The unintended consequences of surgery delays during COVID-19

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The sacrifice Canadians have collectively made to flatten the coronavirus curve also includes immeasurable sufferingfrom postponed surgeries, says a B.C. man who lost his mother not to the virus but to cancer.

JasmineYang, 60, started having abdominal pain, fever and then breathing difficulties in January. She went to an emergency department in Surrey, B.C., and was diagnosed with a rare form of ovarian cancer inMarch.

Her son, Jonathan Hu, 31, said oncologists recommended surgery in early April as the best treatment for Yang's three, late-stage tumours. But the COVID-19 pandemic lockdown included postponing or cancelling non-emergency surgeries like Yang's andan estimated 394,575 others across Canada.

"There is a lot more people who are suffering or dying other than just a number of deaths that you see from the coronavirus," Hu said.

Canada's health-care systems prioritized life or limb-threatening cancersduring the COVID-19 pandemic. In other cases, choices were made tocancel and postpone surgeries as part of efforts to prevent hospital staff and resources from being overwhelmed.

"We were really frustrated," Hu said.

The family "felt powerless" as they watched Yang deteriorate daily during chemotherapy that was not part of the original treatment plan for her sex cord stromal cancer. The surgery was postponed weeks to May 4.

Yang died two days earlier.

"The choice that we made hasconsequences and we're living with those consequences right now," Hu said.

Tough choices

Dr. Iris Gorfinkel, a family physician in Toronto, worries about unintended consequences from those choices for her patients, too.

For example, virtual care excludes the physical exams she performs to quantify the degree of pain a patient has.

WATCH |The complications of resuming surgeries during pandemic:

The complications of resuming surgeries during pandemic

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Many provinces are starting to resume non-emergency surgeries delayed because of the COVID-19 pandemic, but its a complicated balance of trying to clear the backlogs and keeping patients safe.

"You put your hand on that person's belly you see immediately they're not doing well because you can feel how they're reacting," Gorfinkel said. "I know from my own practice I'm more likely to order tests because of that uncertainty, which is another cost to the systembecause I don't want to be wrong."

Patients are also left wondering whether delays in tests and procedures made a difference in their care, Gorfinkel said.

It's one reason why health-care professionals across the country are preparing to do more procedures and surgeries.

Surgery backlog mounts

In May, B.C. Health Minister Adrian Dix estimated it could take up to two years to clear the backlog of 30,000 patients whose surgeries were postponed or not scheduled since mid-March in that province alone due to COVID-19.

In Quebec, Dr. Gilbert Boucher, head of the province's association of emergency medicine specialists, said the flow of patients sick with medical conditions besides COVID-19 has resumed in much of the province.

The last three weeks, however, have included struggles with finding space, including for patients discharged from hospital who are unable to return home or to long-term care.

At Montreal's older hospitals with four-bed rooms, many cannot be used while COVID-19 cases continue in the community. One tertiary care centre lost 30 per cent of its beds during confinement, Boucher said.

Hospitals with wards for people testing positive for COVID-19 had doctors and nurses working overtime for the last three months.

"Those people are getting tired so we just don't have the staff to staff the operating room and to do the gastroscopy and the colonoscopy and all those follow-up" procedures, said Boucher. "It's summer for everybody so people do need a little break."

Safety prioritized

Medical experts say to ramp up surgeries, a "four-sided Rubik's cube" of prerequisites, known as the 4S's, first need to align:

• Screening for COVID-19 safely.
• Increased staffing capacity.
• Supplies such as personal protective equipment and medications like anesthetics.
• Space and systems in place to keep patients clear of COVID-19 before and during hospitalization and for patients and their family members to understand the importance of quarantine in the first 30 days after surgery.

In addition to surgery delays, the COVID-19 pandemic has led to global shortages of some drugs.

Christina Adams, chief pharmacy officer for the Canadian Society of Hospital Pharmacists, said drug makershave increased production of medications for critical care, such as the injectable anesthetic propofol that's reportedly chronically short in the U.S.

Patients with COVID-19 who require continuous ventilation need two to three times the usual amount of propofol compared with patients requiringsurgery under general anesthesia, Adams said.

She added that Health Canada anticipated global shortages and expedited importsof non-Canadian labelled products, such as from the European Union, to ensure supplies weren't interrupted.

"Right now, the situation is not bad," Adams said.

COVID-19 greatly compounds surgery risks

Janet Martin an associate professor of anesthesia and perioperative medicine at Western Universityand an international team of surgery researchers,estimated that 28.4 million elective surgeries worldwide could be cancelled or postponed this year based on the 12-week peak of disruptions to services in hospitals.

For Canada, the cancelled surgeries includehip and knee replacements and procedures to confirm whether or not someone has cancer.

"That's exactly for whom we are doing this type of research," Martin said.

If hospitals successfully increase capacity by 10 per cent by running operating rooms longer and partly on weekends, Martin figures it will take nearly 90 weeks to clear Canada's backlog.

In a study published last month in The Lancet, Martin and co-authors followed 1,128 patients in 24 countries who had emergency and elective surgery this year before March 31.

Nearly one in four patientssick with COVID-19or who became infected shortly after surgery died within a month, the researchers found. For those undergoing elective surgery, the mortality risk rose from below the one per cent to 18 per cent.

One in two (51 per cent) developed serious pulmonary complications, including needing ventilation.

"We were absolutely surprised," Martin said. "That is far and above what we had ever expected."

As the increased risks from surgeries due to COVID-19 become apparent from the new data, Martin hopes hospitals will find ways to better protect patients.

For his part, Hu emailed CBC News looking for information on how many others in Canada like his mother who weren't infected with COVID-19 but missed treatment and died.

It's impossible to know exactly how delays affect an individual patient.

Gorfinkel said while such societal fallout can only be measured in retrospect, there are definitely consequences from postponing routine screenings during the pandemic, such as mammograms or tests to look for blood in feces, whichcan be a sign of a colorectal cancer or a growth that can easily be treated.

"Would an earlier diagnosis have made a difference?" Gorfinkel said of the questions she's anticipating from her patients. "Much of the time it may not but the fact is we can't be certain."

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