COVID certainly has affected just everything, from getting patients into the hospital, from discussing risks and benefits of coming in the hospital with respect to COVID, and post anesthetic COVID. It certainly limited our ability to see the patients in the way we did in the past, and limited with respect to numbers. We're limited with respect to surgical time, and inpatient beds. So really, it has been a significant effect.

Certainly, there were some delayed surgeries that ended up needing to be done. But I hope the outcome wasn't that much different or any different. I don't think I'm seeing anyone now, a year later where I think it's too bad. The ones I'm seeing where that crosses my mind are the ones who couldn't get in and couldn't get access. Not through anyone's fault. They were the ones who were less urgent and got delays. We're realizing we've shifted and learned how we can still give that same level of care without the constraints of what we have.

Wait lists have gone up. For example, our clinics are operating at 30% capacity because of social distancing. And we are trying to avoid using the or for unnecessary things.

I think the surprising thing for me has not been as much as the inability to get patients into the or to fix them that I thought would be a problem. It's patient reticence. Patients are saying, ‘is there any way you can keep me out of the hospital?’ And patients are recognizing that that's a real hotbed of risk that they don't want to take.

We had people with the first wave that were too scared to go to the hospital. So we had people coming in with injuries that were dislocated that were never seen. I remember seeing a patient with an anterior shoulder fracture dislocation four weeks ago. The patient came in a month later after she eventually couldn't manage the symptoms.

It's an evolution rather than a set change. If there's ever been a time for rapid change, this was it. And the evolution now keeps changing. There's lots of shifts in terms of patients coming in […] We're going to run into a shortage of human resources soon. So, if I can do minor procedures in the outpatient clinic with one nurse assisting, (I’ll do that). And they (the patients) don't have to go through a lot of registrations and pre-nursing checks. There's a consciousness in our group of (what we can do) to save the nursing staff.

I think it's changed life for everybody. Everything just gets shut down in the span of like a week, and essentially shutting down ORs, clinics. A lot of people just decided to start treating fractures and injuries non-operatively because we didn't know if it was safe to bring people to the hospital. I think with the first wave there was a lot of non-operative orthopedic care for injuries that we would have normally fixed.

Non-operative treatment has become more predominant in our practice now. We're having longer waitlists on the even urgent waitlist cases for trauma because of the backlog and the COVID restrictions. So, non-operative care is now becoming a more prominent thing we're doing now. We're making sure we establish good communication with the patients and provide them with different nonoperative modalities that they can be using to maximize their need to avoid surgery while they're on these long waitlists.

The main issue for me was bringing a potentially vulnerable patient into the medical environment. No matter how safe you try to be, someone coming in to have some pre-op work done, and get an X-ray done and have their surgery in the hospital and go to physiotherapy afterwards. That involves a lot of contact with other people. And no matter how safe you are, there's always a risk of having them get COVID. A 75-year-old diabetic with a non-union, you don't want that to happen to them. And so, we in the clinic had a lot more interest in non-operative therapy for a while there. Primarily for that reason so as not to expose our patients to covid, and certainly the follow-up.

There's a number of different things we're doing. We have a non-operative form that we give to every patient. We're providing more prescriptions. We're providing more detailed information on how to access these care. For example, when it comes to some of my ankle fusions or my midfoot fusions. The non-union rate in these operations is anywhere between five and fifteen percent depending on what reference you read. I'm a little less quick to jump in and propose a revision surgery now at the six- and nine-month mark because of this backlog. And I'm more quick to use modalities that may enhance healing.

Often a good splint or some kind of assistive device would help people a lot especially in the upper extremity. I do a favorite of that. For me, ultrasound has always been an intrinsic part of my practice. If I have someone with a stable non-union that's not infected, it doesn't have too much deformity. I've often used an ultrasound to type a device to try and augment union and especially if we're reluctant to bring the patient to the hospital for a particular reason.