In mid-March, my sister was diagnosed with breast cancer. Surgery was scheduled for early April. Just a few days ago, she was told the surgery has been postponed. There are not enough CoV tests available to test her and the surgical team — there is a high probability of transmission both ways, if anyone is infected. She is in CA. They will be starting chemotherapy first, and hoping they can schedule surgery after a few months.
After I told friends, they said yes, there was a similar report on NPR.
As Coronavirus Strains Hospitals, Cancer Patients Face Treatment Delays, Uncertainty
The American College of Surgeons (ACS) has produced a detailed triage flowchart, that balances the condition of local hospitals versus the risk in delaying surgery.
This will affect more than surgery, as you may have already discovered. Let’s go over the changes, in hopes that you’ll know what to expect. If you have additional information specific to your state or locale, or have personal experience with triage due to CoV, please share in comments if you’re comfortable doing so.
Let’s first look at the less-drastic forms of triage, and then go over the ACS recommendations for breast cancer surgery, as an example.
Triage for appointments and non-life-threatening problems
I’m going to use King County, WA as an example, since we’re likely a bit ahead of y’all on the pandemic timeline. These changes have already been in effect for several weeks now:
- Appointments will be conducted by phone, whenever possible. Even if tests may be needed, the initial consultation will likely be by phone. Expect more sharing of documents via your provider’s patient message system.
- Many elective procedures are postponed. “Elective” is more broad than things like cosmetic surgery or annual checkups — it includes anything that can be done later without much risk. An exception is phone appointments with providers whose specialty is unrelated to COVID-19 treatment, and who can work from home. (For instance, I recently had a phone appointment with a genetic counselor.)
- Drop-in clinics are closed. They aren’t safe, and the doctors and nurses who were stationed there are now needed for COVID-19 care.
- If your provider has a “consulting nurse” for phone consultation, or is set up to do e-appointments, those are the go-to for minor ailments.
- If you do need to go in for tests, wear a mask. Yep, that advice has now changed. This can be a DIY mask. (I’ll post some mask info in comments.)
- When you arrive at a clinic, be prepared to go through some checks before you’re allowed inside. Your usual parking lot might be taken over by tents. Allow some extra time for this.
- If you can have prescriptions mailed to you, do that. (Scheduled drugs can’t be mailed, so those will still need a pharmacy visit.)
- Visitors to hospitalized patients are restricted. Check with your hospital for their rules. They may now be enforcing visit hours, and only allowing one family member at a time, no just friends visitors. If the patient has COVID-19, visits may not be allowed at all.
I haven’t encountered the following yet, but am expecting that at some point, we’ll need to…
- Be prepared to describe your problems via an online symptom flowchart, or a “where does it hurt” diagram. The more accurately you can describe the symptoms, the better.
- Be prepared to take selfies of embarrassing parts of your body, and upload them.
- Your doctor is not going to be able to poke you and ask if it hurts, so they may ask you to “try this...” and report the results.
Blood donation
Blood banks still need donations, but must be much more careful about procedures and screening. Again, these are the procedures in place in King County — expect they’ll be “coming soon” to where you are.
- Donations will be by appointment only, and you’ll need to schedule in advance, because…
- In order to maintain distancing, they have to restrict how many donors are on site at once. This will mean that your donation appointment may be much further out than you’re used to. (I was used to getting an appointment for the next day, but when I tried to make the next appointment, everything was full for the next three weeks.)
And one suggestion from me:
- Isolate yourself for a week prior to donating. Don’t go shopping, don’t get take-out food, just don’t go where there are other people.
One very new thing, unrelated to triage:
- If you are a COVID-19 survivor, and are out of the quarantine / recovery stage, you may be in great demand as in antibody donor!
Ok, enough with the easy stuff — let’s get on to the scary bits.
Surgery
There are multiple issues where the need to treat COVID-19 impacts surgery. The most obvious is that a patient put under general anesthesia will need a ventilator. And so will COVID-19 patients. But that’s not the only issue…
If the patient happens to have COVID-19, then the process of inserting and removing the ventilator will cause the virus to aerosolize. Normally, the surgical team does not wear virus blocking respirators, nor face shields, let alone full isolation gear that would really prevent transmission of an aerosolized virus. Normally, the surgical team wears surgical masks, which are intended to block the team’s own exhaled / coughed / sneezed droplets from getting in the patient’s open incision. They’re not intended to protect the team from the patient…
Since there is a shortage of respirators and face shields (let alone more stringent measures), then instead, the idea is to test the patient and team for COVID-19 infection. If none have it, then ordinary precautions are sufficient. But if testing capacity is limited, then this can’t be done.
The top of the ACS triage tree is here:
COVID-19: Elective Case Triage Guidelines for Surgical Care
That page links to sub-sections for each major condition treated by surgery. This allows them to label the severity and risk of for each condition using terms and metrics specific to that condition. If you are potentially in line for surgery, find your major category above, and follow the links through to your specific condition.
In the following, I’ll use the triage guidelines for breast cancer to illustrate.
The recommendations are split into three parts, according to level of impact that CoV has had on the local medical capacity. For each medical capacity level, they assign a time horizon — how long can the surgery be delayed before the patient’s survival is significantly compromised?
This is the breakdown, quoted from the guidelines. In this first phase, COVID-19 has not yet severely impacted medical capacity:
Phase I. Semi-Urgent Setting (Preparation Phase)
Few COVID 19 patients, hospital resources not exhausted, institution still has ICU vent capacity, and COVID trajectory not in rapid escalation phase
Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next 3 months
Multiple states are past that phase, and multiple counties within not yet as hard-hit states. In the next phase, there is significant impact from COVID-19, resources are limited, but the system is not yet overwhelmed.
Phase II. Urgent Setting
Many COVID 19 patients, ICU and ventilator capacity limited, OR supplies limited or COVID trajectory within hospital in rapidly escalating phase
Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few days
Yes, they said days. That means, your cancer is progressing rapidly… Under this phase, if your surgery can wait a week or two, you wait.
For breast cancer, that means no actual cancer surgery is done. In both phase II, and in the following phase III, the items still listed for surgery are those that are life-threatening but may not need anesthesia, such as draining an abscess. (Note that for other forms of cancer, that progress much more rapidly and the “next few days” might determine survival, surgery for the actual cancer might still be performed. For breast cancer, that is not usually the case.)
The recommended alternatives are for various sorts of chemotherapy. That adds another dilemma and worry: Some forms of chemotherapy, especially cytotoxic chemotherapy, may suppress immune response. So a patient undergoing such chemotherapy needs to be especially careful to avoid catching COVID-19. For more, see: For Cancer Patients, Coronavirus Pandemic Presents New Risks To Treatment
Waaay back when I had breast cancer the first time, there was still a question as to whether chemotherapy was useful in addition to (and following) surgery, and I was part of a study that intended to determine that. The study was ended early when it was clear that yes, chemotherapy was definitely useful. More recently, chemotherapy prior to surgery is done to shrink tumors or clear up metastases, in order to make the cancer operable — this is “neoadjuvant” chemotherapy.
However, that’s different from what’s happening now… Cancer patients will be participating in a giant, uncontrolled, experiment on the efficacy of neoadjuvant chemotherapy, possibly without surgery at all.
In the third phase, the system is overwhelmed.
Phase III.
Hospital resources are all routed to COVID 19 patients, no ventilator or ICU capacity, OR supplies exhausted
Surgery restricted to patients likely to have survivorship compromised if surgery not performed within next few hours
The distinction between phases II and III is not significant for breast cancer, but will be for emergency / trauma surgery. Without ventilators or surgical supplies...including anesthetics…well, it would be much better not to get into this situation at all.
Flatten the curve, y’all.