E4 - Singapore Sling | Recovery of Elective Surgery | Chris Pearce - Part3

Chris Pearce talks in-depth about the recovery plan for Orthopaedic Surgery in Singapore. At the peak of the pandemic, the focus correctly was on cancer and urgent trauma surgery.  
At the very start, priority detailed plans were created for resuming elective surgery.  As the number of deaths from COVID-19 starts to disappear, Chris explains how elective surgery in Singapore is soon to be back to full elective operating capacity.

Transcript

Ros 

There have been some questions raised around the fact that we're are seemingly all sitting around. It's not that we're sitting around doing nothing, we're actually getting a great amount of time to catch up on all the other stuff that we needed to catch up on. 

But as surgeons, we have a very manually dexterous skill set. Do you have concerns, because some concerns have been raised here, that surgeons are going to have de-skilled?  To get back to operating how we actually do that and is there a framework or guidance or training issues around that?

Chris 

Well, it kind of depends on how long you've been away and what level you were at before.  I have done much, much fewer operations and I would have done normally, during this time, but I'm not doing none. I remember having two months or so off between being a LAT (Locum Appointment for Training) registrar and getting on the rotation.

I went to India and basically did nothing for a while. I remember coming back and being quite nervous about doing a hemiarthroplasty on my own because I hadn't operated for two or three months. And at that stage in my career that actually really mattered. 

That's a straightforward operation, very much a registrar operation, which I was fairly confident to do prior to going to India. I wasn't all that competent when I came back. 

So I got one of my registrar colleagues to come with me and just make sure I did it well.

But as soon as you do the first case you go back to where you were. 

Maybe for the trainees, it might be more of an issue. I think for us (Consultants) it is probably not so much of an issue.  Especially in foot and ankle where it is so varied. I mean, I've done three total ankle replacements here. And actually, none of them was my patient.  All three of them were patients that were put on the list by somebody else. They asked me to do them. It's a bit like riding a bike, once you get to a certain level of experience. I'm not saying that I'm awesome at ankle replacements or anything, but I don't think the one I did here, having not done one for two years was any worse than the ones I've done previously. 

Ros 

I think that's where we do differ (to other surgeons). We're much more like hand surgeons, or plastic surgeons in some ways versus the hip and knee guys or the cardiothoracic surgeons who are doing the same operation over and over.  There are much more repetitive in and have a much smaller repertoire of procedures that they do.

Chris 

That's the main reason for choosing an ankle in the first place

Ros 

Yes, I think it's the variety but also the flexibility with your skill set.  You need to adapt.

Chris 

A lizard just ran over my foot I'm sitting outside and I'm checking it wasn't a bit more dangerous.

Ros 

As everyone's got so much time to work out how we restart things, I'm slightly concerned that there's a negative reaction and we get bogged down in even more red tape.  Whenever something bad happens, there is a reaction. When (Harold) Shipman happened, there was revalidation. There's been some suggestion that it should be two Consultant operating.  It may be that quite a lot of this come from helping female surgeons when they go back after maternity leave, particularly if it's been an extended period.  They may want to buddy up maybe for one or two, I think that makes sense. But I'm, I'm worried that that may become something that is you have to have done 'X' number of procedures with somebody that then signs you off, and as consultants, that's not necessary.

Chris 

Here in Singapore, you have certain operations that you are specifically credentialed for, ankle replacement being one of them.  I have no issue with to dual Consultant surgery.  I think that's a great way forward. And I actually still do that now with a really complex case like a difficult Pilon fracture or ankle replacements.  I haven't done it for a while, and we get the second consultant.  It just turns a slightly stressful time and tough situation into quite a fun situation, and I'm sure the outcomes are better. 

As long as you work well with the person.  Out here it is Anthony Gardner that I tend to do stuff like that with him. We do complex tibial plateaus together as well. And I think we complement each other very well in that in that respect, so I'm all for that in a way.  

The difference here is the workload is less. I'll probably do less than 400 operations a year here. I think the year that I left the UK I did six, seven or 800 operations that year. The opportunities to work together here are easier because we're not quite as busy. If you've, been away from it for a long time, you do need to be a bit confident to be able to do an operation. As soon as you lose a bit of confidence, I think it makes you more likely to make mistakes. 

Ros 

I'm exactly the same as the joint operating. We've got cases, partly because of the fact that we don't have trainees, that I'll do with another consultant.  The revision hip surgeons already do quite a lot of that for the very complex cases.  As long as it remains that it's something that we as the clinicians have the flexibility to decide how we do that as opposed to being imposed on us that I think that's the bit that I would be concerned about 

Chris 

We certainly have no plans to impose regulation on anybody.

Ros 

Having gone through, six months of COVID, what are your fears are about the next 18 months?

Chris 

I'm hoping that we were are now coming out the other end of it a little bit.

Fears professionally. I don't have that many really.  Maybe, slightly more so if Singapore were to run out of money and get rid of all the foreigners! 

Chris 

It would be a shame if conferences went digital instead of face to face.  There is a place for virtual patient consultations, but they should never replace a proper face to face consultation with a patient.

Chris 

Maybe I worry that because some things that were adopted out of necessity because of the pandemic, will remain after, with the excuse of them having worked to as extent during COVID.  

These are not ideal solutions.  Even now I'd much rather be having a beer with you face-to-face instead of talking over the internet. 

Ros

For some patients who have difficultly or anxiety about coming into hospital, technology can be very useful for following some of those patients.

Medicine is about people looking after people. Not technology looking after people. Technology can help with that and improve on outcomes. 

Chris 

Take the NHS 111 hotline, that didn't really change when originally came in years ago.

Ros 

It helped GP practices particularly at the beginning of the pandemic.  When you got symptoms, you called 111 instead.

Chris 

For straight forward general advice, it has a purpose, however, if anybody calls with at symptom that vaguely alerts any sort of alarm bells, such as a slight pain in my chest, they are going to have to go into A&E, because you can't really say no

It might help by managing the cases that didn't need to come in the first place. But generally speaking, in terms of trying to replace what we do on a day to day basis is not going to take a huge amount of patients away from actually being seen.

Ros 

When do you think you'll get back up to 100% activity for your like to service?

Chris 

In Singapore, there are different lockdown mechanisms called 'circuit breakers' which translated into English effectively mean lockdown.

The easing of the first circuit breaker made no difference to us because some of the schools had been already going.  But none of the bars or restaurants are open. In the third phase of reopening, restaurants and bars will open.  In the final phase, everything will open.

It depends on how many community cases there are at any one time.

We have been very lucky that very few foreign workers as they are called here, have become really ill.  There are 30,000 infected and only 23 patients that have died in Singapore. Even now there's something like 25,000 active cases, but only seven in ICU. There is probably not even 1000 infected patients in the hospital. The vast majority are in these isolation facilities as they're not ill.

Chris 

I've been listening to a lot of podcasts and reading a lot about COVID. It seems like it's a slightly different disease here than it is in Europe and the US.  It seems as though there is some sort of the point mutation on the virus.  So now it appears that the virus here and the one in China, seem to be less virulent than the one in the UK in the US.  It is likely to do with the proportion of people being tested.  Here there are proportionally fewer people very ill because our denominator is much higher because there is active testing.  Whereas in the UK, certainly in the initial phases, there seemed to be far less test and trace.  Possibly half the country has already had it and are immune. 

Ros 

There was a survey of Orthopaedic Foot and Ankle Surgeons in the UK to see when they think elective orthopaedics will get back to 25%.  About 60% of surgeons polled said that they don't think that will be by the end of this year, if ever.  Do you think you'll get back to full capacity?

Chris 

We will be pretty much back to full capacity by October.

Ros 

And clearing your backlog. Is there a plan to work through that?

Chris 

We will start off with the day surgery cases that don't affect the bed occupancy. Then the more urgent cases done first, and then those who have waited longest will get done. But our backlog is nothing like yours.  I probably have 20 or 30 patients that were listed for surgery when lockdown started and maybe an additional 10 or 20 since then.  But that's not that many. They could be cleared in four or five weeks.

Ros 

One of the biggest concerns is the diabetic patients although interestingly with the diabetic patients we found that because they've been at home shielding and not going a number of them have healed during this period. So actually, now is the ideal time to operate on them as they have better soft tissues. Particularly if using Minimally Invasive Surgery as a Day Case. 

But a lot of patients are terrified of coming in.  The podiatrists are doing a lot of virtual consultations checking in with patients. They are not needing to see patients as frequently in the hospital.  Patients are all given dressings so that they or a family member can do the dressing for them.  Which is possible at the moment because so many patients had relatives who are at home with them because they had been furloughed. 

Many of the severe diabetic patients tend to be in areas of higher social deprivation. They live in smaller spaces and are not they're not going out and not doing big walks.  Many of these patients with diabetic foot ulcers have anecdotally healed. But because most of these patients have recurrent ulcerations.  There has been no change to the underlying bony abnormality that is causing mechanic pressure on the skin.  They are already in optimal orthotics, and so will break down as soon as they start getting out again. We are trying to look at that cohort of patients and actually measure their pressures to allow early intervention.  It is also a great opportunity to change the management of common conditions. As an example, patients with ankle ligament injuries are so often told they have just twisted or sprained their ankle, but it is really a much more complex injury. For some of these injuries, if they are left untreated, they can eventually lead to significant deformity or arthritis. 

Now is a perfect time to disrupt the traditional model of management of patients treated on a very prescriptive, perhaps slightly outdated way of managing them.  Especially when we now have to consider how patients are managed in a very different clinic space.  We also need to be much more realistic what the NHS can deliver or what the clinic can deliver.  By being innovative and looking at different apps and how technology is tracking people's activity, patients could be helped more to get back to what they used to do.  Some of that technology could be harnessed, particularly for the 'weekend warrior' or the recreational athlete.  The NHS struggles to deliver for 'wellness' injuries.  May sporting injuries in particular, where there is no bone broken, but damage to the soft tissues, even pre COVID didn't get managed optimally in the NHS.  There are now even greater challenges around that.

Chris 

Yes, we don't have that problem here.