This is an excerpt from Second Opinion, a weekly roundup of eclectic and under-the-radar health and medical science news emailed to subscribers every Saturday morning. If you haven’t subscribed yet, you can do that by clicking here.
The sacrifice Canadians have collectively made to flatten the coronavirus curve also includes immeasurable suffering from postponed surgeries, says a B.C. man who lost his mother not to the virus but to cancer.
Min Hua (Jasmine) Yang, 60, started having abdominal pain, fever and then breathing difficulties in January. She went to an emergency department in Surrey, B.C., and was diagnosed with a rare form of ovarian cancer in March.
Her son, Jonathan Hu, 31, said oncologists recommended surgery in early April as the best treatment for Yang’s three, late-stage tumours. But the COVID-19 pandemic lockdown included postponing or cancelling non-emergency surgeries like Yang’s — and an estimated 394,575 others across Canada.
“There is a lot more people who are suffering or dying other than just a number of deaths that you see from the coronavirus,” Hu said.
Canada’s health-care systems made a choice to cancel surgeries and to devote hospital staff and resources to COVID-19.
“We were really frustrated,” Hu said.
Jonathan Hu and his mother Jasmine Yang. He says the family felt powerless watching her deteriorate every day waiting for surgery. (Submitted by Jonathan Hu)
The family “felt powerless” as they watched Yang deteriorate daily during chemotherapy that was not part of the original treatment plan for her sex cord stromal cancer. The surgery was postponed weeks to May 4.
Yang died two days earlier.
“The choice that we made has consequences and we’re living with those consequences right now,” Hu said.
Tough choices
Dr. Iris Gorfinkel, a family physician in Toronto, worries about unintended consequences from those choices for her patients, too.
For example, virtual care excludes the physical exams she performs to quantify the degree of pain a patient has.
WATCH | The complications of resuming surgeries during pandemic:
Many provinces are starting to resume non-emergency surgeries delayed because of the COVID-19 pandemic, but it’s a complicated balance of trying to clear the backlogs and keeping patients safe. 2:03
“You put your hand on that person’s belly you see immediately they’re not doing well because you can feel how they’re reacting,” Gorfinkel said. “I know from my own practice I’m more likely to order tests because of that uncertainty, which is another cost to the system because I don’t want to be wrong.”
Patients are also left wondering whether delays in tests and procedures made a difference in their care, Gorfinkel said.
It’s one reason why health-care professionals across the country are preparing to do more procedures and surgeries.
Surgery backlog mounts
In May, B.C. Health Minister Adrian Dix estimated it could take up to two years to clear the backlog of 30,000 patients whose surgeries were postponed or not scheduled since mid-March in that province alone due to COVID-19.
In Quebec, Dr. Gilbert Boucher, head of the province’s association of emergency medicine specialists, said the flow of patients sick with medical conditions besides COVID-19 has resumed in much of the province.
The last three weeks, however, have included struggles with finding space, including for patients discharged from hospital who are unable to return home or to long-term care.
At Montreal’s older hospitals with four-bed rooms, many cannot be used while COVID-19 cases continue in the community. One tertiary care centre lost 30 per cent of its beds during confinement, Boucher said.
Hospitals with wards for people testing positive for COVID-19 had doctors and nurses working overtime for the last three months.
An empty operating room is seen in a Maryland hospital in March as hospitals worldwide cancelled elective surgeries to make space for COVID-19 patients. (Rosem Morton/Reuters)
“Those people are getting tired so we just don’t have the staff to staff the operating room and to do the gastroscopy and the colonoscopy and all those follow-up” procedures, said Boucher. “It’s summer for everybody so people do need a little break.”
Safety prioritized
Medical experts say to ramp up surgeries, a “four-sided Rubik’s cube” of prerequisites, known as the 4S’s, first need to align:
Screening for COVID-19 safely.
Increased staffing capacity.
Supplies such as personal protective equipment and medications like anesthetics.
Space and systems in place to keep patients clear of COVID-19 before and during hospitalization and for patients and their family members to understand the importance of quarantine in the first 30 days after surgery.
In addition to surgery delays, the COVID-19 pandemic has led to global shortages of some drugs.
Christina Adams, chief pharmacy officer for the Canadian Society of Hospital Pharmacists, said drug makers have increased production of medications for critical care, such as the injectable anesthetic propofol that’s reportedly chronically short in the U.S.
Patients with COVID-19 who require continuous ventilation need two to three times the usual amount of propofol compared with patients requiring surgery under general anesthesia, Adams said.
She added that Health Canada anticipated global shortages and expedited imports of non-Canadian labelled products, such as from the European Union, to ensure supplies weren’t interrupted.
“Right now, the situation is not bad,” Adams said.
COVID-19 greatly compounds surgery risks
Janet Martin an associate professor of anesthesia and perioperative medicine at Western University and an international team of surgery researchers, estimated that 28.4 million elective surgeries worldwide could be cancelled or postponed this year based on the 12-week peak of disruptions to services in hospitals.
For Canada, the cancelled surgeries include hip and knee replacements and procedures to confirm whether or not someone has cancer.
“That’s exactly for whom we are doing this type of research,” Martin said.
Researchers said they looked at surgery delays during COVID-19 to help people like those living with a knee that is constantly painful waiting for a replacement. (Vincent Bonnay/Radio-Canada)
If hospitals successfully increase capacity by 10 per cent by running operating rooms longer and partly on weekends, Martin figures it will take nearly 90 weeks to clear Canada’s backlog.
In a study published last month in The Lancet, Martin and co-authors followed 1,128 patients in 24 countries who had emergency and elective surgery this year before March 31.
Nearly one in four patients died within a month, the researchers found. For those undergoing elective surgery, the mortality risk rose from below the one per cent to 18 per cent.
One in two (51 per cent) developed serious pulmonary complications, including needing ventilation.
“We were absolutely surprised,” Martin said. “That is far and above what we had ever expected.”
As the increased risks from surgeries due to COVID-19 become apparent from the new data, Martin hopes hospitals will find ways to better protect patients.
Janet Martin said she’s thankful to no longer be in the dark about how risky surgery can be during COVID-19. (Western University)
For his part, Hu emailed CBC News looking for information on how many others in Canada like his mother who weren’t infected with COVID-19 but missed treatment and died.
It’s impossible to know exactly how delays affect an individual patient.
Gorfinkel said while such societal fallout can only be measured in retrospect, there are definitely consequences from postponing routine screenings during the pandemic, such as mammograms or tests to look for blood in feces, which can be a sign of a colorectal cancer or a growth that can easily be treated.
“Would an earlier diagnosis have made a difference?” Gorfinkel said of the questions she’s anticipating from her patients. “Much of the time it may not but the fact is we can’t be certain.”
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Patients who are older, don’t speak English, and don’t have a high school education are more likely to experience harm during a hospital stay in Canada, according to new research.
The Canadian Institute for Health Information measured preventableharmful events from 2023 to 2024, such as bed sores and medication errors,experienced by patients who received acute care in hospital.
The research published Thursday shows patients who don’t speak English or French are 30 per cent more likely to experience harm. Patients without a high school education are 20 per cent more likely to endure harm compared to those with higher education levels.
The report also found that patients 85 and older are five times more likely to experience harm during a hospital stay compared to those under 20.
“The goal of this report is to get folks thinking about equity as being a key dimension of the patient safety effort within a hospital,” says Dana Riley, an author of the report and a program lead on CIHI’s population health team.
When a health-care provider and a patient don’t speak the same language, that can result in the administration of a wrong test or procedure, research shows. Similarly, Riley says a lower level of education is associated with a lower level of health literacy, which can result in increased vulnerability to communication errors.
“It’s fairly costly to the patient and it’s costly to the system,” says Riley, noting the average hospital stay for a patient who experiences harm is four times more expensive than the cost of a hospital stay without a harmful event – $42,558 compared to $9,072.
“I think there are a variety of different reasons why we might start to think about patient safety, think about equity, as key interconnected dimensions of health-care quality,” says Riley.
The analysis doesn’t include data on racialized patients because Riley says pan-Canadian data was not available for their research. Data from Quebec and some mental health patients was also excluded due to differences in data collection.
Efforts to reduce patient injuries at one Ontario hospital network appears to have resulted in less harm. Patient falls at Mackenzie Health causing injury are down 40 per cent, pressure injuries have decreased 51 per cent, and central line-associated bloodstream infections, such as IV therapy, have been reduced 34 per cent.
The hospital created a “zero harm” plan in 2019 to reduce errors after a hospital survey revealed low safety scores. They integrated principles used in aviation and nuclear industries, which prioritize safety in complex high-risk environments.
“The premise is first driven by a cultural shift where people feel comfortable actually calling out these events,” says Mackenzie Health President and Chief Executive Officer Altaf Stationwala.
They introduced harm reduction training and daily meetings to discuss risks in the hospital. Mackenzie partnered with virtual interpreters that speak 240 languages and understand medical jargon. Geriatric care nurses serve the nearly 70 per cent of patients over the age of 75, and staff are encouraged to communicate as frequently as possible, and in plain language, says Stationwala.
“What we do in health care is we take control away from patients and families, and what we know is we need to empower patients and families and that ultimately results in better health care.”
This report by The Canadian Press was first published Oct. 17, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
CALGARY – Alberta’s health minister says a new agency responsible for primary health care should be up and running by next month.
Adriana LaGrange says Primary Care Alberta will work to improve Albertans’ access to primary care providers like family doctors or nurse practitioners, create new models of primary care and increase access to after-hours care through virtual means.
Her announcement comes as the provincial government continues to divide Alberta Health Services into four new agencies.
LaGrange says Alberta Health Services hasn’t been able to focus on primary health care, and has been missing system oversight.
The Alberta government’s dismantling of the health agency is expected to include two more organizations responsible for hospital care and continuing care.
Another new agency, Recovery Alberta, recently took over the mental health and addictions portfolio of Alberta Health Services.
This report by The Canadian Press was first published Oct. 15, 2024.
Rana Van Tuyl was about 12 weeks pregnant when she got devastating news at her ultrasound appointment in December 2020.
Her fetus’s heartbeat had stopped.
“We were both shattered,” says Van Tuyl, who lives in Nanaimo, B.C., with her partner. Her doctor said she could surgically or medically pass the pregnancy and she chose the medical option, a combination of two drugs taken at home.
“That was the last I heard from our maternity physician, with no further followup,” she says.
But complications followed. She bled for a month and required a surgical procedure to remove pregnancy tissue her body had retained.
Looking back, Van Tuyl says she wishes she had followup care and mental health support as the couple grieved.
Her story is not an anomaly. Miscarriages affect one in five pregnancies in Canada, yet there is often a disconnect between the medical view of early pregnancy loss as something that is easily managed and the reality of the patients’ own traumatizing experiences, according to a paper published Tuesday in the Canadian Medical Association Journal.
An accompanying editorial says it’s time to invest in early pregnancy assessment clinics that can provide proper care during and after a miscarriage, which can have devastating effects.
The editorial and a review of medical literature on early pregnancy loss say patients seeking help in emergency departments often receive “suboptimal” care. Non-critical miscarriage cases drop to the bottom of the triage list, resulting in longer wait times that make patients feel like they are “wasting” health-care providers’ time. Many of those patients are discharged without a followup plan, the editorial says.
But not all miscarriages need to be treated in the emergency room, says Dr. Modupe Tunde-Byass, one of the authors of the literature review and an obstetrician/gynecologist at Toronto’s North York General Hospital.
She says patients should be referred to early pregnancy assessment clinics, which provide compassionate care that accounts for the psychological impact of pregnancy loss – including grief, guilt, anxiety and post-traumatic stress.
But while North York General Hospital and a patchwork of other health-care providers in the country have clinics dedicated to miscarriage care, Tunde-Byass says that’s not widely adopted – and it should be.
She’s been thinking about this gap in the Canadian health-care system for a long time, ever since her medical training almost four decades ago in the United Kingdom, where she says early pregnancy assessment centres are common.
“One of the things that we did at North York was to have a clinic to provide care for our patients, and also to try to bridge that gap,” says Tunde-Byass.
Provincial agency Health Quality Ontario acknowledged in 2019 the need for these services in a list of ways to better manage early pregnancy complications and loss.
“Five years on, little if any progress has been made toward achieving this goal,” Dr. Catherine Varner, an emergency physician, wrote in the CMAJ editorial. “Early pregnancy assessment services remain a pipe dream for many, especially in rural Canada.”
The quality standard released in Ontario did, however, prompt a registered nurse to apply for funding to open an early pregnancy assessment clinic at St. Joseph’s Healthcare Hamilton in 2021.
Jessica Desjardins says that after taking patient referrals from the hospital’s emergency room, the team quickly realized that they would need a bigger space and more people to provide care. The clinic now operates five days a week.
“We’ve been often hearing from our patients that early pregnancy loss and experiencing early pregnancy complications is a really confusing, overwhelming, isolating time for them, and (it) often felt really difficult to know where to go for care and where to get comprehensive, well-rounded care,” she says.
At the Hamilton clinic, Desjardins says patients are brought into a quiet area to talk and make decisions with providers – “not only (from) a physical perspective, but also keeping in mind the psychosocial piece that comes along with loss and the grief that’s a piece of that.”
Ashley Hilliard says attending an early pregnancy assessment clinic at The Ottawa Hospital was the “best case scenario” after the worst case scenario.
In 2020, she was about eight weeks pregnant when her fetus died and she hemorrhaged after taking medication to pass the pregnancy at home.
Shortly after Hilliard was rushed to the emergency room, she was assigned an OB-GYN at an early pregnancy assessment clinic who directed and monitored her care, calling her with blood test results and sending her for ultrasounds when bleeding and cramping persisted.
“That was super helpful to have somebody to go through just that, somebody who does this all the time,” says Hilliard.
“It was really validating.”
This report by The Canadian Press was first published Oct. 15, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
