Previous TJTO&C Editorials are included below in chronological order.
The End of the Beginning
Published 30 June 2020
From its inception, TJTO&C was designed to be a rapid forum for ideas that could be expressed in the changing environment that accompanied the initial stages of the COVID-19 pandemic. It was intended to provide an opportunity to share these ideas and rehearse controversial opinions with rapid access to on-line publication, which would be unavailable in conventional journals. The large number of excellent articles that have been submitted and encouraging user statistics suggest that this is a useful resource.
We have shared essays outlining personal experiences, opinion pieces about our roles, advice on coping strategies and new approaches to contend with the crisis as it unfolded.
Current metrics suggest that the initial wave may be passing and we are now entering a new phase in this disease but it is not yet possible to predict the future beyond wild speculation. It is therefore perhaps time for a change in emphasis in our thinking, outlook and the continuing role of this journal.
Rather than encouraging more descriptions of ‘what we did’, which were of enormous benefit as the global implications of COVID-19 unfolded, it is now time to consider articles that predict the characteristics of ‘new normal’ and publicise plans to contend with the inevitable changes that are very likely to follow.We therefore encourage you to send us copy reporting ideas about the mechanism and practical difficulties required to return to non-urgent practice, strategies to overcome these challenges and the potential effect on patient care with the attendant ethical and moral imperatives.
We are also planning to change the name of the journal to reflect the changing paradigm and carry TJTO&C into the established publication landscape. We welcome suggestions for an appropriate title and advice on the direction of travel that would be of value to the orthopod on the Clapham omnibus.
In parallel with COVID-19, there are other rapidly evolving societal changes that demand an uncomfortable and far-reaching examination of cultural norms. This ties in with the BOA diversity initiative and we see the potential for using a journal of this type as a vehicle for expressing opinions on this and other contemporary topics.
Irrespective of the issues that have recently been raised about his world view, WSC is undoubtedly a tremendous source of quotations and the following is perhaps particularly germane;
“Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”
Published 03 June 2020
What is in a name?
You only get one chance at a first impression. It sets the starting point for any further adjustments that might be wanted. In the context of appearance and dress it is a familiar concept to which many pay attention; we dress for an exam, an interview, a first date, I even polished my shoes the first day of my consultant post. However, people pay less heed to first impressions when applied to language and concepts. The first to say a number in a negotiation on a price sets the scene, the boundaries are beginning to be defined. Terminology is the first impression we give of an idea so we should take as much care as on the first date. Once the wrong impression is given, no amount of explaining can retrieve the lost ground.
When are we to restart ‘elective’ work? I know what I mean by elective in this context but how do others understand it. Some words that we use in medicine tend not to be confused with their plain language counterparts, a good example is fascia. I recollect that as student when in the dissection room I asked an anatomy demonstrator what ‘fascia’ was as it did not bear much relationship to a car. It was explained that whilst difficult to describe, by the end of the year I would believe that I understood it. I did, and still do, I think? With a word like ‘elective’ there is a bigger problem in that everyone believes they understand it at the outset; sadly they just don’t all understand the same thing. Elective implies choice, in the context or surgery this can imply choice relating to necessity or timing. As a surgeon I have grown to understand that it predominantly refers to timing, but my understanding is no guide to the way the word is interpreted by others. We could do with another term, scheduled may be reasonable as it relates only to timing and not to need.
Why is this important? In the past we have all lamented the slow turnover in theatre as we take the opportunity for a more relaxed cup of tea. There was pressure but it was parochial within our own patch, we had our own theatre rights. However, take a look at the first chart in the ‘Charting the Progress’ it reflects the results of a survey of Clinical Directors. The findings suggest that to service the same number of Trauma patients now as pre-COVID-19 will take 60% more theatre time, 60% more surgeon’s time, 100% more anaesthetist’s time and 260% more scrub/anaesthetic assistant’s time. Should that be replicated across other areas of ‘urgent’ work then there will in effect be a resource famine. The presumption is that work will be done in order of priority, and indeed there is a prioritisation document to guide us here. This document is written for the equivalent of the ‘pleasant’ ATLS triage scenario when there is enough resource and it is just a matter of order. However, with resources as scarce as they may become there is the harsher triage scenario when not everyone will be treated and the overall societal benefit is considered. By labelling our patients as elective we have disadvantaged them in this negotiation should it occur. Pain relief, improved function and quality of life are the motivators for most of our work we and the patient organisations need to make sure they are adequately represented in and equitable distribution of resource.
There may be another first impression to correct. It is over two months since the Transient Journal of Trauma, Orthopaedic and the Coronavirus or TJTO&C first appeared. The word ‘Transient’ could have referred to the pandemic, the publication or just the title. Undoubtedly there is a change in the nature of these strange times, the lockdown is loosening, I can buy a new car and snooker has resumed but the pandemic is not over yet. We continue to receive an encouraging number of submissions for TJTO&C, so the concept of a rapid turnover online journal survives. However, perhaps it is time to change the name to something less Transient and more suitable to continue into the longer term.
The government’s COBRA is a great name, it seems to imply strength and cunning. A sense that when the going gets tough, the tough get going. It is a bit disappointing to find that it is named after the Cabinet Office Briefing Room A. Interestingly, the BBC described that Cobra meetings may occur for two reasons. The first is it (the government) is quickly getting to grips with a thorny issue of immediate national significance. The other is that something bad is happening and maybe they are to blame.
The BOA could use its own snake association for similar gravity in a new title for the online journal. Oddly we tend to read ‘BOA’ as three letters, whereas we could say it like the constrictor as ‘boa’. I suggest that we change TJTO&C to The BoaJ (The BOA Journal) but pronounced Boajay. Should anyone have a better idea then please let us know. First impressions count, the terminology is important. We must be wary of confusing timing with necessity when discussing surgery and when naming a journal it is best not to choose a title that will obviously go out of date.
Published 22 April 2020
We are in a situation quite unlike anything that we are used to. We are asked to and required to make decisions in circumstances for which we are relatively unprepared. The essence of the TJTO&C is that it is close to being live. The submissions may look polished, but a moments consideration of the content will make it apparent that the time from conception to publication is brief. This means that of necessity there may be a greater need for subsequent reflection than in a more sedate journal. There is therefore always going to be space for that response, debate and reflection. Last week’s submission from Swansea on SHiFT clearly prompted much thought and discussion, some of which is aired in the pieces that follow. The editorial is not here to judge, the opinions in the submissions are those of the authors not the editors’ or BOA. However, we do have our own opinions and will express them to entertain, pontificate, promote debate and occasionally inform.
As we all look at plots on a daily basis we try to discern whether we have passed a peak nationally or locally. We guess when lock down will be lifted and in what order, and when it happens what the response on those daily plot lines will be. There is increasing talk of the ‘recovery’, with some people seemingly fantasising that this will be a stepwise return to normal, but most are accepting that the term post-COVID-19 will come to have the same watershed significance as post-war. Things will not be the same, nor should they be. Our circumstances may be very different; if COVID-19 progresses from being pandemic to endemic then organisational and physical structures for delivering safe healthcare will have to accommodate this. We may have COVID +ve and COVID -ve hospitals. Surgical interventions in that new world may have different risks, real or perceived, which may change patients’ and surgeons’ attitudes. As in the post-war period, the post-COVID-19 era will be different not wholly by necessity but also as a result of the opportunity for change. In the natural world evolution seems to hit the accelerator after a natural disaster. For a brief period, the normal inertia of procrastination and foot dragging accompanying every innovation in the NHS may be suspended for long enough for the good ones to become established and persist. Who knows, it may extend to the BOA and the TJTO&C, with perhaps a different title, this may be one of those changes that persists after the age of the dinosaurs.
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 firstname.lastname@example.org 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.
Contributions should be sent to email@example.com with the subject line: TJTO&C.
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.
Contributions should be sent to firstname.lastname@example.org with the subject line: TJTO&C.