Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?
Lakelands Family Health Team, based in Denbigh, Ont., in Addington Highlands, has been forced to close its doors after a health care worker at their centre was diagnosed with COVID-19.
It’s currently unclear which other health care facility has had a health care professional diagnosed with COVID-19, but Dr. Kieran Moore, medical officer of health of KFL&A Public Health, says in total, of the three newest cases identified in the region on Wednesday, at least two of those were health care workers.
“What is a bit disconcerting, and I want to be upfront,” said Moore, “is that the last couple of tests have come back in health care workers who are working in primary care clinics in our area, so, two different family practices in our region.”
In a Facebook post published Tuesday, Lakelands Family Health Team said they were closing indefinitely, until KFL&A Public Health gives them the green light to open once again.
Frontline health-care workers beginning to fall ill with COVID-19
A spokesperson for the health centre assured Global News that public health officials were in the process of contacting close-contacts and telling them to quarantine for 14 days.
The health centre currently serves about 4,000 patients in the region. Moore said the decision to close the clinic was made in “and abundance of caution.” He added that this particular clinic is very well-run, and that staff were taking the appropriate precautions in light of COVID-19 concerns.
KFL&A Public Health said they would not be identifying the other clinic where health care workers contracted the disease but did say the second clinic was closed.
“We cannot identify or confirm the clinics where the health care workers work. This would be identifiable information.”
Nevertheless, Verona Medical Clinic, in Verona, Ont., posted to Facebook Wednesday afternoon, saying that they would be closing their doors due to a “positive case of COVID-19.” Global News has not been able to reach anyone from the clinic to confirm whether the case was contracted by a health care professional.
Moore said it was expected that some health care professionals would contract the disease, and that public health was prepared for this reality.
“So we’re working diligently with them to ascertain if they had any travel history or how they could have contracted COVID-19. We’re also going to be contacting any of their patients that they may have had interactions with.”
Moore said that the health care professionals who tested positive were already practicing a lot of medical care over the phone.
“They’ve been phoning their patients or having virtual care of their patients. So they’ve had very limited direct patient contact in the last several days. They were being prudent and responsible in this new COVID-19 environment. The number of patient contacts will be exceptionally low, but we will be contacting those individuals today and working diligently with these practices.”
Lakeland Family Health Team said although their offices are closed, their team will still be trying to help their thousands of patients over the phone and online.
“Even though our building is closed and our staff are isolating at home, we are trying to provide virtual care to our patients from our homes via phone or OTN,” a statement from the health centre read.
On Wednesday, KFL&A Public Health confirmed that there were 14 positive cases of the new coronavirus in their catchment area, which includes the Addington Highlands.
Moore said despite limited tests in the region, KFL&A has been less stringent with testing restrictions when it came to health care workers.
“We have always been very permissive of testing health care workers who come down with a fever and or a cough and or increasing shortness of breath. It was prudent that at that clinic (Lakelands Family Health Team) they did test a health care worker with those symptoms, and it has turned positive.”
In a board of health meeting on Wednesday, Moore said having two medical practices close for 14 days will have a significant impact on thousands of patients.
Moore also mentioned there was a possibility of calling for an “emergency declaration” if it was found that the health officials had contracted COVID-19 through community transmission.
Other Canadian cities, including Ottawa, have already confirmed community transmission of COVID-19 — cases involving no known link to travel or previously confirmed cases.
KFL&A Public Health says they are still investigating how the two health care workers contracted the virus, and that a decision an emergency declaration has yet to be made.
Answering your questions about coronavirus
Questions about COVID-19? Here are some things you need to know:
Health officials caution against all international travel. Returning travellers are asked to self-isolate for 14 days in case they develop symptoms and to prevent spreading the virus to others.
Symptoms can include fever, cough and difficulty breathing — very similar to a cold or flu. Some people can develop a more severe illness. People most at risk of this include older adults and people with severe chronic medical conditions like heart, lung or kidney disease. If you develop symptoms, contact public health authorities.
To prevent the virus from spreading, experts recommend frequent handwashing and coughing into your sleeve. They also recommend minimizing contact with others, staying home as much as possible and maintaining a distance of two metres from other people if you go out.
For full COVID-19 coverage from Global News, click here.
© 2020 Global News, a division of Corus Entertainment Inc.
'Dynamic' physical distancing could help balance COVID-19 fight, economy: study – northeastNOW
However, the research suggested so-called “dynamic” physical distancing could help keep the health-care system from becoming overwhelmed while allowing “periodic psychological and economic respite for populations.”
Physical distancing is an effective tool to curb the spread of the disease, Canada’s public health agencies have said.
The key, according to study lead author Ashleigh Tuite, is to “ride the wave” — by pegging physical distancing measures to the number of intensive care beds in use, those restrictions can be loosened when ICU numbers drop, then tightened up again when the numbers near capacity.
“Instead of a sharp up-and-down epidemic curve, we have something that is stretched out and kind of goes up and down, up and down, and we basically modulate our responses based on where we are in that curve,” said Tuite, an assistant professor of epidemiology from U of T.
“When things start ramping up again, then we know that we need to enhance our social or physical distancing measures. And when things are on the downturn, then we can potentially return a little bit more to normal life.”
The paper was submitted in late March to the Canadian Medical Association Journal and published as a pre-print that has not yet been peer-reviewed.
Amy Greer, one of the study’s author’s, said this is another method to buy society time until a vaccine is available, which is likely more than a year away.
“In the absence of access to a safe and effective COVID-19 vaccine, we will need to work hard to slow down community transmission while also recognizing that we can’t reasonably maintain long-term and aggressive physical distancing until a vaccine becomes available,” said Greer.
Ben Bolker, a math and biology professor at McMaster University who was not involved in the research, called it a “sensible study.”
“The really hard part is figuring out how it’s all going to work at a government, logistic and bureaucratic level,” he said.
He said one potential method would be to change the laws around how many people can gather at once.
Both Tuite and Bolker said other tools will be arriving soon that could help. For one, they said, exhaustive testing would allow the province to drill down into hotspots and ensure isolation measures are placed on those people.
That also might allow some people to return to work.
“It sucks that we have to keep the economy shut for a bunch longer,” Bolker said. “But during that time we’re gathering information and figuring out how the hell we’re going to get out of this.”
Atif Kubursi, a retired professor of economics at McMaster University, said the study is a good starting point for how to fight the disease over the next year or two.
“This is one of the most important questions right now: how can you balance the risk of increased morbidity and death versus destroying the economy?” he said.
Kubursi points out that the study does not get into economic modelling and the effect of starting and stopping businesses — something he’d like to see future research take on.
“It sounds a little simplistic,” he said. “I don’t know if it’s easy to turn the economy on and off, but I guess there are some measures you can take to make businesses essential again.”
“We’d need to know the answer to the question: Is it worthwhile? Can we get people back to jobs in big numbers for short periods of time?” Kubursi said.
“If we can, maybe that is a way to keep the economy greased, keep it moving. It could be worthwhile.”
This report by The Canadian Press was first published April 9, 2020.
Liam Casey, The Canadian Press
COVID-19 likely to kill thousands in Canada even with tough measures – Ottawa Sun
TORONTO — Amid crippling job losses across the country due to COVID-19, the federal government on Thursday warned the number of Canadians killed by the novel coronavirus would likely double over the next week and could reach thousands over the course of the pandemic.
If stringent measures remained in place, the country’s top public health officer predicted the virus could cost at least 4,400 lives over its course. Had such controls not been implemented, models indicate as many as 80 per cent of the population could have been infected, with as many as 350,000 deaths.
“These stark numbers tell us we must do everything we can now to remain in that best-case scenario,” Dr. Theresa Tam said in a sombre presentation. “We must minimize the population infected … in order to keep deaths, ICU admissions and hospitalizations as low as possible.”
In response to the projections, Prime Minister Justin Trudeau said it would take months of determined effort to temper the worst outcomes. Canada, he said, was at a crossroad, and how scrupulously people observed isolation measures would determine what happens.
“We are going to continue to lose people across this country in the coming weeks,” said Trudeau, who noted normal was still a long way away. “We will not be coming back to our former normal situation; we can’t do that until we have developed a vaccine and that could take 12 to 18 months.”
Tam said the spread of the virus appeared to be moderating somewhat and that Canada could bring the epidemic under control by the end of summer if social distancing and other measures were strictly adhered to. With spotty controls, she said, we could still be battling the tail end of the pandemic a year from now.
The number of Canadians infected with the flu-like virus passed the 20,000 level on Thursday, with 504 deaths. Quebec, with almost 11,000 cases, reported 41 new deaths, 216 in all. Ontario said the virus has killed 200 people so far — an increase of 26. The new total of infections in the province is 5,759 others. One death was a worker at a hospital in Brampton, Ont.
Globally, the flu-like pandemic has infected more than 1.5 million people, about 93,000 fatally, according to latest international data. The U.S. appeared to become the country with the highest number of known COVID deaths in the world — more than 15,000 — with New York State alone having more cases than any country excepting the U.S. itself.
Given the bleak American situation, Tam said keeping the common border closed to all but essential traffic was critical.
“We are different from what is happening in the United States in terms of their epidemiology,” Tam said. “We want to be able to stay within that epidemic control curve that I presented today, so we’ll be doing everything that we can.”
Experts say frequent hand-washing and keeping at least two metres from others is the most effective way to curb the pandemic and ease the burden on the health-care system.
The isolation measures — governments and health authorities have either urged or ordered people to stay home and non-essential businesses to close — have brought commercial life to its knees.
Just how deep the restrictions cut was seen when Statistics Canada reported on Thursday that more than one million people lost their jobs in March. The result was a 40 per cent jump in the monthly national unemployment rate to 7.8 per cent, up from 5.6 per cent at the end of February — a “punch in the gut,” as Ontario Premier Doug Ford put it.
People aged 15 to 24 took the biggest brunt, with unemployment jumping to 16.8 per cent — a 63 per cent increase.
The spike was the worst showing in 40 years of data gathering and the April situation was expected to be even worse, economists warned.
The federal government said more than five million people had applied for the government’s emergency jobless benefit.
One glimmer of light did emerge job-wise: WestJet said it would put 6,400 employees bank on payroll with help from Ottawa’s wage subsidies. Air Canada had similarly said 16,500 of its laid-off employees were taking advantage of the program.
The latest numbers on COVID-19 in Canada
The latest numbers of confirmed and presumptive COVID-19 cases in Canada as of 6:20 p.m. ET on April 9, 2020:
There are 20,765 confirmed and presumptive cases in Canada.
— Quebec: 10,912 confirmed (including 216 deaths, 1,112 resolved)
— Ontario: 5,759 confirmed (including 200 deaths, 2,305 resolved)
— Alberta: 1,451 confirmed (including 32 deaths, 592 resolved)
— British Columbia: 1,370 confirmed (including 50 deaths, 858 resolved)
— Nova Scotia: 373 confirmed (including 2 deaths, 82 resolved)
— Saskatchewan: 278 confirmed (including 3 deaths, 88 resolved)
— Newfoundland and Labrador: 236 confirmed (including 3 deaths, 96 resolved)
— Manitoba: 207 confirmed (including 3 deaths, 69 resolved), 17 presumptive
— New Brunswick: 111 confirmed (including 50 resolved)
— Prince Edward Island: 25 confirmed (including 17 resolved)
— Repatriated Canadians: 13 confirmed
— Yukon: 8 confirmed (including 4 resolved)
— Northwest Territories: 5 confirmed (including 1 resolved)
— Nunavut: No confirmed cases
— Total: 20,765 (17 presumptive, 20,748 confirmed including 509 deaths, 5,254 resolved)
'Different than anything we've seen': ICU doctors question use of ventilators on some COVID-19 patients – Simcoe Reformer
It started in New York City, in the trenches in the battle against COVID-19. Stressed doctors began worrying that the breathing tubes and pressures being used to open up the tiny air sacs in the lungs of the critically sick could be causing worse harm.
Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?
“In many ways, it’s different than anything we have seen before,” Dr. James Downar, a specialist in critical care and palliative care said Thursday from inside an ICU at The Ottawa Hospital dedicated to critically ill COVID-19 patients. On Thursday, the unit was full.
The pandemic virus seems not only to affect the lungs, making them stiff and inflamed, but other parts of the body as well, including the heart. It’s not clear if it’s a direct effect of the virus on the heart that’s causing heart failure in some cases, or if it’s because the virus is playing with the body’s coagulation system, increasing the risk of blood clots.
It’s different in another way, too: In a phenomenon reported in the U.S., as well as Italy, and, now, Canada, some patients with severe COVID-19 are arriving in hospital with such low blood oxygen levels they should be gasping for breath, unable to speak in full sentences, disoriented and barely conscious.
Except they’re not in any sort of distress, or very little distress, compared to the burden of illness. They’re talking. They’re lucid. It’s not the classic acute respiratory distress syndrome doctors are used to seeing, and that most guidelines recommend doctors treat as such. One Brooklyn critical care doctor has likened it to high altitude sickness and is urging his colleagues to be cautious about who is being ventilated, and how. The concern is that the pressure may be harming lungs, and that some patients could be more safely treated with less invasive means such as high-flow nasal oxygen.
“To think that we understand this infection, I think is very naive,” Dr. Ashika Jain, an associate professor in trauma critical care and emergency ultrasound at New York University/Bellevue Hospital Center said on a recent REBEL Cast podcast. “There are so many different theories about how this is behaving. There’s no one cohesive picture. We don’t really understand how to really treat this, because it’s a four-month old virus that we just don’t understand how it’s already running when it didn’t really learn how to walk yet.”
With some Ottawa patients, “we’re giving them all the oxygen we can give them without putting them on a breathing machine, and they’re wide awake and talking,” Downar said. In some situations, people are being flipped onto their stomachs, into the prone position, to improve gas exchanges.
High-flow nasal oxygen, where little plastic tubes are placed in the nostrils, can deliver up to six times the amount of oxygen. “And those high flows actually generate a little bit of positive pressure within the patient’s upper airway, which helps keep the lungs open and improve the oxygen levels in the blood,” said Dr. Claudio Martin, a critical care physician and medical director of critical care at London Health Sciences Centre and Western University.
“The problem with that is, when you’re giving oxygen with such high flows, there is a high possibility the viral particles in the airways are being aerosolized, so you can increase the possibility of spread of the virus in the environment,” Martin said. “Which is why if we do use that it has to be in a negative pressure environment, so that you contain the air in the room. You basically try to contain any virus particles that are aerosolized.” It also means any staff looking after the patient need to be wearing N95 masks.
It’s not the classic acute respiratory distress syndrome doctors are used to seeing
While the vast majority, some 80 per cent of infections, are mild, the COVID-19 virus can cause pneumonia, which interferes with the ability of oxygen to get in through the lungs, and into the bloodstream. Currently, about six per cent of confirmed cases in Canada have required admission to an ICU.
A ventilator does two things: it provides oxygen as well as pressure to open up the alveoli, the little lung units, to allow the lungs to get oxygen in, and carbon dioxide out. While potentially life saving, it can worsen lung injury.
The strategy, for now, is not to rush to intubate, said Downar, who led the drafting of an Ontario “triage protocol” if hospitals are forced to ration ICU beds and ventilators. “Unless somebody seems to be failing, or their oxygen level is truly at this critical life-changing level, we can maybe hesitate,” Downar said. Even when the decision is made to ventilate, in some cases, “you almost end up having to talk them into it, which is a very unusual situation.”
“But let me be explicitly clear here: These are still the exceptions. The majority are failing … They need to have a tube put down (their throats) and put on a breathing machine to help them breathe.”
It’s not clear what proportion will be discharged alive.
A study published this week in the Journal of the American Medical Association involved 1,591 people infected with the pandemic virus admitted to ICUs in the Lombardy region of Italy between Feb. 20 and March 18. A high proportion — 88 per cent — required mechanical ventilation. As of March 25, 26 per cent of the ICU patients had died, 16 per cent had been discharged, and 58 per cent were still in the ICU. The median age was 62; 82 per cent were men.
British Prime Minister Boris Johnson remained in an ICU Thursday, where his condition reportedly continues to improve. The 55-year-old is not on a ventilator; according to a spokesman, he’s receiving standard oxygen therapy.
People who have been ventilated have described the experience as awful beyond belief.
The person is sedated, so that they’re calm. “Sometimes you have to relax the breathing muscles so they’re able to open their mouth and accept the tube being inserted,” said Dr. John Granton, head of the division of respirology at Toronto’s University Health Network- Sinai Health System. “If they’re incredibly sick we need to take over their breathing completely, and so we fully sedate them,” meaning a medically induced coma.
“We don’t allow them to wake up from that anaesthetic until their lungs have healed. And then once they’ve healed, or if they’re not that sick, we can allow them to be reasonably aware,” Granton said.
If this ever happened to me, this is what I would not want to look like at the end
With a tube down their throat, however, they can’t speak. They have to communicate by using a board, or moving their lips. “We’ve become expert lip readers in the intensive care unit,” Granton said.
From the experience with H1N1 and SARS, it can sometimes take several weeks, or a month or more for people to recover to the point they can be “liberated” from the machines. For some with a significant underlying condition, like chronic obstructive pulmonary disease, there’s a risk they may never come off.
If nothing else, the pandemic should be encouraging discussions about what people value in life, Granton said, including conversations such as, “If this ever happened to me, this is what I would not want to look like at the end.”
With hospitals in COVID-19 lockdown, families aren’t allowed inside the ICU. Normally, they’re at the bedside. “We’re trying to update them by phone, we’re trying to do Facetime,” Downar said. “To have to see a critically ill family member through a video call and have your questions answered by somebody wearing a face mask … it’s not the way we like to do things. But it’s better than nothing.”
“We’re tired, but this is our job,” Downar said. “People are sending us food. People are honking their horns and putting up signs … It’s really touching.
“We’re going to do our best, and we’re pretty damn good. This is a really strong team. I wouldn’t want to be anywhere else while this is going on than where I am right now.”
(This story has been updated with comments from Dr. Claudio Martin of Western University.)
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