By William J Nasha, Obi Nzeakob and Aaron Sainic
aSt Mary's Healthcare, Portland, Maine USA
bUniversity of Toronto, Ontario, Canada
cTygerberg Hospital, Cape Town, South Africa
Published 11 June 2020
Introduction
As the COVID-19 virus makes it's impact felt around the world, it is clear that the impact at home has been significant. There has been a significant knock-on effect to the trauma and orthopaedic services across the UK and surgeons in training have had their training interrupted and been placed in stressful and overwhelming situations as part of redeployment to the front-line1. Here, the authors describe the training impact and personal experience of being a training fellow overseas during this pandemic.
William Nash: Post-CCT Foot and Ankle fellowship, Portland, Maine, USA
I undertook a 12 month post CCT fellowship in foot and ankle surgery in Maine in New England in the US. Starting a little late in late August due to visa delays I have been busy since with two full Operating room days and three clinic days per week since. The practice is largely elective with some specialised foot and ankle trauma. Janet Mills the Governor for the state of Maine put the state into lockdown on March 15th 20202. Maine’s centre for disease control (CDC) reported the first death in the state on March 27th 2020 after 155 positive cases3. At the time of writing this at the beginning of June there have been 2181 cases in the state with a total of 95 deaths, only 35 patients remain hospitalised across the state4.
From the point of lock-down on-wards, I have been supporting the postoperative patient cohort and seeing emergency cases in clinic only (trauma, diabetic feet etc). This has effectively changed the working week to one and a half clinic days with reduced patient volume and a half day of emergency operating. We are beginning to increase activity and return to elective working although with restrictions on patient numbers due to physical distancing requirements in out clinic spaces. I estimate that three months worth of clinical experience from the fellowship will be lost which will equate to some 100 surgical cases. However, with regard to my employers they have been incredibly supportive in maintaining my salary for this period despite furloughing healthcare staff in lots of areas, asking salaried surgeons to take a pay decrease for the period and use their annual leave. In our healthcare system we have had very few cases and no staff have been asked to work outside of their speciality to support the emergency department or medical teams.
On a personal level I am here with my wife and young twin boys in a moderate sized two bed condominium. Our children were enrolled in a co-operative nursery school four mornings per week. My wife who does not have a working visa was volunteering one day per week at the same nursery. Schools closed city wide on 16th March 2020 and the children have been keeping in touch via a daily zoom based 'circle time' each day. We are lucky that we have outdoor space for play although we have experienced snowy weather episodically through April and into May, what is referred to as 'mud season' here in Maine. While several state parks have been closed there are abundant trails and woods for hikes and bike riding and some beaches remain open. We remain in contact with our friends and family at home through video and meeting platforms.
Like millions around the world we all experience loneliness and isolation. We do not feel especially threatened by the virus itself as we are all luckily healthy and the outbreak has been limited here in Maine. We are also lucky that we have been well supported by the organisation that employs me both financially and on a personal level. I am unsure what would have happened to our visa status had I been furloughed which could have led to an abrupt and complicated return to the UK at the height of the pandemic.
Obi Nzeako: Post-CCT Upper extremity and trauma fellowship, University of Toronto, Ontario, Canada
I left London towards the end of a blissful July in 2019. I came to the University of Toronto in Canada to commence an Orthopaedic fellowship in Trauma and Upper extremity. Full of hope and zest I brought with me my pregnant wife and my three year old daughter. The summer was like a fairy-tale. This vibrant city welcomed us with open arms. There were festivals every weekend, the sun burned bright every day and Canadians just seemed to be happy, all the time! My team were delightful, my bosses were supportive and the residents were eager. It didn’t take long to get busy. I worked for two very well established surgeons, who took on all manners of orthopaedic trauma. They also ran a tertiary referral practice that included the complications of trauma (non-unions, bone loss, infections, periprosthetic fractures etc.). Before my arrival I had not appreciated just how large the province of Ontario actually is. Almost weekly we received complex trauma cases flown in from elsewhere in the province.
My personal schedule usually involved three to four days per week in the operating room with one to two days of clinic/admin/teaching. It was an almost perfect fellowship. With a great variety of routine and interesting cases and knowledgeable and supportive bosses, one of whom was an official doctor to the Toronto’s Major League baseball team the Blue Jays. This meant lots of free tickets. Sadly, like all around the world, this dream was quickly dismantled. As talk of COVID-19 began circulating in early 2020, the threat became very real to Canadian officials seemingly early in comparison to the US and the UK. Many of my colleagues still gave raw accounts of their experience fighting SARS in 2003. Toronto had been a hotspot, but they reacted quickly and without hesitation to the new threat of COVID-19.
On March the 16th Canadian Prime minister Justin Trudeau announced a lockdown. The borders were closed to international travel apart from/to the US initially and all public gatherings were prohibited. Though Canada had approximately 700 confirmed cases only at the time, Prime Minister Trudeau’s statement left no room for interpretation. This was an emergency and I will never forget this line, in his statement to Canadians, “let me be clear, if you are abroad, it's time to come home”5.
Like elsewhere, hospitals were drastically reorganised. ICU capacity was increased, operating room ventilators were repurposed, junior surgical staff were re-deployed to the emergency department and the critical care units. Focus shifted to use of personal protective equipment (PPE) and religiously tracking numbers of confirmed cases. Elective surgeries were cancelled indefinitely, with no certainty to how long this would last. Guidance and protocols were evolving rapidly. Fracture clinics were reduced from around 70 patients to approximately 20 patients, with the majority of consultations taking place over the phone.
Fellows were placed onto a two week on two week off schedule to minimise the risk of exposure or falling ill (meaning a 14 day quarantine as a consequence). Surgeries were limited to emergencies and trauma cases that could not be managed non-operatively. For most fellows this actually meant one day of operating per week, with most clinics even cut to Staff (consultant) run clinics only. Needless to say, for two and half months this decimated training for the residents and fellows. Furthermore, most of the surgeons within our department including the Canadian fellows were employed on fee for service contracts. This means they bill for surgeries and patient interactions. Their entire salary is linked to how much they are seeing and doing. As an international appointment, I was placed on a salary, and fortunately this has been honoured by the department. Sadly many of my colleagues are facing financial strain. Some of my colleagues have pregnant spouses, young families and one of which has recently just bought a home in the city. Much of the discussion now is about how to keep afloat. We are now beginning to re-introduce elective practice and there is a glimmer of light at the end of the very long tunnel. On a further positive note, early and decisive action seems to have effectively ‘flattened the curve’ in Canada. We did not actually find ourselves inundated or overwhelmed as we had planned for, and the death toll is much smaller than what has been reported in the US or in many parts of Europe. I look forward to restarting some level of normalcy, and now find myself planning a complicated return to the UK.
Aaron Saini: Post-CCT Limb Lengthening and Reconstruction Fellowship, Stellenbosch University, Cape Town, South Africa
I left London on the 22nd February 2020 with a mix of excitement and trepidation to take up a fellowship in Limb Reconstruction at Stellenbosch University, Tygerberg Hospital, Cape Town. Travelling with my wife and 1-year old daughter, we soon settled in, and I commenced work under the supervision of a Professor of Orthopaedic Surgery for bone tumours, infection, reconstruction, and lengthening. The department is a tertiary referral centre with a catchment population of over 3.5 million. The burden of acute trauma is significant, with an average of 600 admissions per month during normal service.
There were less than 10 COVID-19 cases in the United Kingdom and no deaths when we left. I feel embarrassed about how naïve I was, with a feeling that our ‘system’ would control the situation, and considered the real problem to be someone else’s, far away. When we arrived in Cape Town, I was surprised to have my temperature taken and laughed at the taker’s joke when he asked if I had been to China or had eaten any Chinese food recently. There were no cases in South Africa at the time. Over the next weeks the situation seemed to mirror that in the UK, but with a time lag in terms of the numbers and deaths. However, our respective lockdowns started at almost the same time, giving a feeling that in South Africa we were somewhat ahead of the curve.
The service delivery of our department has been restructured; clinics have been reduced to see urgent cases only, and all elective sub-specialty specific lists have been cancelled. However, our clinical lead has worked hard to attempt to maintain the overall theatre sessions available to the department, resulting in one to three full lists per day as well as a 24h trauma/emergency theatre. The registrars’ timetables have been restructured to allow maintenance of our service, while allowing a rotating group of them to remain home and work on research and to be called in should their peers require isolation. Further to this, two have been reallocated to the Intensive Care Unit, and although this currently represents less than 10% of the total, this number is likely to increase. Every speciality in the hospital has been allocated slots in the COVID-19 screening and testing area, and our interns and registrars also cover these.
Given the urgent nature of much of my team’s work, particularly that involving malignancy, acute infection, and complex trauma, our workload has not significantly decreased. This, coupled with the reduced effective workforce, means my training opportunities remain abundant, as does my overall surgical exposure, attending theatre 3-4 days per week. The remaining time is spent in limited clinics or partaking in the extensive academic and research activities within the department.
The lockdown here is one of the most stringent in the world; in the initial stages people were not permitted to leave the house for exercise or to walk a dog, and a complete ban on the sale of cigarettes and alcohol. The measures appeared to have worked initially, stifling the rate of increase, allowing preparation within hospitals and the wider health system. However, numbers in terms of new infections and deaths appear to now be increasing exponentially, and it may seem counterproductive that we are now reducing many of the lockdown restrictions. This has been necessary for a number of economic reasons and the blunt reality that many South Africans are starving either as a direct or indirect result of the lockdown. As put by President Cyril Ramaphosa, "Lockdown cannot be sustained indefinitely, our people need to eat"6. How and if the country's healthcare system will cope with the anticipated surge in cases will be revealed in the coming weeks.
My colleagues have been extremely supportive, clearly mindful that my family and I are in a new country at a difficult time. The airport and borders were closed at short notice, and it is unclear when international commercial flights will resume. We have natural concerns about our family, friends, and previous colleagues back home, and the inability of us to be able to return in an emergency. Regardless, we remain in good spirits and with the hope that as time goes by the country will recover, the fellowship will become even more fruitful, and with a progressive reduction in restrictions we will be able to see more of this beautiful country.
References
- Gonzi G, Gwyn R, Rooney K, Horner M, Roy K, Boktor J, Kumar A, Pullen H. Our experience as Orthopaedic Registrars redeployed to the ITU emergency rota during the COVID-19 pandemic. The Transient Journal. Available at: https://www.boa.ac.uk/resources/our-experience-as-orthopaedic-registrars-redeployed-to-the-itu-emergency-rota-during-the-covid-19-pandemic.html.
- Gov. Janet Mills, (2020). Proclamation of State of Civil Emergency to Further Protect Public Health. Available at: https://www.maine.gov/governor/mills/sites/maine.gov.governor.mills/files/inline-files/Proclamation%20of%20State%20of%20Civil%20Emergency%20To%20Further%20Protect%20Public%20Health.pdf.
- State of Maine Department of Health and Human Services, (2020). Maine Records First Death of Individual Who Tested Positive for COVID-19. [press release]. Available at: https://www.maine.gov/tools/whatsnew/index.php?topic=DHS+Press+Releases&id=2293683&v=dhhs_article_2020
- State of Maine, Department of Health. Novel Coronavirus 2019 (COVID‑19). Available at: https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus.shtml#situation
- Lilley B, (2020). ‘Trudeau to snowbirds: 'It’s time for you to come home'.’ Toronto Sun online. Available at: https://torontosun.com/news/national/trudeau-to-snowbirds-its-time-for-you-to-come-home.
- Rondganger L, Mlambo S, (2020). ‘President Cyril Ramaphosa eases Covid-19 lockdown measures.’ IOL. Available at: https://www.iol.co.za/news/politics/president-cyril-ramaphosa-eases-covid-19-lockdown-measures-47107428.