What It Really Means to Cancel Elective Surgeries

What It Really Means to Cancel Elective Surgeries

04/02/2020

Credit: RICHARD ROSS / GETTY

theatlantic.com

Three weeks ago, Robert Cruickshank went to the ER in Seattle with terrible abdominal pain. The diagnosis? Gallstones. The hospital gave him strong painkillers and urged him to come back again—and soon—to have his gallbladder removed. “It doesn’t have to happen tonight,” he recalls the doctors saying, “but get it scheduled as soon as possible.” No one yet knew that the coronavirus was already spreading undetected through the city. Cruickshank briefly wondered if this virus in the news would affect things when scheduling the surgery for yesterday, but his doctor didn’t seem worried.

By this past Friday, everything had changed. The doctor’s office called to say that his gallbladder-removal surgery would be postponed indefinitely.

All over the country, patients are finding their nonemergency surgical appointments canceled as hospitals prepare for a spike in coronavirus cases. Surgeries for early-stage cancer, joint replacements, epilepsy, and cataracts are all getting pushed back—to ration much-needed personal protective equipment, keep hospital beds open, and to shield patients from the virus. On Friday, the American College of Surgeons recommended that hospitals reschedule elective surgeries as needed. Hospitals in outbreak hot spots such as Seattle, New York, and Boston were the first to act, but more are likely to follow suit.

Some patients are left wondering if they have a ticking time bomb inside them. Others are upending carefully made plans for life-altering surgeries with long recovery times.

Elective surgery does not mean optional surgery. It simply means nonurgent, and what is truly nonurgent is not always so obvious. Gerard Doherty, the chair of the surgery department at Brigham and Women’s Hospital in Boston, which began postponing elective surgeries on Friday, says surgical procedures can fall into one of three categories. About 25 percent of the surgeries performed at his hospital can be delayed without much harm. These might include joint replacements and bariatric surgeries for weight loss. Another 25 percent are for life-threatening emergencies that need to be treated right away: perforated bowels, serious heart problems, bones that have broken through the skin.

The last 50 percent are the tricky ones. These cases, Doherty says, have “some potential for harm to delay”; they might include cancer and problems in the blood vessels of the arms and legs. Brigham and Women’s is postponing some of these surgeries now on a case-by-case basis.

In Cruickshank’s case, for example, the initial bout of acute pain has passed. (That might have been when a gallstone got stuck.) He still feels “a little something” every now and then, and he worries that a flare-up might send him to the ER again. “Now I’m concerned,” he says. “If I go to the ER, are they going to have to turn me away and say, ‘Sorry, we have a bunch of coronavirus patients’?” The middle of a pandemic is a bad time to have a health emergency.

For other patients, the canceled appointments have meant rescheduling long-anticipated and life-changing surgeries. Sherrie Kumm, 33, of Ellensburg, Washington, has epilepsy that causes her to have a petit-mal seizure nearly every day. She can’t drive. For the past six months, she has been preparing to have a small section of her brain removed to stop the seizures—a two-part surgery that would require a two-to-four-week hospital stay. She took a semester off from her online degree, took time off from her job at a school, and arranged for her mother to watch her two sons while she was hospitalized.

As late as Thursday, her doctor’s office had called to confirm the surgery. She had packed a suitcase, complete with the front-opening nightgowns she had specially ordered to wear in the hospital. On Friday morning, her doctor’s office called again, this time to postpone the appointment. “I had been mentally preparing and physically preparing myself and my children for six months,” she says. The sudden cancellation has been hard for her, and she’s unable to plan or reschedule her surgery for now.

Kumm’s neurosurgeon at the University of Washington, Andrew Ko, told me that the policy to postpone elective surgeries came down from the hospital administration on Thursday evening. On Friday morning, he and his office started to cancel some 30 surgeries scheduled for the following two weeks. That included surgeries like Kumm’s, as well as implants for movement disorders and removals of slow-growing brain tumors that patients may have had for years. Brain-cancer surgeries, though, are going ahead. Ko said his hospital is prioritizing surgeries in which “the length of your life is affected.” The “quality of life” surgeries are the ones now getting postponed.

Canceling surgical appointments is also meant to limit the number of people circulating through hospitals. Surgeries like Kumm’s, which require a long hospital stay, during which visitors might be coming in and out, Ko said, may be particularly risky from the point of view of spreading the coronavirus. Hospitals around the country are also limiting patients to one adult visitor.

In general, doctors and nurses are being more careful about conserving personal protective equipment in the operating room. Doherty says his hospital is having nurses stay in the operating room after they set up, so that they don’t have to reenter and use a new set of surgical masks, gloves, and gowns.

At some point, depending on how long the coronavirus outbreak lasts, some nonurgent surgeries could very well become urgent. “Right now, most people are planning for a time period of four to six weeks for the peak to hit, but nobody really knows,” says David Hoyt, the executive director of the American College of Surgeons. “We’re using our best judgment on the fly.” And when hospitals do have capacity again, they will have a backlog of postponed surgeries to go through. Hospitals are going to be busy for a while.

With confirmed coronavirus cases varying so much from state to state, some patients are in a bit of a limbo. Cody Lawrence, 27, of Fort Myers, Florida, needs major thoracic surgery to fix a birth defect that has left him in too much pain to work recently. He and his wife are planning to drive three hours and stay at a hotel in Orlando, where he is scheduled to have surgery in less than two weeks. The specific surgery requires deflating one of his lungs, and he will need to be on a ventilator, which may soon be in short supply. With the coronavirus going around, he’s concerned for his wife, who just finished chemotherapy, and for himself. “If I catch it,” he worries, “I’m pretty much a goner.”

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