Introduction

Never before has the current generation of health care providers seen the dissemination of an infectious disease so devastating and widespread as the COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Initially affecting residents of Wuhan, China, in late December 2019, COVID-19 rapidly spread to every country on the globe. The consequences of this rapid spread, leading to patients with significant symptoms (particularly respiratory dysfunction or failure) to seek medical care in hospitals which, in normal circumstances, were already functioning at capacity. This surge of acute ill patients put a significant stress on the already overwhelmed health care system globally [1].

Despite the fact that no health care system was prepared for an event of this magnitude, hospitals and health care systems have started implementing measures to increase capacity to triage, test, cohort, and provide critical care services following current local guidelines, specific for each country or region [2, 3]. As occurs in any other pandemic or mass casualty event, some patients with regular medical and surgical problems still require medical care. Many of those medical or surgical conditions may be treated at a later time when the pressure of COVID-19 eases; an example may include a myriad of general surgery problems treated electively [4]. To that end, many specialty societies have published their recommendations regarding postponement of what is considered “regular” or “elective” care [5, 6]. However, emergency general surgery conditions and trauma cases still require immediate assessment and timely resolution.

While disease specific guidelines have been published recently by many organizations, few recommendations have been made “by surgeons to surgeons” on the preparation of perioperative environments to support prompt care to emergency general surgery and trauma patients in times of COVID-19.

In response to a call from the Editor-in-Chief of the European Journal of Trauma and Emergency Surgery and the leadership of the European Society of Trauma and Emergency Surgery (ESTES), we develop this manuscript to inform Acute Care and Trauma Surgeons around the world about essential steps to prepare the surgical services of a hospital during these trying times.

The manuscript is a collection of measures implemented by front line surgeons in their health care facilities, regardless of being endorsed by governmental agencies or professional organizations. Some are real life lessons learned “on the spot”, as many of us try to respond to the best of our ability to this pandemic. The content of the manuscript was approved by the ESTES Board and none of the authors reported any conflict of interest related to the manuscript.

We hope these measures and recommendations will help surgeons all over the world to lead in times of endurance and difficulty, and yet preserve and sustain adequate care for critically ill emergency general surgery and trauma patients.

Recommendations for perioperative preparation

See Tables 1, 2, 3, 4, 5, 6, 7, and 8.

Table 1 General recommendations for surgical services
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Fig. 1
figure 1

Chest X-Ray of a symptomatic patient on hospital days 1 (a), 3 (b), and 5 (c). Note the rapid progression of the pulmonary infiltrates over time

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Fig. 2
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Chest CT Image of an asymptomatic patient presenting with a strangulated hernia. CT findings immediately led to patient cohorting in COVID-19 unit post-operatively

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Table 2 Emergency surgery for critically ill COVID-19 positive or suspected patients—preoperative planning and case selection
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Table 3 Operating room (OR) setup
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Table 4 Patient transport to the OR
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Table 5 Surgical staff preparation
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Table 6 Anesthesia considerations
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Table 7 Surgical approach
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Table 8 Case completion
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Final comments

Surgeons will be asked to serve and lead during this pandemic. Maintaining our commitment to surgical patients is our obligation. We must maintain the same standards that we follow every day when treating patients in the trauma center or in the emergency department with surgical problems during these difficult times. No one believes it is easy to do, but it is our duty and our call. The best way to assure the public that we will be there for them, regardless of the circumstances, is to be prepared [17]. Learning from the experiences of many others and following the principles of personal protection, we will keep ourselves and our patients safe.