Tay is a senior urology trainee currently working at Guy’s Hospital, London. In this blog series, she shares her experience as a pregnant surgeon working during the coronavirus pandemic.
I remember the week in March before Boris Johnson announced the lockdown of the country. We heard that London is ahead of the curve, with more cases than the rest of the United Kingdom. I already had a couple of patients whom I had operated on or had seen, subsequently confirmed to have COVID-19. I wondered to myself: should we be informing the nurses, healthcare assistants, and anaesthetists who had come into contact with these patients? Should we ourselves be tested given the close contact without any personal protective equipment (PPE)? What about PPE? What is it? Where do we get it? At that time, I had vaguely heard about fit testing for face masks from an anaesthetist, but was told they were prioritising frontline workers – anaesthetists and intensivists. For surgeons, there was no guidance from our trusts yet: are surgical masks and gloves all we need?
In response to the national pandemic and the potential number of COVID-19 patients our hospitals anticipated caring for, our department made changes to our service delivery plans. Operations were triaged into different categories – routine, urgent and emergency surgery. Outpatient clinics were reduced, diagnostic pathways modified, operating list reviewed daily depending on availability of theatre staff and to free up our anaesthetic colleagues. Patients were devastated to hear about cancelled operations. Our fifty-patient urology ward dwindled to just a handful of patients. Friday departmental meetings (the cornerstone of our department) and multidisciplinary team meetings now took place via video conferencing.
I started to get a little anxious: I am pregnant, approaching my third trimester. I searched on PubMed and referred to the Royal College of Obstetricians and Gynaecologists website, which seemed vaguely reassuring about COVID-19 in pregnancy, but evidence was scant and the guidance initially changed frequently. In addition, the government had announced that pregnant women, along with vulnerable adults, should practise ‘social distancing’. How could I, a surgeon, practise social distancing while seeing patients? I had discussions with my training programme director, clinical lead and trusted consultants, all of whom were very supportive of my situation. I was keen to play an active role within my team despite this pandemic. We did a risk assessment and made modifications to my role to limit my exposure to COVID-19. I arranged for remote access in order to help with vetting of clinics, triaging GP referrals, and conducting remote consultations. Nevertheless, I still feel rather conflicted, as though I was simply watching from the sidelines, unable to put myself in the frontline to care directly for these sick patients, at a time when we are needed the most.
We also started restructuring our outpatient clinics. Telephone consultations became the default unless it was a two-week wait referral. I attended a webinar by the Medical Protection Society on remote consulting and the medicolegal aspects to consider. Remote consulting adds a different layer of complexity. Not being able to see the patient at the other end of the line means missing subtle but important information we usually glean immediately. Do they mobilise with a stick? What is their general body habitus? All these serve as important factors a surgeon considers when tailoring a treatment plan, particularly in cancer treatment. Are remote consultations going to be the new normal going forward? Among the many phone conversations, I am surprised and touched by the concern of patients who have asked after our wellbeing, and thanking us for what we are doing.
As a senior trainee, I manage the middle grade rota. Little did I realise that in a pandemic, this became an odyssey. It started with 13 of us, but within a week, I had a prospective fellow withdraw, colleagues resigning to return home, colleagues stranded in foreign countries, and half the ward doctors on sick leave. Coupled with this was the constant restructuring of the junior doctor workforce within the trust to tailor to the demands on intensive care. No one knew when the urology consultants and registrars would have to step up (or down) to new roles. Together with the clinical lead, we devised multiple versions of the rota to prepare for different eventualities, including registrars being redeployed as house officers, even though some of us had not attended a crash call for 10 years, or know how to write an electronic ward discharge summary. We arranged training sessions: from Advanced Life Support and electronic prescribing, to the donning and doffing of PPE. Surgical training needs and personal agendas were set aside for now, and everyone was flexible and ready to pitch in for the team.
In the last couple of months, I have seen how an invisible enemy has brought a country to its knees, how we live one week at a time, not knowing what the future holds. I have seen my husband, an intensive care doctor, suffer from COVID-19, and us having to live apart for months, to protect our unborn child. I hear of thousands of people who have died, including frontline NHS staff. Yet I am humbled by the response of my colleagues within the NHS. The sense of duty to serve and put patients first, the sense of pride in being able to play our part in this pandemic. I am humbled by the generosity from family, friends and even strangers who have reached out to help the NHS in various forms. Although causing widespread disruption to so many facets of life, it has taken an event affecting the whole world to allow us to see kindness in the society in which we live.
'Pregnant women, along with vulnerable adults, should practise “social distancing”. How could I, a surgeon, practise social distancing while seeing patients?'
On Wednesday 1 July, RCS England is hosting a webinar on parenthood during the COVID-19 crisis. Join us to find out how parenthood has been impacted by the pandemic.