What if you are seriously ill and it is not Covid-19?

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By Danielle Bochove and Emma Court

(Bloomberg) –

At a world-renowned cancer center in Houston, a woman learned that her lung cancer surgery, booked a few weeks ago, could be canceled at the last minute. None of the doctors’ offices in a major hospital in New York are performing procedures. In Toronto, the operating rooms were empty in a hospital specializing in organ transplants and cardiac care, and surgeons were resting at home while the rooms were cleaned to prepare for what was to come.

With the Covid-19 pandemic requiring an unprecedented amount of medical and personnel resources, care for other conditions, even lethal ones, are on hold. In many places across North America, everything except emergency surgery was canceled and in-person care was delayed for all but the most worrying cases. “This is a huge ethical dilemma,” said Ashish Jha, director of the Harvard Global Health Institute. . “There is an absolute danger that we will ignore people who have a critical need for health services who do not have Covid. “

North America is strengthening its health care systems in the hope of avoiding an even darker outcome, the one the world has seen in China and Italy. There, while hospitals were dealing with a surge of coronavirus patients, not even non-pandemic emergencies could be treated.

When hospitals are affected by a high number of acute cases, they sort through a battlefield technique to decide the order of treatment for patients based on the emergency. A short-term measure, triage only works as long as the patient flow continues to shift; once stabilized, they are moved elsewhere to recover.

The problem with Covid-19 is twofold. In the worst case, as the devastation in Italy clearly shows, hospitals exceed their capacity to deal with life-threatening cases, Covid and not, and are faced with distressing decisions about who to save. But even where emergency rooms are capable of staying afloat, the decision to withdraw resources elsewhere in the system and postpone procedures like cancer surgery or organ transplants for weeks, even months, can pose fatal risks.

For doctors, the appeals for judgment are agonizing. At MD Anderson Cancer Center in Houston, all operations that can be canceled have already been canceled, said Mara Antonoff, assistant professor of thoracic and cardiovascular surgery. Texas is still at an early stage of the curve and, in anticipation of more of cases, doctors are trying to determine what non-surgical options may be available for cancer patients, such as radiation therapy or chemotherapy. They also ask whether postponing surgery by three or six months will affect survival. When Antonoff met this week with one of his preoperative lung cancer patients, a woman in her 60s, she had to announce that next week’s surgery may well be canceled. “Things are changing from hour to hour,” she said. “In our department, we have absolutely no new cases scheduled unless the patient is really at imminent risk of dying if we do nothing.” Postponing elective surgeries to prepare for Covid-19 creates a conundrum for doctors treating cancer, where early surgery often offers the best chance of recovery, said Antonoff. “The Catch-22 is that the people who are at an early stage are the ones we think we can delay a little longer during this unprecedented pandemic.”

Hospital crisis

It’s not just a patient care crisis. It’s a hospital crisis. Elective procedures are the main sources of revenue for American hospitals. (Medicine in Canada is socialized.) Postponing it presents major financial challenges for the health care industry, just as its services are needed more than ever. The American hospital lobby, for example, has asked the government for $ 100 billion in bailout funds for health care providers and hospitals.

This week, Tenet Healthcare Corp was forced to withdraw its forecasts for the first quarter and 2020 due to the impact of Covid-19 on business. The Dallas-based company operates 65 hospitals and approximately 500 other healthcare facilities.

On Friday evening, the American Hospital Association issued a stern warning: “Since virtually all regular operations have been interrupted – such as elective or scheduled procedures – revenues are limited, causing serious cash flow problems that threaten the viability of hospitals. It also creates a historic financial crisis, threatening the ability to keep our doors open for the insured and the uninsured. “

For doctors, the concerns are more personal. In addition to considering the health consequences of postponing surgery, they fear that patients who still have access to care avoid it, lest they be exposed to the virus in any medical setting.

Jenny Ahlstrom, a 52-year-old woman in Salt Lake City who lives with multiple myeloma, refrains from taking bone boosters and even doing routine laboratory tests. Ahlstrom’s myeloma has returned after remission, and at some point will require treatment, but she is concerned that it will make her more vulnerable to Covid-19.

“I’m about to need to start treatment and I’m really nervous now,” she said. “Should I enter? I don’t think I will enter it. “

Health care providers face these problems every day. In mid-March, the U.S. Center for Medicare and Medicaid Services said hospitals should limit all non-essential surgeries and procedures during the Covid-19 epidemic, a recommendation that has been widely followed in major hospitals in North America. But defining what is “elective” – ​​a health care term that really means planned rather than optional – is not easy, especially during a pandemic.

Care for those undergoing chemotherapy, radiation, and essential surgeries continued at the Seattle Cancer Care Alliance even as the city became the first US hotspot for Covid-19, said Jennie Crews, medical director of the program oncology community of the alliance.

But providers have delayed elective procedures that require a significant amount of in-person care, or have explored other treatment options, said Steve Pergam, medical director of infection prevention. As such, bone marrow transplants – which severely compromise the immune system and require prolonged hospital stay – have fallen by around 50%, he said.

‘Collateral damage’

In Toronto, the fourth largest city in North America, most hospitals have eliminated all surgeries, procedures and even imaging tests, except for emergencies, to create peak capacity for Covid cases -19.

“All the resources are available for the pandemic, but there will unfortunately be collateral damage,” said Thomas Forbes, president of vascular surgery at the University Health Network. “It can be something that is easily measurable, like death, or something that is difficult to quantify, like a drop in life expectancy, because someone in need of cancer surgery has had to wait longer to receive their care. “

A few weeks ago, San Francisco was facing a growth in Covid-19 cases that closely resembled that of New York, said Robert Wachter, chair of the department of medicine at the University of California at San Francisco. But an aggressive social distancing, associated with early decrees of homework, seems to work. This week, the hospital began to open “very cautiously” to patients requiring scheduled procedures unrelated to Covid-19. Every day, we ask the question, “Okay, if it stays where it is now, do we have space to start doing surgeries?” “, he said. But the hospital is “ready to close it tomorrow if we have to.” In New York, which now has more than 50,000 cases, the scenes of a health system at its breaking point are now well documented, from the arrival of a Navy ship bringing 1,000 hospital beds to a makeshift emergency room under a tent in Central Park.

In a city now filled with closed offices, restaurants, schools and shops, the NYU Langone healthcare system has kept doctors’ offices open for in-person care, albeit in a much more limited fashion.

“People have often asked us, ‘How can you open your offices during a national emergency? Said Andrew Rubin, vice president of clinical affairs and ambulatory care at NYU Langone. “Well, many patients are sick and have been sick and will be sick far beyond Covid-19. “

The healthcare system has tried to keep its offices as thin as possible, including with virtual visits to doctors and emergency care to keep people at high risk and those with Covid-19 at home. Office volumes have dropped 80%, but some people continue to come, including those with chronic conditions “who really can’t wait to see their doctor,” said Rubin.

“It was a very difficult decision to stay open,” he said. “But we have to be there for our patients so that we don’t have another type of health care crisis.” “

With the health care system already strained by limited resources, there could be serious repercussions if the situation in New York City worsens, said Dara Kass, associate professor of emergency medicine at Columbia University Medical Center. Kass, who is recovering from Covid-19 herself, said she and her colleagues treat patients with respiratory failure or cardiac arrest every hour and intubate 200 to 300 patients daily across the city.

“The choice people don’t really treat is: do you choose to save a Covid patient today or another patient tomorrow?” ” she said. “If we immediately exhaust all of our resources, without thinking about what it will look like in a week or two, we will fail. “

© 2020 Bloomberg L.P.

Bloomberg.com

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