COVID-19, Bariatric Surgery, and You
Hi everyone, this Reeger Cortell, your friendly bariatric surgery nurse practitioner and this is the Weight Loss Surgery Podcast, where in normal times, we talk about obesity and bariatric surgery one episode at a time. But these are not normal times. At this moment is 9:34 in the morning, PST, on March 16, 2020. 2 months ago, heck even one week ago, I did not know talking about the coronavirus would be my next episode. Just last weekend, which feels like 100 yrs ago, Dr Walt Medlin and I recorded a great episode on bariatric surgery revisions. I was really looking forward to publishing that episode this weekend. But times have changed and rapidly. We have gone from in January, 2020 just learning about a novel Coronavirus which started making people sick with severe pneumonia in December in Wuhan, China to the World Health Organization declaring COVID-19 (the infection that results from the coronavirus) a global pandemic on 3/11/2020 the likes of which none of us have seen in our life time. All in less than Three months. As of this morning 169,000 people have been infected (and those are just the ones we know about) and 6,500 people have died. The death toll for this new virus is greater outside of China than inside, in the US school are closed in 33 states, with more closing, restaurants are closing, and the CDC recommends that any and all gatherings of 50 or more people be cancelled for the next 8 weeks. Hour by hour this situation is changing. My heart goes out to everyone, everywhere. There is so much information out there, good, scientific evidenced-based information that is open-sourced and available to all of us. Therefore, I am not going to make this episode about proving why we should all be on high alert and rightly concerned. We have not contained the coronavirus. It is out there. Sadly, and frustratingly, the gavel is down on that one and the jury has gone home. But rather, I want to use this platform, use my voice, to speak to directly to my listeners who are pre-bariatric surgery patients that are scheduled for their surgery in the near future. What do I mean by the near future? It’s hard to say exactly but why don’t we just round it out to at least the next 1-2 months, perhaps more. In the very least between March 16th to April 16th. I am sure you are wondering if you should move forward with your surgery? How could you not be asking this question? But on the other hand, I bet you are thinking, ‘Are you kidding me? After all this time, and money, and prep, and waiting, and hoop jumping, and learning (thanks for using this podcast as a resource), and, and, and now this? A Global Pandemic is the reason you might not get your surgery?’ Perhaps you are thinking, ‘the heck with that, lets just do the surgery and we will figure out other issues, including coronavirus if and when we need to.’ And perhaps you are a looking to your bariatric surgery center for guidance. I do know that at least in USA many programs have stopped group visits in different settings- seminar, classes, and support groups. We are all pivoting to offer what we usually offer in face-to-face visits to some form of virtual setting or at least environments that allows for the two words we have all become so familiar with- social distancing. What an oxymoron than phrase is, right? It's right up there with "Bittersweet," "Clearly Confused," and "Deafening Silence". And I can think of many things I’d like to do that start with the word, "Social" but not one of those things ends in the word "distancing." But back to bariatric surgery; Programs in the US and around the world have made adjustments and we are all hoping that that will be enough. However, I am rapidly coming to the conclusion it is not enough. We need all hands on deck for this one, folks. And by "all hands on deck" I actually mean off the deck, so to speak, and away from each other. To paraphrase Dr Micheal Klompas from the Annals of Internal Medicine: This virus is optimized to spread quickly and widely. Infected people are contagious even when minimally symptomatic or asymptomatic, the incubation period can extend beyond 14 days, and some patients seem susceptible to reinfection. The signs and symptoms of coronavirus are largely indistinguishable from those of other respiratory virus infections. Less than one half of patients with confirmed disease have fever on initial presentation. The sensitivity of a single nasopharyngeal swab early in the course of disease is only 70% (Annals of Internal Medicine). Meaning 70% of those who are tested will be correctly identified as either having or not having the virus. Which sounds great until you factor in that 30% will get either a false positive or false negative result and of those people its really the false negatives that are concerning. Therefore if you can minimize your use of the medical system over the next few weeks to months for any forms of elective care, including bariatric surgery, that will leave a bed available for someone who wasn't planning on needing it but needs it anyway; And for the entire health care system that is there to help whichever person is in whatever bed for whatever reason and especially those who contract coronavirus- our parents, our friends, our spouses, our children, possibly even ourselves. So to be clear what I am saying is that if your practice isn't canceling your elective bariatric surgery, I think you should cancel it any way, now, today. On March 13th, The American College of Surgeons recommended that healthcare systems plan to minimize, postpone, or cancel elective surgery cases. And the next day, March 14th the US Surgeon General Jerome Adams, echoed this recommendation. Even factoring in everything you have gone through to get to this point in your bari-great journey. I know am going out on a limb and I may be placing my reputation at stake here. But I would much rather error on the side of caution and be accused of over-reacting than regret underacting by not taking a stand, and by not using this platform that I have built over 6 and a 1/2 years, episode after episode, for the greater good, including sounding the alarm now. It is not hyperbole to state that decisions made now will save lives later. And I’m not just asking this of you as a way to leave needed resources available during this crisis, but also because I am worried for your health and safety. As we all know, even though bariatric surgery in general is very safe, people who are affected by obesity have higher risks for untoward events compared to people without obesity, especially respiratory risks. But then you start looking at the data that is coming out of China, and what it shows is that not only older people are vulnerable to COVID19, vulnerable as in getting really sick and possibly dying, but also people who have chronic medical conditions like hypertension, diabetes, and coronary are disease (CDC, The Lancet). I don’t how many of you listening have at least one of those conditions but if you are like the patients I see in the office, the majority of you have at least one of those conditions. Therefore, lower your risk. Be careful. Stay home. But what would cancelling your surgery look like? For most people, I would imagine we are not looking at cancelling forever, but rather postponing for now. If your surgery was prior authorized through your insurance, then your practice can usually request an extension of the authorization. This is not uncommon. Otherwise, what should you do after postpone your surgery? Well, other than avoiding our modern day Covid19 Plague, like, well, The Plague via social distancing; wash your hands frequently, thoroughly, and often; do not touch your face; clean high touch surfaces with appropriate cleaning products... because did you know that coronavirus can live in the air for 3 hours after it is aerosolized (which is fancy speak for sneezing or coughing) and it can live on copper for 4 hrs, cardboard for 24 hrs, and up to 3 days on plastic and stainless steel (MedRxiv)? Yeah, I just learned that fact too. Sorry, I digress, but what should you do after you postpone your surgery, well, do not give up! Do not stop doing all the health behaviors you have been doing whether they are new or old to you. In fact, if there is an opportunity to up-level, to do more of those healthy behaviors, do them now! Optimize your health as much as you can- things like eating healthy nutrient and vitamin dense foods, getting some physical activity, getting plenty of good quality sleep, staying well hydrated, taking your medications that keep your medical conditions well controlled and taking your vitamins and minerals. Optimize your internal forces to fight this invisible invader- because that's where the fight will happen, inside us. Although you and your bariatric programs are rapidly making adjustments that directly impact your trajectory to surgery, trust me when I tell you we will still be there for you when all this calms down, which it will, and you will still be our patients, and we will still work towards our common goal of your improved health and wellness, which includes bariatric surgery as part of your treatment plan. Lastly, I want to share with you I am currently in self-quarantine waiting for results on my own COVID-19 tests. I have debated back and forth whether to tell you this or not, but I am opting for transparency because really we are all in this together, including me. Last Friday the 13th, (yeah I know right?!) I had an asymptomatic, low-grade fever while at work, 99.9 F/37.7C. I did not know I had a fever until we were routinely checking temperatures on all staff. Because I had a fever, even though I did not feel poorly, I went home. I also developed an ache deep in my central chest, that feels similar to when you step out into a very cold Vermont night after sitting in front of a warm fire; that kind of ache. And I have an occasional dry cough. These are all symptoms that are not common for me. I have been more tired than usual but that is a pretty non-specific finding- all things considered. I have not had a sore throat or body aches. And I am not sure if I still have a low-grade fever or not because I don’t have a reliable thermometer at home and all the stores are sold out. I should be getting a thermometer from Amazon today. In normal times, I would likely be back to work today. But these are clearly not normal times. On Friday, after a little bit of a runaround, and reconciling with my desire to be in denial (I have to confess to that), I was able to talk with a telemedicine nurse practitioner who recommended I get tested for COVID-19. I should also say, I have not travelled out of the US, nor have I been to areas of known higher outbreaks in my region of the US. However, it is no secret that US has been woefully and frustratingly behind on testing for coronavirus. Our low reported case numbers are much more a reflection of low access to testing, than the actual scope of the outbreak. But, I was lucky I did get tested on Saturday at a newly opened drive-through testing center. And I am now waiting for the results. After feeling very worried initially I am now, as of this moment, feeling a lot more optimistic. I hope I get the negative results back in the next day or so, and that I have no fever or other symptoms and that I am able to return to work any day now; because after-all, we do need all hands on deck from healthy healthcare professionals. Either way I will keep you posted, most likely via an email to my WLSP email list, which you can sign up for at my website, weightlosssurgerypodcast.com. Don’t worry, I wont spam you- never have, never will As far as when will my next podcast be and what will it be about? Well, as I mentioned at the beginning, I have an episode on Revisions that I will be publishing but honestly I am not sure when. Right now, even though the topic of bariatric surgery revisions is important, it does not currently feel particularly pressing. We are all playing this day-by-day, me included. When I pause for a moment and consider all the reasons I might break from monthly podcast episodes, a Global Pandemic was NOT one of those potential reasons. But here we are. Links to resources I turn to for evidence-based knowledge are in the shows notes to this episode which you can find on whatever device you are listening to this on and at my website, weightlosssurgerypodcast.com. If you have episode requests, especially those that at this time intersect between obesity and coronavirus feel free to email me your thoughts at [email protected]. And if you simply want to email me, please feel free to do so. Ill do my best to respond in a timely manner. POST CREDITS: I usually tell a kid joke or two in this post credits segment, but honestly even I am not in the mood to tell a joke right now. Rather, I want to remind us all of the wise words from Gandalf in J.R Tolkens "The Fellowship of the Rings" When Frodo said, "I wish it need not have happened in my time." Gandalf replied "and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us."