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Dr. Alexandra Rendely is a staff physician at the University Health Network’s Toronto Rehabilitation Institute. Courtney Sas is a social worker at a University of Toronto affiliated hospital and an adjunct lecturer at the Faculty of Social Work.

This spring, during the first wave of the coronavirus, provincial governments undertook the necessary but difficult step of shutting down elective surgeries. At the time, it was feared hospital systems would be overwhelmed with COVID-19 patients needing urgent care. Scarce personal protective equipment and post-operative intensive care beds were pre-emptively reserved for coronavirus patients. Our hospitals managed to get by without falling into crisis, but now, as the number of COVID-19 infections soar, surgeons fear the government will once again shut down operating rooms.

In Ontario hospitals, discussions surrounding the threat of cancelling elective surgeries have started again. As COVID-19 cases balloon, working groups and hospital steering committees are meeting frequently to discuss each hospital’s next steps. Many surgeons involved are advocating that operating rooms should remain open. The evolving nature of coronavirus requires a daily evaluation of resources, such as critical care beds, to match the fluidity of the situation. A total shutdown in anticipation of over-capacity hospitals would be exponentially detrimental this time round.

As medical professionals who work closely with patients, we have seen the severe impact of delaying these so-called “elective surgeries.” One major unintended consequence is the notable delay in hip and knee replacements. These surgeries have been deemed elective as they do not lead to loss of life or limb. Joint replacement surgery is often a last resort, offered after all other treatment options have been exhausted. With patients suffering at home, in pain and struggling to walk, these surgeries are hardly elective at all.

Behind every delayed joint replacement surgery is a human – a human who is experiencing pain, anxiety, stress and suffering. These stories have been largely invisible in the broader context of the pandemic. Mobility is critical to our well-being. It determines how we function in our homes, interact with people and make a living. It is directly linked to how we function in our daily lives. Our colleague, orthopedic surgeon Sarah Ward, puts it this way: “We know from the literature that some patients waiting for hip and knee replacement surgeries consider their quality of life to be worse than death, which is why I do not consider these surgeries to be elective.”

As surgeons are still playing catch-up from the initial closure of operating rooms, wait-lists continue to grow. The stakes are very high, and quite simply, not every patient can wait. They may remain alive, but how much misery can these patients tolerate?

The most pressing question from these patients is when will their surgery be rebooked. According to research from the University of Toronto it is estimated that between March 15 and June 13, 2020, our health care system created a backlog of 148,364 surgeries in Ontario. We are already experiencing major delays, and should operating rooms close again, it will become an even larger issue. It is likely some patients will never receive their surgeries.

Orthopedic surgeons are now being put in a position to determine who receives surgery before someone else. One strategy surgeons have been using to preserve resources is to prioritize younger, healthier patients, hoping they will be discharged faster. These surgeons are doubling as ethicists while navigating an unprecedented time.

Surgeons need to determine who is highest priority, while factoring in hospital resources and administrative limitations. These limitations are real, and we do not intend to minimize them. Hospitals always operate under a finite number of resources. There are a certain number of in-patient beds, including a set number for critical care patients.

Even with daily case counts on the rise, the resultant surge in intensive care bed needs has still not occurred. Recent daily averages show that approximately 1 per cent of positive cases are requiring intensive care admissions. Canadian hospitals have nimbly shifted resources across departments, implemented virtual care where possible, and transitioned follow-up visits to phone calls. Together, these measures and many others have allowed every department to continue to function. While most surgeons are not back to pre-pandemic caseloads, operating each day has slowly helped ease long wait-lists.

Although there is no current research on the ramifications of COVID-19′s elective operating room closures, as this is happening in real time, physicians and allied health practitioners are preparing for a cascade of further unintended consequences. Physicians have already noted a rise in substance misuse, specifically patients self-medicating as a coping strategy for pain management. Patients can also quickly become more surgically complex if other associated health issues become exacerbated in the interim.

The virus is destructive and there is no anticipated end date to its tornado-like effect. The patients on these ever-growing waiting lists are the invisible crisis. With all of this in mind, Canada simply cannot afford to shut down operating rooms for a second time.

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