Doctors pivot to cope with new reality. DiManno,
When Dr. Kashif Irshad completed operating on a cancer patient the other day, he carefully removed and set aside the single N95 mask he’d used during the procedure.
“I put it in a little envelope and stored it. We’re not going to be reusing it now; we have no process yet to reuse it. But in the future, if we are in dire shortage, we may be reusing them.”
Irshad is a thoracic surgeon. A highly skilled specialist whose deft fingers cut into a human being’s most precious organs: heart, lungs, esophagus, trachea.
But on Tuesday, as on most days over the past few weeks, he was administering to anxious patients in the drivethrough COVID-19 testing station at the William Osler Health System complex in northern Etobicoke.
At this drive-through, just off-site from Etobicoke General, patients never get out of their cars, from registration at the gatehouse to intake screening and perusal of the selfassessment form (five questions posed) at the next pit stop, to nose swab at the giant marquee tent. Then, beepbeep, off you go — unless the symptoms presented are severe enough to require relay to the emergency department. Otherwise, 10 minutes and done, if there’s no queue of cars idling.
A dozen COVID-19 assessment centres have opened at hospitals across the city. Peel Memorial, part of the Osler network, set up testing service on March 11.
“I volunteered because I wanted to be at the front lines,” says Irshad, 46. “I wanted to support our organization and support public health.”
While still doing his other gig, surgery. “We’re getting some cancer patients that we think are important and who may be negatively impacted if they’re not operated on in a reasonable amount of time. We’re triaging them so they don’t fall through the cracks. In the interim, a lot of us wanted to step up. We were urged to and we jumped at the opportunity because we obviously want to help. We want to make sure that our hospitals can deal with this. The surgery volume has come down — we have lots of free time.” Well, hardly free time. Volume for operating-room procedures has indeed been shrunk — what can wait amid a pandemic crisis has been put on hold. And, to be honest, patients would rather not be in ICU or on the ward recovering when hospitals are a petri dish for infection. Same reason that emergency departments are seeing less traffic. If the environment can be avoided, it has been.
Irshad was a fellow at Toronto General, just finishing his training, when the SARS outbreak struck the city in 2003. Like many of his colleagues, he can draw on that experience. Etobicoke General was a SARS treatment centre. “We’re unique because we have that experience.
It was fairly easy to mobilize. We were prepared. But of course we don’t know what’s coming. We’re not 100 per cent sure what will happen next week. We’ve made contingency plans for a surge and we’re starting to see that now.”
As of Tuesday’s briefing by Ontario public health officials, 233 coronavirus patients were in ICU across the province, 187 on ventilators. But the landscape is changing and difficult for even the sharpest epidemiologists to interpret the data.
“We’re not swabbing asymptomatic patients,” Irshad explains. “The criteria changes based on recommendation from the experts. We’re not seeing patients who are destined for the emergency room. We’re seeing patients who have developed symptoms and may end up in emergency. They’ve already sort of screened themselves — pre-screening.”
Yet, as of Tuesday, Irshad said about 90 per cent of the drivethroughs were being swabbed, which is a huge increase from early days, precisely because the public has been paying attention. People are taking their own pulse, monitoring their own symptoms, selfisolating after perhaps virtual consulting with a family physician. Thus, fewer of these drive-throughs — same for other assessment centres — are being sent away without a test.
As well, Irshad has been seeing more patients whose symptoms appeared only up to two weeks after an initial exposure, after they believed they were clear, or even following tests that came back negative.
And of course Canada, unlike some other countries, isn’t testing the general public so there’s no genuine base data for contagion.
“That’s a controversial area,” Irshad observes. “The falsenegative rate is high. Will we starting testing all patients? It’s a possibility. That data is sobering. We haven’t gone there yet.”
Some assessment clinics have practically stalled, yet are bracing for a second round surge.
Dr. Farah Marani has been pulling assessment shifts at Michael Garron Hospital since its clinic — first in Toronto — opened. It’s also the first local hospital to make a public plea for dwindling personal protection gear and has since run donation drives.
“They’re not (welcoming) visitors right now, even to the point if you have a family member in palliation, then you might only see that person for a short period or one at a time. They’re staggering visits. It’s very difficult.”
In the first few days, the volume of patients coming to the centre was quite high, Marani says. “Everybody was anxious and wanting to be tested when they had so much as a sniffle. But since then, the Public Health messaging has gone out that it’s really safer for you to stay at home. Nobody wants to be in a hospital in the middle of a crisis. If you go to a testing site, you might not even get tested.
“Some of the provincial and regional guidelines have been in conflict with one another and we are working to consolidate them.”
Initially, apart from healthcare workers, the emphasis was on recent travellers to outbreak countries, then travellers returning from everywhere. Marani worries about the infected who may have been missed as a result.
“No matter how you do it, no matter what guidelines you have, you’re going to miss cohorts of people. So we’re continually missing people, we just can’t capture them all.”
The guidance remains the same for people who have mild symptoms.
“If they’re asymptomatic and they get tested, then there may be a much higher likelihood of their test result being negative. You go home and you’ll be confident that you don’t have it and you’ll interact with your kids and your elderly parents and that’ll be a risk. So the key is still maintaining social distance no matter what.”
At the Michael Garron clinic, nurses do the swabbing after doctors do the assessment and examinations, scrutinize their vitals. “They’re the brave frontliners,” Marani says of the nurses. “Stable patients for the most part go home, unstable patients go to emergency.”
She looks in particular for breathing difficulties, persistent cough and a crackling in the lungs. “Are they able to finish a sentence without having to take a lot of breaths in between? I care about their breathing and whether they have unstable vital signs. That’s the stuff that’s life-threatening.”
Another assessment clinic doctor, at Women’s College Hospital — she asked not to be identified — emphasizes that most people wanting to be tested don’t actually need it, even as per the expanded protocols. But she does want front-line health-care workers to be routinely tested, whether they present symptoms or not. “To be honest, though, I’ve felt more protected at the clinic, wearing my mask and gloves and gown and shield, than I do going to Loblaws.”
Still, she wonders whether a surgical mask — which is what she’s been issued — is sufficient protection when confronting patients who might be COVID-19 positive, while understanding that the more sophisticated N95s have to be rationed.
“I don’t know if anybody truly understands what appropriate PPE is for this. There’s been so much flip-flopping. But of course there’s the gap between what’s acceptable and what’s available” — in her case, one surgical mask and one gown per shift. “We’re drawing conclusions without clear answers.”
Out at the drive-through assessment centre, Dr. Irshad will finish his shift, head home to his wife and three young children, adopting the same routine that has become … well, routine.
“My nine-year-old, Sarinah, and my six-year-old, Alina, have set up a sanitization centre. I have this big red wagon which we used to pull the kids in when they were younger. In it there’s a sanitizer, a fresh set of clothes, a bag and a snack.
“I don’t know why I get the snack.”