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Waiting for the knife – orthopaedic surgery in the time of COVID-19 Bibhas Roy and James Wilson
H
ealthcare has long recognised that rules are necessary to distribute medical resources equitably in situations of scarcity1. Various models are described, all require ‘triage’ in some way. This inevitably creates ethical questions and requires specific policies.
Bibhas Roy is a Consultant Orthopaedic Surgeon, Manchester University Foundation Trust.
James Wilson is an Upper Limb Consultant Surgeon from Bolton.
32 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk
Waiting for care is a characteristic of many health systems; more so in publicly funded ones2. It is also clear that waiting times statistics exist mainly in countries with tax-financed health systems, rather than countries with health systems funded through contributions3. The COVID-19 pandemic has affected and sometimes overwhelmed healthcare infrastructure and resources4 requiring concepts of ‘triage’ to be introduced. Originating from the French verb ‘trier’ meaning ‘to sort’, triage has been used in healthcare primarily in ‘mass casualty’ incidents. Although used extensively in the military5, the concepts are also used in emergency departments6. Effective triage is a specific skill, and authors have noted that ‘most who write scholarly articles on the subject have never practiced triage, or even witnessed it!’5. It is also important to recognise that demands can create the need to ration medical equipment and interventions7, making concepts of resource allocation necessary for a complete solution.
The three components of triage are sorting, prioritising and allocating resources.8 Sorting requires assigning a ranked value or priority to what is being sorted, which inevitably creates a prioritisation hierarchy. Resource allocation becomes necessary as the magnitude of the problem increases to an ‘overwhelming’ level, highlighting the concept of ‘the greatest good for the greatest number’ and implying a shift in decision making from a focus on individual patient outcomes to population-level outcomes. These concepts are not new, with theories of utility described first in the 1700s, along with other philosophical principles such as the difference principles of justice, principle of equal chance etc9. In addition, triage does not necessarily conform to modern ‘values’ of medicine such as autonomy – the right of the patient to choose treatment via informed consent and fidelity – the clinician is not always able to act on the best interest of individual patients, etc. A system that allocates the benefits of healthcare as well as the burden of limited or deferred care within the population is created.
“Waiting for care is a characteristic of many health systems; more so in publicly funded ones. It is also clear that waiting times statistics exist mainly in countries with tax-financed health systems, rather than countries with health systems funded through contributions.”
Elective orthopaedic surgery Systems to prioritise elective surgical patients10 and their validation have been discussed for many years11. These have addressed the entire patient pathway including the referral, the clinical symptom load, and the management of waiting lists2,10,12. In the setting of COVID-19, elective orthopaedic surgery has suffered particularly as the problem is perceived to be less important than other clinical scenarios such as cancer care13.
