Aisha Mirza is an emergency department physician at Grey Nuns Community Hospital, a major facility in Edmonton complete with an intensive care unit. She intubated a patient the other day and then, rather than being wheeled to the ICU, the individual was loaded into an ambulance.
“I promptly had to transfer them – out of the hospital,” she said. “I was like: ‘I can’t believe this. This patient isn’t going up to ICU because there’s no bed.’”
Physicians and nurses in Alberta’s hospitals are spending an increasing amount of time searching for available beds for their patients as coronavirus victims fill ICUs, emergency departments, and COVID-19 wards.
This week, the number of patients infected with the coronavirus in Alberta’s ICUs reached a new high, which exceeds the number of critical care beds the province typically had before the pandemic. With the prospect that Alberta is just weeks away from exceeding ICU capacity and forcing doctors to ration critical care, Premier Jason Kenney announced new restrictions on Tuesday designed to “stop the spike,” the government’s new COVID-19 slogan. He conceded Alberta Health Services’ stretch capacity of 425 ICU beds, while physically possible, would translate to substandard care across the board because of staff shortages.
If Albertans adhere to the rules, doctors should be spared from choosing who is most worthy of life-saving interventions such as ventilator support. But even so, over 22,000 people currently have COVID-19 in Alberta, including 922 First Nations people. Of all those infected, 4.1 per cent of end up in hospital, although the rate climbs to 7.6 per cent for First Nations. It will take weeks for hospital and ICU occupancy to drop to a more manageable level, given that admissions lag infections by about two weeks.
“You just have palpitations going into work because every patient could turn into a disaster,” Dr. Mirza said. Her intubated patient was ferried to another hospital in Edmonton.
Across Alberta there were 659 COVID-19 patients in hospital as of Friday, including 150 in the ICU. The majority of these are in Edmonton and Calgary, in part because patients from rural communities are shipped to major cities when they need critical care.
Parker Vandermeer, a physician who works in rural northern and central Alberta, said the number of patients seeking treatment at his emergency departments has dropped by 25-to-50 per cent since the pandemic began. However, COVID-19 and the backlog of patients in cities means cases are more complicated and time consuming.
Normally, rural patients in need of critical care are quickly transferred to better-equipped hospitals in bigger cities. Now, it can take up to six hours just to find a hospital that can absorb another patient, Dr. Vandermeer said.
In some instances, patients who would normally be shipped elsewhere stay in rural hospitals because either city beds are full, or physicians are trying to keep some open as a cushion. This calculated gamble is especially risky for COVID-19 patients in rural communities.
“COVID patients can die quickly,” Dr. Vandermeer said. “The patient can go from minimal oxygen requirements to death’s door in a matter of hours.”
Rebeccah Rosenblum, an emergency department doctor at the Royal Alexandra Hospital in Edmonton, said her department is getting busier as a range of COVID-19 patients arrive, some with comparatively minor symptoms and others who need to be intubated and rushed into the ICU immediately.
During her last shift, she was working in another area of the emergency department when she was called to help with seriously ill COVID-19 patients, including one who needed a breathing tube.
“The physicians who were working ... could not keep up,” she said. “We simply had too many patients coming in simultaneously.”
Alberta last week released its triage protocol for ICU patients, which prioritizes those with the greatest likelihood of surviving the next year.
The prospect of denying care is devastating, Dr. Rosenblum said, but she believes the new protocol is a necessary step to ensure physicians have guidance if that eventuality arrives. She also believes everyone will do whatever they can to prevent that from ever happening.
The intensive care unit at the Peter Lougheed Centre, a hospital located in northeast Calgary, had 18 funded ICU beds before the pandemic. The facility has added another 10 beds by double-bunking some patients and expanding into another area of the hospital.
ICU doctor Daniel Niven says it’s not ideal but they’re managing and it hasn’t affected the level of care they can offer. He’s also confident the hospital has room to grow further if, as expected, admissions continue to increase over the next several weeks.
The bigger problem is exhaustion. Doctors, nurses and other staff have been working pretty much full-bore since the second wave, with only a brief reprieve when admissions fell in the new year before the third wave exploded.
COVID-19 patients typically stay in the ICU longer than a typical critical care patient, in some cases remaining in the unit for a couple of weeks. And Dr. Niven said he and his colleagues are spending an increasing amount of time searching for available ICU beds in the city, where space in various hospitals is essentially managed as a single intensive care unit.
“We didn’t really get too far beyond the second wave before the third wave came,” said Dr. Niven, who is also an assistant professor at the University of Calgary’s medical school.
“We’re definitely bracing for more patients. I think everybody’s had to up their game.”
Dr. Niven is optimistic that a combination of increased vaccinations and recently announced restrictions will mean the province won’t need to implement a triage protocol.
Nearly a third of Albertans have received at least one dose of COVID-19 vaccines and as of Monday, everyone in the province aged 12 and up will be eligible.
“There are a lot of mixed feelings. It’s certainly reassuring to know that there’s guidance so you’re not making these decisions ad hoc,” he said.
“At the same time, when you think through how that would actually go down for an individual patient, it is scary and you do hope to not have to get there .”
Deena Hinshaw, Alberta’s Chief Medical Officer of Health, on Thursday said it was a “distinct possibility” that doctors would be forced to ration critical care if the province did not impose new restrictions this week. With hospitals still under pressure, she said her biggest concern now is the forthcoming fallout from cancelled surgeries and residents who avoided or were unable to access treatment for health issues other than COVID-19 throughout the pandemic. Further, she worries about the affect COVID-19 fatigue is having on her colleagues in the health-care system.
“Fatigue in those who have been working in these intense environments day after day, week after week, month after month,” she told reporters.
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