Intensive care physicians and nurses share their concerns as they brace for an influx of patients that threatens to overwhelm hospitals due to the resurgence of the coronavirus and the flu.
When Canadians successfully flattened epidemic curves during the summer, the goal was to prevent hospitals and intensive care units from facing a crush of too many patients with COVID-19 all at once. Health officials wanted to avoid what happened in hospitals in New York City, where refrigerated trailers were used as temporary morgues.
But the recent surge of new coronavirus cases in all provinces beyond Atlantic Canada has already thwarted surgery plans and led to the cancellation of surgeries such as hip replacements at one hospital in Toronto and postponements in Edmonton.
Dr. Bram Rochwerg, an associate professor at McMaster University and critical care lead at the Juravinski Hospital in Hamilton, anticipates a surge of patients with COVID-19, and he worries they won’t be able to accommodate them all as more surgeries resume.
Unlike in the spring, beds and crucial staffing need to be reserved for medical and surgery patients, too. Traditionally, autumn in hospitals means scrambling for health-care workers such as nurses and respiratory therapists to backfill those sick with the cold and flu or who need to stay home to care for sick children.
“We’re all worried about it,” Rochwerg said. “You see the provincial [COVID-19] numbers creep up day by day. We see that critical care numbers [of ICU patients] creep up.”
ICU nurse Patty Tamlin prepares to work with COVID-19 patients in Toronto. Cardiac arrests in hospital are now treated as protected code blues requiring full PPE, which can be fatiguing to wear. (Byron Piedad)
The challenge, Rochwerg said, is to find a balance between adding restrictions to protect vulnerable populations such as residents in long-term care homes while preserving crucial aspects of society.
Lessons learned
Rochwerg also pointed to several lessons physicians worldwide have learned to help take better care of patients critically ill with COVID-19 during the resurgence.
“We should treat them like we would any other patient,” he said. “Sometimes, you just need [to insert] a breathing tube.”
When patients are on a ventilator, it takes the skilled hands of four to six hospital staff, including a respiratory therapist who regularly checks the breathing set up and tubing to ensure the airway is protected, as well as nurses to safely turn or “prone” them onto the stomach to improve ventilation.
There is growing concern that Ontario hospitals and ICUs, especially in Ottawa and Toronto, may not have enough capacity for COVID-19 patients after weeks of rising infections. 1:55
The importance of getting patients up and out of bed, including those on ventilators when possible, as well as excellent nursing care and other day-to-day supportive care can’t be minimized.
“Supportive care is not the sexy part of it, but it’s so crucial,” Rochwerg said.
It gives patients’ bodies time to heal themselves, he said.
Fear of flood of sick patients
Patty Tamlin, registered nurse working in critical care at a hospital in Toronto’s east end, said she’s also concerned about the coming cold-and-flu season.
“One of the biggest concerns is you may be overrun by patients,” Tamlin said.
A nurse tends to a patient suspected of having COVID-19 in the ICU at North York General Hospital in Toronto in May. It can take up to six staff to safely turn a patient on a ventilator onto their stomach. (Evan Mitsui/CBC)
Her message to Canadians? “Tell everyone to get their flu shot.”
In the spring, the Ontario government created more beds for patients needing long-term ventilated care at a rehabilitation hospital. Even if administrators find more space for more beds, adding temp agency nurses can only go so far, she said.
“It’s going to be a long time,” Tamlin said. “It’s fatiguing … to have this constantly on our head all the time about COVID on top of our regular work.”
Experience, though, has helped ICU staff to prepare for a resurgence of COVID-19 patients.
“The more you do something, the more comfortable you are with going in and out of a room,” for example, to perform CPR during a “protected code blue” for cardiac arrest when wearing full personal protective equipment, which can be exhausting. The masks, gowns and gloves need to be donned and removed carefully to avoid health-care workers contaminating themselves.
Dr. Eddy Fan, medical director of the Extracorporeal Life Support (ECLS) program at Toronto’s University Health Network, said the increase in COVID-19 cases so far is “manageable.”
Extracorporeal membrane oxygenation (ECMO) is like an artificial heart and lung machine to support the sickest patients. People with COVID-19 who were intubated at hospitals across Ontario and didn’t improve with conventional therapy were transported to Toronto General for ECMO.
Still, Fan said, “We’re going to need to brace ourselves for another potential flood of very sick patients.”
During the spring, patients were transferred to Toronto General, but family members could not visit. Fan said cutting off patients from their relatives harmed morale not only among loved ones, but it pained people working in the hospital, too.
Dr. Eddy Fan is medical director of the Extracorporeal Life Support program and a scientist at Toronto General Hospital Research Institute. Fan said doctors now recognize how similar COVID-19 is to other viral infections, as well as some important differences. (Submitted by Eddie Fan)
But influenza season also typically brings patients with lung failure who may need ECMO.
“Their families ask questions like ‘they’re dying of the flu?'” Fan said. “COVID is no different as a viral infection. We see even young patients come with very severe lung failure requiring ECMO.”
During Toronto’s first wave of COVID-19, the team successfully treated a 22-year-old with ECMO.
While respiratory failure from COVID-19 can resemble that of the flu, doctors say the scale is much larger.
Dr. Gregory Haljan, head of Surrey Memorial Hospital’s critical care department in British Columbia, said influenza has vaccines and medical treatments to shorten symptoms and improve death rates. COVID-19 doesn’t, aside from corticosteroids for severe cases.
When Haljan and his co-authors across the Lower Mainland looked at 117 people with COVID-19 who were admitted to ICU between Feb. 20 and April 17, they found the mortality rateranged from one in six to one in 10.
In comparison, the first studies from China and Italy showed mortality rates as high as one in two or one in three.
A clinician demonstrates how to use a device applied to the finger to monitor oxygen levels over a video conference. Virtual hospitals to keep patients safe at home help prevent hospitals from being overwhelmed by COVID-19 cases. (Women’s College Hospital)
Safety ‘our primary focus’
Haljan credited having time to prepare, Dr. Bonnie Henry’s “outstanding” leadership as the provincial health officer, the support of British Columbians, hard work and luck.
“We never got overwhelmed,” he said.
To prevent being overwhelmed, Haljan said the hospital and its health region focused on basics, including:
Engaging patients in the community and long-term care homes through a virtual hospital to keep patients safe at home.
Improving communication with centralized repositories of information to avoid mixed messages.
Adapting as the science changes.
“It can be a challenge in that things change very, very slowly because safety is our primary focus,” said Haljan, who works at one of the hospitals caring for among the highest volume of patients in the emergency department, according to the Canadian Institute for Health Information.
“Research is how we keep change safe.”
Haljan said that includes research not only on vaccines and drugs but also measuring patterns and assessing them in areas such as delivering health services.
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
