VOLUME 33, ISSUE 1

COVID-19 (COVID) is caused by infection with a new coronavirus (called SARS-CoV-2). COVID-19 has had a marked impact on anesthesiology groups that has varied significantly both between states and within states. My sense is that Texas anesthesiologists have done well compared to our colleagues elsewhere, but that this assessment may not hold up even when looking at two groups within the same small community. Much like the twisters which visit West Texas on a regular basis, COVID may impact one site quite differently from another despite being “just across town.” Such was the case in Abilene.

Towards the middle of March my group decided to meet in person for a COVID response strategy session. We are employed through a 501(a) entity (Hendrick Anesthesia Network) with Hendrick Medical Center being the hospital partner ensuring the fiscal viability of the group. In the 12+ years I have been with the group, clinical decisions have been the sole domain of the physicians in the group while logistical and manpower issues have been made cooperatively.

This has created an incredibly efficient and competent anesthesiology department and laid the groundwork for us to successfully navigate the COVID crisis.

Our initial March meeting took place prior to Governor Abbott’s edict restricting elective surgery, however, we were already preparing for at least some reduction in elective volume.

Our most senior partner, Stephen Lowry, is currently Chief of Staff for the hospital and was in the process of creating a surgical section committee which would have responsibility for determining what could and could not be done operatively, based on daily hospital capacity. As we anticipated some reduction in anesthetic needs during the crisis, during that first meeting we established a dedicated COVID airway team.

Reports coming from Italy and China at the time indicated a much higher mortality rate than we now know COVID to possess. Because of this and the great deal of unknowns about mechanism of transmission, impact of inoculating viral load on outcome, and symptomatology of the disease, we elected to create isolated teams of 3 that would stay in house and not interact with the rest of the group for a week at a time. We paired a nurse anesthetist with a physician for each shift, placing the CRNA outside the negative pressure intubation rooms and manning a dedicated airway cart we had placed at 3 COVID airway sites in the emergency department, the operating rooms (OR), and the COVID floor. Our initial effort placed the lowest risk physicians and CRNAs on these teams and specifically excluded those individuals we felt were at the highest risk for morbidity if they contracted the virus. While we never had a significant threat to our hospital capacity (indeed we maxed out with a “persons under investigation” census of around 20 in mid-April for a 350-bed hospital) there was significant emotional and interpersonal stress that our group worked through during this time period. It is worth considering that the fear of the unknown, exacerbated by idleness, is perhaps a greater threat to community and collegiality than is the actual threat to life, so long as physicians are consumed with work and purpose in response to that threat – just my observation.

Our main OR was very quiet as April began. Prior to COVID, our typical day included 13-14 routine case ORs, 1-2 cardiovascular rooms per day plus an additional 5 anesthetizing locations at a nearby ambulatory surgery center (ASC). For most of March we were running between 3-5 rooms at our main OR. Our CV volume was minimally altered with cardiac procedures remaining busy. Our ASC remained closed through April. At no point were we furloughed, subject to salary reduction or told that these options were a near term consideration. We DID, however, implement a rotating vacation calendar for our group in solidarity with the hospital administration who were all taking 1-2 days of PTO per week.

As the initial COVID surge receded and Governor Abbott lifted the prohibition on elective cases, we resumed almost completely normal volume within just a few weeks. While we maintained some duties with managing COVID airways, we also implemented new pre-op COVID testing requirements, and modified our personal protective equipment use and routine airway management strategies. However, our day-to-day case load and operational function was more or less normal by the end of May.

All of this lies in contrast to the smaller hospital across town that was owned by an outside entity (Community Health Systems from Tennessee). That facility was staffed by an independent third-party service provider (Emergenc) and had several of their anesthesiologists and nurse anesthetists furloughed early in April. Several of these never returned and the hospital’s traditional medical direction model disintegrated into a supervision model with a 1:8 ratio. Additionally, that hospital, which had rebuffed a merger offer late in 2019 came back to the negotiating table and accepted a new offer from our system which just was finalized in mid-October.

While it would be foolish to imply that the stark difference in success negotiating troubled COVID seas can be attributed to just one or two factors, I think in this case there were two very important characteristics of the respective anesthesiology groups that led to the stark differences in outcome. First, when physicians, rather than corporate entities, are in charge of making clinical and patient safety decisions, there may be a better chance that quality standards and guidelines will be maintained, despite economic pressure. Second, when decisions are made by members of a community rather than a geographically distant third party, the community physicians and health care team are more invested in ensuring that quality standards and guidelines will be maintained, despite economic pressure.

Certainly, the COVID narrative is not yet finished. We are currently experiencing our third surge of COVID cases in Abilene and, once again, may have to curtail inpatient elective surgeries on a day-to-day basis, depending on the hospital census. However, following the merger, that maximum census is now expanded with our hospital system having two hospitals sharing resources and maximizing capacity efficiency.

My group is in the process of recruiting new physicians to accommodate this expansion rather than contracting our available services as so many groups across the country are doing. We anticipate receiving vaccinations dedicated to health care workers soon and, while this certainly won’t be the end of COVID, we are optimistic that it represents the beginning of the end of severe COVID related morbidity and mortality and the start of smoother seas ahead.