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During this COVID crisis, intensive care unit and emergency room doctors and nurses in hotspots like New York City have dangerous, exhausting jobs keeping coronavirus patients alive. But the American medical response to the COVID crisis is bimodal. A minority of doctors and nurses are saddled with these dangerous around-the-clock jobs battling the disease in ICUs and ERs. The majority of doctors and nurses are on the sidelines, waiting for a return to work, just like many other workers in the United States.
This has especially affected surgical teams. COVID-19 is a terrible medical tragedy, but it is not a surgical disease. In the United States as a whole, surgery has ground to a halt. Surgeons, anesthesiologists, certified nurse anesthetists, and operating room nurses are barely working at all now, for the fourth consecutive week.
The Center for Medicare and Medicaid Services (CMS) issued an edict on March 18, 2020 that all elective surgery be cancelled. The logic was sound and was twofold: 1) to keep doctors, nurses, masks, gowns, ventilators, ICU beds and hospitals unused for non-urgent care, therefore freeing up these assets to fight the coronavirus pandemic; and 2) to keep healthcare workers away from each other in a social distancing strategy to stop the spread of the virus.
The shelter-in-place orders that shuttered the economy have sidelined workers in multiple industries: the airlines, resorts, cruise ships, arenas, concerts, churches, retail, education, sports, etc. You can add elective medical care to this list.
According to CMS, what kind of surgery can be done during this pandemic? The CMS document says to “postpone non-essential surgeries and other procedures. This document provides recommendations to limit those medical services that could be deferred, such as non-emergent, elective treatment, and preventive medical services for patients of all ages.”
Ambulatory surgery centers have been almost entirely shut down. The document “Additional Guidance on the ASC Community’s COVID-19 Response” reads:
Examples of cases that might still need to proceed with surgery at this time include:
- Acute infection
- Acute trauma that would significantly worsen without surgery
- Potential malignancy
- Uncontrollable pain that would otherwise require a hospital admission
- A condition where prognosis would significantly worsen with a delay in treatment
Greater that 95% of the surgical cases for my anesthesia group have been cancelled for four weeks running. A Bay Area contingent of the California Society of Anesthesiologists held a Zoom conference last week, and the majority of attendees voiced that they were not seeing COVID duty, but their anesthetic workload had plummeted.
Should these surgical specialists be moved into roles fighting COVID? In Northern California there has been no need. The existing ICU beds, ventilators, and ICU/ER staffing has largely been adequate for the number of COVID patients. Elective surgery has been cancelled at the hospital I work at, Stanford University Hospital, per the CMS edict. According to the Internal Medicine Grand Rounds lecture from April 8, 2020, Stanford Hospital currently had only 13 COVID patients, with 5 of those in the ICU on ventilators. The total overall number of COVID deaths at Stanford Hospital as of April 8, 2020 was 2 patients, and there were 54 unused ICU beds.
The cessation of elective surgery is a source of economic hardship for many medical entities, including healthcare companies, hospital systems, surgeons, anesthesia professionals, and nurses. We’re all waiting for elective, non-urgent surgery to resume when it’s safe for the medical personnel and for the patients. Expect this to occur when widespread testing tells us that the medical personnel and the patients either test negative for the COVID virus or positive for the COVID antibody. Everybody is waiting on the tests. We don’t need thousands of tests, we need millions of tests in the United States.
Unemployed and underemployed Americans from multiple industries, including healthcare, hope this widespread testing will happen within weeks from this date, not months.