of delayed paediatric emergency presentations in which the parents of all cases reported avoiding the hospital due to fears of contracting COVID-19. Half of the children were admitted to intensive care unit and four died. 2 New York has experienced a significant decline in acute coronary syndrome presentations. 3 Similarly, delays in referral to surgical teams result from awaiting COVID-19 clearance as testing is performed on patients presenting with gastrointestinal symptoms as these symptoms have been associated with COVID-19 infection. 4,5 Similar effects were seen during the severe acute respiratory syndrome (SARS) outbreak at the beginning of the millennium. At the peak of the SARS epidemic, Taiwan saw a significant reduction in ambulatory care, inpatient care and dental care patients. 6 Fear of contracting SARS influenced people's willingness and choice to seek adequate medical care. 6 These concerns were reflected in cancer patients at the Taipei Veterans General Hospital, Taiwan, as 63.8% were afraid of visiting hospital during the SARS infective period and 36.2% felt SARS was more severe and fatal than their underlying cancer. 7 Locally, the impact of COVID-19 has led to significant changes in surgical practice. Non-emergency surgeries (category 2within 90 days and category 3within 365 days) have been suspended, protocols regarding intubation and extubation have been developed and the risk of viral exposure from surgical smoke in laparoscopic surgeries continues to be an issue of growing debate. 8 Acute surgical pathologies, such as appendicitis, usually treated by surgical intervention have been reconsidered towards medical management. 8 The COVID-19 pandemic has drastically changed medical practice worldwide and as focus remains on control of the virus, there are concerns over the toll on non-COVID patients. 3 Fear of contracting the virus will undoubtedly impact non-COVID patients seeking adequate and timely medical care. As face-to-face consults are exchanged for alternate reviews, such as teleconferencing, healthcare workers must consider its implication on adequate clinical assessment. The challenge lies in continuing to deliver optimum care to patients, when patients themselves are too scared to seek assistance in fear of contracting, what they perceive as a more serious illness. From the surgeons' perspective, bacterial sepsis left unchecked will result in death or require intensive care support, in a higher proportion than what has currently been seen with COVID-19 within Australasia. This message needs to reach the community, such that late presentations as described within this article are avoided.
While this method may well be too slow to gain widespread adoption, we hope this report encourages increased research into finding techniques with similar low leak rates.
A 59-year-old male of non-English speaking background with no known medical history presented to the emergency department with sepsis and confusion. He was tachycardic (120 bpm), hypotensive (90/55 mmHg) and febrile (38.4 C) with a large 15 × 13 cm left flank necrotic skin infection with crepitus (Fig. 1). Biochemical findings revealed leucocytosis (32 g/L), anaemia (haemoglobin 51) and C-reactive protein (230 g/L). Venous blood gas was suggestive of a metabolic acidosis: pH (7.39) and lactate (12.17 mmol/L). He
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