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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 7-10

Impact of COVID 19 on orthopedic surgeons in India during the early phase of lockdown in South India: A survey-based report


1 Department of Orthopedics, Aster MIMS Hospital, Kozhikode, Kerala, India
2 Department of Orthopedics, People Tree Hospitals, Bengaluru, Karnataka, India

Date of Submission11-Oct-2020
Date of Decision06-Nov-2020
Date of Acceptance27-Oct-2020
Date of Web Publication17-Nov-2020

Correspondence Address:
Pramod Sudarshan
Department of Orthopedics, Aster MIMS Hospital, Mini Bypass Road, Kozhikode - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_3_20

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  Abstract 


Background/Purpose: The pandemic of COVID 19 has swept across the livelihood and economy throughout the world. We created an online survey during the 2nd week of the first phase of national lockdown and assessed the impact of COVID 19 pandemic on orthopedic surgeons in South India, who are almost forgotten in this fight. Methods: The simple survey which included questions divided into categories – demographic details, awareness of the situation, clinical practice, effects on research, training, and personal aspects. The survey was shared on social media and responses were recorded online using Google forms and analyzed. Results: A total of 132 surgeons from various states of India, mostly from South India answered the survey in 7 days. More than 50% responded that their institution had no specific guidelines nor had adequate personal protective equipment (PPEs). Sixty-percent of the surgeons used only standard precautions and not PPE for emergency surgeries. Sixty-seven percent used telecommunication for regular follow-ups and most preferred WhatsApp messenger over SMS or calls. Over 50% were not confident to handle medical emergencies. 53.6% felt postgraduate training was significantly affected due to the lockdown and 58.8% were most stressed about their personal and family health. Seventy-five percent surgeons used this leisure period to spend time with their family. Conclusion: The pandemic of COVID 19 has significantly affected different domains of work and personal life of orthopedic surgeons in India. The survey helped to identify the deficiency and necessary changes which were implemented further. The situation would lead to long lasting changes in clinical practice and view of surgeons in the field of medicine and personal life in general.

Keywords: COVID 19, orthopedics, personal protective equipment, survey, telecommunication


How to cite this article:
Sudarshan P, Nambiar R, Swamy G. Impact of COVID 19 on orthopedic surgeons in India during the early phase of lockdown in South India: A survey-based report. J Orthop Assoc South Indian States 2020;17:7-10

How to cite this URL:
Sudarshan P, Nambiar R, Swamy G. Impact of COVID 19 on orthopedic surgeons in India during the early phase of lockdown in South India: A survey-based report. J Orthop Assoc South Indian States [serial online] 2020 [cited 2020 Dec 3];17:7-10. Available from: https://www.joasis.org/text.asp?2020/17/1/7/300756




  Introduction Top


Coronavirus disease which originated in the year 2019 was given the term COVID 19 and was declared a pandemic on March 11th 2020 by the WHO.[1] The honorable prime minister of India declared a nationwide lockdown for three weeks[2] from March 24th 2020 based on guidelines and regulations following a 14 h voluntary public curfew “Janata curfew.”

As various paradigms of health care is being modified to suit the protocols in each country, the roles of individual specialists are changing based on the needs. Surgeons in general and especially orthopedic surgeons are often forgotten and rather ridiculed in memes regarding their preparedness in this fight. In fact, there are reports of higher number of deaths in surgeons than other specialists at the time of writing this manuscript indicating that surgeons are also vulnerable in this fight. Higher risk in orthopedic procedures which involves drilling, saw, pulse lavage and electrocautery use due to aerosol generation has been documented.[3]

The Indian Orthopaedic Association released an advisory[4] in view of the same and suggested modification of orthopedic practice in India to contribute in country health care, minimize health-care resources, social distancing, and avoiding spread to other patients and health-care workers.

We created an online survey during the 2nd week of first phase of national lockdown (April 1st to 7th) and assessed the early impact of COVID 19 pandemic on Orthopedic surgeons in India.


  Methods Top


The aim of the survey was to identify the strengths and weakness analysis of orthopedic surgeons in India regarding the knowledge and effects of COVID 19. The simple survey was designed in sections which included 36 questions based on:

  1. Demographic details – Age, state, membership status of State and Indian Orthopedic Association, subspecialty and predominant type of practice, number of vulnerable people at home, comorbidities, and experience in handling other outbreaks or natural disasters
  2. Awareness of the situation – Regarding updates, use of media, institutional practice, guidelines, and availability of personal protective equipment (PPE)
  3. Details on current clinical practice – Restrictions in performing surgeries and precautions, use of telecommunication, willingness, and confidence of handling medical emergencies, and the duration which they expect to normalize practice
  4. Effects on research and training – On regular research, practice and postgraduate training and use of online education
  5. Effects on personal aspects – stress, finances, and use of current leisure time.


The answers were either in the form of multiple choices, dropdown selections or checkboxes and answers were kept anonymous. The survey was shared on social media and responses were recorded online using Google forms and analyzed.


  Results Top


A total of 132 surgeons from various states of India answered the survey in 7 days.

Demographics

Majority of surgeons (38.1%) were between 35 and 44 years of age followed by those between 24–34 years and 45–54 years of age. Only 6% of respondents were above 55-year-old. Although there was representation from most states, almost 65% of surgeons hailed from South Indian states of Kerala, Tamil Nadu, and Karnataka probably due to more connections of the authors with the states. Sixty-three percent were members of both State Orthopedic Association and Indian Orthopaedic Association.[Chart 1]



Forty-four percent of surgeons had members of vulnerable age groups at home. 35.1% had some comorbidity or the other with 10% diabetic, 15% hypertensive, and 11% smokers among the responders. More than 80% did not have any experience in managing previous outbreaks? (H1N1, severe acute respiratory syndrome, Ebola, Middle East respiratory syndrome, NIPAH etc.,) or calamities or disasters (earthquakes, war, etc.,).

Awareness of situation

88.7% were up to date with the current COVID 19 situation in India. 30.2% felt that their hospital or institution did not provide regular updates about the situation. Around 11% each followed home quarantine, either on own or advised by institution. [Chart 2]



41.2% respondents responded their institution had specified guidelines for orthopedics in this situation. The alarming response to the availability of PPE in case the numbers rise in their hospital or institution was that only 25.8% felt it was adequate. Out of these, majority belonged to private hospitals and teaching setups indicating either lack of knowledge regarding the availability or inadequate PPE in government hospitals and those involved in private practice with smaller hospitals.

Clinical Practice

Eighty-four percent had stopped all elective surgeries and nonemergency outpatient depaetment at the study period. 56.7% canceled all academic activities and meetings, while 46.4% had adapted to division of surgeons into teams and have a standby team if necessary. Only 4.1% still performed elective orthopedic surgeries but majority (85.6%) continued to perform emergencies. However, only 24% of these surgeons used PPE during emergency surgeries and 60% followed standard precautions like earlier times. Sixty-seven percent had started using telecommunication to communicate with their follow-up patients while only 40% of them advised or prescribed medications to new patients using telecommunication. Only 16.5% of surgeons kept their private clinics open during this period. [Chart 3]



Another alarming data as suggested by the responses showed that 40.2% of the surgeons were not willing to do medical work (nonorthopedic) in an emergency situation. Although 32% of the surgeons were already given a nonorthopedic role in their institutions (majority of the government or teaching setups) over 50% were not at all confident in handling medical emergency procedures (e.g., intubation and resuscitation etc.,). Sixty-six percent of the surgeons felt it would take >8 weeks from now (2nd week of lockdown period) to resume normal practice.

Research and training

A difference from western countries in research was noted in that 77% of the surgeons regular practice involved research to the tune of 0%–25% only. 47.4% said that this situation significantly affected research activities while 53.4% noticed it significantly affecting postgraduate training in their department. 51.5% had already initiated online meetings and education which was a positive feature.

Personal effects

On a scale of 1–5, 32% were moderately stressed (3) and 33% were mostly stressed out (4 and 5) due to the current situation. Thirty-eight percent felt that their financial status was extremely affected due to the situation. 75% of the surgeons used their current leisure time by spending quality time with family followed by taking adequate rest and using it to improve fitness. [Chart 4]




  Discussion Top


The pandemic of COVID 19 has swept across the livelihood and economy throughout the world. By the 1st month of national lockdown in India (end of April 2020), the worldwide deaths had crossed 200,000 and Indian confirmed cases had crossed 27,500 according to sources.[5] Unlike natural or manmade disasters like earthquakes or wars, where orthopedic surgeons have lot to contribute, viral pandemics leaves orthopedic surgeons virtually jobless except for attending trauma or volunteering in medical help. This national survey based study among orthopedic surgeons covers important aspects of the impact of this situation and highlights both the positive and negative effects coming out of it.

Alarming facts about higher comorbidities even in younger surgeons, inadequate availability of PPE to surgeons to perform surgeries, inadequate information or guidelines issues by their institutions, dependence on television and social media for information which carries higher risk for believing on fake news than following guidelines, unwillingness to do medical emergency work and lower confidence in performing emergency resuscitative procedures are highlighted in our results. Significant effect on research and training, higher stress levels among surgeons over their personal and family safety and finances have also been showed.

Positive outcomes in our study like higher use of telecommunication in practice, following restrictions at work at a relatively earlier time, use of online meetings and education and most importantly spending quality time with the family which most surgeons often used to crib about in the pre COVID era were noted.

The survey[6] of COVID-19 disease among orthopedic surgeons in Wuhan, People's Republic of China showed total of 26 orthopedic surgeons from 8 hospitals in Wuhan identified as having COVID-19. Not wearing an N95 respirator was found to be a risk factor and so was severe fatigue. Wearing respirators or masks all of the time was found to be protective. Their study concluded that Orthopedic surgeons are indeed at risk during the COVID-19 pandemic, common places of work could be contaminated and orthopedic surgeons have to be more vigilant and take more precautions to avoid the infection.

Some useful tips for Orthopedic surgeons once they get back to performing elective surgeries are listed out very well by Simpson et al.[7] Increased emphasis on managing patients with nonoperative strategies should be stressed. As those closest to aerosol generation procedures are most at risk, when the generation of aerosols is unavoidable, the sucker should be kept near to the interface of the tool and tissue to remove as much of the aerosol as possible to minimize this risk. Keeping conventionally ventilated theatres fully on during surgical procedures where patients may have COVID-19 infection is beneficial. Avoiding the use of diathermy especially cutting diathermy, pulse lavage and ultrasonic tools are advisable. The use of a tourniquet when possible and considering using a powered air-purifying respirator or a surgical body suit/space suit is ideal.

Several guidelines have been further issued including the orthopedic forum of JBJS[8] and the Indian Orthopedic association[4] for surgeons to follow during the period and going forward to maintain higher personal and patient safety. It is true that COVID 19 has already changed how the world used to function. People are bound to change their practices and it applies well to surgeons too. As the lockdown period extends, amidst further worries about finances and job security, orthopedic surgeons are bound to change their work pattern incorporating the positive features coming out of this survey as described above. Although the survey brings out useful information, the low number of responses compared to the huge number of orthopedic surgeons in South India is definitely a limitation. Nonetheless, this could be used as a representative data of the larger team.

The list of survey questions can be accessed at www.tinyurl.com/covid19orthoindia.

The authors would like to acknowledge all the participants for taking time out to fill the survey and for all those who forwarded it to help get more responses.


  Conclusion Top


The pandemic of COVID 19 has significantly affected different domains of work and personal life of orthopedic surgeons in India. Making sure to improve the PPE availability, better preparedness and training in medical emergency situations and finding ways to avoid stress and anxiety is the need of the hour. The survey acted as an eye opener for various deficiencies and need for changes in the system which was implemented going further in the phases of lockdown. The situation would lead to long lasting changes in clinical practice and view of surgeons in the field of medicine and personal life in general, and we hope it would mostly be in a positive way.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
2.
Jeffrey G, Kai S. Modi Orders 3-Week Total Lockdown for All 1.3 Billion Indians”. The New York Times Company 2020.  Back to cited text no. 2
    
3.
Yeh HC, Turner RS, Jones RK, Muggenburg BA, Lundgren DL & Smith JP (1995) Characterization of Aerosols Produced during Surgical Procedures in Hospitals, Aerosol Science and Technology, 22:2, 151-161, [DOI: 10.1080/02786829408959736].  Back to cited text no. 3
    
4.
Available from: https://www.ioaindia.org/IOAADV.pdf [Last Accessed on 10 May 2020].  Back to cited text no. 4
    
5.
Available from: https://www.covid19india.org/ [Last Accessed on 10 May 2020].  Back to cited text no. 5
    
6.
Guo X, Wang J, Hu D, Wu L, Gu L, Wang Y, Zhao J, Zeng L, Zhang J, & Wu Y. (2020) Survey of COVID-19 Disease Among Orthopaedic Surgeons in Wuhan, People's Republic of China. The Journal of bone and joint surgery. American volume, 102, 847–854. https://doi.org/10.2106/JBJS.20.00417  Back to cited text no. 6
    
7.
Simpson AH, Dall G, Hass JG. COVID-19 potential transmission through aerosols in surgical procedures and blood products. Bone Joint Res 2020;9:200-1.  Back to cited text no. 7
    
8.
Rodrigues-Pinto R, Sousa R, Oliveira A. The orthopaedic forum preparing to perform trauma and orthopaedic surgery on patients with COVID-19. J Bone Joint Surg 2020;102:847-54. [doi: 10.2106/JBJS.20.00454].  Back to cited text no. 8
    




 

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