As COVID-19 bears down, doctors confront difficult choices on elective surgeries
Elective surgeries have been canceled, but the definition isn't clear.
When Nikki Martin finished her last round of chemotherapy in August at Baptist Health hospital in Fort Smith, Arkansas, she clanged a bell at the ward -- a tradition in cancer centers across the country. But there was one more hurdle to clear -- removing the tube inserted into her chest that had delivered more than 600 hours of the lifesaving medicine. That was supposed to happen Monday.
But as the nation is gripped by the relentless spread of coronavirus, procedures that doctors deem elective are being placed on hold at the urging of the U.S. surgeon general.
Doctors told ABC News they are suddenly confronting some very tough decisions -- having to decide whether to proceed or postpone prostate surgeries, colonoscopies, skin cancer removals and a range of other procedures that could mean life or death for their patients, but could also create stress on hospitals bracing for a deluge.
"It's hard to know exactly what an elective visit is," said Dr. Noah Lindenberg, an oncologist in Marlton, New Jersey. "One of the ways that we find patients with malignancies is doing colonoscopies and upper endoscopies. A lot of them start off as elective procedures until you find the cancer, you know what I mean? So that's a challenging situation. You really have to use your index of suspicion."
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Surgeon General Jerome Adams tweeted out the plea to doctors on Saturday to push off procedures, writing, "Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!"
Seema Verma, President Donald Trump's administrator for Medicare and Medicaid Services, followed up during a White House press conference, saying that "the crisis, as it develops, may require the curtailment of the least-critical or time-sensitive hospital services, but any curtailment must be nuanced to meet the needs of all severely ill patients."
Verma’s agency Wednesday night released official recommendations outlining factors that doctors should consider. Those factors include patient risk, availability of beds, staff and equipment and the urgency of the procedure.
"We urge providers and clinicians and patients to seriously consider these recommendations," Verma said. "They will not only preserve equipment, but it also allows doctors and nurses to help those there on the front and it will protect patients from unnecessary exposure to the virus."
Martin, a 48-year-old mother of two, received a "double whammy diagnosis" of colon cancer and non-Hodgkin lymphoma a year ago, the final phase of her ordeal was the removal of her catheter port.
"I found out in mid-February that it was coming out, and I danced a jig," Martin said.
But after confirming Martin’s appointment the day before, the hospital called Monday morning to cancel. Her procedure, they told her, was elective. It needed to wait.
"It just let all the wind out of my sails," Martin said.
On its face, experts said the guidance, which was initiated at the behest of the Centers for Disease Control and Prevention, makes sense.
Dr. Lewis Kaplan, a trauma surgeon with the Hospital of the University of Pennsylvania, said reducing the steady stream of scheduled patients arriving at hospitals is "a very wise maneuver."
"It frees up beds and equipment, and also frees up clinicians," Kaplan told ABC News. "If you are not using the anesthesiologist or nurse or the [gastrointestinal] suite, or the [intensive care] suite nurse, they can be recast as you need if you have large scale influxes of patients."
But as doctors around the country pore over their patient files, they are confronting the difficulties of determining which cases are essential, and which ones can wait.
"It's really very challenging," Lindenberg said. "You have to triage, knowing that it is possible somebody puts off a colostomy by three, four or five months or however long this pandemic is going to last. [But then] you might miss something."
Nancy Foster, the American Hospital Association’s vice president for quality and patient safety policy, told ABC News the group -- which represents nearly 5,000 hospitals and other health care providers -- remains concerned about the issue of elective surgery postponements.
Foster said the association has been lobbying for a policy that would allow medical staff at hospitals leeway to decide which surgeries should continue occurring in their facilities and which should not. The ultimate decision-making "has to be done locally," she said,
When Martin received word her catheter removal had to wait, it was more than just disappointing. She thought postponing the procedure sounded dangerous.
Keeping her port-a-cath would mean returning to the chemo center at least once a month to have it flushed to prevent a complication, and that meant coming into close proximity to cancer patients receiving treatment.
"I could be asymptomatic [for COVID-19], and I'm walking in with the absolute most vulnerable people in the world who are currently getting chemotherapy," Martin said. "This was absolutely a no-win situation. I was going to wind up being a burden either on the operating room staff and supplies, or on the cancer center and their personnel."
Dr. Mark Abdelmalek, a medical contributor for ABC News, said doctors are being forced to find a new way of balancing risk versus benefit. If a cardiologist can see a patient in the office, and make a medication adjustment, that may help keep that patient out of the hospital.
"These are really tough ethical dilemmas," Abdelmalek said. "In the end, every case is different."
And there is no reason patients should not weigh in, he said. Martin did just that. She challenged the decision to delay her procedure, and she convinced her surgeon to go ahead with it. Her port was removed on Monday.
"If you see a better way forward than what your doctor is recommending, ask," she advised. "Ask questions because you know your body better than anybody."
ABC News intern Mel Madarang contributed to this report.