Many scientists worldwide are engaged in predicting the course of the COVID-19 pandemic, but the exact nature of this disease and the “novel” virus that causes it remains largely mysterious.
The numbers of confirmed cases in media reports are dependent on the extent of testing, which has varied markedly from region to region in North America. The scientific community has cautioned policymakers not to rely entirely on “observable” data (i.e., testing-confirmed COVID-19 cases) because such measures are likely to under-report the extent of the problem. That’s one reason why orthopaedic surgeon Mohit Bhandari, MD and his colleagues applied machine-learning tools to estimate the number of “unobserved” COVID-19 infections in North America.
The authors’ stated goal was to contribute to the ongoing debate on detection bias (one form of which can occur when outcomes—infections in this case—cannot be reliably counted) and to present statistical tools that could help improve the robustness of COVID-19 data. Their findings suggest that “we might be grossly underestimating COVID-19 infections in North America.”
The authors’ estimates relied on 2 sophisticated analyses: “dimensionality reduction” helped uncover hidden patterns, and a “hierarchical Bayesian estimator approach” inferred past infections from current fatalities. The dimensionality-reduction analysis presumed a 13-day lag time from infection to death, and it indicated that, as of April 22, 2020, the US probably had at least 1.3 million undetected infections, and the number of undetected infections in Canada could have ranged from 60,000 to 80,000. The Bayesian estimator approach yielded similar estimates: The US had up to 1.6 million undetected infections, and Canada had at least 60,000 to 86,000 undetected infections.
In contrast, data from the Johns Hopkins University Center for Systems Science and Engineering on April 22, 2020, reported only 840,476 and 41,650 confirmed cases for the US and Canada, respectively. Based on these numbers, as of April 22, 2020, the US may have had 1.5 to 2.02 times the number of reported infections, and Canada may have had 1.44 to 2.06 times the number of reported infections.
The authors emphasize that the “real” number of asymptomatic carriers cannot be determined without widespread use of validated antibody tests, which are scarce. Bhandari et al. conclude that policymakers should “be aware of the extent to which unobservable data—infections that have still not been captured by the system—can damage efforts to ‘flatten’ the pandemic’s curve.”
During the COVID-19 pandemic, perhaps the luckiest among us are working from home (WFH), although doing so brings multiple challenges. On yesterday’s Scholarly Kitchen blog, Gabe Harp, Digital Products & Software Services team leader at the MIT Press, shared 8 hard-learned tips for sane and successful WFH. Whether you work in healthcare or some other field, you should be able to apply at least a few of these practical pieces of advice.
His “favorite and most earnest” recommendation: trim 15 minutes from all your meetings. But Harp saves the most important WFH reminder for the end of his post: be grateful for stable employment in a relatively safe environment, reliable internet, good health, and the many other privileges that much of the world’s population lacks right now.
Since the start of the COVID-19 pandemic, The Journal of Bone & Joint Surgery and our associated journals have received >175 submissions related to the novel coronavirus; we have accepted >40 of those manuscripts and have already published three-quarters of the accepted papers.
Due to the unprecedentedly large number of submissions, the only new submissions on this topic that we will consider for peer review and possible publication are those with scientific data and with a truly unique perspective on this topic. In this way, we will keep our readers informed with the highest-quality orthopaedic information related to the pandemic and keep our COVID collection relevant and useful.
We appreciate the efforts of current and future authors of accepted papers for providing potentially life-saving guidance for patients and orthopaedic surgeons during this pandemic.
Marc Swiontkowski, MD
Because of government mandates prohibiting elective surgeries, surgical specialties have been among the hardest hit economically during the COVID-19 pandemic. To reduce overhead, some orthopaedic practices have terminated or furloughed staff or implemented steep pay cuts. But as Powell et al. explain in the latest JBJS fast-tracked COVID-19 article, the pandemic presented a unique opportunity for Orthopedic Physicians Alaska (OPA)–a private, vertically integrated practice based in Anchorage–to transform itself, serve its community, and keep its staff employed and the practice afloat.
Alaska shut down elective surgeries in response to COVID-19 on March 19, 2020, and a statewide stay-at-home order was issued on March 22. While OPA leaders confronted the fact that, under those conditions, the practice would not be financially viable after June 15, the Municipality of Anchorage presented a partnership opportunity to OPA and other local healthcare entities.
Anchorage has a disproportionately large population of homeless people. On any given day in the city of 300,000, the number of shelter beds available is >400 short of meeting the demand. To help prevent COVID-19 deaths on a tragic scale among the homeless, the city emergently created temporary shelters, most of them, apropos of Alaska, in de-iced ice rinks.
But the number of available healthcare workers to staff those facilities was insufficient, so the municipality asked OPA and the other larger healthcare practices in the city whether they’d be willing to provide workers to support both existing and new shelters for the homeless. The proposed tasks were definitely not orthopaedic in nature, Powell et al. report. They included creating workflows for COVID-19 screening, establishing logistics for COVID-19 testing, and providing around-the-clock medical oversight at the isolation and quarantine facilities.
OPA said “yes.” With only days until shelter screening was set to commence, the staff and executive team went into full training mode. Meanwhile, contracts were signed with the city for OPA to be paid an hourly rate compatible with Federal Emergency Management Agency reimbursement for services provided. The surgeons in the practice agreed to assume all clinical orthopaedic duties so physician assistants and other clinical staff could serve at the shelters (see photo above).
OPA transformed an orthopaedic practice delivering musculoskeletal care to a focused COVID-19 healthcare entity within 5 days–while avoiding any furloughs. OPA staff are now screening 1,400 homeless and vulnerable individuals daily. Although the work is neither glamorous nor within the scope of a normal orthopaedic practice, the authors conclude that “cooperation with the Municipality of Anchorage has helped to flatten the curve for the community [and] keep the most vulnerable population safe.”
By definition, a pandemic is a global public health crisis. Consequently, along with reports from North American orthopaedists, JBJS fast-tracked COVID-19 coverage has included data from Singapore, China, Italy, and Portugal. The most recent report, authored by Askari et al., comes from Iran.
Iran announced its first report of COVID-19 on February 19, 2020. As of April 21, 2020, the country had >83,505 documented cases, and the Iranian Ministry of Health (MoH) had reported at least 3,739 deaths from the virus.
Two weeks after the detection of the first COVID-19 cases in Iran, the MoH sent an official letter to all health-care centers—governmental and private—to stop all elective surgeries. Some private-sector hospitals obtained permission to restart elective surgeries, but orthopaedic departments at all governmental healthcare centers saw and treated only trauma patients. Ironically, with self-quarantining in Iran, the number of traffic-related trauma cases has decreased because fewer people are commuting.
Within 1 month after the first official reports of COVID-19 in Iran, most private-sector hospitals completely stopped all their surgeries, and some started seeing patients online. All empty hospital beds were designated for the treatment of patients with COVID-19.
While most orthopaedic surgeons were sidelined from the operating room, the Iranian Orthopaedic Society (IOS) and its branches created multiple social media groups to maintain an open channel for the exchange of scientific ideas and to promote orthopaedic research. Meanwhile, orthopaedic residents, somewhat demoralized because of the cancellation of classes and hospital grand rounds, maintained a level of practical education through trauma surgeries and seeing patients in the emergency department.
The Iran University of Medical Sciences in Tehran is now holding online orthopaedic webinars to maintain orthopaedic education for residents and to exchange up-to-date information regarding COVID-19. In addition, the IOS and its subspecialty divisions have further maintained their case studies using e-learning platforms. However, there are large disparities across the country and among universities in the development and implementation of distance-learning programs.
Overall, Askari et al. concur with orthopaedic surgeons elsewhere in the world that the pandemic has shown that the role of orthopaedists can—and at times must—go far beyond “only tending to fractures.”
In response to the COVID-19 pandemic, an abundance of clinical orthopaedic information has been disseminated in a short period of time. Some of that has been compiled and commented upon here in OrthoBuzz.
On April 12, 2020, the editors of OrthoEvidence, led by Mohit Bhandari, MD, published a report of global recommendations that puts forth evidence-based principles to guide musculoskeletal care in the face of the coronavirus pandemic. The carefully referenced, 65-page report identifies pandemic-related best practices in outpatient care, elective procedures, urgent/emergent procedures, and peri-/postoperative care.
Nearly three-quarters of the 72 publications analyzed for the report were based on expert opinion and/or clinical experience; just over one-quarter were developed using evidence-based methods alone or a combination of evidence-based methods plus expert opinion. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, the report’s authors assign strength ratings for all the recommendations compiled in the review.
The detailed information is best digested from the report itself, but here is a summary of the report’s overarching recommendations for orthopaedic management at this time:
- Ensure patient and staff safety.
- Stay up-to-date about evolving clinical guidelines and your institution’s capacity issues.
- Prevent unnecessary use of personal protective equipment and make contingency plans for supply shortages.
- Schedule only urgent or emergent surgical cases.
- Perform only operative interventions that can be expected to have superior outcomes relative to nonoperative management.
- Convene teams to make decisions about definitive management in semi-urgent or controversial cases.
- Prevent unnecessary follow-up visits.
Most elective surgical procedures in the US have been suspended because of the COVID-19 pandemic, but orthopaedic surgeons continue to provide acute care, and some are being recruited to the COVID-19 “front lines.” Available evidence suggests that older individuals are at higher risk for poor outcomes with COVID-19. In addition, >90% of US orthopaedic surgeons are male, which is thought to be another risk factor for COVID-19 severity.
In the latest fast-track JBJS article on COVID-19, Jella et al. considered those facts when making a geospatial map of US orthopaedic surgeons aged 60 years and older (see Figure above). It turns out that 4 states among those with the highest quintile of orthopaedic surgeons ≥60 years of age are also the 4 states most severely affected by COVID-19: New York, New Jersey, California, and Florida.
The authors did not account for comorbid conditions, nor does their data indicate any direct relationship between older orthopaedic providers and their risk of contracting COVID-19. Nevertheless, Jella et al. make the following observations:
- The high proportion of older surgeons in areas of high rates of disease prevalence may increase their susceptibility.
- The risk of fulminant, possibly fatal disease in older orthopaedic surgeons should be considered in the setting of front-line COVID-19 work.
- These findings could provide a rationale for matching of critically limited personal protective equipment to higher-risk providers.
- The 5-zone before-and-after-surgery protocols described by Rodrigues-Pinto et al. “should be heavily considered if older physicians continue to operate in the midst of this crisis.”
- Implementation of telemedicine services will help minimize contact between older providers and infected patients. Also, older orthopaedic surgeons may serve an important role in resident training during this time, with various digital platforms currently available for remote education.
The authors are quick to add that “the present study does not imply that COVID-19 infection among younger providers is in any way less severe or less important,” nor does it “imply that any particular ethical position should be taken.” The authors emphasize that it is up to individual healthcare systems to choose which surgeons are deployed and in what capacity.
Orthopaedic surgeons are used to taking action—to fix, to heal, to relieve pain. But how are orthopods temporarily sidelined during the COVID-19 pandemic coping with inaction? In the latest JBJS “What’s Important” essay, Jonathan P. Keeve, MD answers that question candidly and compassionately.
“Watching the pandemic unfold, without the ability to immediately jump in as we often do, is an overwhelming challenge,” writes Dr. Keeve, who has ample experience practicing in resource-limited environments and disaster scenarios, including on the United States Naval Ship (USNS) Comfort off the coast of Haiti after the catastrophic 2010 earthquake. But even in those difficult settings, the wounds were visible, established triage protocols existed, and proven treatments were available.
COVID-19 is an entirely different entity. It’s invisible to the naked eye, and delivering the only proven treatment—supportive care—is becoming more difficult every day as hospitals struggle to keep up. In addition, as Dr. Keeve notes, “Every hour, this viral infection is taking down our nursing and medical colleagues, our compatriots, our first responders, and our brothers and sisters at the hospitals.”
Meanwhile, Dr. Keeve and many other orthopaedic surgeons sit on the sidelines, calling patients on the phone to check in on them and advise them. “To stand by is torment, but it is in the best interest of public health,” he writes.
To his healthcare colleagues on the front lines of COVID-19, Dr. Keeve says, “Please know that our hearts and spirits are with you. While [many] orthopaedists are not at the forefront of this battle, … like my colleagues, I remain ready to help in any way possible. For now, despite how difficult it is, that may require standing by.”
JBJS’s first COVID-19 article was about the experiences of orthopaedic surgeons in Singapore. The latest one also comes from authors in Singapore. Soh et al. focus on the impact the pandemic has had on spine surgery in that country. The authors emphasize the need to constantly review and adapt policies amid the moving target that the COVID-19 pandemic represents.
Here’s what the spine service at Soh et al.’s institution (a tertiary hospital and major trauma center) did during the first 6 weeks of the outbreak, which began in Singapore in January:
- Reduced elective spine surgeries by 50%, cancelling all spinal-deformity or revision cases and prioritizing minimally invasive and endoscopic cases that required a shorter length of stay
- Expedited all discharges with transfers to rehabilitation facilities to free up hospital beds
- Rescheduled all non-urgent spine appointments, such as those for acute back pain without neurologic complications
- Offered day-surgery nerve root injections to patients with intractable radicular symptoms
- Continued to receive and operate on emergency spinal trauma and tumor cases
As of April 7, 2020, Singapore instituted a series of heightened measures, collectively referred to as a “circuit breaker,” to further curb community spread of the virus. When the “circuit breaker” kicked in, the spine service again modified its practices. Regular operating and outpatient caseloads were further cut from 50% to 30%. Spine surgery was limited to instances in which a prolonged delay could lead to an irreversible deterioration of function that would negatively impact both the work status and quality of life of the patient.
Precautions during spine surgery are similar to those described by Liang et al for other orthopaedic procedures. Patients with confirmed or suspected COVID-19 and those with pneumonia and unknown COVID-19 status are operated on in a designated OR to avoid contamination of the main operating room and of other patients. In addition:
- Only selected equipment is brought into the OR to reduce the number of items that require cleaning after the procedure.
- The presence of health-care personnel is kept to a minimum to minimize exposure.
- The use of electrocautery is also minimized, with liberal use of suction to remove smoke and aerosols.
Soh et al. also address resident-training issues that were raised in an earlier JBJS fast-tracked article, urging that trainees be reassured they will not be penalized if called upon to modify or sacrifice their training for other responsibilities during this time.
The authors conclude with an acknowledgment of the emotional stress that accompanies a crisis like the COVID-19 pandemic: “During times of crisis, it is important to manage the fears and anxieties of our colleagues as early as possible,” they say. The orthopaedic community must “not forget to look out for one another and bear burdens for one another during this unprecedented time.”
If you are wondering how orthopaedic residents and attendings are being redeployed in the so-called epicenter of the worldwide COVID-19 pandemic, check out the latest JBJS “What’s Important” article by Sarpong et al. The voices therein come from 3 orthopaedists at Manhattan’s Columbia University Irving Medical Center.
To ease the anticipated burden on the ER from a COVID-related surge, Columbia’s orthopaedic department early on created a Musculoskeletal Urgent Care Center. But everyone realized they could do more, and ever since April 5, 2020, every available practitioner in the orthopaedic department—including attending surgeons, fellows, residents, nurse practitioners, nurses, physician assistants, medical assistants, and support staff—has been redeployed to areas of the hospital with unmet needs, particularly the ER and ICU.
The two resident authors, Nana O. Sarpong, MD, MBA and Lynn Ann Forrester, MD, say that when they reported to the ER, the pace there was as fast as ever, but it was eerily quiet because the majority of patients were intubated. Amid a feeling of “both palpable fear and determination in the room,” Drs. Sarpong and Forrester rounded as members of a newly formed ER-ICU Triage Team to help take care of COVID-19 patients who had been admitted to the ICU but had not yet been physically moved from the ER. After rounds, they obtained arterial blood gases from intubated and sedated patients, obtained chest radiographs, and helped transport patients when ICU beds became available.
Acknowledging that all health-care workers are now practicing near the edges or beyond the scope of their training to provide compassionate, high-quality care to patients, Drs. Sarpong and Forrester say their redeployment so far has emphasized that “we are a part of the broader medical community, and thus are inextricably linked to our colleagues on the front lines of this pandemic.”
A similar message comes from orthopaedic department chair William N. Levine, MD. He describes the early formation of a departmental Redeployment Committee, which reviewed the goals and needs of the hospital as well as the assets among among the orthopaedic faculty, taking into consideration their age and comorbidities, family health concerns, and other relevant information. Soon thereafter, to broaden the provider pool and minimize overall virus exposure, redeployed faculty from orthopaedic surgery joined forces with those from urology, otolaryngology, and ophthalmology.
Noting that most every physician cites a “calling to help people” in their personal statements for medical school, residency, or fellowship, Dr. Levine says, “Now we all have the opportunity to do just that.” Despite the emotional roller-coaster redeployment has engendered, Dr. Levine says, “The visceral gratitude demonstrated by our ER nurses, respiratory therapists, ward clerks, and physicians will likely have the longest-lasting positive impact on me from this pandemic.”