A mobile hospital set up in April in Montreal. Months later, doctors say they are more nimble and prepared in their responses to COVID outbreaks.
Doctors are no longer as quick to connect people to mechanical breathing machines as they gain experience dealing with COVID-19.
One evening in mid-March, as a weird and eerie illness was making itself frighteningly real in northern Italy and New York City, Ontario hospitals were instructed to commence shutting down “non-emergent” procedures, in anticipation of a COVID-19 surge.
Dr. Jonathan Irish is a cancer surgeon. He had five cancer operations scheduled the next day at Toronto’s Princess Margaret Cancer Centre. Two of his patients had travelled by plane to get there. All five operations were cancelled.
By end of May, the directive was lifted. In a study published this week in Canada’s top medical journal, Irish and his co-authors estimate it will now take a staggering 84 weeks to clear that surgical backlog owing to COVID-19. Roughly three-and-a-half months to get through “time-sensitive” cases like cancers and coronary artery bypass grafts, and over a year-and-a-half to clear all surgeries, including joint replacements and cataract and hernia repairs — an estimated 148,364 surgeries in total.
In addition to the sheer magnitude of the backlog, “obviously, the impact on our patients has been a profound one,” Irish says.
As Canada prepares for the great unknown, a predicted resurgence of COVID-19 in the coming weeks and months, that is one lesson that can be taken from the first ripple. Flip the emergency switch, and suppress, suppress the virus, and other dominoes can topple.
The surgical ramp-downs were probably appropriate, Irish says, given what little grasp anyone had of this strange new virus. Across Canada, thousands of hospital beds — nearly 10,000 in Ontario alone, including critical care beds with ventilators — were freed in preparation for a feared flash-flood of critically sick COVID-infected people. It was a mass casualty response, Irish says, “as if 100 airplanes had crashed.”
We can’t continue to function as we did in March
That’s a response now off the table. “We understand now that within 24 to 48 hours, we can be responsive — we proved that in March when we created capacity for a lot of patients. It can be reactive to local testing, and it can be regional.” An uptick of cases in Ottawa shouldn’t shutdown OR’s in Thunder Bay or Windsor or across the entire system, says Irish, who is working with Ontario’s health ministry on a plan to keep operating on people who don’t have the virus, in the background of a COVID-19 pandemic.
“Look, I have kids. I have colleagues. We are all anxious about the situation,” Irish says. But where we are now is different from where we were in March. Doctors know better how to treat this once-in-a-century biological entity. “We know better how to identify the disease and contact trace. We can’t continue to function as we did in March, if there were a second wave,” Irish says.
No one can say with any certainty if, when, or how big a second wave will be. Canada’s Chief Public Health Officer Dr. Theresa Tam says provinces and territories should prepare for a “fall peak,” a resurgence, a rebound that could be several-fold worse than their previous experience. There were no actual numbers on a graphic illustrating that peak in the slides released in the latest modelling. “The national epidemic curve could be highly variable,” the Public Health Agency of Canada said in response to a query from the National Post , “and while we are hoping for the ‘slow burn’ pattern, public health authorities are preparing for a potentially high fall peak” followed by other waves “that may exceed their current capacity to respond optimally.”
If systems weren’t overwhelmed in March, and we’re better prepared than we were before, why would capacity be exceeded next time? Tam speculated that something could happen to the SARS-CoV-2 virus that causes COVID-19. It isn’t behaving like influenza. It hasn’t shown any seasonal pattern so far; it continued circulating throughout summer. It’s possible the virus could demonstrate “a certain type of acceleration under certain conditions,” Tam said.
Other countries — Italy, Spain, France, Germany, India, Brazil, Argentina, Russia and South Korea — are grappling with resurgences. U.K.’s Prime Minister Boris Johnson put areas of Northern England under stay-at-home instructions last month. French president Emmanuel Macron made masking mandatory in busy outdoor spaces of Paris in response to flare-ups. White House coronavirus adviser Dr. Anthony Fauci this week pleaded with Americans to behave — wear masks, distance, avoid crowds and other “simple things” — over the Labor Day holiday weekend. Take the pressure off the virus, the World Health Organization’s Mike Ryan has said, and it will boomerang back.
Dial in colder weather, which means more time indoors, school reopenings and a collision with seasonal flu “and we have the makings of a really difficult time ahead,” says emergency physician Dr. Alan Drummond. So what can we learn from our first go around with COVID-19 to prepare for the next?
In the beginning, there was mixed messaging, says Drummond, a lack of clarity, a “desultory, lethargic and reactive and plodding response.” The messaging from federal health officials was a no-drama, “Canada is at low risk” mantra. Except “we could see what was potentially coming and nothing was happening,” Drummond, of the Canadian Association of Emergency Physicians wrote in an email back in May.
The onslaught never happened. ER visits across the country fell sharply. People feared either contracting or transmitting the virus in packed waiting rooms. “What’s happened to the heart attacks,” Drummond and his colleagues wondered, the strokes? The people with appendicitis-like pains? People were delaying seeking care, “and we partly own that,” Drummond said this week. “We should have done a better job letting the public know our departments are safe, we’ve adapted, we’re maintaining physical distancing and it’s safe to come to the emergency department.”
He and others worry hospitals are approaching overload again. The fear at the start of the pandemic was surge capacity, because hospitals had none, and only through drastic measures did hospitals get the capacity needed to absorb the anticipated deluge of large numbers of sick people. As provinces begin clearing the backlogs the numbers are creeping back up again. Safe occupancy rates are 85 per cent, but routinely exceed 100 per cent. “No hospital in this country has seen an occupancy rate of 85 per cent in the last 20 years, until this spring,” Drummond says. “If we allow that number to creep back up again, the resilience of our system is going to be impaired.”
The days of overflowing ER waiting rooms also have to end, he says. Emergency rooms shouldn’t be the nidus of hospital-acquired infections, “and part of the thing we can do as emergency physicians is enhance things like virtual care, more effective telephone triage to prevent people having to crowd like herds of cattle in our waiting room for assessments.”
What other lessons have we learned? The least advantaged, the frail elderly, the homeless, migrants, Black and Indigenous populations have borne a disproportionate burden of the pandemic. Underfunded shelters and long-term care homes “illustrate our moral failures to protect our society’s most vulnerable from being even further disadvantaged during a pandemic,” ethicists Maxwell Smith and Ross Upshur write in the Journal of Bioethical Inquiry.
We either have collective amnesia or collective narcolepsy
Yes, the virus was entirely new to us. “But there were many things we could have done prior to the pandemic, and which we knew were important, that would have averted much of the pandemic’s impact on Canadians,” including bigger investments in public health and primary care, says Smith, a professor at Western University and part of a WHO ethics working group for COVID-19. Whether SARS-1 or Ebola or MERS, every outbreak is a “wake-up” call that’s ignored time and again. “We either have collective amnesia or collective narcolepsy,” Smith and Upshur write.
The first wave of the pandemic took more than 9,100 lives; 82 per cent of COVID deaths have been linked to long-term care homes. Military sent into nursing homes in Ontario and Quebec found residents unwashed, dehydrated, underfed and, in some cases, abandoned. In Ontario, the Canadian Armed Forces was deployed to seven long-term care homes and after the military took its leave in July, the CAF reported “dramatic improvements.” But a July survey of 150 long-term care staff by the Ontario Health Coalition seems starkly different: 63 per cent reported staffing levels are worse than when COVID-19 first hit.
Nine months out, scientists still don’t have a complete understanding of who faces the greatest coronavirus risk, beyond known risk factors like age, biological sex (men’s cases tend to be more serious), obesity and high blood pressure. Dr. James Downar, a specialist in critical care and palliative care at the University of Ottawa, says it’s possible that the people who got very sick in the first round were the most susceptible for reasons we don’t fully understand, and that future waves will be far less impactful. “We just don’t know.”
But scientists are beginning to untangle COVID’s secrets. It can kill by causing hyper inflammation, or messing with the body’s coagulation system, scattering jelly-like microclots throughout the body. Doctors are now better at treating severe cases of COVID-19. They aren’t rushing to connect people to mechanical breathing machines. They now realize people can have low blood oxygen volumes without the usual accompanying breathlessness. People can be rolled onto their stomachs, into the prone position, to relieve pressure on lungs and assist breathing. The COVID-19 death rate in Canadian ICU’s has been starkly lower than what was seen in Italy or China. This week, a flurry of studies provided more evidence that common, inexpensive steroids can cut deaths in the sickest people. “We don’t have the magic bullet yet, but even with basic care, we’re better,” Downar says.
We now know symptoms go beyond fever, cough, shortness of breath, to include a dozen or more, like headache and loss of taste or smell, or fuzzy thinking, and that 20 to 40 per cent of people can have none or only mild symptoms. But for Downar, “the single, solitary success story of the first wave was the effectiveness of public health measures — travel restrictions, social distancing, mask-wearing. Enough people were compliant.”
But for how long? Infectious diseases physician Dr. Andrew Morris has seen a blip in sexually transmitted infections. What rising STI’s tell Morris is that “a certain segment of the population has abandoned all concepts of COVID precautions.” Quebec officials this week warned karaoke can be “dangerous” following an outbreak of COVID-19 linked to karaoke night at a Quebec City bar.
The median age of those infected is falling, and younger people are less likely to be hospitalized with COVID-19. But it’s a double-edge sword, says Morris. Younger people tend to be asymptomatic, or not very sick at all, so it may get us somewhat closer to some concept of herd immunity, Morris says. “The problem is we cannot isolate young people from vulnerable people. It’s just impossible to do that. If you have a large number of people in their 40s or 50s getting infected, you’re going to see substantial excess deaths. Eventually, you lose out on the numbers game.”
But it’s also true that the majority of people do recover, even in the highest risk groups. “COVID is not a death sentence, by any stretch of the imagination,” Downar says.
To dodge that second wave would be “delightful,” Drummond says. Just over one per cent of Canadians are thought to have antibodies to the virus, meaning that the vast majority has no immunity. Procurement Minister Anita Anand said this week Canada could start getting a vaccine “as early as the first quarter of 2021.”
Morris says governments need to massively expand testing capacity. Our surveillance system, he says, “is brutal. The one thing we should have learned but we haven’t is that you can’t rely on symptomatic testing alone to control an outbreak because there are just way too may people who don’t have symptoms.” What’s needed is waste-water testing and pooled saliva testing in classes that allows 10, 20, 30 kids to be sampled at one time. If the sample comes back positive, every child is tested individually. You sample weekly “as a way of being reassured schools are not rampant with viral disease,” Morris says. “Anywhere from JK to fourth-year university.”
Flu shots need to be pushed to get the numbers vaccinated up and doctors need clear directions from public health how to respond to concurrent flu and COVID, Drummond says. “We don’t want to be in the situation where we were last spring, making things up on the fly.”
What annoys Drummond, a family doctor in Perth, Ont., are the naysayers, the people deeming COVID a hoax, a “clinical non-entity,” including physicians “gleefully” espousing conspiracy theories.
“Our view has always been, look, better to be over-prepared than ill-prepared. If, with the passage of time and judgement of history, it’s deemed we overreacted, fine. I would far prefer that than to not have reacted appropriately at all. So we’ll see.”
Copyright Postmedia Network Inc., 2020