Covid-19’s hidden casualties

TWO weeks ago, I had a heartbreaking conversation with a patient of mine in London. She had been diagnosed with a large kidney cancer and I had planned to operate on her to remove it. However, with the impact of the coronavirus pandemic hitting Britain hard, we had lost 21 of the 24 operating theatres normally available in my hospital’s main complex. More importantly, there were no available intensive beds to care for her, which would have been essential given her complex medical needs.

“I’m sorry, ” I said, “but I can’t tell you when it might be possible to do this operation – and there’s a chance that it may be too late by the time we can.” Tragically, this was only one of several such conversations that I have had in recent weeks. Colleagues and I have stared at each other in disbelief after spending hours going through lists of patients who will suffer a similar fate.

The numbers we see on TV daily charting the spread of the coronavirus tell only part of the human cost of this pandemic. Across different fields of medicine, colleagues tell me similar tragic stories.

The dilemmas facing medical professionals are unprecedented. With extremely limited capacity, who do we choose to treat and when? Who should make these decisions?

Early in the pandemic, there was no data to guide these decisions, but we have seen a huge international effort to address this now. Major medical journals such as the Lancet and New England Journal of Medicine have made their sections on Covid-19 free to access for all, and over 200 scientific papers on the subject have been published to date.

One concerning trend that is becoming evident is that people with serious medical conditions are delaying treatment. Many, understandably, are reluctant to expose themselves to the potential risks in a hospital environment while others feel that they would not want to burden the healthcare system during this time.

Some may seek unproven or alternative treatments. Unfortunately, this means that when their condition deteriorates, it may be too late to do anything for them. If you develop symptoms of a serious medical problem – chest pain and sweating that may indicate a heart attack, for example, or limb weakness and altered speech that suggest a stroke – do not delay seeking treatment.

It is less clear how other potentially serious or “red flag” symptoms that do not suggest an immediately life-threatening problem should be managed. To use an example from my field of practice, blood in the urine would normally need urgent investigation with a variety of tests, as it can be a sign of cancer in the bladder or kidney. Should this be delayed until the worst of the pandemic passes?

This depends on a variety of things, including how severe the symptoms are and what resources are available. Speak to a doctor if you have concerns. The wider use of telephone and video consultations may allow you to get an opinion remotely, although there are limitations to this.

What if you have already been diagnosed with a problem that requires treatment? This is a particular challenge for medical professionals from both a clinical and ethical perspective. In some situations, a “next best” treatment may be more practical and safer in the context of a pandemic, as the evidence we do have at present suggests that elective surgery carries a huge risk to patients if they happen to contract the coronavirus in the perioperative period.

For example, some patients with prostate cancer are being treated with hormones temporarily rather than having surgery at this time. Shared decision-making is a helpful process for doctors faced with these dilemmas.

It is vitally important for the relevant professional bodies to support doctors through this period of uncertainty and offer guidance where possible. There is unlikely to be a “one-size-fits-all” solution for the challenges doctors and patients face in this pandemic. Providing the best treatment in a timely fashion needs to be balanced with the increased risk to both the patient and caregivers. Understandably, many will be anxious about their health now, but we in the medical profession are here for you.


Consultant urological surgeon

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Covid-19; hidden casualties


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