Maggie Hilty spent months seeking out a treatment for the chronic ear infections that were leaving her 10-month-old son, Noah Katz, in pain and impeding his ability to hear.

Five rounds of antibiotics and an intramuscular injection did nothing to relieve the underlying problem, which Hilty learned was an excessive buildup of fluid in her son’s ears. Doctors finally determined that tubes would need to be surgically inserted into Noah’s eardrums to allow the fluid to drain. The surgery was scheduled for March 23.

But five days before the surgery was set to take place, Oregon Gov. Kate Brown ordered that health care providers cease all non-emergency procedures to preserve protective equipment for medical personnel treating coronavirus patients. Randall Children’s Hospital called that same day to inform Hilty that her son’s surgery would have to be postponed.

“I think it’s probably the right decision,” Hilty said. “I know that Oregon has been proactive in the fight against COVID and I think postponing things, like this, is going to help in the long run, though it hurts my heart personally for my son and what he’s going through.”

Doctors in Oregon have been forced to postpone thousands of surgeries, tests and preventative care procedures since Brown issued her executive order on March 18. The order will remain in effect for 90 days, unless it is extended or terminated by Brown’s office.

Charles Boyle, a spokesman for Brown’s office, said a non-emergency procedure referred to any procedure that could be postponed for three months without putting the patient at risk of irreversible harm. According to Boyle, it is up to individual doctors to decide whether a procedure could be safely delayed for three months.

In practice, that has meant that the majority of procedures have been postponed. A spokesman for Providence Health & Services said that the group’s surgical caseload had been reduced by 80%. Oregon Health & Science University has delayed approximately 1,500 surgeries. The Portland Clinic, a private, multi-specialty medical group, has gone from seeing 5,000 patients a week to almost exclusively caring for patients remotely through telemedicine.

But while many procedures can be delayed without fear of unintended consequences, other cases aren’t as simple.

“It can be hard to define what’s urgent or elective,” said Kevin Woolf, a cardiologist at Hillsboro Cardiology. “There are a lot of gray areas where it’s hard to sort of know -- the procedure is sort of elective, but the patient probably could benefit from it. … The Governor is doing the right thing in terms of delaying elective procedures, but there will be some collateral damage here, undoubtedly.”

TOUGH CALLS

Woolf said that his office had to make some tough calls when it came to how to manage patients with certain heart conditions. He has asked some patients to wait on valve replacements because those conditions can be managed in the short-term and he doesn’t want to expose elderly patients to hospital settings during the COVID-19 outbreak, if possible. He is also using medication to treat a higher percentage of patients with heart blockages.

“The longer you go, the more patients are going to get into trouble,” Woolf said. “The good thing about heart disease is that, in general, stable outpatients tend to progress in sort of a linear manner. So, if people are getting worse, they’re going to have worse symptoms. They’re going to bring that to our attention. I think for the most part, we’ll be OK by making clever, careful choices for these patients and helping to guide them on an individual basis.”

Ken Azarow, the surgeon-in-chief for OHSU and Doernbecher Children’s Hospital, said that the hospital had left it up to individual doctors and surgeons to determine whether a patient needed immediate care. Every surgery that is scheduled is reviewed by a multidisciplinary committee before it can go forward.

Patients who have had their surgeries postponed are continuing to communicate with their doctors via telemedicine, which allows physicians to consult with patients through video conferencing or other remote means. The use of telemedicine has increased exponentially amid the coronavirus pandemic and Azarow believes that it will remain commonplace even after the crisis subsidies. Through those visits, doctors are able to continue to monitor the health of their patients and ensure that their symptoms haven’t changed.

“If a specific procedure can be put off or delayed without harm to the patient for a period of six, eight or 10 weeks, then we will delay that procedure,” Azarow said. “If we think a patient is going to be significantly harmed by delaying a procedure, then we go ahead with the procedure and deem it as emergent or urgent. We have been delaying as much as we can while making sure we’re not causing any patients undue harm by asking them to wait.”

PATIENTS LEFT WAITING

But some Oregonians are still experiencing pain and uncertainty as they wait to receive care.

Among the procedures that have been canceled in Oregon are knee surgeries and dental care, where patients generally experience some level of pain until the problem is resolved, preventative care, such as colonoscopies, which are used to screen for cancer and other issues, but can be delayed in the short-term for some patients and diagnostic exams for patients that are dealing with unresolved symptoms.

Elizabeth Kenworthy started experiencing intense body aches and fatigue last July that forced her to cut back on her work as a BIM technician doing 3D modeling for structural engineers. She is currently only able to work about 10 hours a month.

Doctors have not yet been able to diagnose Kenworthy, but she believes she may be suffering from fibromyalgia, a disorder that causes musculoskeletal pain and fatigue. She had an appointment with a rheumatologist on March 23 where she hoped she would finally be able to get a diagnosis. But that appointment was canceled.

Without a diagnosis, Kenworthy has been unable to receive long-term disability insurance. As medical bills piled up, she said that she and her husband were forced to sell their house and move in with his mother in Oak Grove.

“I made that appointment in December,” Kenworthy said. “It felt like a long time to wait, three months, and then now, I don’t know when I am going to see somebody. We literally don’t know where this virus is right now. It could be July, it could be August, it could be later than that. That whole time, I can’t claim any assistance. I also can’t claim unemployment because I have a job.”

Dennis Cote, 35, chipped both his front teeth in a scooter accident while he was headed to his job as a barista at the Stumptown Coffee outpost at the Portland International Airport on March 15.

In the days before Brown’s order, many major hospital systems were already cutting back on elective surgeries. Cote said he went to both the Portland Veterans Affairs Medical Center and OHSU’s Russell Street Dental Clinic, but neither facility was able to treat him. He was finally able to get temporary crowns put in at an emergency dental facility, but had to borrow money from a friend to cover the $3,000 out of pocket cost. He expects to wait until at least June to get permanent crowns put in.

In the meantime, Cote said he had been taking pain killers to deal with throbbing toothaches and has been forced to avoid hard or sticky foods that could dislodge the temporary crowns. He said he had lost 12 pounds.

“I think it’s something I can manage for the time being,” Cote said. “I hope to get it actually fixed maybe in like June. I think we all have to make a certain level of sacrifice for patients whose actual lives are in real danger and also for the staff, the nurses, the doctors and other proprietors that also have to protect themselves.”

WHEN CARE IS NEEDED

But Robert Sandmeier, an orthopedic surgeon and director of surgery at the Portland Clinic’s Surgery Center, said he worried that some patients would seek treatment in emergency rooms if they were unable to receive care from their providers for an extended period of time. The Portland Clinic’s Surgery Center, which conducts approximately 10,000 surgeries a year, has carried out just eight surgeries since Brown’s order went into effect.

“I worry about the patients that we usually could treat away from the hospital, but now they can’t get something done,” Sandmeier said. “Let’s say, you have a kidney stone. A kidney stone is something that really hurts. You can’t say, ‘Hey, I’ll wait.’ Normally, we could see that, get their pain under control and get them set up to go to the Surgery Center within the next few days. But now they might have to go to the emergency room where they’re surrounded by people, they could be exposed to COVID and they’re really using hospital resources there.”

On the flip side, Woolf has already seen patients, including those experiencing heart attacks, waiting longer than usual to go to the emergency room out of fear that they might contract COVID-19.

“If you are having a heart attack and you wait longer to come in, the result of that heart attack is going to be more severe,” Woolf said. “We can definitely take care of urgent and emergent patients and we want them to come in when it’s appropriate. Obviously, a heart attack would be a situation where it is, but their fear of exposure to COVID is keeping them at home longer.”

According to Brown’s order, all elective and non-urgent procedures in settings that utilize personal protective equipment must be postponed until at least June 15.

At OHSU, Azarow said that doctors are prepared to deal with coronavirus cases until a vaccine is available, which could take well over a year. But he also said that he was hopeful that hospitals and physicians would be given the opportunity to broaden their definitions of what constitutes urgent care after Oregon gets past its peak of coronavirus cases. University of Washington researchers predict that Oregon coronavirus cases could reach their peak in two weeks.

“Once we get over the peak and we have a firm idea of what the requirement will be for our COVID patients, we’ll be able to maybe broaden our definition as to what is maybe semi-elective and elective as opposed to urgent or emergent,” Azarow said. “When we eventually go back to doing elective surgery, we’ll have a group of patients that need to be at the front of the line because we’re kind of pressing the envelope a little bit."

For now, Hilty is continuing to wait on her son’s ear procedure.

There are days when the fluid in Noah’s ears dissipates enough that he is able to interact normally with his family. On other days, Hilty will turn on “Sesame Street” after breakfast and Noah won’t even react. Suddenly, she’ll realize that he hasn’t heard a single thing that she has said to him all day.

Noah’s pediatrician has warned Hilty and her husband, Jeff Katz, that Noah’s speech could be delayed because of his hearing trouble. But Hilty takes solace in knowing that eventually, after the tubes are inserted in his eardrums, Noah will be able to catch up to the other kids his age.

“If Noah’s surgery being put on hold means the COVID virus stops spreading and that people’s lives are saved, then I absolutely think it was the right decision to postpone,” Hilty said.

-- Jamie Goldberg | jgoldberg@oregonian.com | @jamiebgoldberg

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