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A response to the letter by Lewis et al. from the authors of: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? Michael Cronin, Mark Mullins, Praveen Pathmanaban, Paul Williams and Matthew Dodd
Letter originally published 22 April 2020 in reply to: A letter in response to: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution. https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journal-oftrauma-orthopaedics-and-coronavirus/a-letter-in-response-to-covid-19-causes-a-shift.html.
We welcome the opportunity to reply to the letter by Lewis et al. in response to our paper. We hope our response not only answers the questions raised but also manages to clarify the ethical dilemmas the article was attempting to raise.
W
e agree entirely with ‘a plea for caution’ and wish to stress at the outset that a decision to not operate on a patient with a proximal femoral fracture flies in the face of the traditional dogma and as such challenges every Orthopaedic cell in our bodies. It is not a discussion that was taken lightly and has been discussed thoroughly with the Health Boards Ethical committee. We hoped to raise two ethical discussions and now realise that we need to elaborate on these for the process to be fully understood. The first ethical dilemma is how we treat patients in a healthcare system where capacity is significantly outstripped by demand. We hope that this situation never occurs in any Health Board but it is surely essential that you
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have thought about how you would deal with it, if it ever were to occur. In answer to your first question, “Is the scoring system indicated at present because of a serious and severe shortage of beds/surgeons/operating lists etc.?” As stated, the protocol would only be used in an extreme situation where capacity fell below 20% (an arbitrary figure to be debated locally). We had hoped that readers would have assumed that as Doctors we would exhaust all options to improve this capacity. We have optimised internal staffing models and attempted to recruit extra staff internally. We have investigated extra internal HB capacity such as Singleton and Neath Port Talbot Hospitals, but they rely on the same staff pool. We are constantly exploring
the option of extra capacity from neighbouring Health Boards and have been given some access for ambulatory trauma but not Proximal femoral fracture patients. We have even suggested to the Health Board that a final option would be to ‘close’ the Orthopaedic on-call in SBUHB and divert ambulances to neighbouring trusts, we are yet to receive a response. If despite these measures, any hospital was to be in a position where you CANNOT treat all of your patients, how would you plan to decide on who to treat? Would you still try and treat them all, admitting that the mortality rate for the whole group would be significantly raised? Using data from the last three weeks, had we been reduced to 20% capacity, by day 14, all patients would be waiting nine days for surgery and rising on a daily basis, with the potential COVID-19 tsunami still yet to arrive. The ethical argument used for healthcare systems where demand significantly exceeds capacity is that of Utilitarianism. As discussed in the original paper, treating the population for the ‘greatest good’ remembering that this is not where we want to be but where we may be in extreme situations once everything else has been exhausted. These decisions must of course be revisited on a regular basis and any daily change in capacity used as efficiently as possible. The ethical argument of utilitarianism in pandemic medicine planning is probably the hardest concept to grasp and accept. The concept of treating ‘fittest first’ goes against every aspect of our normal proximal femoral fracture evidence and practice. This concept makes us so uncomfortable that we felt opening
