An Elected Sacrifice in COVID-19’s Wake

With hospitals in U.S. epicenters past (or quickly reaching) their tipping points, American health officials have called for a moratorium on all elective surgeries amid the COVID-19 pandemic. The suspension aims to free up hospital beds, prevent disease transmission, and conserve the nation’s meager supply of personal protective equipment (face masks, gowns, gloves).
 
The highly contagious SARS-CoV-2 virus has infected 802,583 Americans and killed 44,575 people, according to the latest Centers for Disease Control and Prevention statistics (April 21). Cases have been reported in all 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands; in New York, the number of cases is doubling every three days.  
 
“Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs,” the American College of Surgery recommended on March 13. U.S. Surgeon General Jerome Adams quickly supported the group’s suggestion, sending a tweet on March 14 that read, “Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!”
 
Almost immediately, doctors reported an uptick in elective procedure cancellations or deferrals. Interventional cardiologists were most impacted, followed by orthopedic surgeons (23 percent reported cancellations or postponements) and anesthesiologists.
 
Claudette Lajam, M.D., FAAOS, an adult reconstructive surgeon at New York University Langone Orthopedics, spoke with ODT about the American College of Surgery recommendations and the impact of cancelled/postponed procedures on the orthopedic industry.

Michael Barbella: The American College of Surgeons has urged hospitals to postpone elective surgeries like joint replacements, and the number of cancelled procedures is growing. How will this impact orthopedic surgeons, and the orthopedic industry?
Dr. Claudette Lajam: Obviously, there will be a short-term impact on our patients and on our profession. Orthopedics is disproportionately affected over many other surgical fields. However, orthopedic surgeons are among the most dedicated and hard-working people in any profession. Once this crisis is over, we will return to work, likely adding surgical days and extending our hours, so that we can ensure all of our patients receive their orthopedic care. Right now, what’s important is that we band together to defeat this pandemic.

Barbella: How widespread is this issue right now—are lots of patients cancelling joint replacement procedures? Do you expect it to worsen along with the pandemic?
Lajam: There are many centers across the country that have elective surgeries canceled. From speaking with my colleagues, many of our patients are canceling their own elective procedures. We hope that having people stay at home for non-urgent matters will help with controlling the spread of the Wuhan/COVID virus.

Barbella: How confident are orthopedic surgeons that patients will reschedule their procedures once the COVID-19 crisis passes? Might fears linger even after life returns to normal? Is there more/less of a chance of patients rescheduling the longer the pandemic lasts?
Lajam: Right now, we cannot predict what will happen in coming weeks to months. Most people who schedule total joint replacement have severe disease that has not responded to nonsurgical management, so we expect that most, if not all, of them will reschedule surgery once this crisis passes. I know many of my patients are rescheduling already, and asking my office to “hold the dates” for them.

Barbella: How are orthopedic surgeons addressing this issue with patients? Has any guidance been issued by AAOS or any other organization?
Lajam: https://www.aaos.org/about/covid-19-information-for-our-members/ Each surgeon is handling this differently. However, I know that many of us are counseling our patients about the need to conserve resources and also to ensure we do not contribute to the spread of the virus. AAOS and our specialty societies are working hard to ensure surgeons have resources to be able to answer our patients’ questions.

Barbella: Are there cases/instances where a joint replacement, spinal procedure, etc., is not considered an elective procedure? Please explain.
Lajam: Certain procedures are considered more urgent than others. Infections, fractures, progressive neurologic problems, problems with prior surgery that require revisions, and certain disease states may indicate that surgery could be considered non-elective, since leaving these conditions for several weeks or months may cause additional problems. Each patient is unique so it is difficult to make a blanket statement.