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\begin{document}

\title{COVID-19. The US Perspective, Atlanta}



\author[1]{Eltayeb Mohamed Ahmed }%
\author[1]{Edward Chen}%
\affil[1]{Emory University}%


\vspace{-1em}



  
  \date{March 12, 2025}


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\begin{abstract}
Abstract: Background: The COVID-19 pandemic in late 2019 quickly
stretched health care system across the globe. Mortalities, shortages in
health care system capacity, and lack of experience in similar
circumstances required innovation in the way health care is delivered.
Health care systems changed operating schedules, staff work pattern, and
how patients are cared for. The effects of these changes reached
patients, staff and training in different ways. Methods: We search the
Pubmed and EMBASE for articles related to COVID-19. We also searched
local e-mails and information provided to staff during the pandemic
Results: The COVID-19 pandemic affected organisations, patients and
staff. The organisation and staff had to adapt to the times to provide a
safe and appropriate service to our patients. Conclusion: The pandemic
challenged and changed the way we work as health care providers, and how
we train the future surgeons. Changes in the system was effective.%
\end{abstract}%



\sloppy


\textbf{Title: COVID-19. The US Perspective, Atlanta}

\textbf{Short running title: COVID-19. The US Perspective, Atlanta}

\textbf{Authors:}

\textbf{Eltayeb Mohamed Ahmed, M.D\textsuperscript{1}; Edward P. Chen,
M.D\textsuperscript{1}}

\textbf{Authors' affiliation:}

Division of Cardiothoracic Surgery, Department of Surgery, Emory School
of Medicine, Atlanta, Georgia, USA.

\textbf{Authors contact details:}

\textbf{1) Eltayeb Mohamed Ahmed}

eltayeb.kamal@gmail.com

\textbf{2) Edward P. Chen}

edward.p.chen@emory.edu

\textbf{Corresponding Author:}

Professor Edward P. Chen

\textbf{Address:} Division of Cardiothoracic Surgery, Department of
Surgery, Emory School of Medicine, Atlanta, Georgia, USA.

e-mail: edward.p.chen@emory.edu

\textbf{Telephone:} 001 404.778.3484

\textbf{Funding: No funding was required for this work}

\textbf{Conflict of interest: The authors have no conflict of interest
in relation to this work}

\textbf{Keywords:}

Pandemic, Thoracic Surgery, Public health, Education, Review

\textbf{Abstract:}

\textbf{Background:}

The COVID-19 pandemic in late 2019 quickly stretched health care system
across the globe. Mortalities, shortages in health care system capacity,
and lack of experience in similar circumstances required innovation in
the way health care is delivered. Health care systems changed operating
schedules, staff work pattern, and how patients are cared for. The
effects of these changes reached patients, staff and training in
different ways.

\textbf{Methods:}

We search the Pubmed and EMBASE for articles related to COVID-19. We
also searched local e-mails and information provided to staff during the
pandemic

\textbf{Results:}

The COVID-19 pandemic affected organisations, patients and staff. The
organisation and staff had to adapt to the times to provide a safe and
appropriate service to our patients.

\textbf{Conclusion:}

The pandemic challenged and changed the way we work as health care
providers, and how we train the future surgeons. Changes in the system
was effective.

\textbf{Introduction:}

Late in 2019 a pneumonia-causing virus, later identified as COVID-19,
has been identified in Wuhan, China\textsuperscript{(1)}. Shortly, the
virus spread to 19 countries and a world health emergency was declared
as it reached a pandemic status\textsuperscript{(2)}. It was the news
reports from Italy of a healthcare system stretched beyond its capacity,
soaring fatalities, and strict governmental interventions to limit the
spread that alerted most European and North American countries. The
first reported case in the United States was reported on the
22\textsuperscript{nd} of January\textsuperscript{(3)}. As it became
obvious that the disease would spread in the US, health care systems
started developing strategies to combat the spread of the disease,
acquiring resources to deal with unprecedented demands, and to train
staff to protect themselves and provide care for a special subset of
patients.

\textbf{How did the organisation adapt to the pandemic?}

It became immediately evident that communication between the
organisation leadership and staff is key and a daily e-mail COVID-19
update was established. It provided information about the number of
cases in the system, changes in policy, advice for staff on seeking
support both mentally and physically. The daily updates provided
reassurance to the working force and a reliable source to be informed;
they were greatly appreciated by both clinical and non-clinical staff
alike. The daily communication was particularly appreciated with regard
to the availability of Personal Protective Equipment (PPE), as concerns
over a worldwide shortage were voiced.

As the situation evolved the organisation developed seven guidelines
developing teams to guide staff and patients. These teams addressed the
following needs: patients' communication and documentation; COVID-19
positive patients requiring surgery; trainees' oversight and independent
procedural/care guidelines; nasopharyngeal and aerosol generating
procedures; physicians and providers redeployment strategy; COVID-19
perioperative evidence review; and surgical telemedicine.

The number of COVID-19 positive cases across the system in March was 179
cases of which 85 cases were admitted to the intensive care unit. Events
across the Atlantic suggested that an increase in demand on ICU care is
to be expected. The organisation asked for volunteers to be redeployed
to frontline services including emergency department and ICU. The
cardiothoracic surgery clinical team skill set, meant that as a team we
were most suited to support our ICU colleagues.

The American College of Surgeons published guidelines for triaging
elective surgery. At Emory all elective surgeries were postponed. Time
sensitive surgeries were scheduled if they met any of the following
criteria: the procedure is required for the patient's discharge, the
procedure can be done with a very small likelihood of postoperative
admission, or the procedure is required to avoid a re-admission to
hospital. Procedures not meeting these criteria, as most cardiothoracic
urgent procedures, had to go through an adjudication process. A
site-specific surgeon adjudicator, site nurse-in-charge, and site
anaesthetist carried out the adjudication. Elective activity was only
resumed at a quarter of the normal capacity by May, and we resumed our
usual level of activity by June. To date, all patients undergoing
elective or urgent surgery are screened within 48 hours of their
procedure. We certainly identified COVID-19 positive patients and these
cases were postponed.

Telemedicine took a centre stage during the pandemic with an increase in
utilisation \textsuperscript{(4)}. Initially, all outpatient consultants
were cancelled. When it became clear that the pandemic is going to last
for few more months, a move to on-line and phone consultations took
place. The use of web-cameras and on-line consultations became familiar
to most providers very quickly. To this date, as in-person outpatient
appointments are resumed, some patients still prefer on-line consults.

Emory's Vaccine and Treatment Evaluation Unit (VTEU) was also involved
in a phase 1 trial evaluating a vaccine for COVID-19, that was in
addition to a rich portfolio of academic activities centred around the
pandemic. Staff were encouraged to identify research areas related to
their speciality or contribute to on-going research projects.

\textbf{How were patients affected?}

Certainly, the pandemic created a lot of anxiety in the population,
including avoidance of seeking medical help when it is desperately
needed; the most worrisome was the data from New York as the number of
patients presenting with acute coronary syndrome dropped by around
40\%\textsuperscript{(5, 6)}. Surgeons had to deal with late
presentation of diseases, such a post infarct ventricular septal defects
and papillary muscle rupture. The psychological impact is equally
pronounced from major depression to anxiety \textsuperscript{(7)}.

Emory visitation policy, which still stands in September 2020, meant
patients cannot have visitors apart from very exceptional circumstances.
The aim of the policy was to protect patients and staff. Some of our
patients elected to postpone their surgeries, some of which died while
waiting for the pandemic to pass; others died postoperative alone on a
hospital bed.

\textbf{Training in cardiac surgery during the epidemic:}

Cancellation of elective surgery and outpatient activities was bound to
affect training in cardiothoracic surgery. Furthermore teaching
sessions, conferences, and courses were cancelled because of the
pandemic. Residents created a COVID work-schedule. The schedule was made
to ensure that the minimum number of residents are at work at a given
point, that allowed for equal distribution of training opportunities in
the operating room. The gap created by lack of elective activities was
filled by a twice daily virtual didactic teaching sessions. Redeployment
to other services was also discussed and a schedule of residents
available to support ICU team was made. The number of cases logged by
residents in the period March-May was minimal, but a different type of
learning took place, more suited for the times and more purposeful. As
the elective workload returned towards normality, the virtual teaching
sessions reduced in frequency. The COVID work schedule lasted until May
and residents resumed their usual work pattern by June. Clearly, they
effect of the pandemic was pronounced on training opportunities but
residents like other staff groups demonstrated adaptability to the times
and rose to the challenges.

\textbf{Conclusion:}

The COVID-19 pandemic affected the world in a way no one imagined. In
cardiothoracic surgery both patients and staff had to bear the
consequences. It is with resilience and adaptability across the
organisation that we probably managed to pull through the worst period
in this pandemic. Lessons have been learned and we look for a better
future for our speciality and the patients we serve.

\textbf{Author's contribution:}

Eltayeb Mohamed Ahmed prepared the manuscript and revised the final
manuscript.

Edward P Chen prepared the manuscript and revised final manuscript

\textbf{References:}

1. Almaghaslah D, Kandasamy G, Almanasef M, Vasudevan R, Chandramohan S.
Review on the coronavirus disease (COVID-19) pandemic: its outbreak and
current status. Int J Clin Pract. 2020:e13637.

2. Adhikari SP, Meng S, Wu YJ, Mao YP, Ye RX, Wang QZ, et al.
Epidemiology, causes, clinical manifestation and diagnosis, prevention
and control of coronavirus disease (COVID-19) during the early outbreak
period: a scoping review. Infect Dis Poverty. 2020;9(1):29.

3. Harcourt J, Tamin A, Lu X, Kamili S, Sakthivel SK, Murray J, et al.
Severe Acute Respiratory Syndrome Coronavirus 2 from Patient with
Coronavirus Disease, United States. Emerg Infect Dis.
2020;26(6):1266-73.

4. Kichloo A, Albosta M, Dettloff K, Wani F, El-Amir Z, Singh J, et al.
Telemedicine, the current COVID-19 pandemic and the future: a narrative
review and perspectives moving forward in the USA. Fam Med Community
Health. 2020;8(3).

5. Joshi S, Kazmi FN, Sadiq I, Azemi T. Post-MI Ventricular Septal
Defect During the COVID-19 Pandemic. JACC Case Rep. 2020;2(10):1628-32.

6. Braiteh N, Rehman WU, Alom M, Skovira V, Breiteh N, Rehman I, et al.
Decrease in acute coronary syndrome presentations during the COVID-19
pandemic in upstate New York. Am Heart J. 2020;226:147-51.

7. Sljivo A, Kacamakovic M, Quraishi I, Dzubur Kulenovic A. Fear and
Depression among Residents of Bosnia and Herzegovina during COVID-19
Outbreak - Internet Survey. Psychiatr Danub. 2020;32(2):266-72.

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