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Orthopedic Surgeon Challenges the Definition of “Elective” Procedures - Dr. Benjamin Domb, M.D.,

Here is an item from an Orthopaedic Surgeon discussing the value of delivering essential musculoskeletal care in a timely fashion. This includes necessary surgery in an Ambulatory Surgery Center setting, along with taking the appropriate precautions.

When Surgeon General Jerome Adams recently warned that COVID-19 is our generation’s “9/11 moment,” it struck me viscerally.

Like most Americans, I vividly recall the day the twin towers fell, but I lived through the chaotic month afterward as a medical provider on the front lines of that crisis.

On September 11, 2001, I was a young doctor, having just graduated a few months prior from Johns Hopkins School of Medicine. As fate would have it, I was also one of three surgical interns newly stationed that fall in Manhattan’s only intensive care unit for critical burn victims. At 8:46 a.m. on that fateful Tuesday morning, we all stood in horror watching the news as the first plane crashed into the north tower.

By 8:48 a.m., our team quickly realized that we were in for an onslaught of burn victims at New York-Presbyterian.

By 8:49 a.m., hospital staff and I were madly rushing to free up beds in our ICU, relocating every patient that could possibly be transferred to another floor, and moving beds and ventilators into every available space.

Tragically, nearly every injured survivor pulled from the towers was severely burned, and we received them all.

Fortunately, doctors of every specialty in the hospital and the broader New York area mobilized quickly and came to help support emergency efforts. But within a few days after the immediate needs subsided, these specialized medical professionals all returned to their respective hospitals and practices to care for their patients.

Cardiologists went back to treating heart disease, internists to diagnosing diabetes, surgeons to removing gallbladders.

After the “troops” of physicians pulled back at our hospital, the other two interns and I voluntarily moved into and lived in the burn unit for the majority of the next month, providing 24/7 care for our patients as they straddled the precarious line between life and signing up you agree to our terms of service

Sadly, some of those early patients perished, but we also succeeded in saving the lives of the majority of the burn victims we treated. Through that life-altering experience, I learned several valuable lessons about health care, and our system’s response during a crisis and its aftermath.

Today, nearly 19 years later, the medical community is facing a new global crisis with the novel coronavirus pandemic, and just like 9/11, all hands are on deck.

As it rightly should be, the attention is focused on immediate treatment of those experiencing symptoms of COVID-19, or the necessary preparations for the expected surge of patients in every state of the nation.

However, while we remain focused on the urgent medical needs today, a secondary health care crisis is also brewing, and it threatens to be much larger than the crisis caused by the virus itself. It is the crisis of every other medical ailment that is being ignored, postponed or left untreated while we focus on coronavirus.

Federal and state governments have recommended a complete stoppage of all “non-urgent” procedures. Women cannot get annual mammograms. People with heart disease cannot get routine blood tests. Cancer screenings are becoming an afterthought. As a nation, we are in grave danger of pushing aside every aspect of medical care that is not related to COVID-19, and if we do not act quickly to balance our efforts, the conditions we are ignoring may incur a human cost that could far overshadow that of the virus.

As an orthopedic specialist, I’m seeing this come to life in my own practice. Just this week, I performed surgery on a vibrant, 28-year-old young man named Jeffrey who had fully torn his hamstring tendon.

A terrific former high school soccer player who still loves to play a variety of sports, Jeffrey was sidelined from all physical activity due to his injury. In the midst of this public health crisis, it took six weeks for him to get his MRI scan showing a significant tear, and longer yet to get referred to my care. If his surgery were delayed any further, his tendon tear would have become irreparable, and he would have suffered lifelong weakness and chronic pain.

The hospital where he received his diagnostic imaging said he could not have the surgery, because it was deemed “elective.” He disagreed, and so did I. Last week, I safely repaired his tendon at an alternate surgical center, and he is now expected to make a full recovery.

Throughout this evolving crisis, I have thought often of one of my mentors, Dr. Frank Jobe. He devised Tommy John procedure, an orthopedic surgery to replace a torn ligament in the elbow which has helped roughly 1 in 3 pitchers in the major league, and countless high school and collegiate baseball players. Recent media coverage has broadly criticized MLB pitchers receiving this Tommy John surgery in the midst of coronavirus.

As an orthopedic surgeon specializing in a variety of hip injuries, I have spent a large portion of my career treating professional athletes and helping them get back to their sport. However, I have equal concern for the everyday athlete like my patient Jeffrey. People like Jeffrey, who are not professional athletes, also desperately need care now to ensure they can function effectively and avoid causing irreparable harm that can impact the long-term quality of their lives.

Another recent patient of mine, Eric, a 43-year-old father of three young boys, had been suffering from increasing levels of hip pain due to arthritis for several months. In good overall health, he had had not been able to walk due to catching and locking of his hip joint, and he could not play with his children due to severe pain. He had scheduled a hip resurfacing procedure for the beginning of April.

A week before his planned procedure, he received a call that his surgery was canceled because it also was considered “elective.”

That same week, he lost his job as a manufacturing manager when his plant was shut down due to the stay-at-home order. Now, facing indefinite financial uncertainty, and disabled by his hip pain, he pleaded with me to get his surgery done.

With the help of the outstanding nurses and staff at our ambulatory surgery center, I agreed it was warranted to classify his procedure “essential,” successfully performed the surgery and he now is home recovering with renewed hope of someday returning to work fully functional.

Millions of Americans today are suffering from pain, disability, or other ailments and are in jeopardy of going without treatment for other equally debilitating conditions such as heart disease, cancer or arthritis. While acute focus of the health care system on the novel coronavirus crisis is certainly warranted, needed and appropriate, such other problems remain marginalized. More than 2 million Americans undergo “elective” orthopedic surgery annually, and at this moment, most cannot get care.

Delaying or foregoing treatment of problems will, no doubt, cause irreversible damage.

If millions suffering from joint pain cannot get treatment, many will lose employment due to disability, develop opioid dependence or addiction while managing pain, succumb to depression or mental health disease, or worse, die of a blood clot due to immobility. These dire consequences cannot be ignored, and treatment cannot simply be pushed aside as “elective.”

There is a way to prevent, or at least mitigate, this impending secondary health care crisis in America after COVID-19. It starts with us, the doctors. Like in the days that followed 9/11, we must soon return to our specialties, and reopen subacute and preventative health care in this country.

The federal government has given us an opening to use our medical ethics and discretion to do the right thing, with recommendations from the Centers for Medicare & Medicaid Services that we “prioritize services and care to … avoid further harms from an underlying condition. Decisions remain the responsibility of … those clinicians who have direct responsibility for their patients.”

These recommendations have placed the responsibility to do the right thing squarely on the shoulders of physicians, and we must be up to the task.

This is our moment as physicians to go from good to great, and to prevent the suffering and death of millions with medical problems apart from coronavirus. Our nation must focus tremendous efforts fighting coronavirus, but not all of us can or should be treating COVID-19 patients — believe me, no one wants to be intubated by an orthopedic surgeon — and the rest of us must continue to practice the very medicine we were trained to practice.

We must use telemedicine to reach our patients who cannot, or will not, come into the office. We must categorize procedures as “urgent” when we know that delays will put our patients’ health or future mobility at risk. We must use alternate sites of care, such as ambulatory surgery centers, in order to alleviate the burden on hospitals so that they can conserve their beds and PPEs for coronavirus patients.

It is true, I put myself and my family at risk of contracting COVID-19 by exposing myself to patients and continuing to perform surgery. I also will open myself up to criticism for doing surgeries when many of my peers have stopped. Yet, I choose to take these risks because when I became a physician, I took an oath to “first, do no harm.” Sometimes, doing no harm is not the same as doing nothing. This time, doing no harm means doing something to protect the future of our patients.

While we fight the coronavirus crisis in America, I encourage my fellow colleagues to take action to continue care for their patients with all types of ailments. Physicians, let’s do this together.

About the Author:

Dr. Benjamin Domb, M.D., is the founder and medical director of the American Hip Institute & Orthopedic Specialists based in Des Plaines, Illinois. He is a leading innovator and educator in the field of Robotic and Arthroscopic Hip Surgery. Visit

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