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 protected] with the subject line: TJTO&C.