More than 150 critically ill Canadians - many with life-threatening cerebral hemorrhages - have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here.
Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care.
The waits, in some instances, have had devastating consequences.
"There have been very serious health-care problems that have arisen in neurosurgical patients because of the lack of ability to attain timely transport to expert neurosurgical centres in Ontario," said R. Loch Macdonald, chief of the division of neurosurgery at St. Michael's Hospital in Toronto. Those problems, he said, include "brain injury or brain damage that could have been prevented by earlier treatment."
Ontario has the worst problem, though it is not alone.
British Columbia has sent four patients with spine injuries to Washington State hospitals for care from May to September, 2007, though the recruitment of more staff and opening of new beds have helped alleviate the problem. Saskatchewan has sent patients to neighbouring provinces - such as Alberta, which is working at maximum capacity - for specialized neurosurgical services.
But nowhere is the problem of accessing neurosurgery more severe in this country than in Ontario. Since April of 2006, 157 people have been sent to Michigan and New York State hospitals for care. That includes the 62 patients sent so far in fiscal 2007-2008, according to David Jensen, spokesman for the Ontario Health Ministry.
When asked if any patients transported to the United States had died, Mr. Jensen said the "ministry does not specifically record the outcomes of health services provided out of country."
Patients being sent to U.S. hospitals are in the midst of acute medical emergencies, including head injuries, broken necks and hemorrhagic strokes, such as a brain aneurysm that has ruptured.
Unlike other cases where patients have been sent to the U.S. for care - such as radiotherapy for cancer patients - this is the first time doctors have categorically equated delays in obtaining treatment with poorer patient outcomes.
Tim Rutledge, former chief of emergency medicine at North York General Hospital, said physicians are spending "many hours" trying to find neurosurgical services.
"When someone starts to bleed in their head, you don't have a lot of time. You have to take these patients stat," said Dr. Rutledge, who was asked to represent the concerns of Ontario emergency-room physicians before a provincial panel studying access to neurosurgical services. Not only is waiting traumatic for patients and families, he said, but "it's immensely stressful for emergency personnel to watch a patient deteriorate before their eyes while they try to access care." Deterioration, he said, comes in the form of "loss of limb function, seizures and comas."
Despite the urgency of these cases, patients encounter barriers to accessing care at every turn. The problems include: limited access to teleradiology; limited operating-room time; too few intensive-care beds; a short supply of neurosurgically trained intensive-care nurses to staff them, and too few neurosurgeons.
In some cases, neurosurgeons are available to operate, but with intensive-care beds full, there simply is nowhere to put them afterward.
Even the method of funding neurosurgical services is an enormous disincentive. Neurosurgery is funded out of fixed, global hospital budgets and is viewed as a financial drain. Orthopedic surgeons, by comparison, are seen as money makers: The more operations they do, the more their hospitals are reimbursed.
Tom Chan, chief of emergency at Scarborough Hospital, said the process is frustrating for emergency-room doctors, who are the first to see these patients. Typically, the patients come in having had a seizure or complaining of severe headaches, numbness, confusion, or vomiting.
"My hospital is 20 minutes from the best neurosurgery in the country - if not the world - and we can't get to it," said Dr. Chan, who described the situation as "crazy."
When Alan Hudson, head of Ontario's waiting-time strategy, heard about the problem, he immediately struck a panel to study it. "The solution to fix this is within sight," said Dr. Hudson, a former neurosurgeon and hospital president. "What it requires is some organization."
To that end, the Ontario government in November provided an additional $4.1-million to Toronto's University Health Network, to do 100 more neurosurgical cases by October, 2008.
Catherine Zahn, executive vice-president, clinical programs and practice at the University Health Network, said the additional government funding is having an impact, though she conceded the pace is not sustainable as more neurosurgeons are needed. She stressed that the government and her institution are working together to address the problem.
And yet, governments were warned of a shortage of neurosurgical services five years ago. In August, 2003, a report co-authored by Chris Wallace, head of the division of neurosurgery at Toronto Western Hospital, said that "increasingly, the resources are not available to handle neurosurgical emergencies."
At that time, in fiscal 2003-2004, fewer than five patients were sent to U.S. hospitals for care. One year later, 10 patients were sent. That number doubled in 2005-2006, according to Ontario Health Ministry figures.
Dr. Wallace's report mentioned four main areas of concern and made eight recommendations to improve access to neurosurgery and to "plan for the unplanned."
"It has started to reach capacities that are not tolerable and that's what has caused the groundswell and the concern," Dr. Wallace said in an interview. He described the situation of travelling to the U.S. for care as "intolerable for the critically ill."
Two more reports on the difficulties of accessing neurosurgical services followed. An October, 2003, report by Charles Wright found there was a significant shortage of neurosurgeons in some centres. Two years later, a report by the Institute for Clinical Evaluative Sciences said demands were being met by very few surgeons with high workloads, which is not sustainable.
Now, a fourth report, authored by James Rutka, appointed by the provincial government to head the neurosurgery expert panel, has listed about 20 recommendations to solve the problem.
The report by Dr. Rutka, chairman of the division of neurosurgery at the University of Toronto, was provided to government in late December. It recommends a two-phased approach: allocating additional neurosurgical services to one hospital to address emergency out-of-country transfers immediately, and increasing capacity in more centres in Ontario.