key: cord-0927837-eybfeu2d
authors: Congiusta, Dominick V.; Otero, Katie; Ippolito, Joseph; Thomson, Jennifer; Beebe, Kathleen S.
title: A New Role for Orthopaedic Surgeons: Ongoing Changes, Lessons Learned, and Perspectives from a Level-I Trauma Center During the COVID-19 Pandemic
date: 2020-07-30
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2020.07.020
sha: 79f85169e6ad95eb45485af08053e1451617e795
doc_id: 927837
cord_uid: eybfeu2d

Abstract The COVID-19 pandemic has redefined global healthcare. With almost 13 million confirmed cases worldwide, medical professionals have been forced to modify their practice to take care of an expanded, critically ill population. Institutions have been challenged to implement innovative ways to maximize the utility and the safety of residents and personnel. Guided by lessons learned from prior mass causalities, war, and previous pandemics, adjustments have been made in order to provide optimal care for all patients while still protecting limited resources and the lives health of workers. Specialists who are trained in the management of lethal aspects of this disease continue to have a high demand and obvious role. Orthopedic surgeons, with ill-defined roles, have been redeployed to manage complex medical problems. Still, the need to manage trauma, fractures, infections, tumors, and dislocations remains a necessity. Various innovative measures to maximize the utility and safety of residents in the inpatient and outpatient setting. Commonalities to most measures and distinct changes in practice philosophy can be identified and applied to both current and future pandemic responses.

Implicit in the lack of international preparedness for the current pandemic is the need for 26 clear guidelines for non-infectious disease specialists. Our goal is to provide a comprehensive 27 narrative using published literature, reputable news reports, anecdotes, and personal experiences 28 in order to provide a framework for the role of orthopedic surgeons in pandemic response and 29 highlight changes in practice philosophy. 30

The Need for Well-Defined Roles 32

Typically, orthopedic surgeons have protocols to coordinate with specialists as needed 33 regarding critically-ill patients. During surgery, residents, nurses, anesthesiologists, and 34

technicians work together in a large team to provide optimal care for patients. When obtaining 35 imaging, sufficient PPE and sterilization guidelines allow for safe transfer into CT scans and 36 MRI machines. There is often an abundance of resources, which hospital personnel can use to 37 safely care for patients, teach, and account for less efficient practices. 38

Lessons learned from mass casualty events, wars, and previous pandemics, however, 39 teach us that standard healthcare practices must be modified in times of crisis. When major 40 disasters occur, a transition is made from administering optimal care for all patients to providing 41 the greatest good for the greatest number of people. The path from the initial event to definitive 42 management involves the contribution of countless individuals, from bystanders to law 43 enforcement and those involved in transport, facilities management, triage, and medical care. 44

The surgeon's role is, unsurprisingly, at the triage and management end of this journey. From the surgeon's perspective in such a setting, the skills implemented in the operating room are 46 extensions of the skills used in everyday practice 27 . 47

Responding to a pandemic differs from military or mass casualty events in many ways, 48 however. Changes in surgical procedures have included the judicious use of negative pressure 49 rooms, extended periods of room turnover, the use of electrocautery at lower than usual settings 50 to limit surgical smoke, and the involvement of minimum necessary personnel during 51 aerosolizing procedures 4; 24 . Proper use of personal protective equipment (PPE) is of paramount 52 importance. A recent study demonstrated 90% of PPE use was incorrect, particularly regarding 53 the doffing sequence, technique, or use of appropriate equipment 22 . The need for training is 54 evident in order to maximally benefit patient care and minimize risk to care providers. 55

In addition to training, a chain of command must be defined. Decision-making during 56 times of crisis becomes more complex and, consequently, suboptimal outcomes may result. 57

Inexperience and chaos can lead to under-triage, but more commonly, over-triage is seen. When 58 critical decisions are made in the setting of limited resources and time constraints, health care 59 professionals err on the side of caution for fear of complications of delaying care. The decision-60 making process is accelerated, particularly when time available for triage and evaluation is 61 limited. This overcautious approach, however, is not without consequences. On September 11, 62 2001, for example, an unprecedented 95% over-triage at New York University Downtown 63

Hospital contributed to 44% critical mortality, demonstrating the devastating-and potentially 64 avoidable-effects of a lack of preparedness 23 . It is currently impossible to determine the 65 magnitude of effect current policy changes have on COVID-19. However, preparedness in the 66 future through working in pre-defined teams may mitigate the effects of future pandemics.

In the inpatient setting, emergency care of fractures, infections, tumors, and dislocations 71 cannot be discontinued. Trauma specialists support a large proportion of these patients. Non-72 trauma specialists, however, are being utilized to staff clinics during the week and ensure helmets and hoods help to maintain sterility and protect the surgical team from bodily fluids, 89 they should not be utilized solely as a means of PPE, as these helmets can actually pull and 90 condense particles within the hood system 9 . Proper use of PPE, as well as routine cleaning of ray machines, and keyboards, should be encouraged. It may be the surgeon's responsibility to 93 add this element to the routine preoperative checklists and "time-outs" performed before patients 94 enter the room 8 . 95 96

Guidelines suggest that services should be geared toward trauma care with maximal use 98 of telehealth technologies 16 . Telehealth is a tool for providers that has gained increased utility 99 with current social distancing requirements. Although available previously, concerns about 100 billing, insurance resistance, and patient privacy limited its widespread use 18 The predominant feeling among most healthcare workers seems to be that in times of 215 crisis, we must defer to the specialist most closely tied to that field and take a peripheral role if 216 needed. As in mass casualty events, it is often the trauma surgeons and emergency room 217 physicians who assume the role of leadership. In the current pandemic, it may be ICU and 218 respiratory specialists who designate roles, thus highlighting the need for leadership and the 219 explicit assignment of duties. The orthopedic resident may be most useful in obtaining ABGs, 220 ordering imaging, and performing bedside trauma procedures at the direction of others. In 221 surgery rotations and acting internships during training, a common question is asked -"What 222

can I do to help?" In the trying times of a pandemic, this once again becomes our mantra 223 wherever we are needed. 224

Several principles may be extracted from the changes orthopedic surgeons have made and 225 serve as a guideline for both current and future pandemic response plans (Table 1) 

is made to provide the greatest good for the greatest number of people-from an egalitarian to a 227 utilitarian approach to patient care. A surplus of critically-needed anesthesiologists, nursing staff, 228 PPE, or medical equipment is no longer available. The surgeon must therefore use medical 229 equipment sparingly, as well as anticipate and plan for a worst-case scenario. While the goal of care is never intentionally compromised, this balance of situational awareness and single-patient 231 focus differs from the standard mantra focusing on one patient at a time. 232

Often, delaying treatment must be considered to minimize disease transmission and result 233 in alternatives to the "gold standard" of care. To further minimize transmission, dedicated 234 elevators and hallways for transport of COVID-19 patients should be utilized, where possible. As 235 many hospitals do not have the infrastructure to make these changes, however, minimizing 236 patient traffic--and by extension, surgery--may be a viable alternative and further limit the 237 number of surgeries possible. Lastly, senior leadership has been advised to "lead from the rear," 238 in order to minimize the risk of infection of experienced clinicians 3 . 239 240

As in previous outbreaks, prominent feelings among healthcare workers include fear, 242 anxiety, stigma, anger, and frustration 17 . Resident and physician well-being is promoted, 243 however, through education, transparency, and camaraderie. Frequent opportunities for feedback 244 are encouraged among the administration. Having residents take part in the decision-making 245 process ensures that their concerns are addressed and promotes leadership among the team 14 . 246

Over lunch, residents and faculty have an opportunity to discuss life outside of the hospital and 247 connect on a lighter level in this setting or remotely with video conferencing. Stress-relieving 248 exercises and peer support, wherever possible, are integral to mental wellness. For some staff 249 members, just the knowledge of support may suffice, but all should be encouraged to seek it out 250 if needed 17 . 251 as removing clothes from home and keeping them in garment bags before changing into scrubs, 254 cleaning phones after care activities, and keeping phones in plastic bags during work. Removing 255 clothes and washing them upon entering home, reducing physical contact with family members, 256

using disinfectants with at least 60% alcohol content, and frequently washing hands are also 257 recommended 1 . 258 259

Our role in the fight of the COVID-19 pandemic is ill-defined. Many institutions have 261 instituted innovative ways to maximize the utility and the safety of their personnel, and there is 262 unlikely to be one "correct" answer. Nonetheless, commonalities to most approaches can be 263 applied to current and future pandemic responses. Our role may be limited, but that is not to say 264 we do not have a role. The willingness to move outside our area of expertise and help will 265 remain for future times of crisis. 266 267

References: 268

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