Orthopaedics in a resource-poor environment: A personal view

By Fergal Monsell

Fergal “Cassandra” Monsell
The Grand Academy

Published 30 March 2020

You can choose to look the other way but never again can you say that you never knew.” (William Wilberforce)

I am in no immediate danger and write this in comfort, growing weary of the coping strategies that have become popular to assist in understanding what confronts us. In common with many others, I have used speculative actuarial science to confirm my very considerable chance of survival. I have become a self-professed expert on all matters virologic, epidemiological, and ethical and have even had a brief look at the fluid dynamics of ventilators.

I have attempted to be of some use in advising others on how to navigate through these strange times by contributing to sensible guidelines but am prompted to put some of my darker thoughts to paper, on the understanding that I very much hope that this vastly overstates the extent of this pandemic.

This is an unevidenced, entirely personal take on what I believe will be necessary, in spite of a Health Service and a Nation that is responding magnificently, to overcome the situation as it unfolds. Front-line health workers have been elevated to national hero status and whilst we are not in their ranks, we have a vital role to play in supporting them.

The primary goal for orthopaedic surgeons of all denominations is to protect available resources. This will assist our colleagues in critical care and improve adult mortality during the COVID-19 crisis. We must, however, also provide urgent care for our orthopaedic patients and a successful outcome metric will be the lowest sum of adult mortality and non-infective (including orthopaedic) morbidity.

To do this we must accept temporary societal damage due to a lockdown for an indefinite period and also accept that the changes needed to our practice will cause orthopaedic morbidity. We must do as much as we can, for as long as we can in a landscape that is changing by the day and accept that there will be non-infected casualties of the pandemic.

This will be stressful, as it will fly in the face of the orthopaedic catechism but we have a small window that allows us to prepare intellectually and emotionally for what we will confront as orthopaedic surgeons.

The BOA COVID-19 guidelines were constructed to mitigate a theoretical 80% reduction in available resources. This advises on how to strip everything down, managing immediate life or limb threatening cases, stratifying the remainder according to potential long term consequences. This needs informal updating because of the continuing exponential increase in prevalence and rapidly mounting death toll and we would be wise to prepare for a scenario in which >95% of activity will stop for an unknown period.

We will be obliged to return to management algorithms that would have been familiar to our grand-parents and consider managing osteomyelitis with splintage, analgesia and oral antibiotics and reduced to managing septic arthritis with needle washout and oral antibiotics. Open fractures may require an awake washout and stabilisation in a windowed cast or with an external fixator applied under local anaesthetic. Femoral fractures (including neck fractures) may require home management in a fixed Thomas' splint and everything else will be managed in a cast.

We must fundamentally change our mindset to fulfill this supporting role and remember that whilst the 9th circle of the contemporary inferno is being made ready for looters, profiteers and hoarders, there will be plenty of space for the self-serving and unprofessional. We will of course do our absolute best but we should bear in mind that how we behave will be remembered when they are sending out invitations for the victory parade and probably for considerably longer.

As is customary in these troubled times, I hope you stay safe and well.

Fergal Monsell

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