COVID-19: The 'new normal' and how to get there

Listen to Mr Andrew Duckworth and Professor Fares Haddad discuss an overview of and insight into the effects of the pandemic so far and the hurdles that will be faced in attempts to return to some form of normality, or the 'new normal'.

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Transcript

[00:00:00] Welcome everyone. I am Andrew Duckworth and I would like to thank you for joining us for our first installment from our second podcast series on the COVID-19 pandemic entitled COVID-19 the new normal and how to get there.

 At the time of recording this on Friday, the 8th of May, the figures for the world and the UK have unfortunately changed rapidly over the past month since our first series of podcasts. Figures for the UK, as of today are standing at over 205,000 positive cases and greater than 30,000 deaths, which is unfortunately the highest registered death rate in Europe and second in the world, only to the US.

As nations around the world, start to try and move forward out of lockdown and determine the best way forward for everyone, the COVID-19 pandemic continues to loom large over our healthcare systems across the world. 

Through the second series podcast, we hope to reflect on what has happened so far as a consequence of the pandemic for orthopedic and trauma surgery, as well as on our healthcare system as a whole. You will hear from a range of colleagues and specialties on how we move forward as we start to consider restarting or increasing our orthopedic services around the country. 

There are several questions and unknowns regarding our [00:01:00] hospital capacities, patient safety and prioritization, as well as informed consent in the light of COVID-19. We also feel it's an opportunity to discuss the current state of trauma orthopedic related research with regards COVID and how we may consider return to some form of normality from our various research interests out with COVID-19.

So today I have the pleasure of being joined by our editor-in-chief here at the journal Professor Fares Haddad, who will be able to give us an exceptional overview and insight into the effects of the pandemic so far, the hurdles we're going to face in our attempts to return to some form of normality or the new normal as it's been known.

Many thanks for joining us today Prof.

Thanks Andrew, and thank you for stepping up again to run the series. I think it's really important that we communicate with The Bone & Joint Journals community. And at this time with everything changing so rapidly, it's really good to be able to have an ongoing dialogue as to the impact of COVID on every aspect of our lives and particularly on our research and clinical practice [00:02:00] and teaching and training. 

Absolutely Prof, as you say, it is moving very fast at the moment in terms of the change. And with that in mind, sort of, what do you feel since our first podcast from our COVID-19 series just over a month ago now? You know, a lot has developed and changed. What do you feel we've really learned over the past month since we last spoke?

I think we've learned a great deal. We've learned that we have to adapt and live at a time of uncertainty and rapid change. I think we've learned that we need to evolve what we're doing on the basis of limited evidence, being careful not to be swayed by strong opinions by local practices and really to try and move forward in a way that will allow our profession to continue to deliver excellent care to our patients in spite of the ongoing pandemic. I think the biggest thing that I think come home to roost for most people is that this is not an isolated event that [00:03:00] will pass, from which we can just bounce back to where we were. We are going to have to move forward to what we've coined a new normal. We're going to have to move forward to a place that is different from what we're used to. That may be better in some aspects, but will certainly be challenging in many others and that we're going to have to adapt to living with this virus and its consequences and its impact it has on everything from our personal self-esteem, thinking of what our roles are to our patients in particular and how we are going to be able to deliver the care that they need in an environment that's going to look extremely different and that is going to have to change pretty rapidly as we learn more. Because I think one of the stark things we realize is how little we know and understand as we start to step up our practice again. 

Absolutely. Yeah. I mean, you talk about the new normal there. What, for our specialty in particular,   what do [00:04:00] you think the new normal is going to look like certainly in the shorter term? And what do you feel are the key stages for, I suppose, to recovering and getting to that new normal?

So I think we've learned a great deal from the fact that we've continued to do emergency surgery. We've learned from the surgical services that we've continued with cancers. So we know that there are processes that we can put in place to limit risk and to start to deliver some form of urgent elective surgery. 

But within that, there are going to be different stages that we have to go through. I think the first one is a communication stage because we have to communicate to our profession as to what is reasonable, acceptable. We probably recognize, in most places now, that you know, lockdown has to relax, which we'll do a different speeds in different countries and possibly different locations in order for us to really justify being able to start elective surgery and the [00:05:00] risk that poses for staff and for patients. I think we recognize that the new normal will mean a more complex matrix that we have to analyze on a day-to-day basis in terms of the demand out there and the capacity to deliver it. And that's the capacity, not just in terms of surgical resource, but also equipment, anesthesia, critical care. All those other variables that we often take for granted but right now are critical. As we expand one area of surgery, we need to be mindful of the fact that the equipment and resource may be needed elsewhere and that that will vary week on week. 

So we need to be mindful of the bigger picture as we go forward. We need to start thinking about who to operate on and when and where, and those are going to be very, very difficult things to fully define because local availability of institutions and [00:06:00] pathways, including such things as transport that are out of our control will make it extremely challenging. And we need to be able to be very, very clear with our patients. Informed consent is going to be important here. These are patients who are having elective surgery. I think we all accept elective surgery is important. It's not optional surgery, but they can elect to choose a time to have that surgery. And that time may be safest at a point in the future than it is now. We really don't know that. We need to really be sure that we're spelling out to our patients what the alternatives are to the surgical procedures that they're being put forward for, and also to try and put some numbers and some data, and that's really difficult, around the risk to them of coming into hospital, of having an  intervention, and of going through a recovery process that perhaps is not as supported as it would have been in the past. 

So it's not just [00:07:00] the issue that there is a risk that they contract COVID through their hospital journey, but there's also the risk that their rehabilitation will not be as well resourced or supported as it would have been in the past or their follow-up will not be as intensive or face-to-face as it would have been before this pandemic. So I think there's a great deal to consider from that perspective. 

We also need to consider how we start surgery. Urgency is going to trump everything else. So we know we have a collection of urgent cases. Be they failing implants or patients at risk of impending fracture that require surgery, those who really can no longer walk and need arthroplasty, those whose joints are collapsing on them. Those will be at the front end, but we also need to consider as we're learning so fast, whether we start with lower risk cases, whether we start with cases that don't require a general anesthesia. 

And we need to look at our institutions, certainly in the UK, but also I [00:08:00] know from multiple conversations also abroad. This concept of creating COVID free, or as COVID free as we can sites. We are calling them green sites. We may end up calling them gold sites and pathways so that we can get patients to isolate for a couple of weeks, be tested at least once or twice before they have their own intervention and then have their intervention in a facility that is COVID free. And then in and out of that intervention in a very streamlined way is going to be a challenge, but it's something we should look into doing.

That's a great overview Prof. I think in terms of the many... there are always many hurdles there isn't there? I think one of the, like you say, one of the two big points are, we don't have much data at the moment to inform us of these decisions. And also every area and region and country is going to be slightly different in what they can really offer in terms of the services they can provide in having these, like say these green or gold [00:09:00] sites. It's gonna be very difficult and we're just gonna have to collect the data moving forward and probably change with time. Would you agree? 

I think it's going to evolve very rapidly and very quickly. I think this is a classic situation where we need to take a step back and start thinking in an interdisciplinary interinstitutional international way about how we collect data and start to understand what we can do safely and what is less safe and then transfer that information to our peers and to our patients. You know, we've managed to correct reasonable numbers so far, certainly in the UK, around how to create pathways where the risk of COVID becomes low. In other words, with isolation, testing, avoidance of COVID in those institutions. Then that then leaves us in a situation where the number of patients who've had [00:10:00] urgent or  very time-sensitive surgery who developed COVID is relatively small. It's only by combining data that we can really understand the impact on those patients having had their surgery. 

There is one paper that everyone quotes, from Wuhan, with a very high morbidity and mortality rate for patients who became COVID positive after surgery. And until we have more data, we have to accept that that small series should weigh heavily on our thinking as to what we offer and when we offer it.

The other thing we need to consider very carefully, Andrew, is the fact that there is a prevalence of COVID in the community now. It may be small. It may be large. We really don't know. And there's a population of patients who are prospective patients who have had a level of COVID exposure or may have had COVID with mild symptoms. And we still really dont know and haven't seen any [00:11:00] research around the impact of the stress of surgery and anesthesia on those patients. It is certainly feasible. And we may see this as elite sport reopens, that there is a cardio-respiratory impact of COVID at a low level in those patients who aren't being sick and not being admitted, that will be reflected in their response to anesthesia and surgery. So there are still many, many unanswered questions or for those with energy, enthusiasm and drive many research questions that we still need to address in this area. 

Absolutely. And in terms of you just alluded to it before... patient preference, do you think there's a chance that will change? Do you think there's a possibility some people will say, I know I would rather just soldier on with my sore hip or knee. I just don't want to take that risk. Is that something that we've seen already or do you think we will see that?

There's absolutely no question that patient perception here is going to be paramount. We're already seeing that. As we [00:12:00] start to ramp up towards recovery, we recontacted patients. There are those patients who are in a situation where they're shielding and they really shouldn't be coming in. You know they are higher risk, high complexity surgery that probably should wait until we know more. But even at those patients where you are, I might feel comfortable offering surgery at an earlier stage, there are many who now reflect and think this is an evidently unpleasant infection to get. The cytotoxic effects, the outcomes, and those who end up on intensive care are dramatic unpleasant and long lasting. And many of those patients are just going to say, I'm going to wait or I may never have the surgery.

You know, in orthopedic and trauma surgery, we've done a tremendous job over the last two, three decades of moving from, you know, palliating severe pain to really restoring normal function for, in many, many areas, not just the hip and the knee, but outside that. And the reality is much of what we do is [00:13:00] quality of life enhancing, but it's not life or death work. It's not limb saving and patients can carry on for a while... for a long while without that surgery. So I think patients will for the time being walk away and it's up to us to generate data that suggests that we can redeliver the surgery that we can offer that we can do so in a safe way with excellent outcomes all over again, and then to continue to evaluate what the post COVID or with COVID landscape looks like to see how much of that we can offer, because there is going to be a challenge as to how much surgery we can do within the capacity that's going to be available and whether that is worthwhile. So there are really new questions to ask until we really know what the new normal looks like. 

Oh, absolutely Prof. No, I agree. I think like you say though, I think it's becoming on us to develop that research and data so we can inform our patients properly in terms of their risks [00:14:00] and I think that will certainly go a long way into making their decision much more easier.

So moving on to sort of research then Prof. If we move on to that sort of cOVID related research. Could you summarize what has been submitted or published so far in the journal. Anything in particular you want our listeners to hear about. 

No, that's a great question, Andrew. Cause we've, as you know, we've been receiving a whole tsunami of manuscripts related to COVID, ranging from some really good attempts to collate experience across centers to some attempts to really just capture the feeling of countries as they're adapting to this, to small case series that are designed by people to help educate others as to what they're living through. But these are largely just simple case series. They're not necessarily methodologically thought through and [00:15:00] moving forward we must try and move on to a platform where we're really doing methodologically sound research in this area, that's going to help shape clinical thinking, clinical guidelines and evolve patient care moving forward.

So we've been incredibly busy at the journal. What we've tended to do is try and fast track COVID related research and put a lot of it in Bone & Joint Open. And we put some material in the BJJ as a sort of overview guidance, so that we're at least, I hope helping people understand where our thinking is and what we're seeing from those papers.

The BJO papers, the Bone & Joint Open papers are open access, so everybody can get those. And I think your series of podcasts has been tremendous and I hope people have gained information from those and been able to shape their thinking as a result of that. 

We're now entering the phase where we really need to get back to [00:16:00] restarting our pre COVID research. Many NIHR facilities will hopefully start to reopen and people will get back to that and we need to continue to use all the scientific backup that we can get and all the interdisciplinary work that we can do to now start looking at the impact of COVID and understanding it so that we have some really strong data to shape the future.

That was pretty interesting Prof. In terms of, you mentioned there, in terms of getting back to our sort of, I suppose our routine research activities for many of us. Do you think that's imminently coming back? Obviously a lot of the staff involved in various studies and trials have been redeployed elsewhere. Do you think that's just going to be a gradual thing over time? 

I think that it is indeed going to be a gradual thing, but it's part of the recovery process. We need to remember those staff. They're groups of people who've been redeployed, doing things they're not entirely comfortable with some of them, and we need to reintegrate them back into the system. We need to open the labs again, and we need to, [00:17:00] as soon as we're comfortable that we've restarted surgery and can do so safely, we need to consider how we're going to run those research studies and restart recruitment in a safe way. So there is a great deal of work that's necessary to ensure that we go back to study recruitment, that we go back to the basic work that we did before, because that really came to a sudden and unexpected halt. And we're going to have to help that group of academics and that group of researchers and research staff to get back to what will be their new normal too. So whilst we are focused on restoring elective surgery for our patients, you know, we as a profession have always innovated and always try to use evidence to guide what we do. And it's important that we don't stop doing that and that we get back to research as early as we can. 

No totally agree. Prof. Well I think that's actually all we've got time for today, but thank you so much for your excellent overview and insight today. It's [00:18:00] really been very informative and I'm sure our listeners have learned a lot from it. So thank you very much. 

Andrew, thank you. And thanks again for running the series. You do a tremendous job with it. 

Thank you very much Prof. 

And finally, as ever, we'd like to acknowledge and thank our many colleagues around the UK and across the world for their tireless, ongoing contributions over the past few difficult months in the delivery of care to our patients during this pandemic. We at the journal thank you. And we'll continue to support you in every way we can moving forward. Stay safe and well and thanks for listening.