COVID Cancelled My Surgery- Who’s Idea was that?
You finally worked up the courage to have your surgery. You faced the anxiety that comes with relinquishing control and placing your life in some stranger’s hands. Now you have received the call – “Sorry, but due to the current COVID restrictions on elective surgery we must cancel your surgery”.
Here in Massachusetts, it has been mandated that hospitals and surgeons are prohibited from performing elective inpatient surgeries. This is an attempt to preserve hospital capacity to treat the sickest in our communities that have been infected with the coronavirus. Since there is no way to predict how many people will require hospitalization, the system must plan for the worst case scenario. The only constant and predictable source of hospital admissions are through elective surgeries that require admission to the hospital. An example of this type of surgery would be a hip or knee replacement or in my case a spinal fusion. Some surgeries are not elective – in my specialty most surgery for brain tumors or spine tumors are not elective. The public health officials do realize that surgeries to treat cancer, or are life and limb saving are obviously not elective and will continue without interruption.
However, what about pain? And for that matter what is an elective surgery. Many surgeries are performed to treat pain be it abdominal pain from a hernia or sciatic pain from a herniated disc. Sometimes pain is intolerable and causes suffering. Is alleviating suffering elective? What if a delay in performing surgery causes the surgery itself to become more complicated and risky as the disease process continues? If the surgery can be performed as an outpatient – like a hernia or shoulder arthroscopy then that surgery is not expected to result in a hospital admission and can proceed as planned. However, if a surgery is expected to result in a hospital admission how do we decide if this surgery is eligible to proceed.
Enter the MeNTS. No - not “mensch” the Yiddish term for person of honor, but Medically Necessary Time Sensitive procedures. This is a scoring system developed in concert with the American College of Surgeons that provides a tool that assesses risk factors that influence transmission risk to both patient and providers, while taking into consideration the ethical necessity of public health concerns.
There are 21 factors divided into three sections that are categorized as procedure specific, disease specific, and patient’s risk factors for COVID related complications. Each category is scored from 1 to 5 with a minimum score of 21 and a maximum of 105. Higher scores for each factor are associated with worse outcomes and increased risk of COVID transmission. For example, a patient over 65 with hypertension and COPD who is having a back operation who will need close monitoring in the hospital to avoid cardiac and respiratory complications will have a high MeNTS score. In contrast, A 35 year old having back surgery who does not have any risk factors but is bedridden, waiting 2-6 weeks for surgery represents a significant risk of complications such a blood clots in the legs and pneumonia. This patient will have a low MeNTS score and will likely be able to proceed with surgery. The state health department decides what the threshold score will be to allow elective surgery.
While not perfect, the MeNTS score is a tool that provides us with a scoring system to allocate scarce resources. It cannot, and does not, apply to every patient in every situation. However this is what we have and if applied consistently and accurately, can help hospital systems plan for the worst. Sometimes there is disagreement between the surgeon and the administrators when a patient’s surgery is cancelled. This is where a conversation between the physician and administration is crucial. It has been my experience that no patient who a surgeon felt NEEDED surgery had the surgery denied.
As of this writing the threshold score in MA is 32.
Watch the video below to watch me fill out a MeNTS form