Orthopedic practice during the COVID-19 crisis in China

Abstract

The COVID-19 pandemic has been developed into one of the most unprecedented crises in human history. It took almost 3 months to get it under control in China, with some very strict measures like locking down a major city with a population of 9 million people. Here I want to share with my colleagues worldwide some of my experiences and tactics for Chinese orthopedic surgeons coping with this disease. I present this dividing the major timeline into 3 phases: initial onset, peak load, and recovery. Phase I: initial onset—false optimism (end of December 2019 to January 22, 2020) In the end of December 2019, we heard that there had been some “special” pneumonia diagnosed in Wuhan, Hubei Province. But it drew no attention of the doctors from any other provinces in China. Before the middle of January, a special team of experts from the National Health Commission and Chinese Center for Disease Control and Prevention had been sent to Wuhan twice. They also did not realize the severity of this disease and announced that no evidence had been found for person-to-person transmission and the disease would be well under control. But things had turned worse since January 19, as the number of patients began to rocket up in Wuhan, along with the outburst of patients also from other major cities across China. The corona virus was also identified and sequenced at the same time. Now the National Health Commission and Center for Disease Control and Prevention realized that this virus was like SARS that appeared 17 years ago in 2003, or even worse. Although at this time some people began to wear facial masks in public places, hospitals were functioning normally and we orthopedic surgeons were taking routine clinical practice as usual. Then came the lockdown. Phase II: peak load for COVID-19—the lockdown (January 23 to March 15, 2020) The government decided to lock down a major city with 9 million people largely to avoid mass gatherings during the Spring Festival, or the Lunar Calendar Chinese New Year, and prevent spread of the disease. The Chinese New Year is a 7-day holiday. It is the most important Chinese holiday, and there has been a tradition for hundreds of years that everyone goes back home and get together during the Chinese New Year. This means migration of people on a gigantic scale. According to the data from 2018, 2.98 billion people (person-time) traveled by train and 66 million people (person-time) by plane during the 2-week period of the New Year holiday. This does not include millions of people traveled by bus. The Chinese New Year is always in late January or early February, according to the lunar calendar. This year it started on January 25. The virus had picked a perfect time to attack. The lockdown was imposed on January 23, just a day before the New Year's Eve. Unlike any country around the world, we had the real lockdown that was far more stringent than anywhere else. For Wuhan city and Hubei Province, all public transportation including airport, railway station, and highways was shut down, together with the metro system and bus transportation in the city area. Very strict control policies were also introduced in other places and cities in China. During this period, people around the country were asked to stay home 24/7. Thanks to the advanced logistic giants such as Alibaba and JD, almost 100% essential items were available to be ordered online and delivered directly to our doorsteps. So hoarding and shelf-emptying behaviors in supermarkets never happened in China. The COVID-19-specific hospitals were set up in every major city in China. All test-positive and suspected patients were sent to these hospitals and not allowed to be treated in any other hospital. So for these 7 weeks, regular hospitals turned out to be in holiday mode: only the emergency and fever clinics were running for outpatients (every hospital was required to set up the fever clinic during flu season since the SARS pandemic in 2003). All internal medicine doctors were scheduled for the shift to work at the fever clinic. All orthopedic surgeons were lined up for the backup just in case the situation got out of control. Some of the residents from the orthopedic department were also sent to the COVID-19-specific hospitals to help. The medical staff in Wuhan city and Hubei area did have shortage of personal protective equipment, such as facial masks (N95), face shields, protection goggles, and isolation gowns, during the first 2 weeks after lockdown. But with the rush in help of more than 42,000 doctors and nurses nationwide, together with the reinforcement and support across the country, the shortage was never a problem thereafter. As doctors in other cities and places like Beijing, we were lucky because we never had to face the shortage of protection. This is largely because the number of infected cases was far less than the number in Wuhan area. The total number of diagnosed cases in Beijing was only around 1000. All Chinese people should be grateful to Wuhan residents for their sacrifice for the lockdown. All elective surgeries were called off. For emergency room surgeries, special protocols had been issued by the hospital (Fig. 1). If ER surgery was required to be performed, all doctors and nurses had to be updated about the protection levels according to the patients' status. There were 3 protection levels: routine level, strengthened level, and restricted level. These different levels were decided by the 8 parameters regarding the epidemic history and the clinical symptoms of the patient (Fig. 2). Figure 1 Flowchart of the protocols for ER patient admission and surgery. ER, emergency room; CT, computed tomography; OR, operating room. Figure 2 Three different levels of protection for surgery. CT, computed tomography; PCR, polymerase chain reaction. Telemedicine was somewhat boomed during this period of time. Although online diagnosis and treatment suggestions were banned by the Chinese law, patients were allowed to describe their symptoms and upload the images of their clinical condition to seek advice from doctors online. Doctors were also allowed to give advice (not diagnosis) to these patients. For those patients who appeared to be a clear indication for surgery, they were documented by the doctors and prescheduled for an outpatient clinic visit whenever they can come to the hospital in person. Interestingly, there had been another boom in telemedicine: online education. Orthopedic surgeons in China travel a lot. Hundreds of academic meetings, seminars, and workshops are being conducted every year. Because of the virus outbreak, all face-to-face meetings had been cancelled, and online symposiums or case discussion seminars were flourishing. Phase III: recovery—open up and stay alert (after March 16, 2020) As the pandemic had been gradually controlled and the number of patients diagnosed with COVID-19 was decreasing, the whole country began to restart gradually. Apart from Wuhan city and Hubei area, people were allowed to go out and travel, and works had been resumed with very tight monitoring protocols. Everyone has a “green code” generated in his or her mobile phone. People need to show this wherever they go. Body temperature monitoring exists not only at airports or railway stations but also at the entrance of every building or structure throughout the country. If they travel outside their province or come back from outside their province, they need to self-quarantine themselves for 14 days in hotel or at home. Hospitals have been opened again for regular outpatient care, and elective surgeries are allowed with stringent protocols (Fig. 3). The COVID-19 polymerase chain reaction test is obligatory for admission, and different protocols for the polymerase chain reaction test are applied to outpatients, ER patients, and inpatients (Fig. 4). Low-dose lung computed tomography scan is also required if surgery is planned. If surgery is scheduled, the 3 protection levels that were described before (Fig. 2) are also implemented strictly. Figure 3 Flowchart of the protocols for outpatient admission. CBC, complete blood count; ER, emergency room; PCR, polymerase chain reaction. Figure 4 Flowchart of the COVID-19 testing protocol. ER, emergency room; CT, computed tomography; PCR, polymerase chain reaction; OR, operating room. We have not seen an outburst of an increase in the number of patients yet. Actually, we have a reduction of 30%-60% caseload, depending on different hospitals. Take my hospital, for example, as one of the largest orthopedic hospitals in China, 60%-70% of our patients come from outside Beijing. That means if a patient wants to undergo surgery in my hospital, he or she must come to Beijing 14 days before the surgery date to self-quarantine himself or herself first. Therefore, we are now only operating 40%-50% of our normal workload, and most of our patients are local residents of Beijing. I believe that by gradually opening the borders of the cities nationwide, there will be a spike-up of the number of patients in our hospital. At the same time, we will always be on alert for the virus and strict screening protocols will be implemented. Disclaimer The author, his immediate family, and any research foundations with which he is affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this artticle.