Interview by Miguel Cunha.

Dr Reem Alharby is Assistant Professor of Surgery, Head of Clinical Training and Internship Program, and Chair of Surgery Course at the College of Medicine, Princess Nourah Bint Abdulrahman University, and Consultant Colorectal Surgeon at King Abdullah Bin Abdulaziz University Hospital. She is an executive board member of the Saudi Society of Colon & Rectal Surgery, and board member of the Saudi Fellowship in Colon & Rectal Surgery: Certification & Examination Committee. She is based in Riyadh, Kingdom of Saudi Arabia.

Miguel Cunha: Dr Reem, thank you for agreeing to speak with us on the current COVID-19 crisis, concerning surgery in Saudi Arabia in particular.

First of all, we would like to ask you what has been the impact of COVID-19 in Saudi Arabia? Do you have some numbers to share with us, for us to be able to picture your reality (people infected, ICU rate, mortality rate)?

Dr Reem Alharby: Saudi Arabia reported its first case on the second of March 2020. This prompted a national strategy guided by the Saudi Health Council and Saudi Center for Disease Control. The strategy aimed to prevent overloading the Saudi healthcare system with COVID-19 infected patients, build the capacity of the healthcare system and develop robust supply chains to meet the demands of the pandemic and decrease the spread of COVID-19. The last item led to online education being used in schools and universities through a national online platform and this was hugely successful. Governmental services were provided through digital applications. A new future was being created and I believe the society will never go back to the old days. The end result was a low rate of infectivity with a daily rate of new cases in the range of 2,000-3,000 without a bell-shaped peak. The ICU were not overwhelmed, and the mortality rate was 0.6% (441 cases out of 80,185). This rate is compatible with international rates in countries that were not overwhelmed by the pandemic.

MC: Did government or healthcare organisations use any special approaches to help fight the pandemic?

RA: A national committee was established to help build capacity in the healthcare system through the purchase of ventilators, establishment of more ICU beds and mobilisation of resources to meet regional demands. The same committee had a supply chain committee that maintained a continuous supply of PPE material, testing equipment and consumables, sterilisation and ICU equipment along with all pertinent hospital supplies. The third arm of the strategy was directed towards decreasing the spread of the disease which was manifested through closure of malls and areas of possible crowding like universities. The fourth arm was a robust strategy of health education and marketing using online formats like social media and audiovisual outlets. The fifth arm was development of checkpoints for temperature and history of suspicious systems for COVID-19 alone with active testing at supermarkets, crowded housing areas and vital areas to the public like hospitals and places of work that continued to operate during the pandemic.

MC: About the surgical approach, in many countries elective non-oncologic surgeries were postponed with the pandemic - what was your country's approach? Are you seeing any effect of delayed surgeries?

RA: Most Saudi surgical societies developed algorithms based on the most recent available evidence with regard to classification of surgeries into urgent and non-urgent or elective versus non-elective. Hospitals adopted such national algorithms. The Saudi Society of Colon & Rectal Surgery took things a step further and held webinars that educated the rest of the surgical community on how to handle colorectal cases based on the suggested algorithm, how to set up the operating room or endoscopy room, how to approach cancer cases and whom can be offered an outpatient visit and who can wait for 6 or 12 weeks. Moreover, most hospitals developed virtual clinics and offered home delivery of medications.

MC: Globally, how do you think we can diminish the consequences of postponing elective surgeries?

RA: I am not sure; I can't speak for the world; each country has its own factors at play that make a global solution an impractical approach. Having said that, the Saudi Health Council requested all hospitals to develop a 6 and 12 months plan to return to normality in which hospitals must factor in how to handle the postponed electives and also to have strategies in place to handle a second wave of the pandemic or delay in resumption of normality due to continuation of the current risk mitigation policy. Guidelines conveyed by the Saudi Health Council were provided based on several models of COVID-19 spread to help the hospitals allocate their capacities in the proper proportions so they can at any time flip from daily routine practice to crisis management mode.

MC: Were your residents or any of your senior surgeons redeployed to other services during the pandemic?

RA: Yes, residents and fellows were redeployed. Internists from all specialties were requested to handle COVID-19 patients. Dentists were requested to help in swab testing, and they proved the best specialty in providing an adequate sample. Many medical staff were requested to cover in the Emergency Department. Anesthetists were requested to cover in the ICU. That took place in cities where there was a surge in the cases, like Mecca and Madinah.

MC: What technical changes were introduced in the operating room during the peak of the pandemic, and are they still being used? What roles can surgeons play in these circumstances?

RA: I do not want to go over a detailed account of how the operating rooms were changed with COVID-19. Apart from the standard disinfection and sterilisation of the operating rooms. Many strategies were developed to mitigate the risk of transmission to the operating and anesthesia team members. These guidelines were launched by the Saudi Center for Disease Control on its website and in webinars and online sessions to help all the medical community adopt them. The surgeons were among the leaders in these initiatives. For example, lectures on how to set up the operating room and how to operate on a COVID-19 positive patient were developed and delivered, in compliance with the Saudi Center for Disease Control, through webinars by the Saudi Society of Colon & Rectal Surgery. Among the recommendations that were approved by the Society were: all members must use the most appropriate PPE gear; a room must be dedicated to COVID-19 patients with minimal essential equipment that is sterilisable. All intubation and extubation procedures must be carried out under standard protective conditions in the operating room. Minimal staff should be present in the room and no movement of staff is allowed outside the room, etc.

MC: How has the current situation affected your own practice, and are you taking any precautions in your social life?

RA: My practice was down by 75%. It is restricted basically to emergency surgery and oncology cases. The clinic visits were changed to virtual visits for the follow-ups and only new cases that satisfy the requirements for a clinic visit are seen. Endoscopy has diminished by 90%. As a mother, I do worry about my two children. As I arrive home, I consider myself a vehicle for the virus. I have created a room where I get rid of all my clothing upon arrival and shower prior to meeting my children. I also stopped meeting all my other family members and friends. It is really a draining situation emotionally.

MC: How do you think we can continue to provide surgical education during the upcoming months?

RA: I believe we must use all platforms like social media, webinars, emails, position statements from the professional societies and printed articles in the scientific journals. However, for the residents and medical students, we can use online professional education platforms and simulation labs. At Princess Nourah Bint Abdulrahman University, we have the largest simulation center in the Middle East and it was handy during this pandemic.

MC: As a surgeon, what is your view of how surgery will be affected in the upcoming months, in regard to COVID 19 consequences?

RA: I believe it will be chaotic if each surgeon is allowed to develop his own plan in the upcoming months. This is where the professional societies and the health administrators must develop an execution plan that meets the demands of our patients without causing harm and at the same time provide a good efficient utilisation of resources. I really believe a strong collaboration is needed in such plans. For example, ICUs would not want to be overloaded with patients undergoing elective surgery who need elective ICU admission during the next 3-6 months until they are sure they will not face a second wave of COVID-19 patients.

MC: That brings us to the end of the interview! I would like to thank you for giving us the local insight on the COVID 19 pandemic in Saudi Arabia, and I would like to ask you a final question: What are the main lessons we can take from this pandemic so far?

RA: We must accept we have entered a new era. An era where a huge portion of education can be delivered online and through the utilisation of simulation. Moreover, virtual clinics are here to stay. There is a huge cost containment in such clinics especially for follow-ups. Third, we must revise how we look at infection control. It should be an integral part of our daily surgical practice. COVID-19 is here to stay and all patients must be treated as possible cases of COVID-19 and triaged to identify those with high risk features who should be tested and treated as COVID-19 positive till proven otherwise. I believe surgeons should also develop their digital capabilities in communication. The new wave of young surgeons in-the-making depend on the digital format for education. Research must also change; no more documents reviewed in paper formats; documents are now reviewed on online document platforms with several authors working on them at the same time. Robotic surgery is probably the way to go in COVID-19 patients with the least risk of transmission to the surgeon. Finally, surgeons must embrace those changes and not fight them otherwise they will be left out from a really competitive field.

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