Daniel A. Slullitel
MD
Instituto Jaime Slullitel Sanatorio de la Mujer, Rosario, ARGENTINA
Mankind is confronting a unique moment. A single threat is testing all countries in the world. Each country is facing similar challenges that are influenced by its geography, cultural, political, and economic background.
Science is, indeed, helping us in very different ways—mainly by trying to minimize health damage, by limiting propagation of the virus, and of course, by searching for a cure. On the other hand, the Internet is keeping us informed during this period when close human contact should be kept minimal. We are facing changes on our daily life: our freedom of circulation is being jeopardized and limited in order to restrain the spread of the virus, our contact with patients is modified or nullified, and our souls are hit by fear of having the disease and being contagious to others. Governments have taken different strategies, but who knows whether these strategies are right or wrong?
In 2020, the ISAKOS Education Committee, with the full support of the Executive Board, employed its intrinsic worldwide-reaching capabilities to host a series of webinars focused on helping the global community. In each webinar, COVID-19 was present not as an educational subject but as the subject of an informal conversation between distant friends. During these conversations, it became clear that while the threat (COVID-19) and the associated worries are the same everywhere, the ways of fighting the virus are different.
We asked friends from around the world to share their personal experience of this outbreak and have been honored with their written responses in spite of their tight pandemic schedules.
Jeffrey S. Abrams
MD
Seton Hall University, University Medical Center of Princeton, Princeton, New Jersey, USA
The corona virus has been a unique and frightening event all over the world. In the United States, the New York and New Jersey regions were the first to be severely affected. In the early months, many individuals died because of the lack of knowledge on how to treat the respiratory distress syndrome and organ failure. Although many COVID-19 patients were older, many younger health care workers were affected as well. This disease is very infectious and requires protective spacing to limit the spread. The availability of hospital beds, particularly ICU beds, was a problem. Our postoperative recovery room became a COVID Unit monitored by the anesthesiologists.
At this time, we are in a much better place, and the number of hospitalized patients with COVID has decreased. We are better equipped with knowledge, and it seems rare that someone dies of this virus. Work for an orthopaedic surgeon has returned to elective surgery in the surgery centers and hospital. Total joint replacement, arthroscopic, spinal, and extremity surgery schedules are about 85% full.
Patients still have the fear of what may happen to them during surgery, and both patients and staff continue to take precautions regarding spread.
The major differences in our lives have been social. Children are home. Restaurants are closed or only allow limited outdoor seating. Many individuals are working from home or are unemployed. There is very little traffic because of these circumstances. The beaches are pretty full as many continue to look for enjoyable ways to spend their time. We are optimistic and look forward to life returning to what we remember 6 months ago. My suspicion is that this will take another year. Hopefully, next summer will be different as normal activities are resumed, people return to work, world travel picks up, and the family unit returns to normal.
Julian A. Feller
FRACS
OrthoSport Victoria Research Unit, Epworth Richmond, Melbourne, Victoria, AUSTRALIA
In terms of the COVID-19 pandemic, Australia has been fortunate compared with many other countries. Being an island, we were able to close our borders relatively early, and, with only medium-density living conditions, even in the cities, outbreaks never reached the levels seen in other countries. In addition, our health system is well developed and was relatively easily ramped up to deal with an influx of patients that fortunately never arrived.
So things should be good. Indeed they are, at least in some parts of the country. But government responses are going to leave an enormous economic burden, and it may be that the “cure” may end up being seen to be worse than the disease. COVID-19 has exposed some interstate rivalries and jealousies that are deeper than many had realized and that go far beyond the banter of interstate sporting rivalries. Australia is a federation of states. Health and education are state, not federal, responsibilities, whereas aged care is a federal responsibility. So there is plenty of room to shift the blame when needed.
The early governmental response in February and March of 2020 may come to be seen as excessive, especially when compared with the current position of countries such as Sweden, which took quite a different approach. But it was understandable and certainly not unreasonable given the uncertainty as well as the dire predictions from some modelling, and it may have been a factor in our limited caseload. Case numbers and fatalities never soared and settled quickly.
But here in the state of Victoria, a so-called second wave (or “phase” to use the currently preferred term) arose out of poorly conceived and poorly implemented protocols and procedures in quarantine hotels. This factor was compounded by the fact that many of the security personnel came from lower socioeconomic backgrounds and local communities that were very susceptible to spread of the virus. This situation subsequently led to outbreaks and, not surprisingly, increased fatality rates in aged care facilities.
The state government reacted with what can only be regarded as a panicked response. Not willing to admit their role in making the decisions that ultimately allowed the second phase to occur, they became obsessed with driving the numbers of cases to unrealistically low levels, such as 0 daily new cases. This approach led to a second round of restrictions and lockdowns. Compulsory wearing of masks away from home, a curfew from 8 p.m. until 5 a.m., 1 hour of exercise per day (which has now been increased to 2 hours per day), no leaving home for other than a few reasons, no travel beyond 5 km from home, no visiting other houses or meeting friends, no attendance at schools or universities, no sporting activities, and essentially no elective surgery. The police presence is high, and fines for breaching restrictions are steep. Some have questioned how our civil liberties appear to have evaporated so easily and with so little outcry. People have become polarized in their views, and it is all too easy to be labelled as being in one camp or another.
As I write this, we are in the eighth week and our average number of new cases per day is in the low 30s (yes, 30s, not even 300s, despite the fact that Victoria has a population of 5.7 million). Hospitals have 50% bed occupancy, with only a handful of COVID-19 cases, and operating staff are looking forward to next week when we can at last recommence some elective surgery. People want to be able to work.
The effect of this second lockdown has been profound. While we accepted the measures the first time around, there is growing anger and resentment this time, especially when life in other states is quickly returning to normal. We have become a pariah state, with strict border closures imposed on us, in part driven by parochial politics and upcoming state elections. Quite apart from the impending economic destruction, the community is losing its spark. People are becoming less motivated, and depression and anxiety are on the rise. It is particularly difficult for those living on their own and those with young children living in confined spaces. Obesity (so-called COVID fat) is visibly increasing. Selfishness is growing, not lessening. Young people wonder how they will find employment. Few can contemplate the enormous financial cost and the level of debt that governments now carry, perhaps 10 times levels previously thought unacceptable. And for many rural communities, this comes on top of the devastation of last summer’s severe bushfires.
In orthopaedics, this year’s crop of final year trainees are unable to look forward to overseas fellowships, but there are no obvious jobs for them here next year. Surgeons in their early years of practice feel like they are back at the start. Those in sports surgery can’t expect to see any sports injuries in the next 6 months. Surgeons nearing the end of their practice may find that retirement comes just a little bit earlier than anticipated.
Our problems are by no means unique and, in comparison with many parts of the world, they almost pale into insignificance, although it is sometimes hard for individuals to see that. We are a lucky country, but we have not escaped the effects of this virus or the effects of our response to it.
Margaret W. M. Fok
FRCSEd(Ortho), MBChB
Queen Mary Hospital, The University of Hong Kong, Hong Kong CHINA
Because of the proximity of Hong Kong with Mainland China, measures to control the spread of COVID-19 were started in late January 2020. With many locals still having the experience of SARS (2003) fresh in their memories, members of the public diligently started their preparation and precaution by stocking up food, cleaning their homes with bleaches, and wearing face masks, without being commanded by the government. Despite it being the start of the celebration of Chinese New Year, social gatherings were kept low.
In hospitals, many elective procedures were cancelled at the start of February 2020, with the priorities being given to emergency, trauma, and oncology procedures. Hospital staff were reminded by infection-control teams to be vigilant in terms of hand hygiene. Protective gear was given with specific instructions on how it should be put on and taken off in order to minimize the chances of contamination and infection. Some of the surgical wards were emptied and were converted to negative-pressure wards in preparation for potential patients with COVID-19. Measures were established for the management of patients with COVID-19 who needed emergency operations.
Although the number of confirmed cases each day was kept low (mostly <50) in this city as compared with the rest of the world, the public has remained vigilant in terms of mask-wearing and hand hygiene. Because of the population density, the public understand that any spread in the public may be disastrous. As a result, we have succeeded in not having any lockdown and only a minimal number of health
care workers have been infected with COVID-19 by working in the public hospitals.
We have gradually resumed elective procedures, although there was a period during which we kept the number of turnovers in the hospitals low (i.e., by performing one long procedure instead of a few shorter procedures). Zoom meetings and webinars have become the norm, and medical students have had to adjust to virtual learning.
With the borders being closed since March 2020, the general public has missed travelling. Yet, this enables people to slow down, spend time with their family, enjoy nature, and enjoy what the city has to offer.
Eiji Itoi
MD, PhD
Tohoku University School of Medicine, Sendai, JAPAN
The first case of COVID-19 in Japan was confirmed on January 15, 2020, and the first case in my prefecture, Miyagi, was reported on February 28. As of September 1, 2020, we have 67,865 cases of COVID-19 nationwide and 207 cases in Miyagi prefecture. I work at a university hospital, a designated infection-control center. Many coronavirus patients have been admitted to our hospital. As a result, we needed to maintain the number of staff members in the infection unit. To that end, the Hospital Director issued a couple of orders: (1) procedures requiring postoperative care in ICU or HCU should be postponed because we need to keep the number of personnel in the infection unit (most of whom are from ICU and HCU), and (2) elective procedures should be postponed because of the lack of surgical gowns and masks. Between mid-April and mid-June, we performed no arthroplasties, no rotator cuff repairs, and no Bankart repairs; we only performed procedures for malignant tumors and paralytic / paretic cases. We are gradually resuming elective procedures. All patients must undergo mandatory PCR testing for COVID-19 before surgery in our hospital. In terms of the number of new cases (as of September 1, 2020), we are in the middle of the second wave. The death rate caused by this virus is 1.9% in Japan. The problem is that the more patients we accept, the worse the financial status of our hospital becomes. We are requesting the government to support the institutes in which coronavirus patients are being treated.
My professional life has changed dramatically. I used to travel abroad to attend international meetings and invited lectures almost every month. In addition, I used to travel extensively for domestic meetings and lectures. All of these activities have been cancelled, postponed, or changed to virtual. In January of 2020, everything was normal; I attended the Board-Certified Examinations of Japanese Orthopaedic Association in Kobe (a 1.5-hour flight from Sendai) as well as two local meetings in Sendai. However, the first coronavirus case in Japan was found in January and the cruise ship “Diamond Princess” was anchored in Yokohama harbor in early February after a passenger tested positive for the virus. The virus was confirmed in one passenger after another, ultimately affecting >700 passengers from this cruise ship. A great fear of the virus rapidly spread throughout the country. In early February, I had a plan to attend the Nepal / Japan Combined Orthopaedic Symposium in Kathmandu, Nepal, but, because of the fear of coronavirus, I cancelled the trip. I also was invited to the International Biennial Congress of Iranian Society of Knee Surgery, Arthroscopy, and Sports Traumatology in Kish Island, Iran, in mid-February, but that meeting was postponed because many invited speakers started to cancel their trips. From February 2020 until now (September 2020), I have not traveled anywhere in the world, not even to Tokyo; I have just stayed at home and continue to go to my university on a regular basis.
Of course, I have no schedule on my calendar during my travel period. That means I have more time to concentrate on my own work. As I am retiring from the university next March, I am writing a monograph entitled “Shoulderology: It’s Fun to Solve Clinical Questions and Know More About Shoulder” to give inspiration and encouragement to the young generation. Because of this pandemic, I have been able to spend most of my time during the last 6 months writing this monograph, and finally I have completed the draft! This was a great blessing for me.
In our department, a weekly clinical conference has been held on-line since March 2020 in order to maintain social distancing. Professors’ ward rounds and weekly journal club meetings have been cancelled for the same reason. We have very limited contact with each other. Tuesday is my clinic day. The number of patients coming into the clinic has decreased because of the fear of catching the virus. Every week after the clinic, I have lunch with a doctor who helps me to fill out the patients’ electronic charts. In the staff cafeteria, we sit at a table with an acrylic board between us. This looks quite strange, but this is our new lifestyle.
Our daily lives have changed as well. I have not dined out with my family or with my colleagues for the last 6 months. In other words, I have had dinner with my wife at home every day for the last 6 months. This never happened during 34 years of marriage. It is the same for my colleagues. I have made it a rule to go grocery shopping with my wife every Saturday. The grocery stores have placed hand sanitizers at the entrance and at the exit. They have separated the entrances and exits to promote social distancing. Whenever we go outside, we are asked to wear a mask. This summer, the beaches and pools were closed. We could not go anywhere. Instead, we have much time at home, reading books, watching TV, listening to music, and weeding in the backyard during the weekend. I think most of my colleagues and their families are more or less the same. We have now more family time and less social time. Now is the time to consider how to use this newly allocated time of our daily living more wisely and fruitfully because we never know how long this pandemic will last.
Manuel Mosquera
MD
Clinia la Carolina, Bogota, COLOMBIA
It happened 7 months ago, but it seems like yesterday. I was in Santiago de Chile as a participant in our SLARD international congress, and the news media from around the world was talking about the dire situation, with Italy and Spain trying to control the spread of coronavirus and the high incidence of death. I remember sitting in a café with some friends from Spain who were attending the congress as speakers; we had all heard the rumors that Chile would close its borders and my friends began to worry that they would not be able to return to their families. My advice to them was they had to leave Chile as soon as possible even if they could not give their lectures; fortunately, they did so and returned to Spain that same night.
Early the next day, Chile’s president announced its closure of its borders to Spanish people! My friends had made the right decision; meanwhile, I started to worry about my return to Bogota that was scheduled for the next Saturday at 15:00 hours. After the conclusion of the congress, we were able to take our flight to Colombia. Because I felt exposed to the contact with many people during the meeting and in the airport and plane, I decided to isolate myself for two weeks in order to prevent any risk of exposing my family, coworkers, and friends. Nobody understood my decision, and all argued that it was hasty, but when the days began to pass and the news of multiple cases of COVID were present in Bogota, they understood my reasoning.
My isolation coincided with the quarantine decreed by the government, which meant that I had to close my office and surgery for 3 months. Having so much free time motivated me to work every day on my action plan as president of SLARD in conjunction with the executive committee and the new board of directors. As a result, we quadrupled the number of members, we included all orthopaedic societies and / or associations related to the objectives of the SLARD to be inclusive of all Latin American countries. We spent 2 months developing webinar programs and invited our colleagues from all countries to participate in conferences focusing on topics that are controversial in our professional practices, with international colleagues from different continents serving as opinion leaders. We also began to develop a new website in accordance with the needs of our society and launched our SLARD e-newsletter, which focuses on news from the society, clinical cases, surgical techniques, and so on. Finally, we defined the dates of our congresses in Panama and Cartagena for 2021 and 2022, respectively.
During this unprecedented period in our academic history, we were able to refine 5 consensus statements on controversial and frequent topics, with final round of discussions scheduled to take place during the first Latin American Meeting of Arthroscopy, Joint Reconstruction, and Sports Trauma, to be held in Panama on July 29-31, 2021.
While I learned many things during this long isolation, one of the main lessons is that we are very fragile because a microorganism that we do not even have the ability to see has put all of humanity at high risk, killing many people without warning. I also learned that simple things are full of value in our daily lives. We don’t need a lot of money to be happy, because luxuries in these circumstances neither make sense nor have value. But perhaps the best lesson of this pandemic is to reaffirm that nothing and no one is more important than God and family, which in our life before COVID was left in the background because we believed that our jobs are the main thing. How wrong we were!
Joan C. Monllau
MD, PhD
Barcelona (Spain)
The outbreak of the pandemic last March caught me as I was about to board a flight to Santiago (Chile) for the SLARD Congress. The experience at the start was devastating with cases rising daily. The city of Barcelona was put on lockdown while our orthopaedic department had to switch its activity to mainly carrying out only non-operative care and handling trauma cases. We also started doing telemedicine visits. Besides stopping all elective orthopaedic activities, we faced hundreds of new patient admissions every day that called for opening new ICUs and had issues with the supply chain providing the much-needed personal protective equipment. Much more dramatically, we were even discussing limits on sedation and the antibiotics policy. Our colleagues from Internal Medicine were conjecturing and discussing how to come up with treatment plans for our own institution. We, as orthopaedic specialists, did not really know what we had to do to treat those patients.
Therefore, we went back to the medical school and started to learn medicine again. It began by us getting familiar with the stethoscope and even with ventilators and recognising populations at higher risk, etc. We also learnt new terms like “herd immunity”, “case count” (tracking the number of Covid-19 infections) and “return to normalcy/transition to normal” that had rarely been heard before.
Nonetheless, we needed to stay positive and think the situation was just temporary. It might seem like a long time, but there was light at the end of the tunnel. We believed that this crisis would promptly end and we would be together as one, again.
We found opportunity in this crisis as well. We kept connected and discovered several virtual ways to continue the pursuit of education. In my opinion, what we have learned is that we do not have to be afraid of the virus when we are well protected and follow social distancing rules. Above all, we should be prepared for the next wave that may already be upon on. In the hope of a safe and effective vaccine in the near future, we need to be aware of and learn more about the virus’ behaviour.
Last but not least, I wish to express my deep gratitude to the medical community, particularly those in the front line, for their tireless dedication to patient care during this unprecedented COVID-19 pandemic.
