Who is dying of COVID in Canada, and how?
The woman was 52, and the mother of two boys, ages 12 and 15. Seeing her, lying helpless, with her lungs shredded by COVID, reminded Dr. Peter Goldberg of the first wave of the virus, back in early spring, when “it was like a forest fire, and all I had was a garden hose.” No matter what the doctors tried, steroids, everything, her carbon dioxide levels kept rising. At some point they couldn't ventilate her, they couldn't get the carbon dioxide out. She died, “and we watched this,” says Goldberg, head of the critical care program at the Mcgill University Health Centre.
Goldberg never had the chance to speak with the woman, who died of destructive lung disease. She was sedated from the moment she was transferred in from another hospital. “What were her fears? Her hopes? None of that,” he said. It's assumed that people who are sedated have an inability to be fearful, but it is one of the unknowns, another by-product of the virus, where patients, in grave conditions, are kept unconscious.
Thankfully, Goldberg is not seeing as many forest fires, but when they do strike, the experience of watching a person's condition unravel, as a physician, is heart-wrenching. The virus is relentless. The woman, despite being relatively young, had several underlying health problems. PRE-COVID, she might have lived to be a grandmother. Today, she is another statistic, and what doctors still don't fully comprehend is the “crapshoot” nature of COVID-19. Who will get ill? Who will be asymptomatic? Who will be 52, and leaving boys without a Mom? Age is an important variable, as are underlying conditions, but Goldberg has watched as a 44-year-old health-care worker, in otherwise good shape, perished FROMCOVID-19.
The pandemic, to a large extent, has become a story of numbers, a daily summary of cases and deaths, of numbers tested and numbers testing positive. The statistics are dry, nameless, but some patterns have emerged. Doctors are developing models and looking for markers to predict the likelihood of “critical events” and death — signs, like fast breathing, high blood pressure or elevated proteins in the blood, that someone might go from sitting on the edge of his or her hospital bed eating lunch, to sudden intense distress, to being sedated, and being lost.
Canada could cross the threshold of 20,000 to 60,000 daily cases by the end of December, the most recent federal modelling warns. As of Friday, the official death count stood at 11,856. So far, 2,756 people have died in the second wave, beginning Aug. 18. Manitoba and Quebec have the highest per capita death rates, but deaths are increasing at a faster rate than cases in all regions, according to University of Toronto infectious disease researcher Dr. Tara Moriarty.
And globally, Canada has the third highest case fatality rate (3.4) to date among medium-large, high-income peer countries, Moriarty says, “higher even than Spain, France, the USA and Germany.”
This alarming trend is likely because testing in Canada has predominantly focused on people with symptoms and those at greater risk of serious infection, not younger, lower-risk people. The case fatality ratio only estimates the proportion of deaths among identified, confirmed cases. Nationally, the number of tests performed per detected case is nearly as low as it was at the worst of the first wave, “meaning that we're likely significantly underestimating the full size of the epidemic,” Moriarty says.
There was a time in April and May when Goldberg was meeting twice a week with hospital ethicists to have “very disturbing” conversations about how to ration care. With the Quebec government projecting hospitalizations may double before Christmas, those conversations are now being resurrected.
“I don't think the community knows that these conversations are going on. We're talking about them — we're not talking about something esoteric about ourselves. We're talking about how ICUS, if we reach the limitation of our capacity to treat COVID patients, then we're going to have to make decisions about who gets the bed,” Goldberg says.
Some doctors, desperate to turn the narrative around, tired of the pandemic denialism, have begun to describe scenes inside hospital walls.
Last weekend, Dr. Abdu Sharkawy sat down in his makeshift office at Toronto General Hospital and tweeted, “So – this is the COVID ward.” The emotional dispatch described the hollowness of the hallways, the quiet and isolation, and what it's like to witness respiratory extremis, “where awkward gasps of air hit like body blows.”
He tweeted about the meagre Italian he used to get to know an 82-year-old man, “one of the better-looking ones on the COVIDWARD.” He was able to sit on the edge of his bed. He was eating. He was looking so good, Sharkawy called his daughter and, in a conversation that now haunts him, told her he felt confident her dad would turn the corner. Four-anda-half hours later, the man suffered a massive stroke and couldn't move the left side of his body. Things moved faster than they had time to prepare for. He became less aware, less conscious, and ultimately, in respiratory extremis. “The way his abdomen was contorting and the way his muscles in his chest wall and thoracic cage were contracting — when I contrast that to the same guy who poked fun at me in my broken Italian, that was truly heartbreaking for me,” Sharkawy, an infectious disease specialist, said in an interview with Postmedia. “He didn't use a cane. He was full of personality. He was gregarious, he had his wits about him, he was a father. He was life.”
“These are the stories, this is the burden of trauma that I'm seeing inside those walls,” he says. “I feel like so much of this pandemic has been reduced to this narrative of what form of life is more valuable or expendable than other forms of life.”
What lives are being lost to COVID?
The older, those with underlying diseases, those with weak immune systems. Of the more than 9,500 people in Canada who succumbed to COVID in the first wave, between March and July, 90 per cent had at least one other cause, condition or complication reported on the death certificate, according to Statistics Canada.
Dementia or Alzheimer's, the most common conditions associated with COVID-INvolved deaths, were listed on the death certificate of 42 per cent of women, and 33 per cent of men. More than half of seniors aged 80 and older living in long term care have dementia.
Cancer, nervous system disorders like Parkinson's or ALS, respiratory disease, diabetes, kidney failure, heart disease, high blood pressure and pneumonia — all increase the risk of a lethal case of COVID.
All are more common among people aged 65 and older, who accounted for 94 per cent of all COVIDinvolved deaths in the first wave.
But they also affect millions of Canadians.