Musculoskeletal Radiology Practice and Training During Current COVID-19 Pandemic: The Unforeseen

The world engulfed with the COIVID-19 crisis brings about a dramatic shift in management strategies of health services globally. As an Italian doctor has rightly said – “there are no more specialists but only doctors who suddenly have become a part of a single team facing a deluge of patients overwhelming the health-care system.”

Guidelines across all borders – international, national and local are therefore most important in handling these cases and the entire medical fraternity has to present a unified front while dealing with them. Musculoskeletal radiology along with orthopedic and rheumatology services also have to realign itself to the present needs. A large quantum of our work in terms of elective/ planned cases needs to be reassigned or deferred for later date; limiting non-urgent patient movement in the hospitals to contain the disease spread.^[1] All the ultrasound-guided injections and pain relief procedures also need to be curtailed. Emergency or trauma-related work will, however, continue in keeping with best medical practices.

It is advisable that separate fracture clinics are set up in the emergency departments (ED) of the hospitals to directly deal with orthopedic trauma cases from the triage. These services which aim at decongesting the ED are proposed to be expanded to up to 12 h/day, 7 days a week in some countries. For patients requiring emergent resuscitation measures, however, the ED and trauma teams would continue to function as before. Virtual fracture clinics, which allow the radiologists and orthopedic surgeons to directly review imaging and clinical details of a patient from ED online and discuss management either online or telephonically, can further streamline flow of these patients. Moreover, these clinics can be an essential backbone for managing patients requiring follow-up.^[2]

Our emphasis, however, would be on imaging of the admitted and symptomatic COVID-19 patients. Imaging guidelines have been provided by different institutions, colleges, and organizations. In the Indian context, the recommendations provided by the IRIA–ICRI chest subspecialty group are comprehensive and clearly stated. By and large, most of these guidelines advocate the use of portable radiography routinely and point-of-care ultrasound (POCUS) for evaluation and follow-up of ARDS. CT scans are limited to severe respiratory complications (like pulmonary embolism) unexplained by X-rays or POCUS combined.^[3]

Personal protective equipment is essential to the health care workers while dealing with the pandemic and in this regard advice provided by the Royal College of Radiologists, UK for imaging departments is concise and practical. It recommends use of fluid-resistant surgical mask, disposable apron and disposable gloves while in contact with confirmed or suspected COVID-19 cases. Such procedures would include X-ray, CT, MRI, nuclear imaging, fluoroscopy and ultrasound with close patient contact (<2 m). The use of surgical mask only if dealing with patients not in close contact (>2 m) and eye protection if the patient is coughing, is further recommended. A full protection equipment comprising eye protection (goggles, shield, or visor), filtering facepiece respirator (N95 quality), long-sleeved fluid repellent gowns and gloves is recommended in high-risk areas and during aerosol-generating procedures. These would include portable imaging in high-risk areas such as high dependency units, intensive care units, wards with non-invasive ventilation and any area where aerosol-generating procedures are performed. In addition, similar precautions could also be followed in the interventional radiology suits or while performing biopsies, drainages and line insertions.^[4] These guidelines could be further modified as per the locally prevailing conditions and availability of resources.

Moreover, it is recommended to include chest imaging as a part of abdominal imaging for patients presenting with acute abdomen and also before elective cancer surgery. This would reduce the risk of disease spread to the operating team, much to worry about with depleting human medical resources at the peak of the disease spread.^[5]

Medical training and continuing medical education have taken a backseat in the current scenario. Positive ingenuity and initiatives from different organizations and colleges, especially in terms of webinars and internet-based teaching resources, have come a long way in filling up this void. The commitment of Musculoskeletal Society (MSS), India, toward continuing training and education in the field of musculoskeletal imaging through a series of webinars planned over the next few months is noteworthy.

Tough times test resolves of a person, a society, a country, and the world at large. As David Allen once remarked: “There is light at the end of the tunnel, but the only way out is through!” I am sure once the dust starts to settle, there would be a lot of lessons learned and some positives drawn from this humongous tragedy by humankind.