Tough calls may await as COVID slams Alberta
A spike in cases means health workers may need to triage ICU patients
CALGARY—When the first wave of COVID-19 — then an ominous and unknown virus — hit, Kathy Bouwmeester updated her will, put on her gown and face shield, and got to work.
The registered nurse in Calgary has worked in intensive care units for two decades.
She tended the sickest of the sick through H1N1 and SARS, but still sounds surprised at how the events of the past year have pushed hospitals in her province to the brink.
“We’re committed to our patients and their families, and even though there’s limits to what we can do, we’re doing our very best,” she says.
The fourth wave of this pandemic has come on faster than the ones before it, she says, and it’s all the more punishing for being avoidable. It’s been hard watch the unit fill up with peo- ple who aren’t vaccinated, as protesters rage against public health restrictions outside.
“We’re fighting this battle, this war, for people who don’t care.”
Some fear, however, that the worst may be yet to come for Bouwmeester and her colleagues.
There is concern that the assumption upon which Canadian health care is built — that if you’re seriously ill, you will get the best care the system can muster — could crumble in COVID-hammered Alberta, where some doctors fear they may soon be forced to choose who gets critical care treatment, and who does not.
Spiking cases in the province have prompted warnings from doctors that the province is, for the first time, hurtling toward a triage situation for its intensive-care units.
With some of the laxest pandemic restrictions in the country, Alberta is battling a fourth wave that not only threatens to dwarf all previous waves of this pandemic but is the most punishing in the country. During the past week, the Prairie province posted just over 10,000 active cases — more than Ontario and Quebec combined.
With extreme conditions may come tough calls. During the first waves of disease last year, some hard-hit countries made headlines for the heartwrenching decisions forced on doctors. In Italy, for example, some COVID-19 patients were deemed too old or sick to qualify for the most invasive interventions.
Here in Canada, many provinces, Alberta among them, updated their plans for what to do if hospitals became similarly “overwhelmed,” but healthcare workers largely managed to hold the line through successive waves of disease.
Now, some doctors worry Alberta may be the first to have to use its ICU triage protocol.
ICUs are where the battle between life and death has been most often fought during this pandemic.
In can take more than an hour to welcome a new COVID patient to the unit. Patients get a line in their neck to administer medication, a line in their ribs to monitor blood pressure and a bunch of X-rays. Finally, they’re flipped onto their front to help them breathe — a process which requires multiple nurses working together.
So what happens if there are not enough ICU resources to serve every patient who needs them?
The answers to that still-very-hypothetical question are laid out in a 52-page Critical Care Triage protocol.
It’s not clear whether the protocol could be trigged within days or weeks, or even if it’ll be triggered at all. Even doctors raising concerns remain hopeful it can be avoided through stronger public health measures, masks and vaccination. The government says it will do all it can to avoid such a scenario, by opening as many beds as possible, transferring patients and doing what’s called loadlevelling, where staff, equipment and medications are shared within regions, and even within the province, to make sure work is spread out.
But some worry the province is closer than it’s ever been to using the protocol. The province is asking medical staff to brush up on the document, just in case. Here’s how an ICU triage policy would work in Alberta, if it came to pass.
Trying to save as many lives as possible
The decision to use a triage policy would be made by the CEO of Alberta Health Services in consultation with the organization’s senior leadership team. It would apply to all health-care facilities and critical-care units. Measures would be dialed up or down, depending on strain on the system.
Referring to “ICU beds” is a slight misnomer. It’s not the beds themselves or even equipment, such as ventilators, that are the limiting factor, but the highly trained doctors and nurses who treat the patients.
Anticipating brutal decisions
If, say, a 38-year-old COVID-19 patient and a 50-something motorcycle crash victim came into emergency room at the same time, doctors would consult
with critical-care teams to decide who was mostly like to survive in a critical-care bed, explains Dr. Paul Parks, president of the Alberta Medical Association’s emergency medicine section and an ER doctor in Medicine Hat, Alta.
If there were limited resources, that more-likely-to-survive person would get the heightened care.
If doctors can’t decide which of two patients was more likely to survive, each sick person should get equal chance of treatment. That means intensive care beds would be given on a first-come, first-served basis, determined by the first time stamp on their paperwork. If two patients with equal likelihood of surviving arrive at the same time, random selection will be used to decide who gets admitted.
The document notes that everyone has the same “moral worth.” Who gets critical care would not be based on characteristics such as age, sex, race or disability alone, but on individual medical assessments of the patient.
The protocol includes two different stages, with the bar for getting critical-care treatment getting higher as pressure on the system increases. At the second stage, the plan lays out the possibility of discontinuation of care — meaning, doctors would have to decide whether they should take people off support to give their bed to someone more likely to live.
The protocol lists people who have had cardiac arrest and who are responsive to interventions for more than 20 minutes or patients with “severe traumatic brain injury” who have “little chance of functional neurologic recovery” as examples of those whose care might theoretically be discontinued if the protocol were in its second phase.
According to the document, discontinuation of care “is not subject to consent or appeal.”
Would your vaccination status affect your care? Maybe
One issue currently being debated is where vaccination status should rank in ICU triage protocol decisions.
Parks stresses that medical professionals do not judge those who are not vaccinated.
There is data showing that those who have had the shot are more likely to survive COVID-19, which might work in people’s favour when trying to predict whether they’ll survive.
What about people with disabilities?
The same eligibility criteria would apply to all patients, and AHS says people with disabilities will not be discriminated against.
What happens to those who don’t make the cut?
Parks is clear that someone who wasn’t chosen for the higher level of care would not be ignored. Staff would continue to do their best to treat them with the resources available, but it would be inevitable that some would die who might have been saved in normal conditions, he says.
Over the weekend, 65 infectious-disease doctors signed a letter addressed to Premier Jason Kenney calling for action, predicting that the number of COVID-19 patients in intensive care would double every two weeks, pushing the health-care system to the “precipice of collapse.”
The prospect of the triage protocol being triggered terrifies medical staff, Parks says.
“Morale is very low and fatigue very high for all of us right now,” he says.