LETTER TO THE EDITOR

 

Why is there an orthopod in my ICU? - An orthopaedic perspective during the COVID-19 pandemic

 

 

McAllister J^I; Smit R^II

^IBSc, MBChB, FC Orth(SA); Midlands Orthopaedics, Hilton Life Private Hospital, Hilton, KwaZulu-Natal, South Africa; email: james@midorth.co.za
^IIMBChB: DA(SA), FC Orth(SA); Midlands Orthopaedics, Hilton Life Private Hospital, Hilton, KwaZulu-Natal, South Africa; tel: 083 448 9121; email: rianwsmit@gmail.com

 

 

We are a practice consisting of two orthopaedic surgeons working in private practice in Hilton where the first South African case of COVID-19 was reported on 5 March 2020. Isolation of Patient Zero at the designated government facility, Grey's Hospital, was swift and aggressive. The patient's general practitioner (GP), the pathologist who did the diagnostic nasal swab and other close contacts were all quarantined. Public response varied from anxiety and fear to an indifferent 'It's just like normal flu'.

New South African cases slowly started increasing and the national lockdown started on 26 March 2020. We expected a surge of cases as community spread became more prevalent but there were no new cases diagnosed at our institution's COVID-19 testing facility between 27 March and 25 April. Monday 1 June saw our first patient that required admission. At the time of writing, on 15 July 2020, there are 42 cases admitted to the hospital with confirmed COVID-19, all elective surgery cases have been curtailed, the surgical ward has been turned into a general COVID-19 ward, and ICU is at capacity utilising anaesthetic machines as extra ventilators.

We are fortunate to have four intensivists and a large anaesthetic practice that manage three of the ICUs across Hilton and Pietermaritzburg. They anticipated the surge and proactively recruited help across the medical fraternity. During lockdown, the intensivists provided tutorials on basic ICU management, all well attended by GPs and specialists from all disciplines. They planned for a shift system that would include willing non-ICU doctors. Day shift spanned from 08h00 to 20h00, night shift from 18h00 to 09h00.

1 July saw a sudden increase of COVID-19 admissions and the shift system was started on 6 July. ICU 'recruits' generally help during the day shift as part of the ICU team. The whole ICU and high care (16 beds) are now utilised for COVID-19 positive patients and theatre recovery has been repurposed as a COVID-19 negative (green) ICU and high care.

As approximately 15 years have passed since our ICU rotations during our orthopaedic training, it has been extremely daunting to be involved in the care of these critically ill patients. It is helpful to remember though that in ICU every little bit counts, especially when there are severe staff shortages among doctors and nurses alike. The shortages are due to staff being ill with COVID-19 themselves, isolating due to first-degree exposure or understandably avoiding ICU due to older age and other comorbidities. Unfortunately, full ICUs, low patient survival rates and fear for your own safety is probably also resulting in low morale and increased absenteeism.

 

Figure

 

The work includes helping with regular blood gases and re-checking and confirming infusions to placing new central lines and arterial lines and adjusting inotropes. You may even And yourself adjusting FiO₂ and more glorious work before long! The work experience is consistent with how our colleagues in the USA report their experiences.¹ The most difficult part of the work is contacting family and discussing the poor prognosis with them. We try to phone each patient's family at least once a day but you can't leave ICU or remove your mask repeatedly during the day. You end up speaking very loudly through a mask to family who is not allowed to visit their loved ones who have sometimes been in ICU more than ten days and are quite likely not to survive.

On the flip side, much has changed since we did ICU. Ultrasound-guided lines are so much easier than you would imagine and there are YouTube and Vumedi videos on everything from donning and doffing to 'ABG made easy'.

We are in the thick of it now and it has been very rewarding to be involved, albeit in a small way, in the management of a pandemic that is affecting so many lives. The COVID-19 pandemic has also had a massive impact on the lives of all orthopaedic surgeons.^2,3 We are juggling our practice by taking turns to work in ICU and covering our rooms and calls. As stated by Dyer and Lipa, 'For surgeons, there is no bold answer to the virus'.⁴ Sometimes one of us just goes in for a few hours and asks, 'What can I do?' and there is always something needing to be done. There are many advantages to getting involved, not least of which is the cohesion and camaraderie that results from being part of a multidisciplinary team - something that is often absent in private orthopaedic practice in South Africa. We would strongly recommend that our orthopaedic colleagues get involved in fighting this pandemic in any way that they see fit.

 

References

1. Sarpong NO, Forrester LA, Levine WN. What's important: Redeployment of the orthopaedic surgeon during the COVID-19 pandemic: Perspectives from the trenches. J Bone Joint Surg Am. 2020;102(12):1019-21. https://doi.org/10.2106/JBJS.20.00574.         [ Links ]

2. Haleem A, Javaid M, Vaishya R, Vaish A. Effects of COVID-19 pandemic in the field of orthopaedics. Clin Orthop Trauma. 2020;11 (3):489-89. https://doi.org/10.1016/j.jcot.2020.03.015.         [ Links ]

3. Culp BM, Frisch NB. COVID-19 Impact on young arthroplasty surgeons. J Arthroplasty. 2020;35(7 suppl):S42-S44. https://doi.org/10.1016/j.arth.2020.04.058.         [ Links ]

4. Dyer GSM, Lipa SA. What's important: COVID-19 - helpers, not heroes. J Bone Joint Surg Am. 2020;102(12):1032-33. https://doi.org/10.2106/JBJS.20.00601.         [ Links ]