Features
COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? Michael Cronin, Mark Mullins, Paul Williams, Matthew Dodd and Praveen Pathmanaban
“It is not surprising that in talking about uncertainty we should lean heavily on facts, just as the court of law does when interrogating witnesses. Facts form a sort of bedrock on which we can build the shifting sands of uncertainty.”1
N
oted statistician Dennis Lindley is quoted in his text ‘Understanding uncertainty’ which discusses how virtually every aspect of our lives involves situations in which the outcomes are uncertain and how best to deal with them.
Michael Cronin is a Consultant Orthopaedic and Trauma Surgeon with a specialist interest in hip preservation surgery. He is currently the National Joint Registry lead for Swansea Bay University Health Board.
Mark Mullins is Consultant Orthopaedic and Trauma Surgeon specialising in hip and knee arthroplasty surgery. He is currently the clinical lead for orthopaedics for Swansea Bay University Health Board.
28 | JTO | Volume 08 | Issue 02 | June 2020 | boa.ac.uk
The advent of COVID-19 has led to major uncertainty in all aspects of our lives. The current shifting sands in our specialty reflect this with a plethora of guidance documents and advice being produced by our peer bodies. In the face of COVID-19 the GMC and BOA2 have written to support the need for pragmatism and alterations in our practice for clinical decision making on an individual patient basis.
The Swansea Hip interrogation Fracture Tool (SHiFT) has been devised to enable clinical decision making in this extremely ethically and morally difficult area.
Background Swansea Bay University Health Board (SBUHB) experiences a large annual volume of patients with a proximal femoral fracture (fractured neck of femur or #NOF). On an annual basis we treat between 500-600 proximal femoral fracture cases running a 12 hour trauma list seven days a week, alongside 1-2 emergency ‘CEPOD’ theatres.
“In the face of COVID-19 the GMC and BOA have written to support the need for pragmatism and alterations in our practice for clinical decision making on an individual patient basis.”
Patients with a proximal femoral fracture are arguably the ‘bedrock’ of our Trauma practice. But when it comes to interrogating the ‘facts’, for any individual case, how will we actually make these decisions in practice and how will the ‘court of law interrogate us as witnesses’ in the future when the COVID-19 tsunami has dispersed?
Interrogation in social science terms means to ask questions about something as a way of analysing it or finding out more about it to enable the decision making process. In particular for this patient group, it can be used to help us decide how best we should treat them.
Our hospital covers a population of 390,000 patients and routinely operates 20 operating lists a day. Since the Government’s call to prepare for the anticipated surge of COVID-19 cases, the hospital has diverted much time and resource into retraining staff and reconfiguring clinical areas. For the last two weeks, capacity in SBUHB has been severely reduced down to two emergency ‘CEPOD’ theatres to accommodate life and limb threatening surgery only. One theatre runs 24 hours a day, the other only 12 hours. The Health Board have taken the decision to treat all operative cases as potentially COVID-19 positive. All theatre personnel are wearing PPE for aerosol generating procedures (AGP)3,
