DOI: 10.

1590/0100-6991e-20202576 Original article

The trauma and acute care surgeon in the COVID-19 pandemic era
O cirurgião de trauma e emergência na era da pandemia de COVID-19

Marcelo Augusto Fontenelle Ribeiro Junior, TCBC-SP1 ; Tercio de-Campos, TCBC-SP2; Daniel Souza Lima, ACBC-CE3; Antonio
C Marttos-Jr4; Bruno M Pereira,TCBC-SP5

A B S T R A C T
The World Health Organization recognized in March 2020 the existence of a pandemic for the new coronavirus that appeared in China,
in late 2019, and whose disease was named COVID-19. In this context, the SBAIT (Brazilian Society of Integrated Care for Traumatized
Patients) conducted a survey with 219 trauma and emergency surgeons regarding the availability of personal protective equipment (PPE)
and the role of the surgeon in this pandemic by means of an electronic survey. It was observed that surgeons have been acting under
inadequate conditions, with a lack of basic supplies as well as more specific equipment such as N95 masks and facial shields for the care of
potential victims who may be contaminated. The latter increases the risk of contamination of professionals, resulting in potential losses in
the working teams. Immediate measures must be taken to guarantee access to safety equipment throughout the country, since all trauma
victims and/or patients with emergency surgical conditions must be treated as potential carriers of COVID-19.

Keywords: Pandemics. Coronavirus. Personal Protective Equipment . Coronavirus Infections.

INTRODUCTION Brazil. In these scenarios, surgeons are taking care of

these patients who arrive, in parallel with the admission

T he World Health Organization recognized in March

2020 the existence of a pandemic for the new
coronavirus that appeared in China in late 2019, and
of patients with COVID-19, and with difficulties in
protecting themselves with appropriate PPE.
The lack of equipment as well as the overload
whose disease was named COVID-19. It presents an of exposure to COVID-19, mean that health professionals
expressive capacity of transmission and propagation, in are considered a highly vulnerable population. Several
a world population without natural defenses against this papers have shown that thousands of health professionals
disease, and results in considerable mortality especially have already been infected, and hundreds have died
in the elderly and people with chronic diseases. from the disease. According to the New York Times,
Furthermore, it threatens the collapse of the healthcare of the more than 40,000 confirmed cases in Spain,
system, with the sudden overload of hospitals and approximately 5,400 are health professionals (14%),
intensive care units, consuming all essential equipment these numbers are also observed in other countries with
for the treatment of these patients, such as mechanical high rates of infection1. By the beginning of March, China
ventilators, and also leading to the lack of personal reported more than 3,300 infected health care workers
protective equipment (PPE) for the professionals who care and at least 22 deaths2,3. Protective guidelines are more
for these patients, further increasing the contamination essential than ever for emergency professionals and
of the health personnel, contributing to the collapse of surgeons when considering the risks of contamination
the entire system. from invasive procedures.
Also, it should be highlighted that other serious In this context, SBAIT conducted a survey with
problems such as trauma and other surgical emergencies trauma and acute care surgeons regarding the availability
continue to arrive at the emergency departments in of PPE and the role of the surgeon in this pandemic.

1 - Hospital Moriah e IAMSPE, Cirurgia de Urgência e Trauma e Pós Graduação - São Paulo - SP - Brasil 2 - Faculdade de Ciências Médicas da Santa
Casa de Misericórdia de São Paulo, Cirurgia do Trauma - São Paulo - SP - Brasil 3 - Instituto Dr. José Frota e Universidade UNIFOR, Serviço de Cirurgia
do Trauma e Departamento de Cirurgia - Fortaleza - CE - Brasil 4 - University of Miami - Ryder Trauma Center, Acute Care & Trauma Surgery - Miami
- FL - Estados Unidos 5 - Grupo Surgical, Cirurgia de Urgência e Trauma - Campinas - SP - Brasil

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2 The trauma and acute care surgeon in the COVID-19 pandemic era

METHODS those considered ideal for the care of trauma victims

reached 100% availability among the 219 respondants.
This is a prospective questionnaire using the Even basic materials such as gloves (93.6%), surgical mask
SurveyMonkey tool (http://www.surveymonkey.com)4 and (89%) surgical caps (86.3%), which in theory should be
distributed electronically (list of emails and WhatsApp available in 100% of the services were not available in
groups) to SBAIT members, composed of trauma and some locations (Figure 4).
acute care surgeons as well as non-members, totaling
approximately 1,500 forms sent. The questionnaire
consisted of 14 questions, 13 of which were objective and
one that the surgeon could write observations relevant
to the topic. The questions addressed the kind of facility
and region of work, personal safety situation and which
kind of PPE were available to handle trauma patients,
considering both, patients with and without the diagnosis
of COVID-19, and who have potentially surgical diseases.
The data obtained were automatically transferred to an
Excel file, to be analyzed.
Participation in the questionnaire was voluntary
and spontaneous, and all responses were anonymous. This Figure 1. Main surgeons’ workplaces.
type of survey does not require ethics committee approval.

RESULTS

Of the 1,500 forms sent, 219 responses

were obtained (14.6%). The majority of the surgeons
come from the South and Southeast regions of Brazil
(54.3%) as shown in Figure 1. Of these, 82% work in
the emergency room and/or trauma bay, with only a
small portion reporting having had contact with known Figure 2. Type of hospital where surgeons work.
COVID-19 positive patients.
When assessing the type of institution where
the professionals work, it was observed that most of them
had professional activities in municipal public hospitals
(22.8%), public state hospitals (63.9%) or social health
organizations (OSS) (17.3%), and it was also noted that
more than 50% of the surgeons also work in private
hospitals (Figure 2).
Regarding the personal safety of surgeons,
Figure 3. Perception of safety during care for trauma victims during the
in the current COVID-19 pandemic, it can be seen that pandemic.
15.5% of them answered that they consider themselves
safe to work, while 49.7% consider themselves partially When asked about what type of safety
safe and 32.4% do not consider themselves safe to equipment the surgeon used while in the hospital, 115
provide care for potentially infected patients (Figure 3). (52.5%) reported using a conventional surgical mask,
Regarding personal protective equipment (PPE), with 30% reported not using any type of personal
it was highlighted that none of the items mentioned as protective device. As for the types of protection used

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The trauma and acute care surgeon in the COVID-19 pandemic era 3

to care for patients without suspected COVID-19, it and approaches without changes. However, 51.6% of
was observed that 43.8% of surgeons use conventional them have performed thoracic CT scan always and/or in
surgical masks even in non-suspected cases, and 36.5% selected cases and 7.7% have opted for non-operative
of them reported the use of an N95 mask (Figure 5). treatment whenever possible (Figure 7).
When asked about the use of PPE for surgical procedures
in patients without suspected virus infection, the answers
were practically the same as those obtained for the care
of victims without clinical suspicion.

Figure 6. Current indications for laparoscopic procedures during the

pandemic.

Figure 4. Materials available for the care of trauma victims (the surgeon
should check all available items).

Figure 7. Current indications upon surgical cases (traumatic or not)

among trauma and acute care surgeons.

Considering that obtaining a definitive airway is

part of the day-to-day tasks of this group of professionals,
we evaluated the type of material available to perform
oral-tracheal intubation, and the majority of surgeons
(55.7%) reported having the face shield and fan filter
Figure 5. Types of personal safety equipment used against patients who (42%) available. Unfortunately, only a small number of
are not suspected of COVID-19. professionals’ report having the video laryngoscope for
intubation available (Figure 8).
With regards to laparoscopic surgery and As for the PPE available for these surgeons to
the potential risk of spreading the virus through perform an operative procedure, it was observed that
pneumoperitoneum, it was observed that the majority of less than half of them had protective equipment as
surgeons (52.9%) are not performing such procedures at recommended by Anvisa (National Health Surveillance
the present time, 23.7% have refrained from performing Agency) (46.5%). Seventy-nine surgeons (36.1%) report
such procedures only in suspected and/or confirmed having less than recommended and 14.6% did not know
cases and 16.4% of surgeons have maintained the usual about such recommendations.
indications (Figure 6). It this study 63% of surgeons reported having
Regarding indications and surgical management difficulties in obtaining PPE in their hospitals. Finally,
of an emergency case (traumatic or not), it was observed 53.4% (116) of surgeons did not know any health
that 81 surgeons (36.9%) maintain their usual indications professional who has been infected by the virus.

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4 The trauma and acute care surgeon in the COVID-19 pandemic era

alcohol-based hand sanitizers. Such data corroborate the

findings of the present study as shown in Figure 4.
Assistance to trauma victims follows well-
established protocols such as Advanced Trauma Life
Support©(ATLS), which assumes that professionals who
assist such victims must be wearing appropriated PPE,
such as face shields, goggles, fluid resistant gowns and
gloves, and such recommendations have been made for
decades by the American College of Surgeons and its
Committee on Trauma10. Unfortunately, there are few
public and even academic hospitals in Brazil that follow
Figure 8. Materials available for orotracheal intubation by trauma and
acute care surgeons. these rules correctly, placing professionals at increased
risk of being exposed to personal contamination by body
fluids, secretions and more recently to aerosol from the
DISCUSSION airways of potentially contaminated patients.
ANVISA recently published a technical note that
It is well known that injuries resulting from determines that health care professionals who perform
trauma represent the main cause of death in the procedures less than 1 meter away from suspected or
population under 45 years of age worldwide5. It is confirmed patients for coronavirus infection should follow
estimated that about 6 million people die each year as a the following guidelines: hand hygiene, goggles and/
result of such injuries. This number corresponds to about or face shields, surgical masks, which must be replaced
10% of deaths in the world, killing more than malaria, by N95/PFF2 mask when performing aerosol-generating
tuberculosis and HIV combined6,7. procedures, gloves and fluid resistant gowns11,12.
As of April 15, 2020, according to the Unfortunately, the present study shows
Coronavirus Resource Center of Johns Hopkins that among the 219 surgeons who responded to the
University, more than 2 million people worldwide and survey, 32 of them were not even aware of ANVISA’s
more than 30,000 people in Brazil, have been infected recommendations, clearly demonstrating that educational
with COVID-19, causing the death of more than 140,000 actions by medical societies and health authorities, must
people around the world8. be optimized in order to make all health care professionals
In Brazil today, the vast majority of trauma aware of their guidelines and recommendations.
victims are admitted to public hospitals and OSS, where In a recent electronic publication, Machado Jr
approximately 62% of surgeons who responded to the recommends for all trauma centers that surgeons have
current survey carry out their activities. By April 12, 2020 ample access to PPE as well as institutional policies for
the Brazilian Medical Association (AMB) had received airway management13. In the same way, Lima et al,
3,031 complaints about the lack of PPE for patient care. presented recommendations for emergency surgery
At the present time, both the public and private sector during the pandemic, pointing out that the use of
are suffering from the lack of materials and equipment, protective equipment combined with adequate surgical
placing healthcare professionals at risk. Of the 826 technique and correct surgical planning represent the
institutions consulted by AMB, 95% were experiencing best way to reduce contamination rates among health
supply problems9. professionals14.
The scarcity of equipment reported to AMB was Finally when the surgeons were asked about
related to the availability of N95 masks (87%), followed the indications for laparoscopic access for emergency
by goggles or face shields (70%) and fluid resistant gowns surgeries, there was a tendency to avoid or even not use
(66%). The degree of exposure and risk is such that 26% them, in agreement with the current recommendations
of the respondants reported lack of gloves and 35% of of several medical societies due to the risk of

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The trauma and acute care surgeon in the COVID-19 pandemic era 5

contamination of the team by aerosol emission from The concern about the loss of contaminated
pneumoperitoneum15,16. health professionals who will be temporarily out of action
The lack of protective equipment has been and some who will not survive is a huge burden for the
affecting surgeons around the world. In the present society and health systems. The protection of these
study, we can say that more than 80% of surgeons report professionals must be a priority at this time, as well as
feeling partially or totally unsafe for care. In the UK, making information available to everyone.
Rimmer reports that a third of surgeons (32.5% of a total This study has limitations, which, despite being
of 1978 responses) pointed to problems with the supply national in scope, did not reach all states and medical
of protective equipment in their hospitals. More than half services equally. In addition, the proportion of responses
of the surveyed surgeons claimed to have had problems may not be of statistical power to support it since the
to have PPE supplies in their hospitals throughout the last response rate was only 14.6%. Despite this limitation,
30 days17. it was considered a priority due to the need for a rapid
Unfortunately, we can expect casualties to assessment of the situation in the country, and for
increase among the workforce in hospitals, due to both recommendations to be proposed in a timely manner.
the contamination of surgeons working in the front lines as Importantly, this is the first survey conducted in Brazil
well as due to the stress resulting from the daily exposure with this focus during the current pandemic.
to cases not only of trauma but also of those infected with SBAIT published recommendations for surgeons
COVID-19. Lai et al presented the psychological effects in its media channels last month, but it is believed that
among 1257 health professionals who worked in Wuhan communication should still be expanded. In times of
during the peak of the pandemic and identified high rates greatest crisis, the communication process becomes
of depression (50.4%), anxiety (44.6%), insomnia (34%) essential for us to protect more lives21.
and stress (71.5%) among respondents18. In conclusion, the trauma and acute care
The current pandemic was unexpected and surgeons are in a situation of fragility and risk during the
unimaginable for many until 3 months ago. Nonetheless, current pandemic, attending traumatized and critical ill
it has exposed several weaknesses in the healthcare patients in most cases without the proper PPE, exposing
systems around the world, which were not prepared for themselves to contamination. The dissemination of
such an event. Alerts by scientific19 and non-scientific20 information that can protect surgeons is key in this
communities have been made in the last decade, but to moment of crisis throughout the health system in Brazil
no avail. and the world.

R E S U M O
A Organização Mundial de Saúde reconheceu a partir de março de 2020 a existência de uma pandemia do novo coronavírus que surgiu
na China no final de 2019, e cuja doença foi denominada COVID-19. Neste contexto, a SBAIT (Sociedade Brasileira de Atendimento Inte-
grado ao Traumatizado) realizou pesquisa com 219 cirurgiões de Trauma e de Urgências e Emergências a respeito de disponibilidade de
equipamentos de proteção individual (EPI) e do papel do cirurgião nesta pandemia, por meio de formulário eletrônico. Observou-se que
os cirurgiões vêm atuando em condições inadequadas, com falta de insumos básicos assim como equipamentos mais específicos, como
máscaras N95 e protetores faciais, para a atenção de potenciais vítimas que estejam contaminadas. Isso eleva o risco de contaminação
dos profissionais e causa decorrentes baixas na força de trabalho. Medidas imediatas devem ser adotadas para garantir o acesso aos
equipamentos de segurança em todo país uma vez que, todos os pacientes vítimas de trauma e/ou portadores de doenças cirúrgicas de
urgência devem ser tratados como potenciais portadores do COVID-19.

Palavras chave: Pandemia. Coronavírus. Equipamento de Proteção Individual. Infecções por Coronavirus.

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Received in: 16/04/2020 Mailing address :

Accepted for publication: 17/04/2020 Marcelo Augusto Fontenelle Ribeiro Junior
Conflict of interest: no. E-mail: drmribeiro@gmail.com
Funding source: none.

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