COVID-19 Rallies the Orthopaedic Community: Singapore’s Experience

The mind and heart of almost everyone on the planet are now focused to some extent on COVID-19. In the first of what will be a series of fast-tracked JBJS articles about how orthopaedic surgeons are helping mitigate the pandemic, Liang et al. describe orthopaedists’ early experiences in Singapore, where the first case of COVID-19 was confirmed in a tourist from Wuhan, China on January 23, 2020.

Singapore has had a nationwide outbreak-response system (called DORSCON, for Disease Outbreak Response System Condition) since the SARS crisis of 2003 (see Figure). Immediately after the first evidence of community spread of the virus on the island, on February 7, 2020, the Ministry of Health raised the DORSCON status to Orange, which triggered the following outbreak-control measures:

  • Ramping up of contact tracing
  • Mandatory 14-day quarantining of those in close contact with people who had confirmed infections
  • A 2-week mandatory leave of absence for healthcare workers with recent travel histories to China
  • Compulsory, twice-daily temperature screenings of all healthcare workers

The COVID-19-driven changes in orthopaedic practice revolved around 2 strategies:

  • Clinical Urgency
    • Musculoskeletal trauma and tumor patients were operated on as scheduled, but elective surgical cases were postponed to free up beds for confirmed or suspected COVID-19 patients.
    • Orthopaedists were encouraged to consider temporary pain-relieving measures (such as corticosteroid injections or nerve-root blocks) for patients with severe pain whose surgeries were postponed.
  • Patient and Healthcare-Worker Protection
    • Clinicians have been advised to prolong the duration between nonurgent follow-up appointments. All patients attending outpatient clinics are screened for risk factors and have their temperatures checked. Febrile patients are moved to the emergency department for further evaluation.
    • Orthopaedic teams wear surgical masks for all patient encounters and practice strict hand-hygiene practices.
    • When evaluating orthopaedic patients suspected of or diagnosed with COVID-19, all staff wear full personal protective equipment. Whenever possible, such evaluations take place in pressure-negative isolation units, and these patients are co-managed with infectious-disease colleagues.
    • If surgery on a suspected or confirmed COVID-19 patient is needed, it is performed by a dedicated orthopaedic contamination team; these teams are segregated from the rest of the staff to minimize the risk of cross-contamination.

Technology Tools for Training
Telemedicine and telerehabilitation have helped ensure the quality of patient care in Singapore, and technology is also being used to keep orthopaedic training going. Because all interhospital rotations and in-person combined teaching programs have been suspended, residency training programs are relying on videoconferencing platforms for scheduled teaching sessions. For trainees who engage with instructional videos or webinars, faculty members follow up with online discussions.

As residents take shifts in the emergency department to assist with COVID-19 screening, they learn important lessons in management of limited resources and “softer” skills such as empathy and teamwork.

Liang et al. conclude with this admonition to orthopaedic surgeons everywhere: “Stay vigilant even when reviewing low-risk elective patients; be champions of good hygiene practices, and be open-minded in the adoption of novel workplace technologies.”

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