HOSPITALS NEAR TRIAGE TIPPING POINT
`We're going to kill people' deciding who gets ventilators: ICU doctor
Calling the situation in Montreal's hospitals “really critical”, Quebec Premier François Legault again begged Quebecers to avoid indoor gatherings particularly with people over the age of 65, because they are most likely to need hospitalization due to COVID-19 complications.
“The situation is really critical, especially in the greater Montreal region,” Legault said at his latest COVID-19 update in Montreal Monday afternoon. “Surgeries are having to be postponed; there is pressure on our emergency wards. I know it's difficult, but Quebecers are capable to work as a team when necessary.”
More than half of Quebecers living in long-term care facilities — 21,478 people in total — have now received a first dose of vaccine against the deadly virus. And of the 115,375 doses the province has received so far, 80 per cent have already been administered.
But with 1,436 Covid-positive patients in hospitals across the province, many hospitals are overwhelmed, particularly in the Montreal region. The situation is at the point where hospital staff in Montreal are now doing online training for the “advanced triage protocol” to prepare for the horrific, and ever-more likely, possibility that they will soon be forced to choose who lives and who dies in their intensive care facilities.
“It is really scary and people don't realize how close we are to that very scary part,” Dr. François Marquis, chief of Critical Care Medicine at Maisonneuve-rosemont Hospital, told the Montreal Gazette Monday.
“We are going to kill people, because this is what the triage does. You kill people. One is okay and the other one will die. Everyone thinks there is a way out or a way around that process. There is none. You are a number. If they start the triage, what I have to do is I have to give a score to each and every patient in the ICU. Based on that score, some patients will die. We will remove the tube. We will kill them. This is what we are asked to do (in that scenario). That system doesn't care about your beliefs or your religion or personal choice, nobody cares. It is a systematic application of a grid, and it's not only for patients with COVID.”
He said it is not only a question of not providing life-saving treatment but actually removing someone from a respirator who will die, because another patient needs the bed.
The prospect of this scenario has ICU doctors across the Montreal region begging the government to do everything possible to avoid this scenario.
“You could be on a ventilator that you need to survive and I will be asked to remove the ventilator. By withdrawing support you already have, it's not just that I am not giving you access to a life-saving device. You are on the device and I am removing that device. So I don't think it's overly dramatic when I say that they are going to ask (doctors and nurses) to kill someone, because they know that without that machine the patient will die in the next minutes.”
Marquis says his facility's ICU is already two patients over capacity.
Like many hospitals in the region, his lacks nurses and respiratory therapists, needed to operate ventilators that COVID-19 patients need.
During the first wave, his hospital had the staff to treat 30 patients in ICU, but that capacity is now shaved down to 18, due to staff departures.
As of Monday at 11 a.m., his hospital had 20 patients who needed intensive care, including 11 with COVID-19. Two were stuck in the emergency ward, awaiting transfer to another hospital.
The hospital has the physical beds and equipment, such as ventilators, to handle about 24 ICU patients, but a lack of nurses and RTS means the maximum is now 18. Staff are missing due to retirements, COVID infections, or stress caused by the pandemic, he said. A major issue is that many nurses and RTS have been hired away by private placement agencies who offer higher wages and better working conditions, specifically no weekends, no night shifts and no forced overtime.
He wants the government to ensure hospitals with more nurses and RTS transfer some to those who are particularly lacking. But he would also like to see the government order the private placement agencies to provide staff to hospitals around the clock during this crisis. That would be an efficient way to postpone the dreaded “advanced triage scenario” that everyone wants to avoid.
Moving ICU patients, especially those who may need intubation, is very risky, he noted, especially if they have to be moved long distances, which is happening now in many regions of the province. His hospital has been transferring ICU patients almost daily, but mainly to the larger Montreal hospitals, the CHUM, the MUHC and the Jewish General.
At the government's news conference yesterday, the assistant deputy minister of health and social services, Dr. Lucie Opatrny, confirmed that a lack of staff is bringing Montreal ICUS to the brink.
“The issue of a lack of staff is huge ... it is the underpinning, crucial matter,” Dr. Opatrny, who is responsible for medical, nursing and pharmaceutical issues.
She said the province has substantially fewer staffed ICU beds available for many reasons. Many nurses can't work because they are sick or immuno-compromised, she said, while many others have been deployed to CHSLDS or testing centres. She acknowledged that placement agencies have also sapped staff from hospitals.
“The huge amount of absenteeism for different reasons ... is really the critical reason why we are lacking personnel in the hospitals,” she said.
Asked whether he is considering a more severe lockdown, due to the critical situation in hospitals, Legault said he believes current measures, including the new 8 p.m. to 5 a.m. curfew, will keep people from infecting the vulnerable.
“We have to concentrate on people who are 65 years old or more, since they represent 80 per cent of those in hospital with COVID and 95 per cent of deaths,” he said. “Most of those don't work and are not at school. They are at home. So our challenge is really to have fewer gatherings in homes in Quebec, especially (involving) people who are over 65 years old. ... I don't think if we close more companies or close more schools we will solve the problem.”
The issue of a lack of staff is huge ... it is the underpinning, crucial matter.