In early March, McKaylee Prochazka of Lake Nona had emergency surgery for kidney stones and a stent was inserted to drain any pieces that remained. Soon after surgery, the Orange County school teacher developed a urinary tract infection.
By that point, Florida officials had restricted what they considered elective, non-emergency procedures in the era of COVID-19, the new coronavirus disease. The goal was to protect patients and providers, preserve supplies and keep hospital beds open for the coming surge of COVID-19 patients.
Prochazka soon discovered not everyone has the same definition of elective surgery, a viewpoint shared by many physicians across Central Florida.
Despite her swelling, pain and concern about infection, Prochazka was told by her surgeon’s office that her stent removal was considered elective surgery under their new COVID-19 policy. The procedure would have to wait.
In extreme pain and panicked at the prognosis, Prochazka, who also has a nursing degree, reached out to friends looking for suggestions. That’s when she was connected to Orlando Health Medical Group Urology. Within 24 hours of speaking to the practice’s medical professionals, Prochazka was in the office having her questions answered, her stent removed and prescriptions called into the pharmacy.
“I am so thankful I was able to find a practice with people who really listened to me. Patients like me who don’t have COVID-19 also need help,” says the mother of three. “We need to feel better, too. Having a UTI and waiting to get the stent removed until after the pandemic could have resulted in my getting sepsis. I was more concerned about that than I was about contracting the virus.
“Doctors should still be able to see their patients with safety precautions in place for as long as they can, until the surge is here,” says Prochazka. “Orlando Health, in my opinion, is handling this properly. I am so grateful.”
Defining a Directive
The spirit of the state’s directive is well intentioned, but the term “elective surgeries” is a bit of a misnomer, says Dr. Robert A. Hirschl, a board-certified neurosurgeon with Orlando Health Neuroscience and Rehabilitation Institute Neurosurgery Group. Instead, he defines three broad categories of surgery as emergency, urgent and elective.
“Emergency surgeries are time-sensitive -- like a gunshot wound to the head or bleeding in the brain,” says Dr. Hirschl. “The patient has to be in the operating room within 30 minutes of the incident to prevent a loss of life or limb. Urgent surgeries are those that if delayed four to six hours can cause greater harm to the patient. All other surgeries are technically considered elective.
“But just because something is categorized as elective, doesn’t mean it’s not medically necessary. Necessary and needed are more appropriate terms for these times,” says Dr. Hirschl, who is chairman of neurosurgery and medical director of neurosciences at Orlando Health.
Consider a recent patient who broke their neck in a car accident. “It was an unstable fracture, but their other accident-related issues had to be addressed before we could stabilize the neck,” he says. “We operated to stabilize the neck a few days later. This procedure was actually considered elective spinal surgery. But it was also medically necessary for the patient and couldn’t be postponed.”
As hospitals face continuing challenges related to the evolving COVID-19 outbreak, the American College of Surgeons (ACS) issued its guidance on managing non-emergency surgeries and procedures in mid-March. The ACS determined that given the uncertainty of the pandemic’s impact over the next several months, “delaying some cases risks having them reappear as more severe emergencies at a time when they will be less easily handled.”
“Orlando Health’s position continues to mirror the American College of Surgeons’ statement,” says Dr. Jamal Hakim, a practicing anesthesiologist and chief operating officer of Orlando Health. “Orlando Health surgeons will continue to perform necessary surgery and will delay surgeries they determine are unnecessary.
“Some cases can be postponed,” says Dr. Hakim. “But most of them are associated with progressive diseases like cancer, heart disease and organ failure. Without surgical intervention, the health of these patients will continue to deteriorate.”
The ACS also recommends that medical need for a given procedure be established by a surgeon with direct expertise in the relevant surgical specialty to determine what medical risks will be incurred by case delay.
It’s a sentiment many surgeons support.
“We are all in this together,” says Dr. Hirschl. “But treating physicians are the most capable of making medical decisions for their patients as to what procedures can and cannot wait. Orlando Health understands this and allows us as physicians to make the medical decisions that take care of our patients in the best way possible.”
The Case for Continuing
Every obstetric surgical need, severe injury or pre-cancerous condition doesn’t change because of the pandemic. “COVID-19 is serious,” says Dr. Terrence Peppy, a board-certified OB-GYN with Orlando Health Physician Associates. “But we still need to take care of those patients whose day-to-day life is miserable.
“An incomplete bowel obstruction that causes chronic pain? Horrible gallbladder disease and fatty food intolerance where a patient can’t eat? A smoldering appendix? A breast mass? Are we going to postpone these for three or four months? No, we are not,” says Dr. Peppy. “We should not clinically wait on the ones that are necessary and need to be done.”
Take the case of a torn meniscus, which helps stabilize the knee. In the current COVID-19 environment, a surgeon might adopt a wait-and-see attitude on a simple tear. More complicated situations, however, demand immediate attention. It takes an orthopedic specialist like Dr. Michael V. Jablonski to know the difference.
“I had a 20-year-old patient recently, a lacrosse player, who had dislocated his knee, torn three ligaments and ripped his meniscus so badly it had flipped. His knee was locked and he couldn’t straighten his leg,” says Dr. Jablonski, a board-certified orthopedic surgeon and president of Jewett Orthopaedic Clinic Orlando Health.
Dr. Jablonski reconstructed the ligaments and repaired the meniscus. “If we had delayed that surgery, there would have been negative long-term implications – including the onset of arthritis in his knee at a young age,” says the orthopedic surgeon. “Someone outside our specialty might not see the seriousness of this injury. A torn meniscus can often wait. It’s the rare tear that’s bad enough to cause a knee to lock. I don’t know any orthopedic surgeon who wouldn’t agree this surgery was necessary.”
Such cases exemplify why medical urgency cannot be based on broad generalizations across specialties. “It is inappropriate for me to judge another surgical specialist as to what is appropriate care for their patient or not,” says Dr. Jablonski. “Each patient has a different story. It’s hard to interpret a diagnosis and say it’s not indicated until you have walked in the patient and his surgeon’s shoes.”
A Patient’s Predicament
Eighteen months ago, Jerry Johnston’s dermatologist biopsied a suspicious mole on his shoulder that turned out to be stage 3 malignant melanoma. Johnston did a year of immunotherapy. In February 2020, six months after finishing treatment, doctors discovered a 6 mm tumor on his lung, diagnosing him with stage 4 lung cancer.
Johnston, a 54-year-old father, wanted to start radiation and immunotherapy treatments immediately, despite the pandemic. “Sure, we would love to wait out COVID-19,” says Kim Johnston, his wife. “When Jerry starts treatment, he will be immune-compromised. But to suspend or delay a procedure your doctor feels is important because of COVID, well, that is just insane. I can’t imagine the unquantifiable amount of death that will occur if people don’t get the treatments they need when they should.”
The confusion is real, potentially preventing patients from seeking care and physicians from offering it. Cancer survivors diagnosed with melanoma, for example, are encouraged to get frequently scheduled full body scans. But COVID-19 concerns have shuttered some dermatologists, making these necessary scans difficult to get.
“I emailed our dermatologist to schedule Jerry’s appointment,” says his wife. “But they are closed because of COVID-19. It’s crazy to me that I can go play golf or take a boat out, but I can’t get my husband in for such an important checkup. I wonder who else is out there putting off a procedure that might save their life because they can’t see their doctor.”
Problems with Postponing
Delaying some procedures, like bariatric surgeries, creates more than a health hazard for the patient. It also stymies the months of work the patient has done preparing for surgery. Because insurance authorization requires them to go through a weight-loss program and psychological testing, bariatric patients put in 6 to 12 months of work before they even get to the operating room. A delay in surgery may result in the patient having to start the insurance process all over again.
“Our procedures are not cosmetic in nature,” says Dr. Muhammad A. Jawad, a board-certified surgeon and the medical director of Orlando Health Weight Loss and Bariatric Surgery Institute. “A bariatric patient has many other conditions like hypertension, diabetes, undiagnosed sleep apnea, GERD with asthma, and congestive heart failure. These are all risk factors that make them more vulnerable to COVID-19. Fortunately, most of these risk issues resolve within a week or two after surgery because of the rapid weight loss.”
Like many of the surgeries currently performed at Orlando Health, bariatric patients do not require ICU beds or respirators. The procedure is done laparoscopically and the supplies that are used don’t strain the healthcare system’s resources. Providers are protected and patients are released back to their homes within 48 hours.
Surgeons must constantly weigh the unknowns of the pandemic with providing the best patient care possible. “We don’t know how long COVID-19 will exist,” says Dr. Jawad. “Is it three to six months? Do we keep our patients out of surgery for that long? I can understand perhaps two weeks of not operating. But to delay some patients further is to delay their return to health.”
A Window for Care
Orlando Health also supports those specialists who choose to postpone surgeries in their practice. “Specialty surgeons know their patients, the diagnosis and what can be done, when it should be done and what can be postponed,” says Dr. Jablonski. “We have the support of our CEO and administration to make those decisions.”
Continued communication from the healthcare system’s leaders helps physicians make informed decisions. Physicians on Orlando Health medical staffs receive daily pandemic updates that include the number of available beds, ICU beds, isolation rooms, ventilators, N95 masks available and ordered, as well as the number of COVID-19 patients being treated.
“There is a lot of fear and anxiety around COVID-19,” says Dr. Hirschl. “But a pandemic doesn’t mean all other healthcare problems go away. We still have patients with immediate issues. Their elective, medically necessary surgeries have also not diminished our ability to treat COVID patients in any way.
“We have a window right now,” adds the neurosurgeon. “We are not overrun with COVID patients at this time, so we can and should still do necessary surgeries safely.”
Orlando Health leadership constantly monitors the situation and is ready to pivot should the need arise. “If an inpatient surge of COVID-19 patients materializes and begins to threaten internal resources,” says Dr. Hakim, “Orlando Health may need to delay certain necessary surgeries as well.”