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.”
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.”