Previous TJTO&C Editorials are included below in chronological order
Published 21 April 2020
An Orthopaedic Surgeon is a ‘Someone who modifies a procedure the first time they try it’ was an observation shared with me by theatre staff. As my mother told me “many a true word is said in jest”. However, in this case that truth does not apply only to surgeons but is a part of being human. Tools are used by various species, some very similar to ourselves. Tool lineages in chimpanzees show that the same tool is used unchanged for generations. The archaeology of tools in Australia shows that those used by native Australians blossomed rapidly from a common source into a multitude of variants. It is one of our great strengths as humans, allowing is to adapt to the circumstance in which we find ourselves.
However, that creates a problem with guidelines, protocols, codes or whatever they are called. We have a natural desire to nuance, improve and re-invent them, which can be destructive. This can be overcome by good old fashioned discipline, and with the right structures in place this will work. The military can implement a new behaviour or practice more rapidly and consistently than a civilian group. Where that inherent discipline is less secure I believe a different approach is required, it can be considered in the context of PPE.
There needs to be sufficient logic in the presentation of any guidance to allow not just the blind following of instructions but also an adequate understanding. This will ensure that any subsequent re-interpretation to deal with local circumstances will be more predictable and follow a logical progression. The PPE guidelines are written for groups, which include many who are used to scrutinising text; should they identify flaws in the logical progression of the arguments and advice this undermines the intended message.
Every medical action should have a purpose. That purpose should not be implicit but explicit. So what is the purpose of PPE in the current crisis? Is it to protect the health of the individual using the PPE, the patients they are treating or for some general societal gain? They are very different. If we believe we are doing it to protect ourselves from a more severe manifestation of COVID-19, this introduces fear into the balance. If not, then we are doing our bit for the good of all. To help us understand this we need to be given some information or at least share the beliefs of those writing the guidelines. Crucially in relation to Coronavirus, clarity on two points would help: is there a relationship between the size of the inoculum and the severity of the disease, and is it believed that however we behave, the great majority of us will have COVID-19 in some form over the next few months.
In some viral illness there does seem to be a relationship between the infecting dose and the severity of disease. Should that be the case with Coronavirus, we can consider who and under what circumstances the greatest inoculating doses occur. Should there be no relationship of illness severity to dose, then presumably the severity of an individual’s illness is down to their host factors. This latter would imply that I am likely to be just as ill if my exposure is as an anaesthetist with a difficult airway or due poor social distancing in the queue at the supermarket. This brings us to the second question; barring complete isolation, is it presumed by those doing the planning that we are all going to get it at some stage? Thus, if no dose relationship and we are all going to get it, then the purpose of PPE is only to control the timing of our own illness and the rate of spread.
Those charged with guiding us through this crisis are being guided by science. Colleagues are trying to read the runes to advise the politicians. Predicting anything from a model is naturally based on assumptions. I have been involved in NICE guidelines and have sat through the careful economic analyses of our recommendations. But human endeavour is a tricky thing to quantify. How does the cost of a cemented hemiarthroplasty or a long nail for a hip fracture in a 97 year old balance against the chance that that person will raise over £20 million for the NHS two years later. Major Tom Moore is both an inspiration and a lesson to us all. The lesson being to make us think carefully how we treat that most common of trauma admissions, the hip fracture, in these difficult times. This matter is debated further in the TJTO&C this week.
The lockdown continues but its relaxation is anticipated. We are turning our newfound proficiency with Zoom or Teams to talk of the ‘Recovery’ or a ‘Trauma Tsunami’. Wondering how either can be dealt with whilst only operating on two cases per day. Submissions resolving these and other problems would be welcome. As ever send to email@example.com with the subject line: TJTO&C.
Getting the Priorities Right
Published 06 April 2020
The TJTO&C is gaining its own identity. There wasn’t a great strategic plan at its initiation beyond creating a readily accessible forum and hoping that words would flow. Thankfully this has been rewarded by a wide variety of submissions.
In the first editorial I referred to the Hitchhikers Guide to the Galaxy, whilst possibly a little light-hearted for our current dilemma I still believe the Book has something to offer. ‘Don’t Panic’ were the words on its front cover and I borrowed them to put alongside the title of the TJTO&C. At the time it seemed ‘neat’ just as in the Book, but I continue to think it appropriate. One of the consequences of emotion interfering with decision making is a tendency to either freeze or go off into random undirected actions. Whichever happens the result is a cessation of useful activity.
How do we address or pre-empt difficult situations? We think, argue, reflect, plan and then write endless guidelines, protocols, codes, advice sheets etc, etc, etc; we have a lot of these. But, we know better than that. Some years ago Atol Gawande wrote the Checklist Manifesto and documented the thought behind and the rise of the WHO checklist; it is a brilliant book. In it there are extensive references to checklists in other walks of life. Should you be building a multi-storey office block, a highly detailed itemised checklist is necessary to ensure smooth satisfactory progress. For instance, specifying order of actions; the cooling system on floor 26 is to be installed before the walls so that you can actually get in. This is a methodical approach in a controlled environment suited to a clipboard bearing obsessive. However, the checklist to help us when things are rapidly going wrong needs to be quite different. Just a few items, Gawande suggests four or five, not to cover every detail but just aimed at resolving the situation. Taking the example of that for pilots he notes that the checklist does not itself fly the plane, you (the pilot) have to keep doing that. So the number one item on their checklist is advice not to neglect flying the plane.
Based upon this I believe there is an equivalent for a health service, I suggest:
- Keep treating patients
- Decide which patients to treat
- Assess / increase resources
- Repeat cycle
Whilst the checklist itself must brief the explanatory notes are allowed to be longer. So why ‘Keep treating patients’ as the first line? This is first as there is otherwise the risk of freezing or being distracted, the result being that treating patients stops. Whilst some people should be doing the thinking the rest of us should be doing the doing; and initially that doing can be relatively close to normal. In the current crisis many places are now beyond this but by no means all.
Whilst observing point 1 we can initiate point 2. We should now consider which patients we should treat. In the current crisis there can be a momentum either planned or unconsciously evolved to concentrate solely on the COVID-19 patients. We all want to do our bit for the huge effort to manage those of us unfortunate enough to become patients requiring hospitalisation with that disease. However, that should not obscure a proper global discussion of which patients to treat. Heart attacks, strokes, triple A’s, hip fractures etc will continue to occur and deserve a balanced consideration for their care alongside the COVID-19 patients. There are difficult comparisons to make, but with finite resources they must be made. Currently the most precious resources for surgical patients are a theatre and an anaesthetist. Using a theatre to ventilate one or two patients for 14 days has to be weighed against the societal benefit of 14 days of time critical surgery being carried out.
Point 3 is to concentrate the mind on having full knowledge of and addressing shortfalls in resource. Having done that, just like we were all taught in ATLS go back to the beginning and make sure we keep treating patients. The objective is surely that at the end of this crisis we will be able to look back and believe that we did our best to treat to best effect the maximum number of patients be their major problem COVID-19, heart attack, stroke, triple A or hip fracture. We don’t want to look back and see that despite all efforts when we look at the whole patient population that there was unnecessary morbidity and mortality in the non-COVID-19 groups.
The national effort is quite rightly motivated by the needs of the COVID-19 patients. The national emotional response is naturally focussed on these patients and we risk being swept along with this to the extent that professional judgement is skewed. However, we have a duty to provide the best overall outcome the circumstances allow considering all patients. For T&O this translates to two obvious tactics firstly not treating patients unnecessarily, and secondly when treatment is required carrying it out with minimum impact on the rest of the service. However, there is a final point that for our time critical patients we must be their advocates to secure for them neither more nor less of the resources than they merit. For our patients the pinch point is theatre and anaesthetics. As a surgical discipline we need to be involved not just at the beginning of an individual day assessing priorities within the resource we are given for the next 12 hours, but strategically in the allocation of those resources. Whilst difficult triage decisions may unavoidable for some locations and for some periods, we should not accept them as a new norm. Whilst all doctors should be prepared to stand up for all patients, there is no doubt that in each speciality we should continue to be for advocates for those we know best.
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Published 26 March 2020
What a difference a week makes. As highly trained professionals we like to feel that we have some control, now like people everywhere we realise that we are being swept along by events.
The 42nd anniversary of the Hitchhiker’s Guide to the Galaxy was last weekend. In the Book’s introduction it was noted that although ‘although it contains much that is apocryphal or at least wildly inaccurate’ that it had advantages over the standard texts in being slightly cheaper and having the words ‘Don’t panic’ written on the cover. In these times of stress the new TJTO&C can have a similar relationship with the more established JTO. It is a transient online publication to fill a gap in the market.
There is much happening both to us and around us. We are thrown together by a communal threat and our response to it, and yet in so many respects we are more isolated. That ‘We are all in this together’ is a cliché, but with our social distancing we are indeed all in this apart. The TJTO&C as a transient online Journal will be published as frequently as there is sufficient material (so possibly just once). The content should be at least one of, but hopefully more of, informative, thought provoking and entertaining. As with any Journal it is the sharing of relevant ideas and insights which is the main and laudable objective, however, in the current circumstances there needs to be scope to sweeten the pill of knowledge with some content of a more responsive, lighter and looser style.
I suspect that the camaraderie evident in some around us as they pull together for the common cause may mask the worry and loneliness of others. We know that there are physical risks to be faced over the ensuing weeks and there is much being said about their mitigation. Indeed, as practical people it is our tendency to focus on those tangible problems. But, there is also mental anguish; the daily tussle with yet another teleconferencing App or the squabbling over bandwidth with the other victims cabin fever in a locked down home. Don’t succumb to the temptations of binge watching just because you have taken out a new subscription. Don’t maim yourself in an ill judged attempt to deal with the suspect guttering that has bothered you for ten years. Instead, write something for your colleagues. Success will depend on submissions, 500 or so words of wisdom should be the target. Do bear in mind that TJTO&C will be on the BOA website which is open access.
This first edition sets the scene for those to follow. The four articles are all reactions to the current crisis. The inclusion of the ‘Transient’ in title is an acknowledgment that what anyone writes today may seem dated by the end of the week, if not the end of the sentence.
We must accept that the face of T&O is changing to combat Coronavirus. In one instance at least this change is not just figurative but literal. The result for me has been thermally disappointing but does allow an excellent seal with the PPE.
Write something to inform us and to cheer us up.
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