Surgery in the Time of Covid

Patients must balance the chance of a life-threatening Covid-19 exposure against the opportunity for relief from a condition that may be painful but is not considered urgent.

With the Covid-19 pandemic raging across the country, many people hoping to undergo elective surgery can expect their operations to be on hold indefinitely. Hospitals in many places are at or near bed capacity and facing staff shortages. Even facilities still able to handle operations not considered urgent are likely to experience cancellations when patients themselves, fearing contagion, postpone the procedures.

My brother, for example, was scheduled for a total knee replacement mid-December in upstate New York. But when three stores he frequented closed early in the month because employees got Covid and the community’s infection rate climbed through the roof, he opted to reschedule the procedure.

Better to risk missing another season of tennis than to miss his daughter’s wedding in the spring and old age altogether. As a 75-year-old who had open-heart surgery two years ago, he knows he’s high-risk for a life-threatening Covid infection. Even if an overnight hospital stay were not a risk, he feared possible exposure to the virus during the weeks of rehab afterward.

Two of my friends scheduled for elective surgery managed to sneak under the wire this fall; one had a knee replacement in early October and the other a hip replacement in early November. But if you or a loved one is on a surgeon’s schedule for a similar optional procedure in the weeks ahead, you may want to rethink your plans, depending on where you live.

In a list of “guiding principles,” the American Academy of Orthopaedic Surgeons cautioned its members that during the pandemic, decisions to proceed with elective surgery “should be locally based” and take into account “incidence, prevalence, patient beds, hospital beds, ventilators and personal protective equipment,” in addition to local shutdown orders and whether there’s been “a sustained reduction in new cases of Covid-19” in the area.

Likewise, there are many issues for prospective patients to consider before proceeding with an elective operation. First and foremost is an understanding of what “elective” means and whether there are less risky alternatives to consider, at least until the pandemic surge abates or most Americans are protected by a vaccine.

Elective surgery means it is not urgent. The condition requiring surgery may be life-limiting and compromise well-being, but it is not life-threatening or in imminent danger of becoming so. Thus, fixing the problem surgically can be safely postponed.

However, “elective” may not be the most apt description for people with frequent or constant pain that inhibits their ability to function on all cylinders. A better term may be “nonurgent,” but even that can be a problem for someone who lives alone or is unable to work productively. Still, even some patients with clogged coronary arteries or a cancer considered low-risk can often delay an operation until surgery and aftercare becomes less risky.

You might want to wait until the hospital staff has had a chance to recoup their pre-Covid stamina. As three experts pointed out, “basic human factors, exacerbated by Covid-19, can threaten the safety of patients and staff.” Dr. William Berry, a research scientist at the Harvard T.H. Chan School of Public Health, Dr. Kedar S. Mate, president of the Institute for Healthcare Improvement, and Lindsay A. Martin, a health policy instructor at the Harvard public health school, listed fatigue, lack of routine practice, distraction, overload and emotional stress as medical staff issues that could compromise patient care.

Doctors at Stanford University expect that “a tremendous effort will be required to clear a surgical case backlog estimated to be nearly five million cases, which could take up to three months.”

Meanwhile, anyone anticipating elective surgery can make use of the time to become better informed and better prepared for the operation, starting with a very basic question: Do I really need this surgery? Have you exhausted other treatment options, like oral and topical medications, physical therapy and at-home exercises?

Ask about the surgeon’s experience with the operation. How often does the surgeon perform it, with what success rate and what kinds of problems do patients report? You might ask to speak with a previous patient.

You may be aware of the potential benefits of surgery, but are you equally well-versed in its risks and possible complications? And do you know how to minimize these, say, with strengthening exercises, weight loss or dietary adjustments?

Is there anything in your health history that could make the surgery riskier than usual? Are adjustments needed in the medications you usually take? If you take any medication, even baby aspirin, that thins the blood, were you warned to discontinue it well before surgery? If you have diabetes, what will be done to make sure you maintain a safe blood glucose level before and during the operation?

What are your options for anesthesia? Is a general anesthetic necessary or might the surgery be done under a regional or local anesthetic? Make sure the anesthesiologist knows if you’ve had a prior adverse experience with anesthesia.

What can you expect in terms of recovery from the operation? When might you be able to return to your usual activities, including work, lifting, driving, exercising? Here’s where you need to prepare for the worst while hoping for the best. Surgeons tend to provide patients with the best possible outcome, often leaving them unprepared and frightened when their recovery is not as smooth or as fast. For example, when I had my knees replaced, I was told I would be back to my normal level of activity in six weeks when in fact it took twice that long before I could safely drive.

What sort of personal assistance might you need when you return home, and for how long? My friend’s postoperative recovery from her hip replacement was faster and easier than she expected. But she lives alone and benefited greatly from having a competent adult stay with her for a week to prepare meals, assist with dressing and bathing and keep track of a complex medication schedule.

Postoperative medications, which nearly always include drugs to control pain, can be challenging. They can cause dizziness, upset stomach, constipation and other distressing side effects. Make sure you know what reactions to expect and how to minimize them.

If you will need physical therapy, how will this be arranged? Can a therapist come to your home for the first few weeks? When you’re better able to navigate, where can you go to get further therapy? The quality and extent of physical therapy can be at least as important as the surgeon’s expertise in determining the result.

Finally, don’t forget cost! Will your insurance cover all or most of the expense? Does your coverage include postoperative rehab? If your insurance is limited, you may be able to negotiate a payment plan with the surgeon.

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