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How do you determine who gets surgery during a pandemic?

As the backlog of Americans who have delayed

As the backlog of Americans who have delayed surgeries because of the coronavirus grows, how will medical professionals determine who will be treated first after the danger has passed? Credit: Getty Images/iStockphoto/Wavebreakmedia

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In March, when all but the most pressing surgical procedures ground to a halt to save staff and precious supplies for the fight against COVID-19, operating suites across the country became nearly unrecognizable. At one hospital in Boston, where I live and work, more than 40 operating rooms went dark, 25 of them stripped of ventilators and other equipment — like oysters that had been shucked and devoured.

The operating rooms that remained open were reserved for urgent needs. Amber Anderson, for instance, showed up to her local emergency department in April with a throbbing pain in her side. Tests showed her urine was infected and obstructed by kidney stones, a combination that could make her very sick. Pandemic or no pandemic, she needed treatment, and a surgeon promptly threaded stents — flexible plastic tubes roughly the size and firmness of al dente spaghetti — up her urinary tract to bypass the blockages, draining pus from both kidneys.

The stents were left inside her body temporarily to keep her safe until the infection quieted down and another surgery could be scheduled to treat the offending stones. But the stents themselves left Anderson doubled over in agony. As a urologist, I've seen how torturous stents can be, and under normal circumstances, I try hard to remove them as soon as it's safe to do so. But in the midst of a pandemic, the decision to expedite surgery becomes less straightforward.

After months of being allotted only a sliver of operative time — often only enough to perform single-digit surgeries each week — many departments lag behind by quite literally thousands of cases. Somehow, in the months ahead, this mounting backlog will need to be addressed, even as capacity remains constrained by both the realities of COVID-19 and the rigorous standards of safe surgery that are as important to uphold during a pandemic as they are in more ordinary times.

The question weighing on everyone's mind is how. Patients who were once scheduled for surgery, only to be unscheduled for it, wait in a vestibule of uncertainty — not knowing if they'll be summoned next week or next month, not knowing what the rest of the world will look like when it happens. Meanwhile, their surgeons have been hard at work building decision trees to triage cases in the backlog. One department developed a color-coded rubric: "red" surgeries needed to happen within a few weeks; "yellow" surgeries had to be performed within a few months; "green surgeries," constituting the longest list by far, were acceptable to postpone longer.

Another department came up with a numerical ranking system, assigning each procedure a priority score from 1 to 4. A third took an entirely different approach, dividing its limited allotment of operating room time equitably across its surgeons to use at their discretion. Guidelines issued by the Center for Medicare and Medicaid Services earlier this month recommend prioritizing services that, "if deferred, are most likely to result in patient harm," but the onus falls — appropriately — on health care institutions and clinicians to weigh competing risks of harm.

So far, the process has been manageable. But as hospitals ramp up volume, head-to-head comparisons of surgical priority could quickly grow unwieldy, and even more complex triaging systems may be required to ensure that no patients fall through the cracks. One gentleman, diagnosed with intermediate-risk prostate cancer in December, arranged a consultation with a surgeon in January — no need to ruin the holidays for his family, he figured. The surgery to remove his prostate was originally scheduled for March but, due to the pandemic, was pushed to May, with the possibility of getting postponed even longer — a cumulative delay no one would have recommended at the outset.

Even with extended operating hours, many are predicting it will take months or longer to get through the backlog. The surgeon who came up with the color-coded rubric estimated that "green" surgeries — the least pressing — easily might get pushed to the fall or winter. If another wave of COVID-19 cases hits late this year, as some anticipate, those delays could be further compounded. Meanwhile, new demand will bubble up as clinics start seeing more patients, raising questions that blur the line between fairness and pragmatism. Should the "greens" keep getting postponed as more urgent demands arise? Or would it be better to cap the amount of time in the queue so that patients don't end up waiting indefinitely or, worse, simply giving up?

Outside of surgery, too, the backlogs are daunting. Laura Cohen, a cardiology fellow in New York City, worries that, with most heart imaging and testing on hold for the past few months, many complications could continue to go undetected due to poor coordination and follow-up. "I've been telling patients with stable chest pain that while they can't get a stress test now, they really should get one done in the future," she said. "But it will probably be up to them to ask for it, which makes me worried about the patients who are less likely to advocate for themselves."

In the days before COVID-19, my colleagues and I would give patients who were at risk of getting "lost to follow-up," as it was called, a certain unspoken priority; we lived in fear that if we loosened our hold even a little, they'd slip through our fingers and disappear into the distant haze with their bleeding bladder tumors or their failing kidneys. More often than not, when they did disappear, there was a good reason. They could no longer get transportation to the hospital; they lost their insurance; a family member fell ill, and they were forced to choose between being a caregiver and being a patient.

With unemployment levels at a historic high and support networks strained by social distancing, the hardships that result from this pandemic could be significant. Does that justify hurrying along the care of patients who are most vulnerable to losing access, even if others have more severe symptoms? So far, the primary focus of triaging has been medical urgency — but as the backlog stretches on, it's hard not to think about the many other realities that determine whether patients actually get the care they need.

And the longer it takes to sift through the backlog, the harder it will be for patients to seek treatment for minor issues before they grow into major ones, or practice preventive care. One colleague in gastroenterology, whose department faces a backlog of thousands of procedures, told me that colonoscopies performed for routine cancer screening will fall to the bottom of the list; there are too many time-sensitive cases that need to get done first. It might be years before we fully recognize the effects of these disruptions to chronic disease management, diagnosis and prevention.

While wariness of hospitals has made it easier to accept postponements in care so far, as fear of the coronavirus shifts from acute terror to chronic concern, patience for ongoing delays could wane, too. Anderson finally underwent stone surgery and got her stents out last month. At a different hospital, the man with prostate cancer underwent surgery as well, and not a moment too soon; pathology revealed the cancer was starting to spread beyond the prostate. Numerous others remain in the wings, wondering when their turn will come. Just as living in a world with COVID-19 has required new norms — social distancing, wearing masks in public, and soon, as society reopens, many other unfamiliar behaviors —surviving the aftermath of the surge could call for new levels of both tolerance and personal health vigilance.

"I'll have to remember to keep on it," said Caitlin Kent, a Bostonian whose heart imaging study, like so many things these days, has been canceled indefinitely. "Otherwise, my guess is it just might not get done."

Rena Xu is a pediatric urology fellow at Boston Children's Hospital. She wrote this piece for The Washington Post.

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