Orthopaedics and COVID-19

Dr Manish Kumar Varshney

The COVID-19 pandemic took the world by storm and is seemingly unending in its vagaries. Most of the activities (service sector, social, personal, economic) have come to a halt due to the uncertainties in future progression, possible damage and fears of outcome of the disease and its ultimate impact. The service sector has been hit most badly amounting to huge economic and job loss. We still are not able to gauge the impact of current or possible future damage that may result from the COVID-19 pandemic virtually altering the service sector system, presently crawling at a slow pace to find its fate. Medical services is one such sector reeling under the turmoil of unexpected outcomes due to poor understanding of the COVID-19 disease itself, its behaviour and inability to formulate concrete guidelines that would serve to provide the much needed light in unending dark tunnel. This has also raised many concerns in the minds of patients who are unable to understand how to avail the medical services as the guidance from hospitals, Government agencies and doctors is patchy, scratchy and inconsistent. In all there is a lot of confusion. Let’s clear some of it here.
Doctor’s perspective, rationalization and providing services: Why is there so much confusion in hospitals and medical sector including Government agencies regarding making provisions for COVID-19 patient care or care of patients otherwise? The brief answer to this is – No one has ever encountered this disease or pandemic before so no one knew the extent of it and its real seriousness. There were quite contradictory reports from different nations about containment and seriousness of the disease ranging from very early containment in New Zealand to high mortality in European nations overwhelming the healthcare system. The doctors remained confused in the initial 2-3 months of the disease progression throughout the world. There were 4 different types of responses from doctors. First were “totally scared” of the disease and gave-up in the beginning fearing of bad outcome as if world is coming to an end and they will not serve till it gets over. The second group was “fearful but observational” that remained aloof from patient care expecting some solution in near future. The third group was ‘balanced group’ who quickly understood the behaviour of the pandemic and stated aligning to the disease with quick adaptation of re-furbished medical care. The “fourth group” was a rarity who believed the pandemic was farce and the last strata was the “under-pressure” group including general physicians and intensivists who were thefront liners in COVID 19 management and could not shun away from patient care from day one irrespective of which four thought processes they had as above. All these raised different voices partly adding to confusion. Over a period of time normalization occurred and fear mongers realized that the disease is not so severe while the extreme opposites started believing in the disease and need for precautions. Orthopedicians were not so directly confronting the disease but the services definitely got affected along with economic impact. Surgeons in private practice also feared loss of clients. These latter factors are important as it drew a strong necessity to resume work for some while slowly coming to truce with pandemic. Some eminent surgeons lost their lives while involved in patient care and that raised alarms. Similar news in allied faculty further raised fear levels. Lockdown further jeopardised the availability of implants used for fixation of bones and resources got constrained. After a lot of topsy-turvy moves rationalization prevailed and work seem to have resumed with improving SOPs atleast to calm the minds. I could continue work without break since the beginning of pandemic due to magnificent and rapid response by the internal COVID committee at SMVDNSH that devised SOPs and mitigation plans for management. This helped and streamlined the patient care providing resources needed for patient management. The OPDs are an important contact with patient. Mostly a contact for more than 15 minutes with COVID-19 positive patient at a distance less than 4-6 feet places one at risk of acquiring the disease (highly variable). Screen the visitors for COVID-19 like symptoms and travel history (this is becoming irrelevant with rampant disease presence). For suspected visitors follow COVID -19 protocol (chest X-ray screening and orange zone consultation – use complete PPE kit, a separate consultation room, dressing room and plaster room for patients and waste like dressing material, gauges etc. of suspected patients). For all others definite precautions are to be followed like mandatory sanitization before and after patient contact, using an ultra-particulate filtration mask like filtering facepiece-2 (FFP-2) or N95 throughout the contact period (better for the whole duration of OPD without touching/removing the same), keeping doors continuously open during OPD hours so as to minimise fomite contact (door knobs) and continue airflow so that dilution occurs in case of accidental positive visitor, additionally washing hands with soap in case of touching mask, wiping the surfaces with 1% hypochlorite solution twice during the OPD hours (four times a day for emergency areas). Respirator/ultra-particulate filtration (>95% of 300nm particles) masks with or without membrane valves are good for doctors but may not have positive impact for general population (patients included) as membrane valve masks may increase shedding of virus particles; pigeon type vs. duck type mask may be irrelevant however the former has been proposed to have better efficiency. Using PPE or absorbable material gowns is not recommended for OPDs. Online consultations are being promoted and considered fashionable but to be true they are good only to sympathize with patient and no better than a quack consultation as it involves lots of guess work and no clinical examination. This technology may be useful to triage new consultations and conduct follow-up or non-urgent post-operative visits in quarantined patients. Physical therapy (physiotherapy) involves mandatory patient contact so its use should be highly justified before institution. Fortunately, online resources are ample and can be aggressively instituted. Tele-rehabilitation should be encouraged for all non-essential treatments.
To summarize, aim of an orthopedic surgeon is to provide optimal treatment to patients with orthopedic problems along with ensuring the protection of the patient, himself, other health care workers and other patients with optimal use of health care resources. Doctors are the main brains behind understanding of pandemic so their opinion and attitude towards it will place the yardstick for others to follow. Resuming work only on the basis of economic impact and fear of losing practice should not be the guiding force. Optimisation of resources and modifications in the orthopaedic practice as above appears to be the balanced perspective to be continuously instituted without any breaks (especially unnecessary fears). This also implies selecting the most appropriate strategy to deal with pain and disability while considering patients’ comorbidities and expectations. In situations of clinical equipoise where both conservative and operative management are equally indicated it may be prudent to prefer conservative treatment.
Patient’s perspective and future possibilities of availing services: Patients have been big sufferers in the disease pandemic due to dual whammy from uncertain and rapidly changing administrative guidelines and non-uniform response from physicians due to factors mentioned above. Hospitals were considered hot zones for the treatment as well as transmission of COVID-19 (possible community transmission). Patients also had varying views primarily altered by rumors and unconfirmed reports. Some patients even did not come out of their doors, some avoided health care in the fear that they would be quarantined if they are diagnosed positive. Third were those who had emergencies that pressurized them to face their fear head-on. It is important not to believe in unconfirmed rumor and gossips. COVID-19 is expected to cover a very large population and hospital is not a place to infect persons, one must realize that if somehow infection occurs then hospital should not be just recklessly blamed. The healthcare services are available and open to all but some care should be taken. Companions to patients should be kept to minimum and ideally they should not be allowed, except for pediatric (or immature to understand clinical impacts), non-ambulatory and disabled patients. For trivial ailments and even long standing low-level pains one can visit nearby facility and avoid long travels. General precautions should be followed whenever visiting healthcare facility.
One should reveal the facts correctly especially travel history and symptoms instead of hiding them for larger society benefit. Keep the visits as short as possible and follow-up should be kept at minimum unless necessary. OPDs should not be crowded and one may insist for a bit longer treatment advice say 10-15 days instead of 3-5 unless required.This should be however balanced in a way that one does not take unnecessary medications for a longer duration unsolicited. I understand it is easier said than done but pains persisting for 8-10 days or pains increasing continuously over 5 days or pains with definite swelling or sudden onset unbearable pain involving whole limb or joint need evaluation by clinicians. Otherwise general pains that occur intermittently or keep changing their location in body or those that occur only with certain postures or vanish within 4-6 hours may be managed with simple remedies like fomentation and local ointment application. In all to conclude for patients’ perspective I would suggest that one should not look COVID-19 pandemic as end of world. Possibly the worst is over or is going to be over very shortly.
(The author is a senior consultant Orthopaedic and Joint Replacement surgeon with Shri Mata Vaishno Devi Narayana Hospital, Kakryal, Katra)