Cancer surgeries to remove certain tumors have been delayed, as doctors try other treatments.
Operations to treat semi-clogged heart arteries or remove a gallbladder have been put on hold when possible, as hospitals try to conserve protective equipment for treating a surge of COVID-19 patients.
Children needing complex orthopedic procedures wait as the risks of delay are balanced against the chance of being exposed to the coronavirus while recovering in a hospital.
Delays of nonessential surgeries in Minnesota have caused anxious waits for patients needing treatments that sound a lot more serious than the word "elective" might imply. The good news, doctors say, is a delay in the surge of COVID patients combined with an increase in testing capabilities is creating a chance to get more procedures done in the near term.
Getting through the backlog won't be easy, though, since thousands of surgeries have been postponed already.
"We have a group of surgeons who are reviewing this on basically a daily basis, and it is really hard work," said Dr. Tim Sielaff, chief medical officer at Allina Health, which operates 11 hospitals. "There's a really significant gray area between 'clearly it has to be done,' and 'clearly it doesn't have to be done.' "
In mid-March, when Minnesota had confirmed just a few dozen infections of the novel coronavirus, hospitals across the state started postponing surgeries to conserve resources to treat COVID-19 patients. Gov. Tim Walz issued an order that postponed "all nonessential and elective surgeries and procedures" beginning March 23 and stipulated that delays should not create "undue risk to the current or future health of a patient."
The phrase "elective procedure" might conjure visions of cosmetic surgeries and low-key treatments, but that's a far cry from the surgeries that Claire Lindell needs to address a curvature of her spine.
The 4-year-old from Prior Lake was scheduled to undergo surgery March 30 at Gillette Children's Specialty Healthcare in St. Paul to begin correcting the spinal deformity. After the operation, she was to stay in the hospital for up to six weeks followed by a second surgery.
In mid-March, the Lindell family was getting in the car to drive to a final doctor's appointment when they learned the surgery was being delayed indefinitely.
"There are a lot of plans that were laid out over the course of a five- [to] six-month period and just — poof! — they all went away," the girl's father, A.J. Lindell, said.
Claire was born with a genetic condition that affects her lungs and heart, and scoliosis contributes to respiratory troubles by compressing one of her lungs. Impaired lung function puts patients at risk for COVID-19.
When surgery was still on the schedule, A.J. Lindell said he was apprehensive about his daughter spending so much time with COVID-19 patients being treated nearby. With the delay, Lindell now wonders if Claire will have to repeat some of the pre-surgery work — she went through more than a dozen appointments and tests before the postponed operation.
"You have the uncertainty of her condition in the meantime," added Lindell, who says he understands why the surgery had to be put on hold. "We're hoping that we see a little bit of a light at the end of the tunnel here, and maybe the hospital will figure out a way to partly open."
Delaying surgery for 30 to 60 days might be reasonable in Claire's case, but things get more risky as more time passes, said Dr. Tenner Guillaume, an orthopedic surgeon who is chief of staff at Gillette Children's. With children, delays in treatment can have lifelong impacts.
Delaying procedures to prepare for COVID-19 has been the right decision, Guillaume said, but it's created a growing dilemma for the health care system. So far, Gillette Children's has postponed more than 10,000 appointments.
"Right now, as physicians, we're trying to work out: What does a return to normal mean?" Guillaume said. "With the backlog of cases now, we're going to have to develop new systems to try to figure out how do we get this all done for everyone, and how do you begin to prioritize one case over another."
When Tara Hershberger was diagnosed with Stage 3 breast cancer in early March, doctors at the Mayo Clinic scheduled her surgery for March 30. Five days before the operation, the clinic called to say the procedure had to be postponed.
Hershberger, 39, of Fountain, says she trusted her doctors, but also felt anxious because she wanted the cancer out. Rather than operate, doctors prescribed medicine that can slow or stop the growth of a tumor by blocking hormones.
About two weeks later, she learned Mayo Clinic doctors could operate after all and the surgery was a success.
"But during those 14 days, none of it made sense — none of it," she said. "I thought it was all wrong."
Mayo Clinic officials did not comment on Hershberger's case. But the clinic, like cancer centers across the country, has been postponing cases where possible, said Dr. Robert McWilliams, a medical oncologist. In many cases, doctors are flipping the sequence of care, McWilliams said, by providing chemotherapy, hormone therapy or immunotherapy before going to surgery.
"Nothing in medicine we do has zero risk," McWilliams said. "We did everything we could to minimize that risk."
Mayo decided it had to delay procedures following episodes in March in which doctors operated on patients who later tested positive for the coronavirus, McWilliams said. The exposure resulted in entire surgical teams being sidelined, since there's a higher risk for the virus to spread when inserting a breathing tube into a surgical patient.
In addition, with an expected surge in COVID-19 patients, Mayo had to create hospital capacity.
The pause helped Mayo determine how to air out operating rooms between cases, McWilliams said, to reduce risk of airborne exposure. The clinic also devised a process for coronavirus testing — surgical patients now take the test two days before an operation, McWilliams said, and are essentially isolated until the surgery happens.
"Patients who are COVID-positive and go through a surgical procedure, they are at higher risk for complications," McWilliams said. "So, it's not just about protecting the medical teams."
Increased testing supply is helping the clinic work through the backlog of delayed procedures, McWilliams said, with priority for those that must get done first.
At Allina, about 4,000 surgeries have been delayed within the last month.
Many hip and knee replacements have been put on hold, although doctors don't want to minimize pain with the underlying condition, said Sielaff, the chief medical officer. "If you're waiting to have a hip replaced, your life is not happy," Walz said last week during a call with reporters.
There's no holdup with emergency trauma surgeries or operations for symptomatic cancers, Sielaff said, but some uncomplicated gallbladder removals and cardiovascular procedures have been postponed.
"There is a potential risk associated with a delay in their necessary surgical care," Sielaff said. "What we have been trying to do is balance the risk of exposure, or the risk of having an operation and harboring COVID, vs. the benefits of the operation."
Doctors are now "cautiously optimistic," Sielaff said, that they can perform more surgeries due in part to the recent push for Minnesotans to stay home to prevent the virus from spreading. It seems the expected surge of COVID-19 patients has been delayed as a result, he said, adding that doctors can care for more patients within the limits set by Walz.
There's a similar move across the country with the American Hospital Association and two prominent physician groups issuing this month a "road map for readiness" on when and how to resume more elective procedures.
"When we start talking about COVID not being over with for a year or 18 months … we need to start getting those patients in and getting their treatments done," said Dr. Mary Dale Peterson, president of the American Society of Anesthesiologists.