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EDITORIAL
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 69-71
 

COVID-19. The missing link


Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial hospital, Mumbai, Maharashtra, India

Date of Submission18-Jun-2020
Date of Acceptance18-Jun-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Dattatraya Muzumdar
Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial hospital, Parel, Mumbai, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpn.JPN_158_20

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How to cite this article:
Muzumdar D. COVID-19. The missing link. J Pediatr Neurosci 2020;15:69-71

How to cite this URL:
Muzumdar D. COVID-19. The missing link. J Pediatr Neurosci [serial online] 2020 [cited 2020 Sep 22];15:69-71. Available from: http://www.pediatricneurosciences.com/text.asp?2020/15/2/69/288307





   What We Know Top


The COVID-19 pandemic is unprecedented. The last pandemic flu was in 1918–1919, which affected over 500 million people, causing 50 million deaths. However, as today’s pandemic is in a different era, the strategy has to be planned and executed in a different manner. The health, economic, and social implications all over the world are enormous as we are living and working in a highly advanced technological era with widespread global connectivity. The impact of COVID-19 has dealt blow on personal, family, and professional duties, causing profound disruption. On the contrary, there exists global confusion regarding the understanding of viral pathophysiology, testing, and treatment protocols. Till date, due to the different mutant strains of the virus, the clinical manifestation has varied from asymptomatic, mild fever with sore throat, dry cough to pneumonia and severe respiratory distress syndrome. It is also known to promote and cause thrombosis of blood vessels, leading to myocardial infarction and stroke. There is no possible cure for this viral infection but social distancing, maintaining hand hygiene, and properly worn masks have been able to control the spread of the disease. Several pharmacologic therapeutics, including antiviral agents, antibiotics, anti-inflammatory drugs, steroids, and immunosuppressive drugs, have been incorporated into treatment protocols on the basis of past experiences as well as trial and error basis. There is poor information about the possibility of relapses following primary infection. There is no effective vaccine in sight.

The imposition of lockdown of people’s movement in the country was the need of the hour to contain the viral transmission as well as to gather time for preparedness of health infrastructure for a large-scale outbreak and health emergency. The challenges for the Indian government were unique. A large population density, overcrowding, living conditions, and socioeconomic disparities posed difficulties for the implementation of preventive and definitive therapeutic measures. However, the lockdown was largely successful in preventing an early catastrophe in terms of morbidity and mortality.


   Clinical Practice Implications Top


The impact on clinical practice has been tremendous. The practical and ethical challenges of treatment require an urgent response. It requires a creative and focused decision-making on health priority of both patients and colleagues. During the lockdown period, due to lack of transport facilities, many patients were forced to agree willingly or unwillingly for a delayed follow-up or the transition to telemedicine. A stringent screening process of case selection and prioritization was performed for the indoor patients. The elective cases included those which can be rescheduled after 1–2 months, namely tethered cord release, craniofacial surgery, and Chiari decompression. A heightened vigilance was adopted for life-threatening conditions. The acute cases included head trauma and acute intracranial hemorrhage with mass effect, acute hydrocephalus or shunt malfunction, myelomeningocele repair, and spinal cord compression. It was thought convenient to use phone services for triage. A detailed case history was taken to understand whether the patient or its contacts had any flu-like symptoms. It was mandatory to do so as it was not only the neurosurgeon but also the entire health-care fraternity working closely in contact with the patient, who are at enhanced risk. There was always a possibility that pediatric neurosurgeons would be called for help in extreme circumstances for ventilator management or supervised front-line screening, in case of dire need.

The pediatric neurosurgery faculty and residents are resilient and hardworking. They are divided into teams, and rotations are charted so that minimum manpower is used for maximum work output and also minimizing exposure to potential COVID patients. Social distancing was strictly followed for all group activities and conducted with as minimal personnel as possible using the appropriate protective gear. The use of telemedicine and videoconferencing was used to its maximum for patient consultations, revisits, resident briefings, faculty consults, as well as for neurosurgical education and collaborative research, nationally and globally.

Surgery is performed with due care using a full personal protective equipment (PPE) by all the health-care personnel involved in the surgery. The COVID antigen test of the child and the immediate relative was mandatory at least 2–3 days before surgery. During intubation and extubation, minimal personnel would be allowed in the room half an hour before and after the procedure is over.[1],[2] A negative pressure operating room is advisable but it was technically difficult to set it up in this period. The availability of blood products and intensive care unit (ICU) beds was prior ascertained to minimize postoperative exposure to the operating room personnel. It has been observed that neonates and children had a relative resistance to COVID-19, which made them amenable candidates for major surgical neurosurgical procedures without any significant morbidity.[1],[2]


   What and Where Is the “Missing Link” Top


The current pandemic is an immense learning lesson for the entire humanity. It is unprecedented. There is not one live human help from the last pandemic in 1919 to guide us in this difficult time. It is universal, and the whole world has been in a state of global lockdown, necessitating the cessation of human movement. The thought of the interconnectedness of life, admiring the intelligence of creation helps to comprehend the fragility of our existence. Over the last 100 years, there has been a revolutionary change in the human psyche, which is unmatched compared to last few centuries, more so in last 25 years. Although helpful, an exponential technological and digital revolution has resulted in unfathomable greed and unethical rat race. It has eroded human values in a detrimental manner, resulting in undue consumption and remarkable violation of nature and natural resources. This has caused deterioration in climate and pollution. The human mind and body is under tremendous mental and physical stress due to hectic work schedules. The perpetual increased sympathetic tone results in persistent tachycardia, which is thought to have an adverse effect on coronary artery filling, causing increased chances of fatigue, cardiac, and neurologic disorders. The reversible changes in nature and natural resources as well as decrease in the rate of myocardial infarction/strokes in the last 2–3 months during the pandemic provide a direct evidence to it. It is a learning experience from the master teacher called “Nature,” whose primary function is to “nurture” and not to destruct. Humans should raise the “humanity” quotient within.

The virus is novel. It has varied manifestations from mild to severe, which is difficult to predict in a given affected subject. There have been multiple theories about transmission of this virus but controversy still exists. The virus enters into the human body through the respiratory passages, affecting the gaseous exchanges (O2, CO2) and causing acute severe respiratory distress syndrome, and may result in multi-organ failure. The virus has been kind to the newborn babies and children. The majority of COVID-positive mothers giving birth to non-COVID babies and the relatively less infection rate and more resistance in children with COVID are a subject of research. There is no cure, and a global confusion exists regarding the management of this condition.

The universe is giving us a pause to reflect on our external and internal existence. The perpetual centrifugal human nature with relentless zeal to win and excel at all costs has been abruptly halted and forced to look centripetally, within itself termed as introspection. The social distancing, which is advocated as a safety measure, is meant in principle to keep people apart and remain focused on self and introspect. It has given an opportunity for the family to strengthen ties and function as a single unit. The collateral effect of social distancing and lockdown has also helped to reduce pollution significantly and has also given an opportunity for the nature to heal itself at no extra cost. It has transformed the world into a center of global meditation.

Maharishi Patanjali (second century bce) states the following in the very first line of the Yoga-Sutras: “Atha-Yoganusasanum.” This translates as, “now the discipline of yoga.” It suggests that the various things that were tried to curb the spread of the virus—physically and in our minds—have not borne fruit. This is the ideal time for yoga—discipline toward one’s self and others, keeping the body clean internally and externally, maintaining integrity, self-study and swadhyaya, physical fitness, mental fitness, and self-reflection. This could also serve as a pathway to freedom if desired and destined.

The virus has been a yoga teacher in the true sense, the Ashtanga yoga that is initiated with leading a disciplined life, regulating Prana or the life force and mind through controlled breathing and tone of the body through “Asanas” or calibrated physical exercises. Indeed, this has also been advocated to keep our body and mind afresh at all times if performed daily and in a correct manner. This provides the basis for igniting the spiritual fire within us and helps us to achieve equilibrium in life and behavior in the society, at large.

The lockdown period is an eye-opener for the human population on this planet. The value of freedom from bondage has been deeply rooted within due to this unique experience. A COVID fatigue has now set in, and the patience of people has started dwindling. There is a need to unlock and normalize life. The hype about COVID in the social media needs to be demystified. Communities need to be responsible themselves and enforce reasonable compliance with safety regulations. The existing health-care resources must be focused on the needy with clear protocols for admission to hospitals and treatment paradigms. The hope for development of herd immunity and effective vaccine in the near future should be ascertained. In addition to the length of the lives, its quality also needs to be enhanced. The awareness of “missing link” needs a second look once the lockdown ends and normalcy is attained. The “missing link” is relevant to pediatric neurosurgical community as we are adults responsible for the care of pediatric patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al.; Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children. N Engl J Med 2020;382:1663-5.  Back to cited text no. 1
    
2.
Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients. Can J Anaesth 2020;67:568-76.  Back to cited text no. 2
    




 

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