In chronic pain, Mary O’Donnell can’t get around much. At most, she manages to walk for a short time in her kitchen or garden before she has to sit down. “It’s just frustrating at this point,” said Ms. O’Donnell, 80, who lives in Aloha, Ore. “I’m really depressed.”
She had been preparing for back surgery scheduled for Aug. 31, hoping the five-hour procedure would allow her to be more active. But a day before the operation, at OHSU Health Hillsboro Medical Center, she learned it had been canceled.
“Nope, you can’t come, our hospital is filling up,” she said she was told.
Faced with a surge of Covid-19 hospitalizations in Oregon, the hospital has not yet rescheduled her surgery. “I don’t know what is going to happen,” Ms. O’Donnell said, worrying that her ability to walk might be permanently impaired if she is forced to wait too long.
Echoes of the pandemic’s early months are resounding through the halls of hospitals, with an average of more than 90,000 patients in the United States being treated daily for Covid. Once again, many hospitals have been slammed in the last two months, this time by the Delta variant, and have been reporting that intensive care units are overflowing, that patients have to be turned away and even that some patients have died while awaiting a spot in an acute or I.C.U. ward.
In this latest wave, hospital administrators and doctors were desperate to avoid the earlier pandemic phases of blanket shutdowns of surgeries and other procedures that are not true emergencies. But in the hardest-hit areas, especially in regions of the country with low vaccination rates, they are now making difficult choices about which patients can still be treated. And patients are waiting several weeks, if not longer, to undergo non-Covid surgeries.
“We are facing a dire situation,” said Dr. Marc Harrison, the chief executive of Intermountain Healthcare, the large Utah-based hospital group, which announced a pause of nearly all non-urgent surgeries on Sept. 10.
“We do not have the capacity at this point in time to take care of people with very urgent conditions yet are not immediately life threatening,” he said at a news conference.
In some of the hardest-hit areas, like Alaska and Idaho, doctors are taking even more extreme steps and rationing care.
When they can, some hospitals and doctors are trying to seek a balance between curtailing or shuttering elective procedures and screenings — often lucrative sources of revenue — and maintaining those services to ensure that delays in care don’t endanger patients.
The industry was largely insulated last year from the revenues they lost during the pandemic after Congress authorized $ 178 billion in relief funding for providers. Some large hospital groups were even more profitable in 2020 than before the virus took its financial toll, with some going on spending sprees and buying up doctors’ practices and expanding. Many had started seeing operations return to normal levels.
A few large hospital chains did not meet the criteria for aid they had received, and returned some of it. It’s unclear how much more hospitals can expect, even if they shutter some of their operations during this latest wave. The Biden administration said earlier this month that it planned to release $ 26 billion in remaining Covid relief funds.
Officials have also had to weigh the risk of admitting patients who could infect others.
But doctors have also been monitoring some of the long-term effects of long waiting times for non-Covid patients during the pandemic, wary of the specter of unchecked cancers or ignored ulcerative conditions if screenings are postponed.
And the waiting is still extremely stressful, troubling both doctors and patients with pressing illnesses who do not view their conditions as non-urgent.
In Columbus, Ga., Robin Strong’s doctor told her a few weeks ago that the rising Covid caseloads there would delay a procedure to repair a vocal cord that was paralyzed in a previous surgery.
Because of her condition, she chokes easily and has a hard time breathing. “I just cry all the time because of my situation,” she said.
Compounding the physical discomfort is her frustration that so many people in her state won’t get vaccinated against Covid, and they are getting sick and taking up hospital beds.
Only 66 percent of adults in Georgia have received at least one vaccine dose, compared with 77 percent of all adults in the United States who have received at least one dose of the vaccine, according to the latest data from federal and state health officials.
“They are punishing people like me,” Ms. Strong said.
In some areas, doctors are explicitly rationing care. On Thursday, Idaho state officials expanded “crisis standards of care” across the state, a standard that had been limited to the northern part of the state earlier in the month. “We don’t have enough resources to adequately treat the patients in our hospitals, whether you are there for Covid-19 or a heart attack or because of a car accident,” Dave Jeppesen, the director of the Idaho Department of Health and Welfare, said in a statement.
With precious few available intensive-care beds, Idaho hospitals had largely stopped providing hernia surgeries or hip replacements before the new order. Now they are postponing cancer and heart surgeries, too, said Brian Whitlock, the chief executive of the Idaho Hospital Association. The hospitals there “have been doing their level best,” he said.
In Alaska, the state’s largest hospital, Providence Alaska Medical Center in Anchorage, has also begun rationing care as patients wait for hours to get to the emergency room and doctors scramble to find beds. “While we are doing our utmost, we are no longer able to provide the standard of care to each and every patient who needs our help,” said the hospital’s medical staff in a letter to the community in mid-September.
When the pandemic first slammed hospitals last year, many institutions found no alternative to postponing nonessential procedures. “We weren’t sure what we were really going to face,” said Dr. Matthias Merkel, senior associate chief medical officer for capacity management and patient flow at Oregon Health & Science University, the state’s academic medical center in Portland. “We pre-emptively stopped elective surgeries and emptied out the hospitals.”
In this latest round, hospitals and doctors have been more willing to continue doing procedures like colonoscopies for some patients if they can. “We want to continue to do as much as we can in all areas,” Dr. Merkel said.
His hospital, he added, hadn’t “yet recovered from the backlog we created” from delaying treatments earlier in the pandemic.
Even so, some patients with serious conditions are living in a precarious limbo. Paul McAlvain, 41, had waited months to get a surgery opening at OHSU to repair a leaking heart valve.
“They kept saying how bad I was and how they needed to get me in right away,” said Mr. McAlvain, a helicopter pilot for Life Flight Network, which ferries critically ill patients to medical centers. He had developed an irregular heart beat from his condition, and was finally scheduled for surgery Sept. 1.
But the spike in cases this summer further postponed his operation. “I had made work arrangements, life arrangements, got mentally ready,” Mr. McAlvain said. The surgery took place on Sept. 8.
Dr. Merkel acknowledged the toll that uncertainty can take on patients. “It might medically make no difference, but emotionally it could have a huge impact,” he said.
Some hospital officials say they have been assessing the effects of delayed care caused by the shutting down of elective procedures earlier in the pandemic. “It was very clear that many of these folks had decompensated or were more acutely ill than they would have otherwise been,” said Dr. Bryan Alsip, the chief medical officer at University Health in San Antonio, Texas.
Though his hospital is confronting yet another wave of Covid cases, Dr. Alsip said, it is still scheduling surgeries that do not require an overnight hospital stay.
In North Carolina, the pent-up demand for care has added a new layer of strain now that Delta has pushed some hospitals to their limits.
“From an overall community perspective, this time, compared to March and April, our E.D. volumes are at all-time highs,” referring to the hospital emergency department, said Dr. John Mann, a surgeon who oversees surgical and specialty care services for Novant Health, a large hospital group based in North Carolina. “It’s every illness imaginable. They’re all coming in for care.”
This year, unlike last, Novant is not making any universal decisions about how to handle cases that have been deemed non-urgent. While rising Covid cases forced it to stop elective procedures at its Rowan Medical Center for weeks, orthopedic and colorectal surgeries are continuing at Novant Health Clemmons Medical Center, a much smaller hospital. “We’re doing it facility by facility,” Dr. Mann said.
While hospitals have generally been better able to predict what resources they will need as the pandemic ebbs and flows, making them less likely to halt elective procedures, more have started to do so recently, said David Jarrard, a hospital consultant.
Hospitals are also still struggling with a severe shortage of nurses, but are less worried about running out of critical equipment like N95 masks.
“We all learned a tremendous amount over the last year and a half,” said Dr. David Hoyt, the executive director for the American College of Surgeons, which released guidelines to help surgeons adjust their caseloads rather than cancel non-urgent procedures.
Government officials have also been much less likely to call for an absolute stop, which occurred frequently in the early months of the pandemic. Amber McGraw Walsh, a lawyer with McGuireWoods who has closely monitored Covid restrictions, said state, local and even federal agencies do not have the appetite this time around to prohibit elective surgeries.
Now, hospitals are much more likely to work with public health officials and their competitors to better manage the higher demands for care, making decisions as a group rather than individually. “You do see a lot of local hospital associations coming together, making their own rules of the road,” she said.
Still, the last few weeks have tested nurses and hospital staffs like no other period of the pandemic.
As an anesthesiologist and intensivist working in critical care, Dr. Merkel described the last two weeks as the most difficult of his career.
Despite widespread vaccine availability, Dr. Merkel and his colleagues are now caring for younger patients, those under 50, who are dying of complications from Covid, including organ failure and acute respiratory distress syndrome. Many were transferred from other hospitals because they were so ill.
“It is hard to see a patient’s life ending from something where we could have had a preventive intervention,” Dr. Merkel said.