“Our current guidelines from the hospital and our national societies are if the patient is not at risk for a major cardiac event in the next week we should defer surgery.” The words hang in the now virtual air of the hospital’s weekly multidisciplinary endocarditis conference. The young woman whose case we are discussing has bacteremia with two different organisms and a very large infectious mass on one of her cardiac valves. By all objective measures, she needs surgery to address her endocarditis in order to avoid potentially devastating, life-threatening complications. But when would this occur? Would her valve fail in one week or three months? The statistics suggest that she has a 5 to 10 percent chance in the next week of the infection breaking free from her valve and embolizing to another part of her body. Was this risk sufficient to justify surgical intervention? There was no way to answer these questions with any scientific certainty.
The COVID-19 pandemic has had an unprecedented impact globally and nationally. In addition to the individuals who have been afflicted by the disease, the virus has had devastating economic, educational, and social impact. Naturally, these disruptions and deviations from normal life have led to uncertainty and accompanying fear for all individuals. Health care systems have had to adapt to the crisis, canceling surgeries and other procedures in order to ensure there are hospital beds and ventilators available for COVID-19 patients. Additionally, scores of health care providers have been pulled from their primary roles to care for the massive influx of sick individuals. While there has been discussion about the impact of panic amongst the general population, there has been less discussion about how health care providers, the group perhaps most at risk for acquiring COVID, are coping with the current situation.
As health care workers, we are often taught, quite reasonably, to ensure our own safety before acting on behalf of a patient. Typically, it is not challenging to assess the risks to personal safety that accompany patient care. However, with COVID-19, there is new information reported every day, and this constantly changing stream of recommendations for personal protection can be overwhelming. In the absence of hard data and in order to protect patients and frontline health care workers, hospitals have resorted to stopping almost all but emergent testing, procedures, and surgeries. On the surface, these interventions seem prudent, but when looked at individually, they open a veritable ethical can of worms.
The patient from the opening paragraph has a severe infection of her heart valve that, under normal circumstances, would clearly benefit from surgical intervention. However, whether she meets the new, somewhat arbitrary criteria for surgical intervention during the COVID pandemic is difficult to determine. This young woman does not have COVID (in fact, she has tested negative twice), and she otherwise is a very suitable candidate for surgery. There is no benefit to her for deferring surgery, and it would be difficult to argue that there is a benefit to the surgical team. Yet she is not being offered this crucial intervention. This scenario is playing out every day in hospitals throughout the country. Necessary surgeries and procedures such as echocardiograms or bronchoscopies, normally considered the standard of care for a number of diseases, are not being offered to patients who do not have COVID. Even more troubling, physicians are focusing on COVID as a diagnosis at the exclusion of other more likely diagnoses. This pattern has led to patients with three negative COVID tests remaining isolated on a COVID ward, increasing their risk of contracting the disease, and requiring health care workers to unnecessarily use scarce personal protective equipment. At the root of these behaviors is fear, a very natural emotion given the circumstances. And while there is nothing inherently wrong with fear, the troubling pattern emerging is our inability as health care providers to acknowledge that our fear is leading to, at times, an irrational approach to care that threatens to harm our patients.
Yes, let’s identify which tests and procedures are truly needed and which ones can wait. Yes, let’s test for COVID in patients undergoing aerosol-generating interventions. But for those patients who need our help and do not have COVID, we still have the opportunity and duty to provide care. Rather than letting our fear prevent us from providing the compassionate care that we have all been trained to give, why not embrace our fear as a human emotion that we share with our patients? We can talk about our concerns with our colleagues, families, and friends. We can take the opportunity to utilize the virtual mental health resources that many hospitals are now offering. It is OK to be scared, but it is not OK to let our own anxieties harm our patients. As we tackle the numerous crises created by the COVID-19 pandemic, let’s acknowledge our fear and draw on the logic and clinical reasoning that we have spent years cultivating. We can be scared and scientific, anxious, but courageous. Let’s not create two causalities from one disease, the patient who dies from coronavirus and the patient who dies waiting for surgery because they could have had coronavirus.
Sami El-Dalati is an infectious disease physician.
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