COVID-19 Conversation: Resuming Surgery Safely

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From the Field

COVID 19 Conversation: Resuming Surgery Safely

Our promise of improving health and dignity during the COVID-19 pandemic endures. We're helping front-line health workers stay safe, nourished and empowered to better serve their patients by providing life-saving supplies and equipment, as well as remote training to bolster their response. We’re also providing nutritional assistance, hygiene kits and virtual health services to support people and their health needs so they can thrive. If you can, when you can, help us keep our promise to care for children and create hope for tomorrow.

Now, more than ever it’s our charge to safeguard the health and well-being of individuals around the world. We’re building upon our expertise in delivering cleft surgery and care in resource-limited settings as well as our history of improving the health and dignity of those we serve.

That’s why we’re finding the most meaningful ways that we can support people and their health needs in the communities where we work, even when medical missions are postponed, care centers are closed, and the future feels uncertain. It’s in this uncertainty that our swift action is required, and we’re doing everything that we can to help patients, families, and countries as this affects them.

While we're still unable to provide direct patient care in nearly every place where we work, we're beginning to resume direct activity in places where health authorities have deemed it safe to do so. In late May, we were able to resume providing surgeries in Vietnam and Italy.

This “COVID-19 Conversation” featured a live question-and-answer session on the topic of resuming surgery amid the pandemic with Dr. Ruben Ayala, Operation Smile Chief Medical Officer; Dr. Domenico Scopelliti, maxillofacial surgeon, Operation Smile Italy and Smile House Rome; and Viet Nguyen, Regional Vice President of Development, Operation Smile Vietnam. The session was hosted by John Streit, our managing editor and writer; and Laura Gonzalez, our digital content manager moderated the audience’s chat and questions.

Click here to register for future COVID-19 Conversations and watch past events.

Event Transcript

John Streit: We'll go ahead and get started. I'm John Streit the Managing Editor and Writer for Operation Smile and alongside my colleague Laura Gonzalez, a Digital Content Manager. We spend a lot of our time following our COVID-19 response and, now, our phase back into activity around the world very closely. We're really pleased to bring our panelists to you today for a really great conversation on how we've been able to resume surgeries safely in both Italy and Vietnam.

We're really excited about that and understand the level of undertaking that that has transpired over the past several weeks to bring people to surgery that they need and deserve. My colleague Laura will be moderating the chat portion. Do you mind giving people a heads up on how they can engage?

Laura Gonzalez: Sure. Hi, guys, and thanks again for joining. There are two options for interaction. There's the chat and then there's questions. I encourage you to input in the “questions” category and then at the end, once we hear from Ruben, Viet, and Domenico, we'll go ahead and have a live Q&A portion.

John: Awesome. Alright. We'll dive right in. I'd like to introduce our panelists today.

We have Dr. Ruben Ayala, Operation Smile's Chief Medical Officer. Ruben is a physician and public health specialist from Panama with 25 years of experience with Operation Smile. He first became involved with the organization as a student volunteer and has served in many programmatic roles before reaching his current position as Chief Medical Officer.

He is also the current President of the Permanent Council of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care and represents Operation Smile in the Global Initiative for Children's Surgery, the World Health Organization's Global Initiative for Emergency and Essential Surgical Care and the United Nations Economic and Social Council. Welcome, Ruben.

Dr. Ruben Ayala: Good morning. Thanks for the opportunity.

John: Absolutely. We have Dr. Domenico Scopelliti, maxillofacial S=surgeon with Operation Smile Italy, and Smile House Rome.

Dr. Domenico Scopelliti: Hi.

John: Hi, Domenico. Dr. Scopelliti is the Director of the Maxillofacial Surgery Unit at San Filippo Neri Hospital in Rome. He has served on over 40 Operation Smile medical missions and also serves as a Director of Smile House Rome, a comprehensive cleft care center. He has served as the president of the Organizing Committee for the Roman Days on Maxillofacial Surgery, the President of SMORRL Hospital Medical School in Rome, Lazio District, and the Italian Society of Cleft Lip and Cleft Palate and is a select reservist of the Italian Navy. Welcome, Domenico.

Domenico: Hi, everyone.

John: We have Viet Nguyen … the Regional Vice President for Development and the Chief Representative for Operation Smile in Vietnam. He holds 24 years of experience serving Operation Smile in different positions and capacities and plays a vital role in the growth of the organization in the Asia Pacific region.

He's a longtime member of the American Chamber of Commerce in Vietnam, and currently is serving on boards of many Vietnamese student groups. Welcome, Viet. Thank you for joining.

Viet Nguyen: Hi, everyone. It's a pleasure being here with you guys today. Thank you, all the way from Vietnam.

John: I thank each of you for bringing your insights and expertise to the table, and thanks to everyone who's joining us today. We're looking forward to this. We'll dive right in. Ruben, our first couple of questions are for you.

In March, Operation Smile made a decision to postpone surgeries amid the COVID-19 pandemic. Could you tell us more about the factors that led to that decision? I know it was a very fluid and complicated emerging situation at the time.

Ruben: Surely, and to preamble that answer, I will just go back to two areas that I've seen historically in Operation Smile that made me really believe in the heart of the organization. One is the utter commitment to offering help to people with remote access or without the ability to reach that care. The other one is the huge safety culture that the organization holds around the world, and a commitment to implementing that safety as we roll out any interventions.

When we had to make the decision to halt activities, it was a difficult decision from the sense of we realized that we're having to stop things that people receive that they believe, and we believe, are hugely impactful on the lives and well-being of the children and communities. At the same time, when you look into the safety aspect, it was almost unavoidable. We feel it was the right decision at the time. Some of the things we wanted to do was definitely protect our patients, our volunteers, our staff, our partners, and our communities from the potential impact of COVID-19.

We saw the deteriorating epidemiological profile. The virus started to spread at a rate that really opened our eyes and it was right in front of us. We, normally, in order to achieve the goals of taking care of hundreds and hundreds of children, we end up mobilizing a lot of volunteers from the countries and from different parts of the world. We end up mobilizing communities and families to places where we can converge and offer intervention.

We realized that doing that, in the midst of the potential threat of an outbreak at that time, wasn't probably the right thing to do. We did not want to be responsible for introducing the virus either into a country or in the community, or worse, in situations on the country side, where they are already feeling the extent of the virus. The other part was the environment of the agent – the symptomatology of the virus from what was originally observed in China and as it spread to Italy, and other places.

Also, this was a new thing, this was a novel virus. The response from different countries and governments and leaders was fluid. They were changing situations, where countries deciding on responses with governments restricting travel, restricting specific transport for specific countries or populations, the way in which the quarantines were being put forward for those with either symptoms or potential exposure, which made us really believe that it was going to take some time to have a cohesive approach towards prevention.

Ultimately, it's just a desire that whenever we work with people in the communities to take care of children, we realize that we're coming together and using our time, our talents, our resources to do this together. We realize that countries were now having to face and communities were now having to face this new agent. We did not want to overburden or disrupt efforts in the preparation or response to COVID-19.

John: Absolutely. I know safety is one of the major underpinnings of this organization. It completely makes sense that we would want to contribute to that, how we can in the midst of the pandemic. Shifting back to the topic of cleft surgery, obviously, we want to keep people safe and prevent the spread for the virus, but cleft surgery is essential for those who need it. Could you speak more to why cleft surgery is essential? What factors are we taking into consideration when determining how we can resume surgery safely while COVID-19 is still out there?

Ruben: Let's just report from the fact that (since) the initial decision to stop up until this point, a lot has happened in a very short few months, which seem like an eternity to so many people, a lot has happened. There's now a lot of more awareness and knowledge about COVID-19. There's also a greater awareness of what we don't know, and we're actively trying to get answers every day, and even greater connectivity between providers who are trying to come up with solutions to some of the challenges that are posed.

Our initial response, which we believe fervently that it was the correct one. We believe that the conservative approach to even the resumption of activities is still the correct one, but let's also put things into context. This apart from the fact that the choice to not provide care to people, either surgery or comprehensive care, is not a benign one. Children are still suffering because of it.

We have to start asking the question of how much of that suffering can we overcome, or how much of that suffering can we alleviate in the short, middle and long term in the midst of challenges that COVID-19 poses to the world? The reality is that the longer we wait, the longer more children are going to have difficulty eating, speaking, there will be issues in their growth and development.

We also need to avoid the suffering that might come from issues such as malnutrition and all that it brings for children who are suffering from cleft lips and palate. The constant inner ear infections and upper-respiratory issues, stunting in growth – there's a plethora of things that, in the short term, you can probably say, "Hey, let's keep this on time." Over time, the longer you wait, the longer you miss the opportunity and truly help and the more likely you are to perpetuate the negative impacts of their suffering.

You're going to have to weigh the pros and cons and really start to think of what are the things that you can do. We need to step back from the all-or-nothing approach to one that is a bit more based on the knowledge that is constantly evolving and the awareness. Today, we have the ability to really start looking at the epidemiological data that is available for countries, provinces, regions and communities. We have the ability to look at the systems that have been able to be put in place to track and trace potential people exposed to the virus.

We have the ability to understand which areas, countries or communities have the ability to test and match up to the epidemiological profile of those communities and understand the predictive value of that testing. We have the ability to understand now a bit more about the ability of different countries to cope with an emergence, to cope with the potential resurgence, and whether our interventions do not take away providers from a potential necessary response.

We also have the ability to continue to strengthen our partnerships with local entities, ministries of health, departments of health, members of the private sector, members of the civil society to figure out a way forward. We also now have had a chance to look at human resource availability to offer assistance, and to offer guidance and support to our foundations at the local level and to get feedback from them as they're dealing with the challenges.

There's also the ability to provide ongoing surveillance. As we start some activities in different places, if we are committed to the surveillance, and we see some challenges coming our way, we should scale back just as we did before, having a very comprehensive review of the evidence for the improvements that we can put forward and are applicable in the context of the communities that we're working with.

All that to say is we can step back from the all-or-nothing response, start to understand what is happening in a specific area and use the arsenal of knowledge, of the ability to respond, the ability to prevent, and the resources that we can put forward to make a decision of how much of the suffering we can tackle in the short, middle or long term.

John: Excellent. Thank you, Ruben. That leads us right into Viet, and in Vietnam, where we've been able to resume surgery much further ahead of the curve than we would be able to in many other countries. That relates directly to all the factors that Ruben was just speaking to. Viet, in May and June, we provided surgery for 202 patients in Vietnam. That was our first surgical missions back since postponing, still, to this date, almost all of our programs around the world. You were the first ones to be able to get back in and provide surgery for children in Vietnam. We know you worked closely with the Ministry of Health to prepare for the mission last month. What were the factors that led to the decision to be able to resume surgery?

Viet: Well, thank you for your question. This is a great question. As you might know, we just resume our normal surgical activity about a month from now, a little bit more than a month. There was about more than 200 surgery that our medical team in Vietnam has been able to perform and bring in positive changes to these patients and families. To be honest with you, the first six months of, we call the COVID years actually is very challenging for all of us, it's not just for us here in Vietnam. I'm sure as for many of you into the other side of the world as well.

I think the reason we were able to step back and resume our activity in the country, there's different factors. I think the first factor that would allow us some confidence to get back into this work is we've been seeing a safe environment in the country. As you might know that in Vietnam, as of today, there's only 335 positive cases in the entire country since the pandemic was started, no deaths. There's no new cases in Vietnam for the last 60 days, which is close to two months.

Then, I think that the Vietnamese government, plus the Vietnamese people, who are actually using a lot of control measures. We immediately close the borders, preventing people from flying them from oversea into the country. We also make sure that everyone who's getting to or arrive into Vietnam is going to take 14 days in the camp for the quarantine and also have to self-quarantine for another 14 days at home. Everyone has to do the test for the symptoms of COVID-19, in case that they have contact with all the other positive cases. I think that the first factor actually allows us to go back and to resuming our work is actually will feel that we now have safe environments in the country.

The second factor is, I think, regarding the way that when the COVID pandemic has happened, it's changed everything in the country. It changed the way the world is thinking about an epidemic. It changed the way that people were working daily. It changed our habit. It changed everything.

I think that also leads to the fact that every single hospital in the entire country, these 1,400 hospitals in the entire country, had to change its ways of setting. Instead of just letting people to go in like normal, now we have to set up the isolation areas, it’s a must to provide the PPE for the doctor, the medical professionals working in the hospital.

I think that’s required the prompt action from every hospital in the country and also the prompt action from everyone who actually goes into the country. That means it creates a more than safe environment for us to go in if we resume our work with our partner hospitals in Vietnam. Some of the hospitals actually as requested by the Minister of Health of Vietnam, they have to turn the hospital to be ready or to be the COVID-19 hospital which is an additional requirement from the health sector or the Ministry of Health of Vietnam.

The third factor I think that's also allowing us to go back and work actually is, we strictly follow all the guideline from the Ministry of Health of Vietnam. We're hearing it, seeing this day-by-day, depends on the situation, how has it been progressing. Then the Ministry of Health of Vietnam will allow us and turn on the green light for us to go back and resume our work. That's how we were able to do the very first mission in May in Hanoi. Then because of all the successes that we were able to achieve for that mission, including the safety measurements, now we were allowed to continue with our second mission in Ho Chi Minh City.

It led to the fact that we were able to provide more than 200 surgeries for these people and (will) continue to do more in the next couple of months. The third reason I think is that actually from the Operation Smile perspective, also, I think that because the first six months, we would not be able to do anything. We focused on being safe, staying well, and taking care of ourselves, and sort of thing.

We foresee that the demand for this sort of surgery is still very high. Particularly, for this time of the year, it's the summertime, so people do not need to go to school, they're going to the finish the school year very early. People keep calling to our hotline and making sure that they ask when we're going to be able to resume our surgeries and our daily work. We consult with our Ministry of Health of Vietnam and our partners to make sure that we'll be able to bring them back with the … Ministry of Housing and …

Overall, I think that there's a couple of factors that we can simplify. First of all, it's positive progress. We feel safe. We strictly follow the guidelines, we're making appropriate decisions. We're actually doing a great collaboration with our in-country partners and also with headquarters of our Operation Smile in the U.S., and we did it at the right time. That's all the factors bringing us back into the resuming our work in Vietnam.

John: Amazing. Ruben, are there any countries where we're looking at resuming medical or education programs soon? Is there anywhere similar to Vietnam that we're looking at?

Ruben: Yes. China is another example where the government of Yunnan, which is a province in the southwest part of the country, has requested Operation Smile to restart its work with additional measures in place. They haven't had a COVID case in over two months other than what they would consider an important case. Their schools are open, they're coming back to the normal activities.

Yet, when we look at China, we watch the news, and you see that there might be some activity in Beijing right now in some concerns of the potential spread of the disease, which does make us really evaluate. At the same time, we put things in perspective, Beijing to Yunnan, we're talking about a distance of about 1,400 kilometers, which will be the equivalent of someone from Florida flying all the way to Bogota, Colombia.

We do have to acknowledge that there's potential threats, but we also can continue conversations with that ongoing monitoring on what can be done in a place where there hasn't been contagion of any magnitude and people are coming back and believing that we have potential ingredients to resume that activity. That's one. Morocco has resumed their activities at their centers – non-surgical activities in a very step-by-step version following some very specific protocols and quite strict guidelines imposed by the government, as well.

If we look at the epidemiological profile, there are no higher in cases – they are very close in than cases to the (profile) of Australia, for instance. In Australia, if you know, they have a bubble between Australia and New Zealand of traveling and communication. We have other countries such as Guatemala, Dominican Republic, Nicaragua and others who are looking to reopen their centers in the next few months. We're having really careful and thoughtful discussions about the projected activities, the level of activities, and how that may be impacted given the human resources and the need of the patients, the setup of the epidemiological profile of the places where they're located and much more.

Again, the common theme is we're hopeful, and we want to reach our children because we're committed to them and to their well-being, and at the same time, the safety component is critical for us. The same things that made us, at some point, halt activities are things that we will continue to keep in mind even as we look to reopen some of these activities as well. We are responsible to the communities and the countries but also responsive to the needs of our children.

John: Awesome, Ruben, thank you. Domenico, when COVID-19 reached Italy, I mean it was a really hard hit for your country, as we all know. And I know it deeply impacted the care you were able to deliver at the Smile Houses across the country, all four of them. Tell us more about how COVID-19 impacted that delivery of care when it first reached those really peak levels?

Domenico: Yes. You can imagine that here in Italy, we had to face the pandemic even three or four months before the western countries and maybe at the same time of some eastern countries. The impact in Italy was unpredictable, because we were not ready in terms of facing the emergency. That time was a very dramatic event that obliged us to immediately, in two days, reach the total lockdown of all activities. The public health system allowed us just to continue the emergency tumor (surgeries) and other services that are not possible to postpone.

The root activity, including the activity that we're running with the project that was Smile House in all the Italian territory, was blocked totally for two months. We have to take a decision, because as an organization that makes a program with the public health system, we have two options. Rest hands-on and wait until the finish of lockdown and suspend any kind of (checkups), but is not possible because you can imagine, it's not just surgery that we provide, but the entire path that follow the kids from the pregnancy until the end of growth. We take the responsibility of a wide range of patients and the families that we have to follow.

We took the decision from one hand to support the emergency of the pandemic even in the hospital where we have Smile House. Providing any kind of PPE, supporting the Civil Protection Agency with a donation and supporting our staff or volunteers that suddenly was involved in the treating emergency to face the COVID infection. The problem that we have, on the other hand, we provide the other kinds of activities, so video calls for speech consultation and for prenatal and pregnancy support for the family and supporting with other kind of activity of our group of volunteers and professionals involving the public health system in Milan, Rome, Vicenza and other cities.

On the other hand, we will help the doctors that are not routinely involved in emergency with training, because they have to face it, to do something that they are not able to do in their ordinary activities. We organized a training course online on the basic treatment of patients affected by COVID that was dedicated to volunteers and was online courses that benefited over 200 people.

We also did an international webinar on treating patients with antithrombotic disease for Operation Smile with our volunteers, Professor Salvatori from the University of Sapienza. It was an experience that was benefiting many, many, centers because, as they discover the pathogenesis of the COVID, was a dramatic change in treating those patients.

We also did a teaching course for the European Association of Medical Students and just to training and to maintain the attention on the activity of Operations Smile. And also, we also, five webinars on orthodontic care … for cleft patients and other topics that (our volunteers are interested in). For us, it's very important to continue training people and teaching them to create this national network that supports the Smile House project in the entire country.

The criteria, at that time, was just to have the time to realize the second phase, because during the emergency, we are projecting how to continue, because we imagine that the emergency will be over not soon – we hope that it should be soon. The project here is how to face a journey before the time of the vaccination, how we can run, how we can restart. I, very often, use a term of navigation, because when we describe our journey, imagine that we’re going to the point A to the point B and the COVID pandemic moved our boat to point C. The route is totally different. We have to project another route. We have to provide another way to rethinking the entire path to arrive to the point C. That is very important, because it's not a simple restart.

We have to consider a new way to face the problem. As Ruben mentioned, we have to be more careful in safety, considering the medical legal consequence, if we spread out the virus thanks to our activity. We have to protect the entire path and protect the patients, the family and also the medical staff. We have to create new criteria.

We have to respect our job, because we can't wait such a long time, because everyone knows that if you treat patients with cleft deformities, we have to respect them and to be on time. Timely surgery is very important, because if you do the right job at the right time, you reduce the risk of having functional consequences. It's important to respect that time because if we promise to operate all the newborn kids in the first years of age, we have to maintain our promise in any way, because otherwise we're going to have consequences.

When we re-project the new activity and restart with the activity, first of all, we have to block any kind of possibility that the virus comes in. We have to imagine a totally COVID-free activity as much as possible. Obviously to protect the 90% is very high aims that we would like to achieve. But normally, we can protect, because it is in the experience of hospital and that's treating patients with infection that there is a way to protect the people that work there and to protect the entire path that is selected, the area where the virus cannot spread out, cannot run away.

First of all is creating a specific area, COVID-free. That means every kind of test has to be performed outside of that area. Testing people, the general criteria even in the peak of the epidemic event, or in the phase two. The important thing is to maintain out, as much as possible, the possibility of (the contagion) in the safe area. That means that testing has to be performed before. In the criteria that suggest, all the epidemiology suggests that to test, tracing, and treating, and all these things have to be performed before the access of that area.

That if you test, reduce the risk of the people coming in with high potential infection that can be dangerous for the entire area. The second thing is to change any kind of DPI. The people that come from abroad and try to have access to that area, and normally even in this time, comes with their personal PPE. That means that they wear gowns or mask that they come from the home, but they can be contiguous in that journey that came from the house and before they have access.

We do the test, change completely … and we give them our personal PPE, and we save in a specific plastic bag all their personal items, their personal belongings, and any kind of things just to reduce the risk of contagion with the items that they carry before to have access. Then they have access in the waiting area, and one by one, have access to the ambulatory services.

This is for the ambulatory services and there's two different ways to go in and out, so it's not possible to go out from the same access where you come in. This is a different door or entrance, and the way out allows us to reduce the risk that you can bring out and in people. Even the doctors are obliged to do this kind of access. For the medical staff, they have to change every time their personal protective equipment every time they change patients. It's very important and even also the decontamination of the entire area is provided by the hospital, but there are personnel that are dedicated every time the personnel changes to provide another decontamination procedure before having access to another patient.

For the surgery, the fix is a bit different, because you know that there is scientific proof that if you treat patients, even asymptomatic patients but they're COVID positive, the surgical risk is very high. For all the patients that are going to undergo surgery, it will require a negative swab for patients 48 hours before the surgery day. We prefer to have the patients the same day as we have a negative results of the test in the ward. That allow us to have total control, because if the area is safe and the patient is negative, the access is correct.

Then the serological tests has to be performed. Even for the parents, the one parent is allowed, or the guardians, but just one (has the test) performed (because) it’s faster to have results. We oblige even to the parents to have the serological test before they have access to the hospital. Even during the recovery time, we oblige all the people to leave personal clothing and items in safety bags, so nobody has the opportunity to bring their own items, their personal belongings, into the area.

Giving personal PPE for patients and the other person and maintaining always the social distance even in the ward. In the ward, where we have normally four people, we have just two. In the rooms, when we have access to eight people, we accept maximum three or four. That is very, very important, because we consider even if it's safe and we follow any procedures for decontamination, it's very important still to maintain the social distance.

For the medical staff, we are adopting (safety measures for patients receiving other kinds of surgery) that require the use of drills or cutlery or other things that they produce aerosol. Aerosol enormously increases the risk, even during the intubation of the patient at the time at the start of a surgery. Even during the surgery ...

There is a specific helmet that was invented, first of all, from the orthopedist that you can see (here). This is a specific guideline suggested for anesthesia and for surgical staff, plastic surgical staff, maxillofacial, are produced by different companies. With these helmets, is this very full head-cover system with active air filtration to protect the clean room and provided the use of comfort.

It's very comfortable for the surgeon to wear this helmet, but it's very safe, because we don't have any kind of contact of external ambience and protected totally from any kind of aerosol produced during the surgical time.

John: Wow, it's amazing.

Domenico: Yes, this is very very useful. We have another personal PPE that I would like to share with you. It was invented for NASA, for the (International Space Station), and produce (hydrogen) peroxide and give a decontamination area 90%, 90% of decontamination from any kind of bacteria and virus. This is possible, that can use as a personal, you can wear and create a free zone, a safety zone of five cubic foot excluded zone around the head and protect and increase the protection of the normal mask. That is very usable.

Under this helmet, you can wear any kind of mask, because you are totally surrounded. We just use, as you'll see, a normal protective mask. You can also choose to not wear anything because you are surrounded by a shield that protects you.

John: I think it's really great to see that you're leaving no stones unturned in terms of safety for our patients. I think when we say that we have this commitment to the safety of our patients, their families, our staff and volunteers, I think everything you're speaking to just symbolizes, shows and demonstrates that commitment, Domenico. I'm sorry, I hate to interrupt, but we do need to move things along a little bit. Is there anything crucial that we're, we're missing from the things you're describing here?

Viet: I could add three small things that I think that actually is a great learning for all of us, it's not just for Vietnam particularly. I think that, we're thinking making early and decisive actions, taking early and decisive action is one of very important thing. As far as you know, when the very first cases was happening in the country, the government just really considered the COVID-19 as a major threat even before the announcement from the WHO.

I think that's one of very good learning for us because that's how we were able to control that a little bit earlier than others. They follow with different restrictions, a steering committee was set up (and created) sectoral responses plans … to cope with the COVID-19, so that's the first thing.

The second thing, the learning lesson for us, it's that we have a capability to verify the target and make it very serious without an exception. Any patients that contaminated with positive COVID or people in the same contact with COVID-19 patients will be immediately quarantined. All the treatments, actually, as of now are still provided free by the government. We set up point of entries for borders, airports … I think that we identify good targets and we set serious restriction without any exception.

The third thing is pretty much related to Operation Smile, I think that for the first time since COVID-19, you see people work together. Shoulder by shoulder, side by side to treat patients. All the doctors, regardless of where they’re from, what kind of specialty they are, once they get into the hospital, second to the situations that treating the patient with COVID-19, they treat them with dignity. They’re working side by side, working so well together.

They all see the patient that they never met. It’s a good reflection of the work that Operation Smile does, not just for Vietnam, but many other countries of Operation Smile around the world is we also would like to treat our patients, our children, people we've never met, but we treat them with dignity. We treat with the best service that we offer, with a good standard that the organization has.

I think that we underrate the fact that by working together, we will be able to make a difference. By working together, by involving people, we will be able to bring in and creating more miracles. That’s one, the reason why they are pushing Operation Smile in Vietnam, into the states that we have to work with our in-country partners and key stakeholders to resume our work as soon as the COVID-19 situation is getting better. That's led to the fact that we were able to do the very first two mission in the country. That's a good lesson learning for us.

John: Awesome, thank you, Viet. Ruben, one more question for you, and then we're going to kick into the Q&A portion. We know that around 70 emissions were postponed and that led to just under 10,000 patients waiting for surgery. How do we evolve to address the growing need moving forward? How are things going to change and how are we going to pivot to be able to, one, not only keep our promise to each of those patients, but also to be able to continue our work into the future?

Ruben: That's the challenge, right? I equate this to trying to land a plane on an aircraft carrier in the midst of a bit of a stormy ocean. You're going to have to really adapt and become very, very innovative and keep a huge amount of coordination and communication. If you hear any of the statements from Dr. Domenico Scopelliti and from Viet, you will quickly realize that even resuming activity does not absolutely equal business as usual.

Domenico looks like an astronaut. He might as well be getting ready for docking to the International Space Station versus doing surgery in that picture that you showed. The things that led to Vietnam, even being able to do that, were pretty significant. When we look into the future, how are we going to tackle the huge amount of need out there that is now getting backlogged?

I got a few things come to mind. One, because we had to realize we're going to have to make even bigger investments. We're challenged to acquire more resources because I might not be able to get our teams with a spacesuit in a low middle-income country setting but we do have the responsibility to offer them with protective gear that's required for them to do safe work and to remain safe themselves. That requires additional investments along with the plethora of other interventions and coordinate activities that we've mentioned before.

In terms of the innovative approaches, even the basic processes of offering care and standards now have another layer of how to do all those things and what guidelines can we follow to and what technology can we use to offer care in the midst of COVID-19. Operation Smile has this very, very robust Global Standards of Care, very, very detailed policies and procedures, and on top of that, we now have to create the guidelines that will allow and give answers some of which Domenico has been in a very detailed way of talking about, as you showed in the diagram of how they're rolling out interventions in Italy.

There's a greater number of partners and hospitals with whom we can engage. We're going to have to figure out a way to turn the equation of one plus one equals two into one plus one equals four. We're going to have to figure out a way to make sure that every investment we're making to take care of the children also as to the strengthening the health system. What can we do as we take care of children, increase the preparedness and the ability of respond that hospitals and entities have with investments in equipment and access to supplies and better access to training.

How can we use technology the same way? I don't know, 10, 15, 20 years ago, we wouldn't be talking the way we are talking today, but we have the ability to use technology to still reach out to patients and connect with them and offer ongoing assistance in specific disciplines that might not require a physical intervention at a given moment in time. It used to be that this benefit will only be in low resource environments. Now we see that in low-income countries, a lot of our patients have phones in a way that they didn't have before.

We now have access to the villages and the communities that are remote. How can we continue to engage with them? Better coordination between all partners of civil society as different organizations are focused on different activities and different goals. We have to be talking to each other and working with the hospitals that are our partners to better align the sequence of interventions that we offer and minimize any potential disruption out of having four or five different agendas that are integral to one partner.

We have to have a very strong relationship with the health department and our ability to connect our activities with the epidemiological surveillance of the entire country or region and even outward in areas where there's a need, and we might be able to offer some assistance.

You can keep going: community awareness and response. A lot of us, when we talk about care immediately it gravitate towards happening to the hospital, but care can happen at the community level. It starts with education and spreading really good scientific-based information, factual information that can be understood in a way that that can be understood by the communities to keep themselves safe or to know when to actually seek care. We can use TV, radio, phones, social media to continue to coordinate with health workers and community leaders to prevent some of the hardships of COVID and prepare for the goodness of the interventions we offer.

Anyway, I can keep going. At some point, we hope sooner than later, vaccines will become available. When that comes, what is the size of the programs that we can put together that would allow for us to still take care of the massive need with high quality, with great safety while we're minimizing the potential spread of an illness like the ugly one that we're dealing with?

A whole world ahead of challenges, but if we focus on that commitment to children, we would unavoidably become really innovative in how we address the challenge. We look forward to partnering with other organizations, to partner with governments, to partner with private entities, private to civil society and especially with the communities and the families and most importantly, the patients to see a way forward and an opportunity for all.

John: Awesome. Thank you so much Ruben and thank you to Viet and Domenico as well. We just so appreciate your insights and expertise and lending them to us on this call, this virtual event today. We're going to go ahead and roll right into our Q&A portion. I will let Laura take over from here.

Audience Q&A

Laura: Thanks John and echoing the thanks to you guys, our panelists, as well. A few folks have asked, "Will volunteers who come to medical missions be required to quarantine for 14 days before starting that mission?" This was from Sarah, who I believe is from Vietnam, then also Diana. Maybe Viet, on the missions that you hosted, were the medical volunteers required to quarantine beforehand?

Viet: As of now, with the restriction from travel and everything, the mission we've been conducting is pretty much a local mission type of thing. We're using the in-countries medical volunteers, so they don't have to be in the 14-day quarantine because they don't travel. However, they have to strictly follow all the guidelines and the restrictions from the hospital and also from the Ministry of Health of Vietnam.

For example, the very different thing that we have to do right now is if, in the past if we do the mission, we will gather about 100 patients and families. There's few hundred of them at the hospital. Right now with the situation, we'll only be able to bring in each and every day about 10 to 20 patients to the hospital every day. We have to do the screening process as usual, more time, but actually that's a very good way for us to bring the safety to our patient, family and also to our medical volunteers.

We tend to use the medical volunteers. In the past we bring in a mixture of volunteers from different hospital in the country. As of now we tend to use a one team from one of that hospital only. Then we're also asking people who actually follow to the hospital they need to do the travel history the correlations even within the country, so we know where they've been to. Then they have to declare in the form.

Right now, you even download the app and you can do it from your phone as well. The hospital requires you to wear masks and keep a minimum social distance with people. As of now, you don't have to be entitled 14 days of quarantine unless you traveled from overseas into Vietnam. We're not fully open yet. Just for a few cases that they come in, they will have to do 14 days of quarantine, and then also follow another 14 days of stay-at-home, quarantine at home. For the local mission we're using our 100% of our local medical volunteer and professional so you don't have to be doing that.

Laura: Thank you Viet. Then Ruben, I'm going to direct this one at you. This is from Ricardo, a pediatric intensivist in Brazil. He's wondering about the basic life support and pediatric advanced life support credentialing process that all Operation Smile volunteers must have. He says that in Brazil and other Latin American countries, this credential can be quite expensive. Considering that all of the missions for this year in Brazil and potentially until January 2021 in Brazil will be postponed, will there be changes to the volunteer credentialing process when we are able to resume surgery or can you speak to that topic at this time?

Ruben: Yes. That's great, Ricardo, thank you for that question. A couple of things. We're having certain communications with the American Heart Association as one of the authorized entities to roll out the training. We realized that if we're looking at the American Heart Association, they have given us an effective way of extending the credential period for volunteers who already have the credentials.

The whole purpose is to maintain safety. I think that if a year from now we were to able to restart and we haven't been able to offer the maximum amount of training certifications that we had, that we normally would and we would have to, A, look at the risk of those type of gatherings and training but also, B, be really aware of the historical pattern of performance of some of the incredible leaders and volunteers that we have around the world.

If we have from anesthesiologist or intensivist or people who have performed outstandingly as so many of them do, to tell them you cannot take care of a kid because you don't have this clause at this stage, it becomes another challenge, another barrier. Remember that when we instituted PALS and ACLS and BLS as a safety measure were in excess of what was already being required by the current certifications and training that all these providers have.

I would be hard-pressed to tell someone like Ricardo that you can't help us take care of a kid who's in need because I can't offer a pediatric advanced life support certification. We have to really, really be thoughtful and at the same time as an organization, we would have to recommit to offering Ricardo and others the opportunity to get certification at the earliest possible time.

I hope that answers it. Again, there's some evolving and being trained but some of this knowledge through the certifications gets fine-tuned but as providers, we realize that experts like Ricardo and others are very aware of this knowledge and this knowledge that doesn't go away.

Laura: Yes. Ricardo has said, "Thanks, and send my best to Ruben and Viet." I think you answered his question. Following that similar tune of events, I just wanted to again thank you, Ruben, Viet, and Domenico for lending us your expertise and for sharing the learnings that you've had from resuming surgery and patient care in your countries. To our audience, thank you all for joining. We will be sending a recording of this event in the next day or two. As always just reach out to us if you have any questions. We're here to help. Anything else to add guys?

Ruben: No, just a huge thanks to you.

Viet: Yes, we want to thank everyone for joining together on this.

Ruben: Yes, and for accompanying us on the journey of trying to figure out a way to going back to taking care of children.

John: Absolutely.

Laura: Perfect.

John: Thank you so much.

Laura: All right. Thank you, guys.

Viet: Thank you very much, you guys.

Domenico: Bye.