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The bone prone team

  • Sagar Kulkarni
    Correspondence
    Department of Critical Care, Intensive Care Unit Milton Keynes University Hospital NHS Foundation Trust Standing Way Milton Keynes, Buckinghamshire, MK6 5LD, United Kingdom.
    Affiliations
    Department of Critical Care, Intensive Care Unit Milton Keynes University Hospital NHS Foundation Trust Standing Way Milton Keynes, Buckinghamshire, MK6 5LD, United Kingdom

    Oxford University Clinical Academic Graduate School Medical Sciences Division, University of Oxford John Radcliffe Hospital Headington, Oxfordshire, OX3 9DU, United Kingdom
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      Abstract

      When the COVID-19 pandemic arrived in the United Kingdom, elective orthopaedics was halted. This article tells the tale of the orthopaedic surgeons who rose to the challenge of helping to treat coronavirus patients on the intensive care unit.

      Keywords

      Orthopaedic surgeons are famed for their strength. “As strong as an ox,” as the saying goes.
      • Subramanian P.
      • Kantharuban S.
      • Subramanian V.
      • Willis-Owen S.A.G.
      • Willis-Owen C.A.
      Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study.
      However, when the COVID-19 pandemic hit the United Kingdom, and all elective orthopaedic work was cancelled, their drills fell silent, their oscillating saws were switched off and their mallets lay unused. The orthopods were vacant.
      Keen to join the ‘war effort,’ the orthopaedic surgeons volunteered on the frontline of the pandemic – the intensive care unit (ICU). Considerable debate occurred over what tasks should be allocated to them. Eventually, it was decided that their abilities would be best utilised for one specific task – proning. Thus, the bone prone team was born.
      Proning is the act of turning a patient onto their front to improve their oxygenation. At the peak of the COVID-19 pandemic, almost all patients on our ICU needed to be proned. Proning an intubated and ventilated patient is challenging – care must be taken to ensure that the endotracheal tube, central line, arterial line, nasogastric tube, urinary catheter, rectal tube and several peripheral intravenous cannulae are not dislodged during the manoeuvre. Furthermore, the patient must be placed in such a way as to avoid injury to the eyes or skin. The ICU nurses were working flat-out and did not have time to prone patients. Our orthopaedic colleagues were very much needed.
      I recall the first time we called the orthopaedic surgeons for assistance. A lone, lumbering orthopaedic consultant arrived, his eyebrows slightly furrowed, unsure of what was about to happen. He looked around the ICU, at the ventilators, the invasive blood pressure monitoring equipment and the infusion pumps. Like a boy on his first day at school, he was thrust into an unfamiliar environment.
      Initially, proning was haphazard. The ICU would bleep a surgeon to request help with proning, only to find out that the surgeon was occupied. Once, an orthopaedic surgeon attended the ICU after a challenging trauma case, asking,“I got bleeped two hours ago; is everything okay? Do you need my help?” Some would say he was late, but his enthusiasm to help us was undeniable.
      Quickly, however, they learned, morphing into a highly efficient proning team. With typical orthopaedic precision, proning would happen on a schedule – every day, the bone prone team, composed of several consultants, registrars and senior house officers, would attend the ICU at 8am and 5pm, ready to prone. Additionally, if proning was needed at any other time, we would bleep the orthopaedic registrar, who would immediately send their consultant (sometimes multiple consultants) to prone.
      One morning, the bone prone team attended the ICU, like a sports team descending from a tour bus. Amidst chatter of tendons and joints, one of them called out,“We’re ready when you are!”
      As I was donning my personal protective equipment (PPE), I saw Mr Jones (not his real name), one of the senior surgeons, approach me. I wondered whether he was about to scold me for doing something wrong. To my surprise, he said,“Shall I do up your gown?”“Oh, that’d be great, thanks.” I replied, surprised at this out-of-character offer.
      Once we (the ICU and orthopaedic teams) had all donned our PPE, we entered the unit together. Mr Jones grabbed the pre-proning checklist and assumed his position.
      “You take the left, I’ll take the right. Ready, steady, slide!”
      In a fluid motion, we proned the patient, like synchronised skaters. That day, we had a good round of proning, successfully flipping four patients. Six weeks later, all patients who were proned on that day survived ICU. We thanked the orthopaedic team for their help, to which one of their number responded,“We aren’t the heavy-lifters here – you are.”
      As time went on, proning became a communal activity in the hospital. At our scheduled proning times, doctors from emergency medicine, haematology and surgery rubbed shoulders to prone, for the benefit of the patient. At times, we had too many hands on deck, and had to turn people away. When asked why they wanted to join in, they all had the same response,“It’s the least I can do to help.”
      By late April, our caseload began to decline, and proning was needed less frequently. Eventually, the bone prone team was disbanded, its cause now defunct. However, the camaraderie behind it still persists. To me, proning came to symbolise our struggle against coronavirus – the doctors of my hospital, and indeed the nation, came together to defeat a common enemy.
      The COVID-19 pandemic brought about a new sense of unity in the National Health Service (NHS). Hospital hostilities became collegial; expanded wellbeing services were offered to staff; and clinicians, like the orthopaedic surgeons, stepped into unfamiliar territory for the greater good. As the number of coronavirus patients wanes and we begin our return to normality, one can only hope that this spirit of kindness, generosity and teamwork will persist in the NHS.

      Funding

      No funding was required for this paper.

      Declaration of Competing interestCOI

      No competing interests to disclose.

      Ethics approval

      Not applicable.

      Consent to participate

      Not applicable.

      Consent for publication

      Not applicable.

      Availability of data and material

      Not applicable.

      Code availability

      Not applicable.

      Authors’ contributions

      I, Sagar Kulkarni made substantial contributions to the conception and design of the work. I drafted the work and critically revised it for important intellectual content. I gave final approval for this version to be published. I agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

      Reference

        • Subramanian P.
        • Kantharuban S.
        • Subramanian V.
        • Willis-Owen S.A.G.
        • Willis-Owen C.A.
        Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study.
        BMJ. 2011 Dec 24; : 343