Hospitals and health professionals across Canada are confronting the complex, urgent question of how to safely start treating more non-COVID-19 patients without jeopardizing the ability of the health care system to function.
Thousands of Canadians have had surgeries, treatments and regular disease management checkups postponed in recent weeks as hospitals tried to empty their facilities in preparation for a possible surge of COVID-19 patients. So far, most of Canada has been able to avoid the flood of coronavirus cases that overwhelmed hospitals in, for example, northern Italy and New York. As a result, many hospital beds are unoccupied and some operating rooms are empty.
While the threat of COVID-19 is still present, medical experts say hospitals in Canada need to develop a road map for how to safely start seeing and treating more patients in the coming weeks. Otherwise, those patients risk becoming collateral damage of the pandemic, they say.
“We have to balance life and death situations of our non-COVID-19 patients,” said Shady Ashamalla, a surgical oncologist at Sunnybrook Health Sciences Centre’s Odette Cancer Centre. “It’s okay to be a little late with loosening physical distancing. It’s not okay to be late with loosening our hospital restrictions.”
Robin McGee is one of many patients who faces potentially life-changing consequences as a result of the health care system being put on hold. Ms. McGee, who lives in Port Williams, N.S., was scheduled to undergo surgery in May to remove cataracts that developed after she underwent a treatment for cancer. She said the cataracts are damaging her vision at a rapid rate and that she may not be able to see in a matter of months.
But her surgery was cancelled, leading her to worry she could end up going blind. Ms. McGee’s cancer has returned and she is set to start treatment soon, after which she won’t be able to receive the cataract surgery because of the risk of infection.
“It leaves me in a dilemma,” said Ms. McGee, who is hoping to find an alternative solution. “Your choices are an unopposed cancer or blindness.”
Sandy Buchman, president of the Canadian Medical Association, said routine management of conditions such as diabetes and chronic obstructive pulmonary disease can only be delayed for so long. While virtual care can help some patients in the short term, many patients still need to have regular in-person visits to manage their conditions, he said.
“People are going to start getting sicker and even become more emergent if they’re not dealt with,” Dr. Buchman said.
In some cases, sick individuals are avoiding the hospital or waiting too long to be seen because they’re worried about COVID-19. Jim Kim, a Vancouver anesthesiologist, said this is endangering the health of some patients and that people need to know it’s safe to be at the hospital.
“In most parts of the country, the hospital has lots of capacity,” Dr. Kim said. “If you’re sick ... you’re still safe to go to the hospital.”
Despite the growing urgency, ramping up patient visits, surgeries and other treatments during a pandemic is not a straightforward process. One of the primary concerns is that opening up the system too quickly could leave it stretched in the event of an upward spike in COVID-19 cases.
Another problem is the scarcity of personal protective equipment for health care workers. Hospitals have been forced to ration masks among health professionals in the midst of a global surge in demand. There is a real worry that there may not be enough for everyone once hospitals start to perform more treatments and surgeries.
Many people with COVID-19 experience mild symptoms, which means a surgical patient could unknowingly be infected and inadvertently spread the virus to the health care team. While masks, gowns, gloves and face shields can reduce this risk, they are in short supply.
Daniel Bainbridge, president of the Canadian Anesthesiologists’ Society, said the lack of N95 respirator masks is a particular concern for anyone performing surgery. Anesthesiologists regularly intubate patients before surgery and that procedure can generate tiny aerosolized virus particles that increase the chance of COVID-19 transmission. N95 respirators help block those particles, but the masks are still scarce.
“In terms of health care workers, we are very concerned. No one wants to get COVID from asymptomatic patients that we are intubating,” said Dr. Bainbridge, who is also a professor in the department of anesthesia and perioperative medicine at the University of Western Ontario in London, Ont. “If we don’t have a lot of N95s, it’s going to be hard to ramp up to full scale.”
Widespread screening and testing for COVID-19 is likely not a feasible solution, experts say.
At Sunnybrook, Dr. Ashamalla said the current protocol says anyone undergoing emergency surgery must receive a computed tomography chest scan, which can reliably identify signs of COVID-19 in the lungs. But it would be a challenge to do scans on every patient, he said. Similarly, simply testing every patient for the illness is also problematic, as some people with mild illness can produce false-negative results.
Instead, health care workers are treating every patient as though they may have COVID-19, which requires full-scale use of personal protective equipment.
“Everyone in the operating room is using the same precautions as if they were confirmed patients,” Dr. Ashamalla said.
Dr. Buchman said in the coming weeks, a slow-and-steady approach will likely be used throughout the health care system to gradually increase patient visits and treatments, with everyone watching the trajectory of COVID-19 cases at the same time.
“We still have to be cognizant of second and even third waves of this disease,” Dr. Buchman said. “We’re going to have to do it in a very regulated fashion.”
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