In December, Christine Rayburn detected a painful lump in her right breast that biopsies would later show included two different types of cancer. One had invaded her lymph nodes.
Rayburn and her doctors settled on a plan. First, surgery to remove the tumor was scheduled for March 20 at Providence St. Peter Hospital in Olympia. Then, chemotherapy.
Two days before the operation, Rayburn got disturbing news from her surgeon. The procedure had been postponed due to the spread of the coronavirus.
“I actually burst into tears and started crying,” Rayburn said. “I really wanted that cancer out … I felt like I was being sacrificed … for the good of the people.”
Rayburn is one of many Americans whose surgical procedures, tests and examinations have been canceled as part of the broader response to the rapidly unfolding crisis. These disruptions represent a huge but largely hidden toll of the pandemic, which has slashed services available to patients and inflicted a major economic blow on hospitals and health care workers, one intended to be softened with $100 billion from the stimulus package approved by Congress last week.
These actions have been impelled by the need to conserve scarce protective gear for health care workers. They also represent an effort to reduce the risk of sickening patients and those who treat them, and to dedicate more space, staff and ventilators for the expected increase in hospitalizations of people with COVID-19, the disease caused by the virus.
The measures were initially called for by national recommendations from the Centers for Disease Control and Prevention. Then, in Washington state, a March 19 emergency proclamation by Gov. Jay Inslee banned medical procedures that would not be anticipated to cause harm to the patient if delayed for three months.
Inslee, in his order, noted that some scheduled surgeries, such as removal of serious cancerous tumors, could proceed. And after inquiries from a state legislator about her case and an appeal from her surgeon, Rayburn learned Thursday that Providence St. Peter had rescheduled her operation for Monday.
But there is no easy formula for this rationing of health care, and The Seattle Times has found a wide range of care pushed into an uncertain future, with some of these delays having potentially serious consequences for patients. They include an operation to remove a throat lesion in an 11-year-old girl, a stent repair of a swollen artery (a condition known as an aneurysm) at the base of man’s brain, and a procedure to remove an intrauterine birth-control device causing a woman intense pain during menstrual cycles.
Other conditions deferred involved surgery on a herniated disc that made it difficult for a man to walk and cutting away a portion of a prostate to allow removal of a catheter that poses a serious infection risk due to the weakened condition of an elderly patient.
There also have been large-scale cancellations of routine appointments that include measles vaccinations and screenings, such as colonoscopies and mammograms, that can detect possible cancers.
Dr. Peter Benda, a Kirkland-based pathologist who interprets biopsies from such tests, said that the volume of his work has dropped dramatically. “The untold story is that we put the rest of the health care system on the back burner … If we are not making diagnoses, patients don’t know if they have cancer.”
As the flow of patients implodes, so does the revenue that sustains clinics and hospitals.
Dr. Sara K. Benda, a pediatrician married to Dr. Peter Benda, said she works in a physician-owned private practice on the east side of Lake Washington that has had to lay off 30% of its staff and cancel all face-to-face checkups with the exceptions of babies 15 months and younger.
Hospitals large and small are struggling.
A Providence network of 11 hospitals in Washington and Montana has suffered a 50% decline in revenue due to the reduced services, according to Melissa Tizon, a Providence spokeswoman.
And the 25-bed Three Rivers Hospital in Brewster, one of three in Okanogan County, will run out of money within a month without an infusion of federal or state money due to the lack of general surgeries, according to its CEO. It is one of five smaller hospitals facing “imminent closure” cited in a March 20 letter to Gov. Jay Inslee from the Washington State Hospital Association.
“We have always kind of struggled in an underserved community, just doing enough business to cover our costs,” said J. Scott Graham, chief executive of Three Rivers and North Valley Hospitals. “There is a lot of sleepless nights and anxiety about whether we are going to make it through.”
Who gets a procedure, who doesn’t
For doctors paring down caseloads, the coronavirus outbreak represents a difficult foray into triage, a term often used in wartime to decide difficult decisions on treating battlefield wounds. The American College of Surgeons has embraced the technique in developing guidelines for what operations to postpone. The guidelines are keyed to how many coronavirus patients are in a hospital, and call for tightening restrictions on surgeries as these numbers climb.
At UW Medical Center’s Montlake campus in recent weeks, surgeries have dropped by about half. A lot more could be postponed if more coronavirus patients are hospitalized there. That scenario — if it does happen — would likely unfold in April.
“We’re still at a phase where we feel we can do cancer operations. But we might get to a phase two or three weeks from now where … we can only do true emergencies — someone who might die right now,” said Dr. Douglas Wood, who chairs UW Medicine’s surgery department and helped develop the guidelines for the American College of Surgeons.
Wood is increasingly hopeful that a big surge will not happen, as the numbers of coronavirus patients last week were less than anticipated, but he says the UW must stockpile personal protective gear in case it does.
Wood says UW Medicine has left it up to individual surgeons to decide which cases to keep on the schedule and which to postpone. He has not heard of patients who contested these decisions. If there are complaints, cases could come under broader scrutiny from UW faculty and hospital leadership.
Within the Providence hospital network, Christine Rayburn, the cancer patient, and her husband, David Forsberg, did push hard for reconsideration.
They emailed three Olympia-area legislators for help. They also talked repeatedly with a Providence St. Peter administration official who said there was a hospital decision to suspend elective surgeries, which then would be taken under review by doctors, according to Forsberg.
“It’s OK to be a squeaky wheel to ensure that you get the care and attention that you need,” Forsberg said.
Elaine Couture, chief executive of Providence, Washington & Montana Region, said a few weeks ago as serious COVID-19 cases rapidly escalated in the Puget Sound area that hospitals had to quickly make tough decisions to scale back.
The scarcity of personal protective equipment quickly emerged as a major constraint. Providence Everett went through the same amount of gear in three months as the entire Providence network of western hospitals typically consumed in the same time period.
Couture told The Seattle Times that surgeons — not hospital administrators — were making the key decisions about which procedures could continue at the Providence hospital network. Once a patient’s surgery is put on hold, Coutere said, doctors review cases several times a week, and approve them if they need to be done.
“The process is working. We’re not putting people on a list and their names go away,” Couture said.
Wide range of operations on hold
For patients whose appointments are canceled, the stalled medical care can add to the anxieties in an already anxious time.
Glen Godwin, of Leavenworth, is cooped up indoors with a herniated disc that was scheduled to be operated on at Wenatchee Valley Medical Center. Godwin, 60, said he injured his back last month trying to lift a snowmobile. One of his legs is so numb he can barely walk, and he has a mix of light- and heavy-duty pain pills prescribed to help him through his days.
“The last I heard it would probably be June before they could do the surgery,” Godwin said.
Corey Miller is a Seattle oncology researcher whose husband, Timothy, had surgery for colon cancer last year, and was due for a colonoscopy this month. Instead, the appointment was canceled for at least six weeks.
“I was surprised when we got the word. The protocol is for a one-year check up to ensure that there is no return,” Miller said.
Patra West is unsettled by a lesion in the throat of her 11-year-old daughter that was removed last summer and has since grown back. An initial ultrasound indicated it is likely benign. But Patra didn’t want to take any chances and opted to have it removed in an operation this month that has yet to be rescheduled at Seattle Children’s hospital.
“Obviously, there is a growth where there shouldn’t be,” West said.
For the patients who are able to access hospitals for scheduled appointments, there can be a kind of eerie calm on some floors.
Rayburn, in recent days, has been able to resume some cancer care at Providence St. Peter. Last week, she got an echocardiogram of her heart, a prerequisite for the chemotherapy that will follow Monday’s surgery.
As she waited for the examination to begin, Rayburn watched a hospital staffer make call after call canceling the appointments of other patients who needed echocardiograms.
“I was the only one there. I felt incredibly lucky,” Rayburn said.