Anticipating, managing and anticipating again: The phases of COVID-19 in surgical practice

Before the first wave of COVID-19 patients hit Michigan Medicine in early March, preparations were well underway. Scott Regenbogen, M.D., associate chief clinical officer for surgical specialties in the medical group, was tackling the surgical side of preparations—the medical equivalent of boarding up windows and getting the flashlights and generators ready before a hurricane makes landfall.

He was thinking about which operations and office visits could be put off to ensure the safety of patients and providers and free up hospital capacity.

He was considering the consequences of the PPE supply chain and physical hospital space being overwhelmed if case volumes tracked with the terrifying models.

He was accounting for staffing shortages that would occur if health care providers got sick from the virus in numbers like they did in Italy.

Celine Gounder, M.D., a former colleague who is now a clinical assistant professor of medicine and infectious diseases at New York University’s Grossman School of Medicine, called to ask how it was going. The conversation, recorded for a podcast, captured the heaviness and the uncertainty of the time.

“It’s scary and it’s a lot to have riding on our shoulders right now,” Regenbogen said of all of the endless what-if scenarios.

Around the same time, Anna Boniakowski, M.D., chief resident in integrated vascular surgery, presented at Grand Rounds—virtually, right after Michigan locked down. She administered a “Which Winnie the Pooh Character Are You?” quiz to illustrate intellectual diversity and the role it plays in building surgical teams.

Regenbogen was pegged as Rabbit:

You are the voice of reason among your friends. You’re highly organized. You are very encouraging to those around you. At times you can stress out over little things, but that’s only because you care and you're concerned for your loved ones.

He printed it out and hung it in his office to remind him why he felt the way he did.

The passage of time, and a new mindset

A month later, Regenbogen spoke to Gounder again. He had moved from the anticipation phase into the managing phase. From not knowing what was coming to managing what had come.

What had come wasn’t as bad as the models had predicted. Things weren’t good—Michigan Medicine by then had settled in at about 220 COVID-19 in-patients per day—but they were better than what the worst-case models had forecast.

A field hospital tentatively planned at the University of Michigan indoor track facility was put on hold. The numbers at the main hospital had stayed steady rather than rising. The waters were not receding, but they weren’t threatening the levees.

The staffing shortages hadn’t occurred as projected. Michigan Medicine based those estimates on Italy having seen 20-30% of its healthcare workers falling ill.

“We planned for that. We set out our faculty and staff work schedules on the assumption that we were going to lose a third of our workforce, and it just didn’t happen,” Regenbogen said.  

While it’s unclear why those staffing shortages didn’t occur, Regenbogen is grateful they didn’t, and said it is evidence of effective and innovative PPE use—even if it wasn’t ideal. 

PPE shortages were widespread throughout the country, and Michigan was no exception. Michigan Medicine accepted donations of masks and other equipment from the public and implemented guidelines for reprocessing N95 masks for multiple uses, for example. 

As of April 30, 288 Michigan Medicine employees tested COVID-19 positive and 1,573 tested negative.

The shortage of ventilators that many feared would occur didn’t, despite how many patients were acutely ill.

Social distancing had proven an effective sandbag, especially in the local communities Michigan Medicine primarily serves.

“We modeled what would happen if things don’t change. And we also modeled what would happen if things did change. And what happened was the rate of transmission, especially in our local area, changed much faster than predicted. You can back-calculate how well people did at distancing themselves,” Regenbogen said.

Still, tough decisions had to be made about putting off surgery in order to protect patients and make sure the hospital had capacity for the higher-than-normal ICU load. The word “elective” was parsed and the team worked together to define what could wait, and what couldn’t. The directive: Nothing should wait if waiting was likely to cause harm.

“We triage stuff all the time. ‘How urgent is this? Can it wait for my next OR date, which might be three weeks from now or does it have to be now? I have two patients, and one OR slot next week, so which one do I do? Or patients ask, ‘Can this wait until after my daughter’s wedding?’ and we say yes or no... We’ve never done it to the degree that we did it recently,” Regenbogen said.

While there was some guidance from various institutions and surgical groups, the challenge was that the scale of the problem varied widely.

“What you saw was lots of people try to come up with structures and rubrics you could use to try to make these decisions...The problem was it really depended on what your local situation was. There were some places where they were obviously going to go on with cancer surgery because they only had a few patients in the hospital,” Regenbogen said.

The path forward

Even when things return to “normal,” whatever that looks like, Regenbogen is thinking about the myriad challenges of getting surgery back to full speed.

He’s gone from anticipating to managing to anticipating again.

With the case volume seemingly at peak and the curve flattening locally, time-sensitive, non-emergency surgery has slowly started picking up, but it’s not as simple as flipping a switch and going back to what things looked like on March 1.

Surgical faculty and residents have been re-deployed to work in the ICUs to help with COVID-19 patients, and can’t be pulled back right away. ICU beds are still tight, so operations that may require intensive care need to be approached with caution. And then there’s the directive from the state to stay home for anything but essential activities.

“There’s still a statewide stay-home order, so every patient we bring out of their home for medical care, we have to ask ourselves is that the right thing to do, or would it be safer for them to put off their medical care? For whom is it clearly more problematic to wait, and can we still safely take care of them within our current restraints,” Regenbogen said.

When people are allowed to move freely, will they still resist coming in for care?

If the conversations with people about why surgeries could be safely put off were difficult, the conversations telling them they can come back in may prove just as challenging. Regenbogen cited an example of a patient he’d talked to about putting off their surgery weeks ago. It could go forward as planned after all, he recently told the patient, because community spread in the region was slowing down.

“I called them and they said, “No, I don't want to have surgery right now. I want to wait like we talked about,” Regenbogen said.

It’s another thing for Rabbit to consider.