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Tuesday, March 31, 2020

Is It Wrong for Baseball Players to Get Tommy John Surgery?

On March 13, a recommendation came from the American College of Surgeons: Minimize, postpone, or cancel all elective surgery amid the spread of coronavirus. This instruction was shared the next day by the U.S. Surgeon General, and in the two weeks that have followed, it’s been echoed in executive orders issued across the country.

In that same time frame, MLB teams announced pitchers who would undergo Tommy John surgery: Tyler Beede of the Giants, Chris Sale of the Red Sox, Noah Syndergaard of the Mets. But what does it mean to have the procedure in a pandemic? Especially when every medical resource is precious—and pro athletes are already under fire for receiving preferential testing and treatment.

Legally, teams and players are on solid ground. The national recommendations are just recommendations, and it’s still feasible to perform a surgery like Tommy John in many parts of the U.S. Among the states that have issued executive orders on the subject, there’s varied language on what exactly is prohibited, from “elective” procedures (New Jersey) to “non-essential” (Ohio) to “non-urgent” (Kentucky). In many states, doctors themselves can determine which of their own procedures fit that terminology, at least for now. So, barring additional local regulations, an individual practice can quite easily make a legal determination that its essential procedures may include Tommy John.

“I think it’s a really fuzzy line,” says Christopher Scott, the chair of medical ethics and health policy at Baylor College of Medicine, when it comes to defining what procedures are, legally speaking, essential or not.

Anyone here with the grounding in medicine, the law, or general ethics needed to fully assess this question?


QLE Posted: March 31, 2020 at 12:51 AM | 18 comment(s) Login to Bookmark
  Tags: ethics, tommy john surgery

Reader Comments and Retorts

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   1. Rally Posted: March 31, 2020 at 08:16 AM (#5935162)
I think the doctors doing this are extremely specialized. There are a small number who repair the elbows of pitchers, and I don't think they are treating coughs and fevers when they don't have a pitcher elbow to work on.

I could be wrong, never had to deal with this myself. I felt a strain in my elbow when I was 16 and backed off pitching for a while, but 33 years later still no tear.
   2. Jose Needs an Absurd Ukulele Concert Posted: March 31, 2020 at 08:27 AM (#5935164)
Rally hits the point I’vebeen wondering about. If these doctors aren’t doing this surgery are they going to be available to treat other patients? Is a ventilator necessary for TJS?
   3. Mefisto Posted: March 31, 2020 at 08:36 AM (#5935167)
I think the issue is the overall burden on the hospitals and health care system. In lots of places right now they're stretched to the limit. *Any* extra usage would be a burden in NY right now, I expect. That might not be true everywhere, but still they'd need masks, gowns, anesthesia, etc. that could be used elsewhere.

Yes, if we just focus on half a dozen baseball players the burden is likely minimal. But there are lots of other people needing/wanting various procedures and the question is whether to start drawing lines or just issue a blanket prohibition.
   4. Ron J Posted: March 31, 2020 at 08:55 AM (#5935173)
#3 On a related note, a rugby player with a serious spinal injury was sent home even though he wasn't ready.

But it was the bed and other hospital resources they needed, plus hospitals are a bad place to be right now with an immune systems that isn't working properly (apparently this is common with spinal injuries)

But to my knowledge TJ surgery doesn't require a hospital stay, so the only issue I can see is any medical supplies used in the surgery.

However, the surgeons have at least as much training as final year medical students (despite having gone in a very specialized direction after graduation) and those are being pressed into service in some places. I'm certain there are ways to make use these surgeons. I don't think there's a current need to do what amounts to a draft yet, but it has to be in the list of options.

And having thought about it, I think that kind of move is what amounts to style over substance.
   5. SoSH U at work Posted: March 31, 2020 at 09:21 AM (#5935179)
I think Misirlou raised the most important point - surgeries sometimes produce complications, which can result in the need for hospitalization. If for no other reason than that, they shouldn't be performed now (I also find it hard to believe that none of their supplies couldn't be better used by hospitals in need).

   6. Mefisto Posted: March 31, 2020 at 09:54 AM (#5935188)
For me, the best example would be pregnancies. Deliveries are certainly not "elective". But here in CA, where the hospitals are not yet overloaded, they're restricting visitors and taking other measures to reduce system usage. If they're going that far for non-elective procedures, I can see the case for more restrictions on less urgent ones.
   7. Pasta-diving Jeter (jmac66) Posted: March 31, 2020 at 12:26 PM (#5935234)
James Andrews suspends TJ surgeries
Famed orthopedist Dr. James Andrews has made the decision to temporarily suspend performing Tommy John elbow surgeries at his medical facility in Gulf Breeze, Florida, a spokesperson said.

"We are not performing any non-urgent or non-emergent procedures, including Tommy John surgery, in compliance with the governor's executive order," the spokesperson for the Andrews Institute for Orthopaedics and Sports Medicine told the Boston Globe. "We are adhering to these restrictions and all such cases are suspended at this time."
   8. jacksone (AKA It's OK...) Posted: March 31, 2020 at 12:30 PM (#5935236)
Of course TJ surgeries are elective and shouldn't be happening now. Good for Andrews.
   9. The Duke Posted: March 31, 2020 at 02:27 PM (#5935272)
Rich people always get what rich people want - this rule of life is not impacted by a tiny virus
   10. Russlan thinks deGrom is da bomb Posted: March 31, 2020 at 02:38 PM (#5935274)
I am a psychiatrist that works in Windsor, Ontario. Windsor is a border city just across from Detroit. I do some inpatient work and I also do ECT. I can tell you that the hospitals in Windsor have stopped all elective surgeries and that they have actively discharged people preparing for when things get worse. I think there's going to be a time when things like medicines used for anaethesia, materials like masks, etc will run low. I think in the long run pharmaceutical companies and industry will step up to provide that gap but there is certainly concerns that there won't be enough "materials".
   11. Karl from NY Posted: March 31, 2020 at 02:56 PM (#5935276)
I don't get the impression that Andrews really agrees with suspending, just that he can't really do anything against the prohibition.
   12. SoSH U at work Posted: March 31, 2020 at 03:05 PM (#5935280)
ElAttrache confirmed Syndergaard had an acutely torn ulnar collateral ligament and recommended his surgery as essential.

"I know that I'm going to get criticized for taking care of these kinds of guys, but it's essential to their livelihoods," ElAttrache told the San Francisco Chronicle on March 24.

He seems to misunderstand how essential is being used in these circumstances.

   13. Captain Joe Bivens, Elderly Northeastern Jew Posted: March 31, 2020 at 03:20 PM (#5935288)
this rule of life is not impacted by a tiny virus

Read this in the voice of Schwarzenegger.
   14. Misirlou cut his hair and moved to Rome Posted: March 31, 2020 at 03:43 PM (#5935294)
He seems to misunderstand how essential is being used in these circumstances.

I keep going back to a construction worker getting an elective hernia operation right now. It's essential for him, and he isn't getting one right now.
   15. Walt Davis Posted: March 31, 2020 at 04:42 PM (#5935317)
At this point where the majority of the cases are still linked to travel, especially internattional travel, it is a disease that is hitting the affluent more frequently than the poor. That will change of course if local transmission can't be controlled. But in any epidemic, being socially isolated before the epidemic is advantageous -- the issue for those areas/groups is that in the modern world nobody is THAT isolated so eventually it will get in. Once it gets in, it's a matter of how interactive they are within the community -- there's no escaping it on a cruise ship or in a nursing home.

Anyway, the factoid I saw the other day was something like counties that voted Trump in 2016 comprise about 45% of the population but only 16% of the known cases. It has hit travellers (usually above-average income) and now the general population in urban areas (where interaction is nearly impossible to avoid in regular life). It's a virus, it will eventually get spread everywhere and it may already be too late for more isolated communities and those counties will soon catch up but there's never been a better time to be a cabin-dwelling mountain man.
   16. bbmck Posted: March 31, 2020 at 06:54 PM (#5935356)
Cabin-dwelling is vastly over-stated. 11 confirmed cases and 164k people locally, which for the New York metro area would be 1412 cases and they have 43,139 cases. New York City is about 25% of the confirmed cases in the US and 6.5% of the US population.
   17. Hysterical & Useless Posted: March 31, 2020 at 08:01 PM (#5935372)
A friend sent us the link to a video done by an ICU doc at Weill Cornell here in New York. Originally a live-streamed event, giving info on covid-19, answering questions,etc. Did it on March 22. At that time, he said the entire hospital, 1200 beds was given over almost entirely to covid-19 patients. Can't imagine they have more space available for other patients now.
   18. Walt Davis Posted: March 31, 2020 at 09:30 PM (#5935388)
11 confirmed cases and 164k people locally, which for the New York metro area would be 1412 cases and they have 43,139 cases. New York City is about 25% of the confirmed cases in the US and 6.5% of the US population.

Yeah, NYC is bad. But 11 cases can become 100 cases in the matter of a couple of weeks. It's more a question of when was your town's first case ... and how soon after that did people start practicing social distance? There are obviously differences in the likelihood of transmission/infection that will vary by region (all those people riding the subways in NY for example) but not much reason to think that New Yorkers are more likely to become infected when they come into contact with it.

This is a case where raw numbers not just rates matter. I know nothing about, say, Decatur, IL (pop 76,000) but I would guess not that many of its residents travel internationally nor does it get many tourists (international or domestic). It would be a place where this virus would be less likely to get started (but still pretty likely eventually). Once it does get started there, it's mainly about how much interaction there is among its residents. A small city, probably limited public transport, no beaches for people to congregate, no big concerts, etc. ... but presumably plenty of small group interaction.

Again, in the extreme, if you could guarantee the ship, its crew and the passengers were virus free just before it left dock, a cruise ship is exactly where you'd want to be for the next month. If even one person on that ship has it, it is among the last places you want to be. It's a social network problem. A community that is isolated from other communities but highly interactive within the community will either not get the virus (because it never gets in) or will be inundated (because it gets in then spreads like wildfire). (Think Amish or Hasidic communities maybe) A community that interacts reasonably often with other communities but doesn't interact much within might do OK -- the virus will get in via several people but those people won't be likely to pass it on. (Not sure there's a good example there.) A community that is highly interactive within and without is in big trouble. (NY)

But of course in the modern world, we're nearly all members of multiple communities so you might be safe at home but in danger at work and at church and playing rugby on the weekend.

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