By Namal Perera
Foot and Ankle & Major Trauma, St George's Hospital, London, UK
Published 13 May 2020
Six weeks, the widely recognised orthopaedic unit of time, have passed since the UK lockdown in response to COVID-19. It seems an apt moment to reflect on the situation so far, looking at the changes within one orthopaedic department and how we adapt to the coronavirus threat. The following account may help other institutions reflect on their own reaction and then consider how to move on…
Week 1 (23rd – 29th March): haematoma and inflammation i.e. early preparation and acute response
Like the body, always pre-primed with its white blood cells, cytokines and stress hormones, the hospital preparation has been under way already. Increasing COVID-19 admissions have drawn in the staff from all quarters to respond to the trauma. It’s a mass of neutrophils, growth factors and other cytokines rushing in to complete their roles. All staff are familiarising themselves with the new environment, training in use of personal protective equipment (PPE) is the priority. A daily COVID-19 boot-camp is up and running for testing clinical scenarios. And remember bone, whose marrow provides blood components for the long-term fight, B-cells for immunity. One knows things are serious when seven orthopaedic consultants are seen receiving basic ventilator training.
As the organism focuses on the injury, non-essential functions wind down: elective operating was suspended the previous week1.
With regards to the trauma, prioritisation is more important than ever. How to cope? All patients are presumed to be COVID-19 positive. A shift to non-operative care, with management of possible complications at a later date, is acknowledged by national guidance. Actual operations, however, take longer and are more uncomfortable for everyone wearing PPE inside the theatre. Pre-op briefing, a pre-WHO-checklist check, takes double the time. It’s all quite painful.
What about the brains? Credit must be given to Clinical Leads as well as to a military colleague with the mind-set for logistics under tough conditions. There is a coherent plan for deployment of personnel, resource allocation and escalation. We feel well organised and ready.
Week 2 (30th March – 5th April): early reactive phase i.e. coordinated mobilisation of resources to ‘tidy up’
Just as macrophages enter to clear up the clot, removing fibrin and debris, orthopaedics has moved quickly to sort out the situation. Standard operating procedures are created and refined. Remote access and regular Teams meeting are rapidly established.
A new emergency rota is in place: three teams of consultants (to cover all subspecialties) rotating on site during the long days. We manage our own elective clinics and other duties remotely during ‘off-days’. I believe macrophages have other roles too. Normal job-plans were far preferable but the new rota brings clarity and structure in uncertain circumstances. And a hands-on orthopaedic consultant led service yields immediate benefits in all clinical areas, especially since many orthopaedic junior doctors have been re-deployed elsewhere…
Week 3 – 4 (6th – 19th April): organisation and early repair i.e. ‘differentiation of staff’
The early reparative phase may have started but the organism is still injured. COVID-19 cases continue to ramp up. The country has closed down. Everyone in the hospital anticipates the peak. The Prime Minister is admitted to an ITU in the City. Swelling is not confined to the fractured bone, the entire limb is affected.
Team Orthopaedics has knuckled down into new routine. Having lost the majority of junior staff to ITUs and the wards (is that ‘de-differentiation’?), there’s a new matrix being formed. One in which orthopaedic consultants attend medical ward rounds to refresh old knowledge and do discharge summaries, conduct regional trauma planning meetings and engage in sourcing PPE. Proning teams have been trained, organised and deployed2. Orthopaedics has allocated a consultant to lead proning on ITUs each day, with twenty-plus patients being turned to improve their ventilation on one particular day. At least it’s also a time to catch up with our registrars, doing sterling work in an unfamiliar specialty. Throughout the hospital, people have adapted to new roles and gone the extra mile to ensure there is no further fracture.
So thankfully, the hospital has maintained capacity. It has not been overwhelmed. The situation appears stable; primary callus has formed so the hope is that osteoblastic differentiation will lead to solid healing. All the elements of the staffing body have come together to create this fragile stability as the new tissue forms.
Easter weekend arrives and goes but, as there is no distinction between weekdays and weekends and no prospect of any holidays, it is barely noticed. Free Easter eggs, distributed around the hospital, did help lift spirits along with many other public and corporate contributions. Extra calories are always appreciated as the body recovers.
Weeks 5 – 6 (20th April – 2nd May): late repair phase i.e. start of hospital remodelling
Acute, COVID-related workload starts falling. With less ITU proning work and an abundance of doctors covering such wards, the shift in focus changes towards delivering best possible care to non-COVID-19 patients. Within the confines of coronavirus conditions, the department must concentrate on managing our more urgent elective waiters.
General talk surrounds firing up the normal work of the hospital. Well, the ‘new normal’ as there is widespread agreement that new protocols are needed and the system may never be the same again. Greater emphasis is placed rightly on the safe delivery of care within our specialty. Eager to return to operating and to wind down this emergency schedule, we hope for measured central guidance and an efficient local response. The reactive and repair phases are over.
At six weeks, most fractures are healed enough to allow return to more normal function. Remodelling is a longer phase and rehabilitation can be a painful process. It requires a realistic plan, determination and forbearance. As a department, hospital and society, it’s time to start that rehab.
- Houston J, David Smith D, Nguyen A, Puntis M. Proning in COVID-19; What, Why, How? A Brief for Orthopaedic Surgeons. The Transient Journal. 2020 April. Available at: https://www.boa.ac.uk/resources/proning-in-covid-19-what-why-how-a-brief-for-orthopaedic-surgeons.html.
- Stories from the coronavirus frontline – Repurposing an orthopaedic centre into a COVID-19 ITU. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. 2020 April. Available at: https://www.boa.ac.uk/resources/stories-from-the-coronavirus-frontline-repurposing-an-orthopaedic-centre-into-a-covid-19-itu.html.