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Embracing the Change

1 April 2020

When I was asked to write a short blog and reflection by the Director of The Faculty of Surgical Trainers I spent some time considering how I might try and convey some positivity in regards to surgical training during the current COVID-19 crisis.  As with other areas of medicine and surgery that deal with the airway and respiratory system, we know that in cardiothoracic surgery there are plenty of ways in which we can be exposed to the virus.  Many areas of our everyday work, from bronchoscopy to management of the chest drain with an air leak, present risk to the entire team caring for our patients.  Despite these worries I think it affords the trainee the opportunity to refine skills in team leadership – ensuring that patients are adequately risk assessed and that all staff members follow best practice in respect of personal protection and risk management. Clinical guidance is changing rapidly but keeping up to date is important for a surgeon at any stage of their career and this crisis reinforces the need to do that. 

In thoracic surgery there is still likely to be a need to operate on a nearly daily basis but the case mix may change and we should embrace that.  This last week there has been plenty of acute work including several patients with empyema.  This means that the surgical trainee continues to operate and can continue to progress toward ARCP requirements/ CCT.  Other acute work, including airway management and pneumothorax, will continue needing surgical management.  We may even see an increase in some aspects of our acute work, given that COVID-19 predominantly affects the lungs.   

Elective cancer work is still underway and this normally represents the major workload for the thoracic surgeon.  However, lists are limited and patients are carefully being managed according to clinical priority.  For the senior surgical trainee who, in a centre like my own in Leeds under excellent consultant supervision, is normally allowed the majority of the major lung resections this may change.  Pressure on time and space on operating lists is one reason that consultants may need to undertake these cases.  There is of course the idea that a surgical mistake from a trainee may further pressure already stretched resources.  If the pulmonary artery is damaged during a lobectomy and the patient ends up needing a pneumonectomy it pressures an already very busy critical care service.  However, even if not the operating surgeon, there is still plenty that can be learnt. 

Given cancer work continues to proceed there is still a need for the MDT and clinic.  However the way these are conducted has changed and potentially require different skills.  MDTs are now frequently carried out by video link or over secure email.   Many of our clinics are becoming virtual.  This may mean that pre-operative patients, mainly for their own safety, are assessed and counselled over the telephone.  The inability to physically examine a patient means that the greatest attention needs to be paid to every detail.  I have noticed a need to maximise effectiveness in communication to ensure that things are not missed or neglected.

Our on calls remain busy and diverse.  Having just completed the last weekend I have had plenty of calls regarding thoracic trauma.  I noticed an increase in major trauma admissions relating to drinking in the home!  One of the major issues on call has been ensuring the seamless post-operative management of our patients.  Avoiding any complications is essential with stretched critical care resources.  And additionally, the management of our patients needs to be considerate to the idea that these patients are at very high risk if exposed to and infected with COVID-19.  We have had to ensure that patients can mobilise to progress in their recovery without being put at unnecessary risk. An example of system improvement during a time of crisis.

While the current situation puts the NHS and its staff under strain I think it is still possible for the surgeon in training to continue their own development but with the acceptance that the landscape will remain very different for the foreseeable future.  

About the author: 

Michael GoosemanMichael Gooseman MEd is a Specialty Registrar in Cardiothoracic Surgery working at Leeds Teaching Hospitals NHS Trust. He has been an FST member since 2015.

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