INTRODUCTION
Our tradition in medicine, dating back to the Hippocratic oath in the
fifth century BC,1 has emphasized the importance of
putting our patient first, avoiding choices that might harm them, and
not considering issues unrelated to that particular patient’s health as
we make our medical decisions. Public health considerations involving
risks to providers and other patients have not normally been factored
into the decision. Furthermore, what we have known to be best for the
patient in the past, has not involved calculating the risk of
contracting a potentially fatal infectious disease while merely walking
into the hospital.
Recently, however, the unprecedented and now-familiar events related to
the COVID-19 pandemic have affected communities all over the
globe,2,3,4 including South Florida. By the time of
this writing, Newsweek reported, based on U.S Center for Disease Control
and Prevention (CDC) data, that coronavirus had surpassed heart disease
and cancer as the number one killer of Americans on a daily
basis.5
On March 14, US Surgeon General Jerome Adams recommended in a tweet that
hospitals stop all elective procedures amid the COVID-19
outbreak.6 The same day our two hospitals’
administrations issued an electronic communication asking surgeons to
cancel all elective surgeries at our facilities. On March 20 the
Governor of Florida issued a formal ban on elective
surgery7. Permissible procedures included “removal of
cancerous tumors, transplants, limb-threatening vascular surgeries,
trauma-related procedures, and dental care related to the relief of pain
and management of infection.”7 In practice, in
oncologic surgery, it was left to each institution to determine what was
urgent, and which patients would be best served by receiving surgery,
despite increased risk to the patient, providers, and other patients
during the pandemic.
Our approach, as we addressed surgical triage, was to consider each
patient’s risk of complications related to receiving surgery in the
midst of the pandemic and deciding if that risk ”tipped the scales”
towards delaying care or planning an alternative treatment. Though data
was scarce, experience in China and Italy indicated that the risk of
either directly developing a coronavirus infection, or of ending up with
a complication requiring care in the midst of a situation of inadequate
medical resources, might outweigh the benefit of receiving cancer
surgery earlier in certain cases.3,4,8
The greatest paradigm shift that occurs in times of crisis, however, is
the concept that the good of society, and the health of the caregivers
and other patients, may have some weight in the equation, even as
clinicians continue to make our patients’ well-being our primary goal.
Considering these additional factors is the part that we may find most
difficult to adjust to. Furthermore, as we approach so called “surge”
conditions in any disaster, and resources approach the point of being
overwhelmed, these factors may become more important, and even approach
or surpass those of the patients themselves.9,10
In times of crisis, it is clearly recognized that standards of medical
care may have to be altered. In an almost clairvoyant publication,
intensivist and disaster management expert Michael Christian, MD,
published an essay entitled “Triage” in October 2019,9, just before anyone imagined the events that were
about to unfold in Wuhan, China. He defines triage as “allocating
scarce resources in order to do the greatest good for the greatest
number”. He emphasizes that appropriately performed triage, while
difficult, can save large numbers of lives, by preserving resources for
”salvageable” patients. One must add to this equation the need to
protect caregivers so they can attend to other patients. There is an
extensive literature on appropriate crisis triage, based on experience
during warfare 11,12,13 and natural disasters.14,15 This was most recently seen in our own country
with the crisis in New Orleans in the aftermath of Hurricane Katrina,
when physicians in hospitals had to triage civilian patients in a manner
normally seen only in the midst of battle.14,15
While we can extrapolate from triage and management models developed for
times of war or natural disaster, this global pandemic is a different
entity entirely, affecting almost the entire planet at
once.2,3,4 It involves an ascension to a peak volume
and then a descension, rather than a single disaster date as would occur
with a natural disaster or act of war, and it is affecting Asia, Europe,
Africa, and the Americas within months of each
other.2,3 The SARS-CoV-1 epidemic of
2001-2004,16 the H1N1 influenza epidemic of
2009-2010,17 the Middle Eastern Respiratory Syndrome
(MERS) of 2012,18 and the West African Ebola
epidemic19 of 2013-14, were much more geographically
confined. Perhaps for this reason, there are no published reports of a
need for cancer patient triage during such epidemics. H1N1 Influenza, in
particular, was known to be virulent in patients with hematological
malignancies 17, especially if undergoing treatment,
but we found no reports that access to health care was threatened,
requiring triage of solid cancers. There were limited anecdotal reports
of health access issues during the Ebola crisis in West Africa; they
hinted at some of the issues we currently face.20,21,22
The ethics of triage and management in situations of crisis including
pandemics have been extensively discussed, modeled and prepared for, and
it is widely accepted that the rules need to be adjusted to each new
situation.9 Biddison et al.,10, in a
consensus statement in the critical care literature, identify 23 ethical
guidelines for crisis situations. The importance of communication with
patients and families and the possibility of consulting ethicists is
emphasized. Moreover, they comment: “We suggest critical care resources
be allocated based on specific triage criteria, irrespective of whether
the need for resources is related to the current disaster/pandemic or an
unrelated critical illness or injury. “
Our purpose here is to provide a practical working example of how one
large head and neck oncology group sought to ensure that patients
requiring head and neck surgery received appropriate triage during the
pandemic, and were neither put at increased risk of a poor outcome from
their tumor nor from Covid-19 infection.