‘It’s 10 minutes before the patient arrives’
- Kwak Sang-keum, head of the Infection Management Team at Myongji Hospital
The Ministry of Health and Welfare and the Korea Institute for Healthcare Accreditation held the Covid-19 Medical Staff Inspiring Case Contest from July 22 to Aug. 19. The following is surgical memos by Kwak Sang-keum, a nurse and the head of the infection management team at Myongji Hospital. She has won the Grand Prize for introducing the medical staff’s effort to receive a Covid-19 patient and successfully perform an urgent appendectomy. Korea Biomedical Review is publishing Kwak’s entire memos. – Ed.
At 8:30 p.m. on May 26, I saw an emergency medicine resident and a security officer, tightly armed with Level-D protective gear, standing in the waiting area next to the Covid-19 screening facility on the first floor.
After giving them a brief nod for greeting, I wore a gown, gloves, and an N95 mask. Then I shouted, “10 minutes before the patient’s arrival.” My voice trembled, unintentionally. The two people next to me must have felt it, too. They glanced at me with a light smile.
The patient we’re anxiously waiting for is having acute appendicitis. He was not just a normal appendicitis patient but a confirmed Covid-19 patient. He was urgently transferred to our hospital because he needed emergency surgery after developing appendicitis during Covid-19 treatment in an isolated ward at another hospital.
Kwak Sang-keum, head of the Infection Management Team at Myongji Hospital
This surgery will not be easy because doctors and nurses are highly likely to be exposed to the patient’s respiratory secretions during surgery. It requires a lot of concentration and safety in the procedure at each stage to protect both the patient and the medical staff. The surgery needs 27 staff, a three-fold number compared to a normal appendectomy, and a negative pressure operating room.
Four hours before the patient’s arrival, I was preparing materials at the Infection Management Office to report on the status of Covid-19 inpatients. I got a phone call from Professor Kang Yu-min of the Infectious Disease Medicine Department.
“Something we thought would come someday has finally happened.”
“What, professor? What happened?”
“We had an urgent call from the Gyeonggi Province’s Covid-19 sickbed assignment team. A coronavirus patient at another hospital developed abdominal pain from two days ago, and the CT scan shows that the patient had acute appendicitis and intestinal perforation, requiring an urgent operation. They know that our hospital has a negative pressure OR and they’re asking to receive the patient and perform surgery. I consulted with Professor Oh Dong-kyu of the Surgery Department a while ago, and he said he would be willing to do the operation. We should do it!”
“What? Surgery on a confirmed patient?”
The unexpected phone call left me speechless for a moment. While taking notes on the phone call, a thousand kinds of thoughts came and went inside my head. ‘Is it necessary to operate on a Covid-19 positive, confirmed patient, not a normal one? Did that happen in our hospital? Why is it have to be our hospital, no, why did the professor say yes,’ I thought.
Then I came to my senses and thought I couldn't just deny it and blame others. I started to think about how I should arrange the procedure. ‘If it's acute and perforated, he needs the operation as soon as possible. Should we correct and supplement the normal procedure,’ I asked myself.
Then, I could feel a sense of duty as a medical professional to save a patient and assurance that I could do this if I work hard. At the same time, I was writing on my notepad the list of whom to contact immediately for an urgent meeting.
It was two hours before the patient’s arrival. We held an urgent meeting for the surgery on the Covid-19 patient. Twenty-seven staff gathered from the Department of Infectious Disease Medicine, Anesthesia and Pain Medicine, Surgery, Nursing Department, General Affairs Team, Facility Team, Radiation Team, and Infection Management Office. Professor Oh shared the operation scenario.
“Why don’t we receive the confirmed patient in the emergency negative pressure room on the first floor of Building E, do the pre-operation exam and contrast abdomen CT, and then take the patient to the negative pressure OR on the third floor of the main building A? After surgery, the patient can recover at the OR and we can move him to the state-designated negative pressure ward on the fifth floor of the building E,” Oh said.
Medical staff at Myongji Hospital discuss the post-patient transfer process outside the operating room before the patient arrives.
As soon as Oh finished his presentation, Infection Management Office Leader Lee Ki-deok marked the location of each area where the patient will pass by, on the whiteboard in the conference room. Then, he presented safety plans.
“We can receive the patient as we normally do for a Covid-19 patient. Particularly when we perform anesthesia, the aerosol may be generated. So, you must wear Level-D protective gear and a face shield. While the patient can undergo urgent surgery safely, our staff should not be exposed to the virus. Team leader Kwak, please review the situational protective equipment and movement again, and monitor the surgery… Lastly, to minimize exposure to other patients and caregivers, the surgery will be performed at midnight, which will make our staff difficult. But let's work hard together to save the patient.”
The head of the infection management office, who made it sure to protect the medical staff from the viral infection risk, encouraged us and boosted our morale.
After the meeting, no one left the place immediately. Instead, they spend 20 minutes asking and answering questions about what they can complement in each stage. On an agreement that we should save the patient and protect ourselves, too, everyone left for each department. We had to take care of our safety too because if get infected, we cannot treat patients.
One hour before the patient’s arrival. I ran to the office and made a time table. In the order of work for each area according to the scenario shared at the meeting, I wrote each department’s area in charge, details of work, and level of protection, and the contents and methods to be shared between departments.
Time flew. It was 30 minutes before the patient’s arrival.
I distributed the time table to the participants of the surgery and changed into surgical clothes. Then I got a call.
“This is 119 paramedic. It is 30 minutes before the arrival of the patient from the other hospital. Where should we enter?”
“Yes, sir, enter the hospital’s main gate and you’ll see an isolated screening facility on the right. If you come there, our staff will give you a guide. Please call me 10 minutes before you arrive. I’ll see you soon.”
“It’s 10 minutes before the patient’s arrival.”
At 20:40, the patient has arrived. A 119 ambulance came in through the main gate. The patient then entered the emergency negative pressure room according to the scenario. I delivered the patient arrival information to each department. In the negative pressure room, pre-operative tests such as blood tests were started to check the patient's condition, and we waited only for the results after being fully prepared.
At 21:00. I got a call from the OR. “We’re covering all the walls of the negative pressure OR with plastic. We consulted with the negative pressure and air conditioning facilities team. When we finish this, we will request fumigation. Now, a resident from anesthesiology, five nurses, and I have prepared supplies and protective equipment, and we are waiting. Nothing will happen, right?”
At 23:15. An hour passed while we were waiting for the test results. “There are no abnormalities in the test results, so we’re moving the patient to the CT room. Please check the preparation at the OR.”
Twenty minutes after the phone call ended, the negative pressure cart came out on the moving route of the patient. The patient was wearing a mask and lying in a negative pressure cart. In the corridor within the negative pressure zone stood an emergency medicine resident wearing Level-D protective clothing, who entered the patient’s room.
At 00:20 on May 27. “We’re entering the negative pressure OR No. 8.”
We took a CT scan of the patient on a negative pressure cart in Building E and tried to go to the main building A. I saw the patient’s guardian. I ran to explain the situation and quickly secured the movement.
The patient entered the OR on the third floor. The OR was covered with plastic, and the medical staff who participated in the surgery wore Level-D protective clothing over the surgical clothing and were waiting in resolute determination to save the patient. I checked that there was no problem with wearing protective gear one by one. The patient in the negative pressure cart finally entered the OR.
At 00:40, the operation began. The surgical team leader and I constantly monitored the OR through the glass window of the door of room No. 8 in the hallway.
At 01:20, a scrub nurse looked at the glass door while pointing at the face shield. It seemed to be steamy. I quickly wrote, “If you feel uncomfortable, please let me know. You need to change it,” and put it on the glass door. The scrub nurse confirmed this and nodded.
At 01:40, I saw a foreign matter like pus being removed on the monitor. The OR’s circulating nurse kept taking notes such as there was anything the staff needed in the OR.
At 02:00, the surgery was finally completed. I reported the end of the surgery but the patient was still in the OR. I couldn’t relax because I had to check the post-surgery situations.
At 02:10 in the operating room, the medical staff checked if the patient’s consciousness was returning and moved him on to the negative pressure cart, and began to wipe the negative pressure cart with a disinfectant tissue.
At 02:30, the transfer team arrived and pulled out the negative pressure cart carrying the patient. The patient left. The operation was over. However, procedures for removing protective equipment, handling reusable equipment, and environmental disinfection management procedures remained.
It is more important to take off protective clothing than to wear them. It took an hour for each individual to take off the protective gear. To prevent infection from the sweat-soaked protective clothing that doesn’t come off easily, they took them off one by one and I checked them carefully. A long time has passed. One doctor almost cried and said, “I just want to throw everything off.” Perhaps because the doctor was tired of working in the OR for more than two hours.
More than 10 quarantine waste bins were containing the removed protective clothing. The surgical team leader, the circulating nurse, and I transferred the quarantine waste bins to the elevator area exclusively designated for waste, and we moved all reusable devices to the washing room within the OR area.
At 03:40, I said to everyone that they did an excellent job. Then, I notified them that they were subject to active monitoring for Covid-19 and explained the procedure. After delivering the final information, I left the OR area.
"Yes! We saved him. We saved a confirmed Covid-19 patient who needed urgent surgery. We did it!”
As I stepped forward and thought about this in my head, I could feel that my body and mind came back to life again.
As they performed the first surgery on a Covid-19 patient, our medical staff committed to saving lives in a crisis situation. They did not have a moment to wipe their sweat and took the risk of being exposed to the virus to treat patients with protective clothing on. Because we have our medical staff, I look forward to the “ending scene” of Covid-19 soon. I will prepare an enthusiastic standing ovation.
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