key: cord-330676-urr9oqfc authors: Keny, Dr Swapnil; Bagaria, Dr Vaibhav; Chaudhary, Dr Kshitij; Dhawale, Dr Arjun title: Emergency and Urgent Orthopaedic Surgeries in non covid patients during the COVID 19 pandemic: Perspective from India date: 2020-05-12 journal: J Orthop DOI: 10.1016/j.jor.2020.05.012 sha: doc_id: 330676 cord_uid: urr9oqfc OBJECTIVES: To Evaluate the results and the protocols of our Institution for 18 Emergency and Urgent Non Covid Surgeries during the Covid 19 Pandemic METHODS: 18 patients underwent Emergency and Urgent Orthopaedic Surgeries at institution. The Protocol was Screening, Segregation, Selection, Isolation, theatre modification, and Online Follow. RESULTS: Two adverse events including, one death and one intensive care admission due to underlying morbidity were recorded. Average Hospital stay was 2.5 days with no patients becoming covid positive at follow up. CONCLUSION: Strict Surgical protocols need to be followed for surgery during the Covid19 pandemic. The World is faced with a unique situation at this moment of time. A population of 7 seven billion interwoven with threads of hyper connectivity have been forced physically apart due to a Pandemic. The information we receive from various parts of world today appears fragmented and at times contradictory. We debate disjointedly, about ideas concerning optimal treatment strategy, emergency and elective surgeries. In these times till, robust data emerges we need to count on each other's experience. Fortunately, India lagged behind most countries whose economy and health care systems faced the unprecedented impact of the COVID 19 virus which helped us to be better prepared. The slight edge we gained from having witnessed the experience of Wuhan, Italy Spain and New York helped us formulate strategies to protect health care professionals. Today this state capital city is in the midst of a crisis, with seven thousand affected patients and is almost contributing to a third of affected patients in the country. We believe that our small series from the city of Mumbai that is epicenter of this pandemic in India will offer insights to other parts of the world. Effectively translating science into both operational and policy action is an universal challenge during an emergency. Aligning the interests of clinicians, patients, hospital and government policy makers can be especially difficult (1, 2) . In these exceptional times, it is imperative to consider the possibility that surgical facilities become hampered by staff sickness, reduced supply of surgical materials, limited availability of recommended operating rooms (ORs), facilities, and trained anesthesiologists for improvised intensive care unit (ICU) pods for patients with . Though recent literature describe specific guidelines for setting up orthopaedic operating rooms, the use of PPE and disinfection protocols, there are very few case series of being patients operated for Emergency and Urgent orthopaedic Surgeries in literature. Previous experience of dealing with mass emergencies and man-made/ natural disasters have shown the advantage of following preset guidelines and a protocolized approach. Due to the prior experience, adhering and adapting to rapidly changing scenario enabled our team to provide necessary orthopedic service to community during this pandemic. This case series describes our experience of the first 18 emergency and urgent surgeries performed at a tertiary care institute in India during the COVID 19 pandemic following the protocols set up by our centre as per government guidelines and International recommendations. Between March 20th 2020 and April 30th 2020, over a span of 40 days, 18 Emergency and Urgent Orthopaedic Surgeries were performed on non COVID patients by four surgeons at our centre in the city of Mumbai , in India as per protocols set up at our institution. This tertiary care centers caters to a population of about Forty Million and has 8 other major tertiary care private hospitals in its vicinity. In the earlier part of the pandemic, on the containment directives of the authorities, six out of these eight hospitals were locked down secondary to medical personnel testing positive for COVID 19 secondary to hospital acquired infections. In the wake of such developments, strict protocols were set up at our centre for all patients visiting the hospital, which included stopping all outpatient services except Accident and Emergency services and all elective surgeries. All outpatient services were converted to online consultations. The Segregation was started in the Perimeter of the hospital, with dedicated gates for patients, male and female staff members, ambulances and private vehicles. Every member of staff was screened at the staff screening booth by a team of medical personnel wearing a PPE with an N95 respirator. Every staff members who screened negative for COVID 19 symptoms was asked to place a sticker on the front pocket of their clothes. ( Fig 1,Fig 2, Fig 3) Every patient coming to the ER was screened at a screening booth, located at a distance of 20 metres. The screening was done by medical staff wearing a Hazmat suits and disposable double surgical gloves. Once the preliminary thermal screening for Pyrexia and symptoms of COVID 19 was performed, the patients were directed to 3 different containment zones in the ER All Emergency surgeries were performed by personnel from the surgical team, the anesthesia team and the medical support staff wearing PPE's. In the Urgent Surgeries category, if the patient was COVID negative on throat swab and had no infiltrates on the CT scan, then the member of the anesthesia team who administered anesthesia to patient had donned a full PPE. The rest of the team members including those from the surgical team and other medical personnel donned water Impervious disposable surgical gowns, disposable hoods with goggles, double sterile surgical gloves and protective leggings over foot wear (figure 6). As per protocol, all members of the Surgical team were asked to step outside the OR during administration of General Anesthesia. Water impervious sterile disposable drapes were used during each surgery. The use of Power instruments was minimized, and pulsed Lavage was avoided in all cases. Absorbable suture materials were used in all cases and a transparent dressing was applied Table 1 and Table 2 mentions the details of all patients. Members of the surgical team were then asked to step out of the OR at the time of extubation. Patient were observed for thirty minutes in the operating room and not shifted to recovery room. A period of thirty minutes were given for all possible aerosol to dry up after the patient is wheeled out and before the deep cleaning of the operating room is started. The operating room was shut for a period of 4 hours before the second surgery was undertaken. Key differentiators during COVID time: 1. Preoperative Anesthesia Consultation via Video consultation by a member of the anesthesia team. 2. Regular consenting and Special COVID consent as directed by the authorities. 14. Cleaning of the operating room begins 30 min after the patient is wheeled out to let any remaining aerosol to dry up/ cleared. 15 . Theatre to remain closed for 4 hours before the next case is taken. There were 9 females and 9 Males. The average age was 57. Surgical patients may be classified into three risk categories for COVID-19: confirmed and suspected patients, high-risk patients, and low-risk patients (11) . Hence these patients need to be triaged and isolated in the emergency room as was done at our centre Antigen testing for COVID-19 is for patients with active infection but currently reported false negative rate of between 10 and 30%. However, testing is currently restricted to patients who require hospital admission. Hence, it is pertinent to collect a throat swab of all patients for a RT_ PCR COVID 19 test. The turnaround time for RT PCR is between 6-24 hours, and this time lag can be a challenge in an emergency situation .Ai and colleagues1 report on 1014 patients who received both RT-PCR and CT in Wuhan, China, during their epidemic. They found that 97% of cases with RT-PCRconfirmed diagnoses had CT findings of pneumonia, and conclude, "CT imaging has high sensitivity for diagnosis of COVID-19" (8,10). Hence a pre-hospitalisation screening may be able to detect a silent case in the incipient phase. All suspected patients who need emergency surgery need to complete COVID-19 blood test and chest CT scan before admission; pharyngeal swab sampling should be completed before surgery. Patients should be placed in the transitional area while waiting for results (9,10). Hence following a throat swab and a CT, all patients were isolated on a specially designed isolation floor. Healthcare workers should strictly follow the procedures for putting on and taking off personal protective gear, and it is forbidden to wear PPEs when one leaves the contaminated area. Sanitation and disinfection need to be implemented according to the regionalised zoning (11) . Hence the OR was zoned in such a way to that the donning and doffing procedures were segregated to different zones while maintaining a safe sterile passage. If the patient is not already intubated but it is necessary for surgery, intubation and extubation should be performed either in a separate dedicated room for intubation/extubation, or in the operating room without the surgical team present (20) (21) (22) During the surgery, all objects that come in contact with patients including blood, secretions, and excreta should be considered as potentially contaminated. In particular, medical staff in operating theatre should avoid exposure to aerosols generated while using electrosurgical equipment. There are many examples that viruses do survive in surgical smoke created by electrosurgical instruments (12) . Though it is not proven that coronavirus can be transmitted via surgical smoke, it may be worthwhile to take precaution until we have evidence it does not. To reduce the hazards, surgical smoke should be minimised by suction device, and electrosurgical equipment should be used at the lowest effective power. Hence every attempt was made to minimise the surgical time. It is strongly recommended to use absorbable suture material for all wounds to prevent revisits of patients. Transparent dressing tape has been recommended for surgeons to assess soakage of wounds to avoid unnecessary dressing (13) (14) (15) (16) (17) (18) (19) . After a procedure on a COVID-19 suspected or confirmed patient, the operating room should be left vacant, time dependent based on air changes per hour for your operating room ventilation system, while the OR air exchangers clear any airborne contaminants that may remain (20) (21) (22) 27) . In view of the COVID 19 pandemic, to minimise the need for early post-operative follow-up, advisories and guidelines have been issued for using absorbable suture for skin closure when possible to eliminate the need for an early post-operative visit for suture or staple removal. In cases where sutures or staples are preferred, the patients can be sent home with a suture or staple removal kit with written instructions and links for how to do it themselves. Successful removal can be confirmed via a telehealth visit (23) (24) (25) (26) . In our series of patients we followed a hospital protocol of telehealth and telerehabilitation during their convalescence . The times of COVID 19 pandemic has significantly altered our methodology of treating emergency and urgent cases which need Orthopaedic care. Though guidelines, protocols and advisories are evolving, it is prudent to take utmost care while treating patients with Orthopaedic conditions during this pandemic. 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