Orthopedic

Surgeons in The Era

of COVID-19
Prepared by:
Dr. Ramzy Shokri
2nd year board student
Duhok center of KBMS
21-4-2020
Introduction
• Primum non nocere. A Latin phrase that means "first, do no harm.

• one of the principal precepts of bioethics  that all medical students

are taught in school and is a fundamental principle throughout the
world.

• It should be implemented in this situation…to protect patients and

healthcare workers (HCW) all the same.
Introduction
• We DO live in a pandemic Era, though our cities have limited number of
cases, but all cities around us along with nearby countries still have surges of
covid-19 cases.

• No vaccine and no treatment so far.

• 30-70% of cases( mainly in the ages of 20-29 demographic) are

asymptomatic and/or have very mild symptoms.

• Better safe than sorry.

Stats all over the world
• Statics all over the world give a rough estimate of 10% of corona positive cases being in the HCW
population .

• In a country such as Spain , which has the highest number for HCW affection
( 14% , 15000 doctors and nurses are affected) .

• A HCW is five times more likely to contract the disease

• A HCW is more likey to experience a severe form of disease due to high viral loads exposure and
the subsequent cytokine storm

• 139 doctors have passed away so far in Italy due to this disease.
When you operate not knowing
the patient has the disease !!!!
 Would you operate on a Covid-
19 case?
• The problem for medical professionals is often portrayed as simply one of sourcing extra masks,
goggles and plastic gowns — or personal protective equipment (PPE). But this is only part of it. 

There are three other layers of complication.

• First, the issue isn't only PPE shortages, it’s that the kind of equipment that’s used commonly
isn’t appropriate for all medical practitioners, such as many surgeons.
• Second, the absence of adequate testing, including routine checks of patients, increases the
chance that doctors will fall ill.
• And third, it seems that, when exposed, some doctors are at greater risk of being among those
who get the most serious form of the disease, like those unfortunate names on the Italian list.
Alister Hart, chair of orthopaedics at
University College London and a surgeon
at one of Britain’s largest orthopaedic
hospitals:
• “ Nearly all orthopedic surgery requires power tools, hammers and
other implements. Not to get too graphic, but lots of material gets
spread around, which could facilitate the virus’s transmission. Though
blood and gore may not be its favored route, research into airborne
transmission(such as SARS and MERS) supports the idea that Covid-19
is an opportunistic invader. Blood donors are now screened for the
virus in Wuhan.”
He continues:
• “the combination of power tools, high-velocity blood splatter and
ventilation systems , operating rooms will soon be like

viral labs in a wind tunnel.

The result will be long lists of casualties among the medical
profession.” 
So again , will you ??
• The answer should be based not only on the availability of PPEs , but
also on having local guidelines and protocols on how to act in the
perioperative period.

• In an ideal world , all patients will be tested for COVID-19 as part of a

pre-op work up, same as we do for HIV and hepatitis

• In an ideal world , we should have negative pressure ORs with

anterooms for donning and doffing.
So let’s start with PPEs
Masks :
Bandanas and local made clothes turned to masks have no
protection.

Face masks (single layer and double layer) have little proven effect for
protection

Surgical masks ( triple layered) when properly fitted ( no air leak) ,

can give up to 80% ( same as a FPP1 respirator)
Masks

Fpp2 and fpp3 respirators ( 95% and 99% protection respectively)

(again needs personal fitting test to make sure it has no leak)

PARP ( Powered air purifying respirator) –has most protection from

all the items mentioned before ( superiority)
Single and double layered
masks and clothes
Surgical mask( triple layered)
Respirators
PARP
FITTED MASK
CLEAN SHAVEN , PROPER SIZE MASK, FIT TEST ,
USE TAPE,PLASTICS AND VARIOUS THINGS TO
MAKE IT HAVE A GOOD SEAL
Now , cover alls
Surgical gowns
Over alls ( water repellent)
Hazmat suits ( superior)
Surgical gown
Over all suit
Hazmat suit
PPEs , cont.
• Face shields and goggles ( reusable when properly disinfected )
A realistic approach
What is available in our OR at emergency teaching hospital ?

Scrubs ( bring in your own if possible)

Head and shoe cover
Surgical gowns, surgical gloves and surgical masks
Bring in your own goggles and/or face shield
Bring in your own respirator (aka fpp2s) if you have one
Throw in a cover all in there if you have access to one.
Get a plastic zip bag for your phone if you wish to take it inside with you
Let’s be better !!!
• The realistic approach can be made much better and more protective
for us and everyone working in OR.

• For that we need to understand this virus better and take a look
around at what other countries are doing.
Proper OR for a COVID-19
patient : AIIR
Some tips all over the world
Droplet precautions : keep your PPE on the entire time , frequent hand washing and deal
with every surface as contaminated.

Aerosol precautions ( for us mainly when a case gets intubated) do not be present in the
OR unless necessary and wear a respirator during surgery on such a case that is intubated.

Limit OR Traffic as much as possible.

When using cautery , use the minimum current( monopolar better than bipolar), vigorous
suctioning of aerosols from cautery.

Drilling and power tools are regarded as aerosol generating procedures same as
intubation and oxygenation.
From UK , ROYAL COLLEGE OF
SURGEONS
The impact of Covid-19 on the
orthopedic department
• On patients (consultations, follow-ups, electives)

• On doctors ( training wise ,psychological ,financial )

Outpatient clinics
• Telemedicine .
• Virtual outpatient clinics.
• Ambulatory clinics and minor surgery ORs ( France).
Who gets surgery ??
Whom to operate on
Some examples
• Immediate : Fracture with major neurovascular deficit, Compartment
syndrome…etc

• Urgent : compound fractures for example

• Expedited : Tendon and nerve injuries, Stable & non-septic patients

for wide range of surgical procedures

• Elective : plate removal for example, cysts and ganglions…etc

Going Home, What Should Be Done to Keep
Your Family Safe?
(American college of surgeons)

Healthcare institutions and systems may make hotel accommodations available for
healthcare workers who cannot or prefer not to go home following patient care activities.

Be alert to the fact that viral contamination of surfaces is a known means of transmission of
infection.

Keep hand sanitizer and/or disposable gloves for use of ATM, vending machines, gasoline
pumps, and transfer of items at the time of purchases.

Clean your cell phone frequently before, during, and after patient care activities. Cell phones
may be kept in a Ziploc bag during work activities. The phone can be used while in the bag.
At home,
Consider removing clothes and washing them upon arrival home.

Consider reducing physical contact with family members and wash

hands frequently.

Clean hard surfaces at home with an effective disinfectant

solution (e.g. 60% alcohol).
In conclusion

COVID-19 represents an uncertain challenge that could generate large

numbers of patients in a short period of time. How best to manage
this is evolving. There will not be an ideal solution so all are requested
to work together to solve the challenge.
Thank you