56TH MASTERY IN SURGERY ANNUAL CONVENTION

VIRTUAL MASTERCLASS 2020

A REFLECTION PAPER
BY
TRISHA DENISE D. CEDEÑO

In the country, the Philippine General Hospital (PGH) has been the COVID-19

referral center. Hence, we can just imagine an overflowing number of patients flocking

the facility in dire need of treatment, especially with the increasing rate of infection spread.

Even before the pandemic began, PGH has always been a busy institution that has been

tirelessly working on several non-COVID-19 cases. However, due to the demand in both

facilities and manpower for COVID-19 cases these days, how is the institution dealing

with it so far? More so, what about the non-COVID-19 cases, especially those which are

severe and/or malignant in nature? How is the institution dealing with the changes and

challenges brought by this pandemic? These were just some of the questions I had in

mind prior to attending the “PGH Department of Surgery Annual Convention Virtual

Master Class Webinar Series 2020”.

The webinar series commenced with an opening message from Dr. Carmencita

Padilla, chancellor of the University of the Philippines Manila, wherein it was emphasized

that Surgery, as a department, has been very much affected by COVID-19. Nonetheless,

despite the safety risks brought by the pandemic, Dr. Charlotte Chiong, dean of the UP

College of Medicine, said that a very important skill in surgery is to know when to do

surgery or not, especially during this pandemic. Nonetheless, as surgeons, the

cornerstones of being successful ones include mindset of creativity and the grit to

succeed.
 There was a topic on, “Resiliency Amidst the Pandemic: Neoadjuvant/ Adjuvant

Therapy for Breast Cancer During COVID times”, as presented by Dr. Mark Kho, wherein

a map was shown which tracked the global outbreak. The two big C’s, according to the

presentation, were known to be “Cancer” and “COVID-19”. Elective surgery is determined

to be postponed such that there is a waiting period for at least two weeks and re-retesting

is also done. Meanwhile, schedule is also very important among healthcare workers. For

the trainees, specifically, at least one week worth of rest period is given (although prior to

the pandemic, two weeks is usually given). Any sort of duty post requiring contact with

any person with unknown COVID-19 infection would equate to being put in quarantine.

However, no regular testing would be conducted.

There has been a question with regard to the delay in the delivery of services

and/or availability of chemotherapeutic drugs/ treatment because of the pandemic—as

they said, this was indeed a “big problem”. Logistically speaking, the problem lies within

food, basic necessities, drugs, etc., such that if we’ll try to look at drugstores, there really

is imbalance between the supply and demand.

When it comes to the topic of COVID-19 being a threat to surgical training, this can

also be equated to the infection being a threat to the treatment of sarcoma, breast cancer,

and other malignant disease entities. With this at hand, another question was raised

during the webinar, “Can you say that COVID helped enhance the training because we

paid more attention now?” To which the question was noted to have a valid perspective.

For instance, it was said that we can look at COVID on a positive side such that there is

more rest/time with the family and ability to do things that we never had time to do before.

Meanwhile, with respect to learning online, it was also noted that everything is discussed
in greater depth. In fact, during zoom meetings with consultants, healthcare professionals

are now able to discuss all the options as compared to last year prior to the pandemic.

COVID-19 also taught us about resilience. Due to various limitations with respect

to learning procedures from the get-go, we become more innovative in terms of strategies

in addressing the problems that arise. Resources are also now more maximized since we

have to be critical with the expenditures we make especially during this pandemic.

Nonetheless, for surgeons, it should still be kept in mind that they ought to be doing

business in the operating room and residents should be able to see patients.

Another topic in focus was “Colorectal Surgery in The Time of COVID-19”. For this

topic, a timeline was presented by Dr. Marc Lopez as follows: January – first case of

corona; February 3 – first person under investigation in PGH; March 18 – all elective

procedures in PGH were suspended; March 19 – UP PGH requested by DOH to be an

official COVID-19 referral center; March 30 – PGH functioned as COVID-19 referral

center and surgical procedures were limited to life-threatening patients as well as trauma.

From March 30 to June 3, 2020, only twelve (12) surgeries have been performed as

compared to 344 procedures last year—this reflects a drastic decline with the institution’s

capacity to attend to various surgical procedures needed by the people due to the

pandemic. Additional protective and safety protocols are also being followed. Patients

were to be admitted to non-COVID and COVID-segregated wards and intensive care units

with separate personnel.

Meanwhile, “Telekonsulta” was established as one of the solutions that would help

connect patients and physicians virtually in order to lessen physical contact, and thus,

lessen the risk of COVID-19 transmission. Out of 163 distinct consults, > 60% were
related to colorectal cancer. Platform OCRA (Online Consultation Request and

Appointment) system was also initiated. However, it was observed that this method would

render inability in building patient-physician rapport, in doing proper physical examination,

and in meeting the family members who are also crucial in the treatment paradigm of the

patient. Moreover, there were also issues with internet connection.

Another strategy was mobilizing PTEC (Preoperative Testing and Education

Center). With this, patients do not need to wait too long prior to operation as this helps

cut pre-operative waiting and costs for patient. Unlike during the earlier days of the

pandemic, we now have a walk-through RT-PCR testing center as well, which enables a

more accessible and efficient system for the Filipinos. What about the residents? What

about medicine students who are trying to continue with their learning and skills training

online? For this, the division utilized “Telegram” wherein participants were assigned

various colorectal topics. Case scenarios were then discussed with sharing of some

technical input.

Additionally, the webinar series also tackled timing of surgery after COVID-19

infection. It was suggested that surgery shall be done 4-8 weeks after recovery and earlier

surgical procedures were highly discouraged. The host physicians were honest enough

to admit, however, that at the moment, they still don’t know the exact effects of COVID

among patients even though they have already recovered. The basis of such protocol, for

now, rely on expert opinions in the literature, however, even such have no data supporting

the claims. Nonetheless, in this time of crisis, it’s better to be safe than sorry. Hence, as

for elective surgery – as much as possible, it’s safer to delay the surgery, especially for

COVID-19 patients due to its unpredictability.

 Again, one of the most important things to know apart from the timing of surgery

after getting infected by COVID-19 is the best time to do surgery in a patient at the very

least. In certain cases, like mild for mild gallstone pancreatitis, it is suggested to perform

surgery during the admission or within the same admission because we might lose the

patients during follow-up. Meanwhile, with respect to diagnostics, it’s important to take

note that lipase or amylase are not used to monitor or predict severity of the disease

condition in a patient—it need not to be monitored (“unless…”, as stated verbatim by the

speaker, “you own the laboratory”). Lipase and amylase were emphasized once again

that they are mere diagnostic tools, such that if you diagnosed a patient with pancreatitis

via lipase or amylase, there is no need for monitoring anymore. Such enzymes are not

utilized for the clinical evaluation of a patient—only for diagnostic purposes.

It’s been eight months since the COVID-19 pandemic has started to claim the

strength, hope, and freedom from the lives of many struggling Filipinos today. Like a huge

blackhole, COVID-19 has sucked out most of the energy there is, as people try to fight off

not only the disease itself, but as well as the negative effects it brought, especially into

the economic and financial sectors. Of course, one of the sectors that has been gravely

affected by the pandemic is none other than the health sector—among which are the

doctors we have who bravely risk their lives every day to battle with an enemy that they

cannot even really see. Hence, if there is, any perfect timing to hold on to the promises

we committed with this profession, it is no other than now that we are badly needed by

the people. As the webinar series puts it, “Medical care need not to be compromised,

even in a time of a pandemic.”