Health-care workers, particularly anesthesiologists who must insert a breathing tube during sedation for surgeries, known as intubation, have been asking institutions to end elective surgery for much of the month, according to interviews with more than a dozen health-care workers nationwide, some of whom spoke on the condition of anonymity. The anesthesiologists raised concerns about scientific reports that found covid-19 can be aerosolized during intubation and spread from patients who have not been tested.
They describe facilities with barely enough surgical gowns to go around, masks in short supply and doctors discussing how to reuse single-use N95 masks. One doctor put maxi pads inside to make it last longer. They also said there are shortages of drugs, including propofol, used for sedation, and saline. One nurse said it is “immoral” that the drugs are still being used for elective surgery.
Workers fear that using these supplies will prevent health-care workers from being adequately protected when a wave of covid-19 patients overwhelms their hospitals.
As the federal government is asking Americans to stay home and limit gatherings to fewer than 10 people, many wonder why surgery centers — where patients interact with numerous people — are still open for elective procedures and why the federal and state governments are not being more aggressive about shutting them down.
“If we’re trying to do this social distancing thing, what are we doing having people come to the elective surgery center and have totally elective surgeries? That’s totally bananas to me,” said a doctor in Connecticut whose hospital is still performing elective surgeries. She, like most other doctors interviewed, declined to give her name for fear of losing her job.
Jonathan Zenilman, a prominent epidemiologist who is professor of medicine at Johns Hopkins School of Medicine, said the practice of continuing elective surgeries without proper protections of medical workers and patients is “ethically repugnant.”
“If you need your boobs done, why can’t that wait?” he said.
He added that dropping these procedures is a real conundrum for hospitals that are facing dire financial straits from the coronavirus crisis.
“The hospitals rely on elective surgery to actually keep themselves solvent,” he said.
One anesthesiologist in San Antonio said the ambulatory care center where she works is going “full steam ahead” with surgeries this week despite the federal guidance. She worries that people who are contagious but not showing symptoms can spread the virus, potentially infecting both people in the waiting room and the surgery team.
“They closed down casinos in Vegas,” she said. “They’re doing the right thing, and we’re not?”
The doctor said she can barely sleep at night because of her anxiety about continuing to work on surgeries. She also cannot find N95 masks; her father has some in his home metal-working shop and plans to drive them to her home.
Eric Shepard, an anesthesiologist at an outpatient surgery center in Maryland, says he has been receiving dozens of anguished messages from colleagues at multiple surgery centers across the country who are facing quandaries.
He says the surgery centers should instead be helping with the crisis by doing urgent operations that would free up the hospitals to treat people with the virus. Instead, he says, many are trying to stay afloat by performing purely elective surgeries that hospitals have stopped doing.
“This needs to stop, and it has unfortunately become obvious that many centers will not stop voluntarily,” he said.
Another anesthesiologist in Texas said doctors are being issued one mask a day and her surgery center is running low on supplies including gowns. She worked a steady stream of surgeries including hernia repairs and colostomies this week.
A month ago, she said, doctors were being chastised for not throwing away their masks after each use.
“I feel like as physicians we have taken an oath to do no harm to our patients, and I do not feel that doing some of these cases, I’m able to do that,” she said. “I don’t feel like bringing in 80-year-old patients to have a hernia repair that does not have to be done today may be the safest thing to do for them.”
But for some operations, shutting down elective surgeries is shutting down their whole business and potentially the livelihoods of their staff.
Roger Friedman, a surgeon who runs the Plastic Surgery Institute of Washington in Bethesda, said Wednesday that in a difficult situation, his clinic is taking what precautions they can. They are screening patients based on foreign travel and symptoms. The clinic is also avoiding having patients in the waiting room and is for the most part only treating one patient a day.
He said his anesthesiologist had not raised concerns about intubation. “We’re like a family,” Friedman replied when asked if he had given staff the option of not working, “If anybody would request that, I would honor that. But nobody has.”
A nurse in Maryland quit her job Monday after being told a surgery center that is still performing elective procedures was running out of masks and would not receive any more.
“I feel like I can’t be part of a surgeon taking advantage of a bad situation. A global pandemic isn’t time for us to make money,” she said.
On Wednesday, the federal government issued voluntary guidelines, calling on surgeons, physicians and dentists to limit nonessential surgery and medical procedures.
The guidelines are not mandatory. They leave final decision-making authority to state and local health officials, as well as physicians and patients.
“The reality is the stakes are high, and we need to preserve personal protective equipment for those on the front lines of this fight,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services, which issued the new guidelines Wednesday.
The tiered system proposed by the government recommends postponing “low-acuity” surgeries and medical procedures such as carpal tunnel releases and colonoscopies in healthy patients, and screening endoscopies for unhealthy ones. It asks doctors to consider postponing care such as knee and hip replacements, low-risk cancer surgery and elective angioplasty.
And it says most cancer surgery, as well as transplants, trauma surgery and cardiac surgery for people with symptoms should not be postponed.
Tens of millions of these scheduled surgeries and procedures are performed each year in hospital outpatient departments and ambulatory care centers.
Chip Kahn, president and chief executive of the Federation of American Hospitals, which represents the 20 percent of hospitals that are for-profit, said, “CMS has been extremely careful in designing these guidelines to make it clear that local communities, hospitals and physicians need to make the ultimate decision with their patients on what care is essential. That policy will help us work our way through this crisis.”
Rick Pollack, president and CEO of the American Hospital Association, the umbrella group for U.S. hospitals, also praised the CMS approach.
“The cancellation of elective procedures — which the medical community needs to be prepared to implement — should be determined at the local, community level in consultation with hospitals and the clinical recommendations of physicians and nurses,” Pollack said in a statement. “It is important to recognize the definition of ‘elective’ procedures includes important life saving measures that will continue to be necessary.”
Even the American College of Surgeons has called on hospitals, health systems and surgeons “to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures” until there is confidence that the health-care system can support a massive increase in critically ill patients.
Given the guidance, the situation is changing rapidly around the country, with many places ending elective surgeries this week. In Massachusetts, officials ordered hospitals and surgery centers to stop performing nonessential surgery, effective March 18. Ohio, Colorado and Minnesota have also moved to restrict surgeries.
But in other places, they are continuing at a regular clip. One anesthesiologist, who works at a hospital in Connecticut that is still doing elective surgeries, said doctors and nurses are having to choose between their jobs and their safety all for the sake of lucrative but non-urgent procedures. She works for a private practice that is contracted to the hospital, and her boss worries about losing the work. So even cosmetic surgeries have gone ahead.
“It’s pretty clear that this is about the hospitals’ bottom lines,” she said.
Among the procedures she has prepared patients for this week: a breast lift, a tummy tuck and a hernia operation.
She says the hospital has provided sporadic information about once a week on plans to treat coronavirus patients and to protect doctors. But it is running low on protective gear and has begun rationing even as doctors are asked to reuse disposable equipment and draw down stocks for the unnecessary procedures. Some of the staff have begun improvising reusable face masks intended for construction work that they bleach in between operations.
The University of Utah Hospital in Salt Lake City stopped doing elective surgeries Monday, said Candice K. Morrissey, vice chair of safety and quality in the department of anesthesiology. Morrissey is her department’s point person on coronavirus and said the hospital is taking aggressive steps to protect employees. Two anesthesiologists now perform intubations while wearing head-to-toe protective gear, including powered air purifying respirator masks. The doctors each work eight-hour shifts, she said, and are the only two people in the room while the breathing tube is being inserted.
Morrissey said the lack of testing is having an impact on the hospital workforce. Every time a worker is sick, even with what appears to be a run-of-the-mill cold, he or she must stay out of work for 14 days because there are not enough coronavirus tests.
“We just know we have to fight for it every time we want to get a physician tested,” she said.
Frances Stead Sellers and Jennifer Oldham contributed to this report.