Beyond the numbers: Who is dying from COVID?
EXPERTS SAY THE GROWING CASE COUNT AND DEATH TOLL DON'T CATCH THE FULL SCOPE OF THE TRAGEDY
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 healthcare worker, in otherwise good shape, perished from COVID-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 August 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 U.S.A. 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 COVID ward.” 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-and-a-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 the National Post. “He didn't use a cane. He was full of personality. He was gregarious, he had his wits abut 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 con
ditions 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 Covid-involved deaths in the first wave. But they also affect millions of Canadians. Some three mil
lion are living with diabetes, more than seven million with hypertension.
The World Health Organization defines a death due to COVID as a death resulting from a “clinically compatible illness, in a probable or confirmed COVID-19 case,” Statscan says. “There should be no period of complete recovery
from COVID-19 between illness and death.”
Death from COVID is not unlike dying from an infectious respiratory disease. Respiratory failure is the “primary driver of passing” about a third of the time, says Dr. Anand Kumar, an intensive care doctor with the Winnipeg Regional Health Authority. “If these are young people or middle-aged people we can offer some extraordinary support measures, like putting you on cardiopulmonary bypass basically.” A machine pumps and oxygenates the blood. You can do that for a period of time, maybe weeks, and hope that the lungs are healing. About two- thirds develop multiple organ failure, where their heart starts to fail, the kidneys fail, the liver starts to give out. This tends to occur in people on dialysis or with diabetes-related organ injury. “The one unusual way that people with COVID-19 die is with bleeding and clotting problems,” Kumar said.
The other stark difference are pandemic restrictions banning visitors and family, meaning people dying of COVID are dying alone. “If there is anything more distressing than seeing someone die, it is seeing them die alone, or a nurse holding up a phone on Zoom or Skype so that family members can watch this.” Everyone gloved and gowned. The physical intimacy and comfort, touching skin to skin, lost.
The majority of people with COVID have mild symptoms. But Goldberg says we need to get the denominator down, the number of people getting infected. In Quebec, there aren't the same hospitalizations or ICU admissions as the first wave, though Goldberg worries that the numbers are ticking up. He worries about “long- haulers,” the people who don't seem to be fully recovering from COVID-19. He worries about the mass of ICU survivors, like the previously healthy man who came into hospital with COVID five weeks ago, ended up on extracorporeal life support (that heart-lung bypass system) and now, while he's breathing on his own again with oxygen, is so de-conditioned “he may be 60, but he probably feels like he's 90.”
“We're going to be following some of the sequelae of this acute, news- grabbing issue for the next several years. Only it won't be so news- grabbing, because it will just be people with chronic disease that happened a long time ago with something we called COVID.”