During the initial COVID-19 outbreak, St. Anthony Summit
Medical Center declared that all elective surgeries would be postponed. This resulted in multiple surgery
cancellations, including all prescheduled ACL repairs. The majority of the ACL repairs were scheduled
with a newly hired OR doctor, who was within his first year of practice, but
had extensive experience with ACL repairs. Due to the lack of surgeries the OR
doctors were ranked based on seniority and those with the lowest seniority were
asked to go on call for emergency surgeries only. One week later, a patient
comes in complaining of knee pain and is diagnosed with a ruptured ACL. The
orthopedic surgeon on shift schedules the patient for surgery. This
information, that an ACL repair is being performed as an emergency surgery, reached
the newly hired orthopedic surgeon, who specializes in ACL repair. He came into
the OR attempting to stop the surgery for he believed there was no
justification for why an ACL repair scheduled by a senior doctor, who does not
specialize in ACL repairs, should be classified as an emergency surgery when all
of his scheduled ACL repairs were considered nonemergent. He also believed the
operation exposed not only the patient, but the entire OR staff to COVID-19
risk that did not outweigh the benefit of performing the surgery. The senior
doctor argued that the patient was a healthy youth athlete that would suffer
from scar tissue, loss of motion, and other consequences requiring additional
surgeries if this ACL repair was not performed immediately. This dispute
required the active engagement of multiple management personnel. The ultimate
decision allowed the senior orthopedic surgeon to perform the ACL repair as an
emergency surgery. As a result, new guidelines with exact protocol for COVID-19
emergency surgeries were released by corporate and the newly hired orthopedic
surgeon resigned.
This type of surgery hits close to home for me. As someone who has gone through three ACL repair surgeries, I understand the want for the repair but not necessarily the need immediately. Recently in fact, I am currently awaiting an MRI next week to check to see if I damaged my ACL once more. This damage occurred during exam week which was roughly almost two and half weeks ago. My experience just to see my surgeon was longer and had additional precautions taken prior to meeting with him as one would expect with COVID-19 happening. When I first tore my ACL, I was actually leaving for a two week trip the next day and specifically remember the doctor saying I would be okay to schedule the surgery for after. At the moment I was in pain but after a few days it did subside it was just unstable.
ReplyDeleteFrom a standpoint of the doctor, I understand acting in beneficence to “do no harm” however, at some point the possibility of contracting COVID-19 through exposure instead seems as if it could do even greater harm. Especially if the hospital had guidelines in place, it does not seem okay as an ACL repair is not life threatening. In a study done on optimal ACL timing, the authors Evans et al. (2014) argue that the best time to receive an ACL repair is around three weeks as the patient can be at risk for increased for arthrofibrosis if they wait longer. They argue that too early of too late can come with complications but it’s still difficult to access as each patient physique and lifestyle is multifactorial. Once other thing I found interesting is that the patient wanted a doctor that was although senior, was not a specialist. Coming firsthand, the ACL is a tricky repair and I would indeed want a doctor that specialized in the ACL even if they were indeed newly hired as the ACL repair technique is evolving.
Evans, S., Shaginaw, J., & Bartolozzi, A. (2014). ACL reconstruction - it's all about timing. International journal of sports physical therapy, 9(2), 268–273.
There is a big ethics question here. Normally, an emergent surgery means that immediate action needs to be taken to fix what is going wrong. If you keep that definition during covid times, you run the risk of having patients who are do not fit the definition of a classical emergency but could none the less suffer extensively if their surgery is delayed. The individual in your post is a perfect example. He could potentially have many complications in the future if his surgery is not handled properly now. Where do you draw the line for these individuals? How do you find a balance between protecting people from Covid-19 and helping people who require surgery now to improve their quality of life, but do not qualify for emergent surgery?
ReplyDelete