Dr. Wael Haddara is a Chair Chief of Critical Care Medicine at the London Health Science Centre. (Wael Haddara)
There are more people than ever before being treated for COVID-19 in intensive care units across Ontario.
No one knows what that looks like or its implications better than London Health Sciences Centre’s Chair Chief of Critical Care Medicine, Dr. Wael Haddara. He spoke with London Morning guest host Allison Devereaux.
Q: What is the situation at Victoria Hospital and at University Hospital?
We’re seeing an increase in numbers, along with the rest of the region and the province. We’re not as hard hit as some other hospitals, but the pattern has certainly been very alarming with the increase in admissions over the last two weeks or so.
Q: What have your days been like since the second wave hit?
They’ve been long and challenging. You know, we deal with the sickest of patients in the ICU. And so the entire team in the ICU, nurses, physicians or therapists, pharmacists, social workers. You know, we have to continue to coordinate for the care of the patients, often in full PPE garb. And so that makes for very long and difficult days.
Q: Can you elaborate on that a little bit more? How are the challenges related to a COVID-19 illness different from what you would normally see in the ICU?
Sure. So, you know, this is a brutal virus. Some people, as you know, are entirely asymptomatic with the virus, and that’s how they pass it on to other people. But a subset of people, it hits them very, very hard. And for many of us in intensive care, it’s unlike anything that we’ve seen before in terms of how sick people get and how quickly they deteriorate. So it feels like you’re almost always playing catch up to the disease. Some of the traditional things that we do in ICU don’t quite work for these patients. Some of the ways that we traditionally, say ventilate patients, don’t seem to do much good for patients who are severely hit. And so we cycle through a lot of different ways of managing and treating patients until we find the one thing that works for a particular person.
Q: How do you deal with the anxiety that you or someone in your family could contract it?
This is a challenge that I think all of us deal with. We try to deal with it in in the professional way that we’re trained to. You focus on what you can do. You focus on good infection control habits. People are obsessive about washing their hands, changing their clothes when they get home. If they’ve had an exposure, they report early and make sure that they’re monitoring themselves for symptoms. But it weighs on you for sure.
Q: Should the lockdown have started sooner?
It’s certain that the numbers have been going up for a number of days, and I think many people have been calling for a lockdown earlier. But I don’t want to make light of how difficult a decision this is. There’s obviously disease transmission, but there’s people’s mental health, particularly over Christmas, and the sense of social isolation that can be very real for some people. And then, of course, there’s the economic side of things. So I would have liked to see a lockdown earlier but I think we have to understand that for the government, this is an exceedingly difficult decision.
Q: What message do you have for Londoners who question the seriousness of COVID-19?
My message is to say, we have done so well for so long, you know, nine long and agonizing months. We need to barrel through this, you know, for the next eight weeks before the weather gets better and we can get outside and socially distance. Let’s try and reach within ourselves to find the resilience. It’s only a short period of time.
This interview has been edited for length and clarity.
Left Dr. Robert Arntfield, right Dr. Wael Haddara.
LONDON, ONT — While it may be human nature to grow increasingly concerned over the rising positive COVID-19 case counts in Ontario, a pair of London’s top intensive care unit physicians say it’s not the only measure we should be looking at. Far from it, in fact.
Thursday saw yet another day north of 400 as far as positive cases in Ontario, but such numbers are not unexpected, says Dr. Robert Arntfield.
“If we increase socialization, if we engage with one another, we put people back in schools the cases going up is not a mystery or surprise. In many respects it’s not even news in my opinion, it’s expected.”
Dr. Arntfield is the medical director of the intensive care unit at Victoria Hospital, London Health Sciences Centre.
He says rather than just case counts, a more complete measure of covid-19 severity is hospitalization rates and deaths.
“Other countries that have seen really big second wave numbers, a lot in Europe, have seen a really different response in terms of hospitalizations and deaths. They have not seen the same magnitude. There certainly is a magnitude and there is an importance to that, but it is not anywhere near the same level that we saw back in the early wave.”
As of Thursday there were fewer than 100 COVID-19 hospitalizations in all of Ontario, and in London there have been none in the past week according to Dr. Wael Haddara, the Chair of Critical Care at LHSC.
He says if that changes, intensive care units are far better prepared than in spring.
“We have a very robust plan in place in terms of IC beds, creating capacity to accommodate patients if we need to. So we’re hoping for the best but preparing for the worst.”
And while it’s a message that’s heard time and again, both doctors continue to stress that how well we follow social distancing rules will go a long way to determining how we fare during this second wave of infections.
According to the Ministry of Health and Long Term Care, people under the age of 40 account for roughly two-thirds of the most recent cases. While their hospitalization rates are much lower than older demographics, it’s still a major concern says Dr. Haddara.
“The challenge is that younger people don’t and should not to exist in a bubble from the rest of society. And so as younger people encounter older people the rates of hospitalization will be very similar to what we saw in the spring. No man is an island.”
A new research study from Western University researchers says that returning students in university towns could double the number of COVID-19 infections.
The study by researcher and lead author Lauren Cipriano, associate professor of management science at Ivey Business School, who is also cross-appointed to the department of epidemiology and biostatistics at Schulich School of Medicine & Dentistry, projects that the return of university students can lead to a doubling of infections over a single semester in mid-sized communities with previously low levels of COVID-19 activity.
The new research paper, “Impact of university re-opening on total community COVID-19 burden”, said more than two-thirds of infections attributable to the return of university students occur in the general population, leading to increased COVID-19 hospitalizations and death.
Cipriano said the findings are important for making public health decisions and suggests that mass screening and high-frequency testing of students can make a significant difference.
While screening the student population frequently may be challenging, the study argues a one-time mass screening event at the end of September would help identify and isolate a large fraction of asymptotic infections in the student population to reduce community infection.
“We know a third of cases are asymptomatic and as we move into a younger demographic more people are asymptomatic, and it’s important to identify those people not necessarily for their own health information but testing for prevention,” Cipriano said.
“The choices communities make around what types of businesses to open, diligent masking, and the amount of physical, social interaction will determine the feasibility of maintaining essential activities like in-person primary and secondary education and continued access to elective surgeries.”
The research, funded by the Western University Catalyst Research Grant and a grant through Johns Hopkins University, uses a model of COVID-19 transmission and hospital resource utilization in London.
“Fortunately, university students are an identifiable high-transmission group, and our research shows that even a one-time mass screening event early in the term can identify asymptomatic infections and influence the transmission trajectory,” Cipriano said.
As of Tuesday, at least half the 49 cases reported over the last week involved Western University students. At least two outbreaks declared by the health unit last week were associated with Western students.
One outbreak, declared in the wake of a large house party last weekend, has been linked to at least 17 cases, while another, “Western Student Outbreak Alpha,” has also left at least 17 people infected.
At least two COVID-19 cases reported in the area are Fanshawe College student.
Cipriano said they modelled the study off of what is happening in London but said the work represents a lot of midsized cities with large college and university populations across North America.
The model looks at the number of infections expected in the university student population, the general population, and long-term care residents, with and without the return of the student population. It also incorporated people’s responses as numbers increase and hospitals gain more patients also taking into account the COVID-19 mortality in the community.
“We have a limited opportunity to make a significant difference in the course that this virus will take in our community, and the time for a coordinated mitigation event is now,” says Dr. Wael Haddara, study co-author and chair and chief of critical care medicine at London Health Sciences Centre.
Haddara said they hope they can build on the strong partnerships that are already in place between the city, university, public health, primary care, long-term care, and the hospitals to bring evidence-informed mass screening solutions to practise.
As the first wave of the coronavirus is subsiding, we have time to begin to survey the damage it is leaving in its wake.
We have already become aware of the impact of the coronavirus on minority and disadvantaged communities. We are now attuned to the dismal state of elder care, particularly in the two largest provinces in Canada. We have a sense of the deep disarray many public health units are in, and the fragmentation of our public health response. We felt the absence of a national procurement strategy for the supply of sufficient personal protective equipment to the front lines.
But there is one gaping need that has been exposed during this first phase of the pandemic that has not caught the public’s attention, and that is the sustainability of our health-care system. Unless policy is crafted carefully over the next few months and years, the nature of our universal health-care system will be one of the victims of the coronavirus.
When we think of health-care costs, many Canadians, abetted by politicians, think of doctors’ billings, nurse salaries and drug costs. While those are important drivers of cost and performance of our health-care system, one other item rarely shows up on the spectrum of costs: capital investment.
Capital investment is needed in three major areas: infrastructure, technology, and training and human resources.
Many hospitals and institutions are housed in buildings that date from the middle of the last century and require significant infrastructure support to bring the buildings up to the necessary standards of the third decade of the 21st century. The result is inadequate facilities that sometimes hinder best practices in infection control and patient-centred care, but also incur exorbitant costs associated with any renovations due to the age of the buildings.
The pandemic has exposed the dearth of investment in technology at many levels. Within hospitals, patients must still be brought to areas where an additional level of care is available rather than have the technology and the appropriate level of care delivered in their location. Surgical patients must be moved from surgical wards to the intensive care unit to receive a particular kind of monitoring or certain drugs or to have eyes on the patient. Yet sophisticated remote monitoring exists that would allow patients to receive the appropriate level of care in many instances in the environment where caregivers know them best.
This applies even more urgently to smaller community hospitals, which often must transfer patients to larger centres simply for higher levels of monitoring. In contrast, in the United States, remote or virtual ICU technology is part of the health-care landscape with larger centres providing remote monitoring and advice for patients in smaller hospitals without having the added burden and cost of transfer.
Finally, the pace of new equipment and procedures has accelerated in the past two decades. Training nurses, physicians and other health-care workers to become competent with these procedures and equipment requires ongoing training. Many hospitals have had to significantly limit their training budget as their operation funds have been clawed back by successive government cuts.
As the acute phase of the coronavirus recedes, and hopefully the epidemic is brought under a measure of control with the arrival of a vaccine, we will be left with the economic devastation that has resulted in terms of not only a changed economy, but also the added debt burden.
Before the coronavirus struck, Canadian provinces had a debt burden ranging from 44 per cent (Saskatchewan) to 75 per cent (Ontario) of GDP. These figures do not include the federal debt. While the cost of borrowing will likely remain low for some time, the impact on government spending will be inescapable.
Historically, capital spending on health care has gone through wild swings that outlast the election cycle. Without innovative solutions, it is likely this pattern will continue, and be exacerbated by the current economic outlook.
The situation is not entirely bleak, however. There are a range of possible solutions that would both protect the public coffers as well as provide the necessary investment for our health-care system to not only survive but also be ready for the next major crisis.
Investments in technology, including remote monitoring, can result in immediate cost savings and may be possible to implement through public-private partnerships. Investments in infrastructure can result in avoidance of billions of dollars in maintenance. For example, a 2015 study estimated deferred maintenance costs accumulated by Canadian hospitals to be between $15 billion and $28 billion.
We will face difficult economic choices in the near future. But if we are to preserve a universal health-care system that lessens rather than exacerbates structural inequities we must invest in innovative ways of rebuilding the system. To carry on as before will result in the certain dismantling of our health care, and by proxy, possibly the last remaining equalizer in our society.
Wael Haddara is chief of critical care at London Health Sciences Centre
In this series, AMS Healthcare addresses the challenges facing healthcare today – particularly in light of the COVID-19 pandemic. The AMS Community promotes compassionate care, development of the leadership needed to realize the promise of technology and the understanding of how our medical history influences the future of our healthcare. A new piece will be posted every Friday on Healthy Debate.
The order of business for most countries today is responding to the COVID-19 pandemic and preparing for what may come before a vaccine is available. Governments and nations are focused on essential tools such as hospital beds, personal protective equipment and physical distancing while also worrying about how to stave off economic disaster.
However, the success or failure of this battle will not only be determined by material readiness, which is of course essential. There is one other factor that will make the difference: Character, both of individuals as well as the collective.
We have been engaged in an effort to highlight the impact of character-based leadership on the practice of medicine. The pandemic has brought this important but sometimes neglected element of medical education to the front and centre.
History has much to tell us about how nations survive pandemics. As Western societies, we often boast of the Athenian roots of our brand of democracy and Athens can teach us an important lesson in the importance of character-based leadership in pandemics.
Plague in an ancient city.
In 430 BC, the city-state of Athens was a dominant force politically, economically and culturally and its citizens saw themselves as morally superior and enlightened. Then came the great plague of Athens that devastated the city. As the historian Thucydides chronicled, “When it attacked anyone, it was beyond all human endurance. The bodies of those dying were heaped on each other, and in the streets and around the springs half-dead people reeled about in desperate desire for water.” Almost a third of the city perished.
What followed was a breakdown of social order. Athenians became despondent, demoralized and unhinged and their sense of decency, virtue and honour withered. Those few whose character, courage and selflessness drove them to help others suffered the highest mortality and this weighed heavily on people’s consciousness. Many refused to behave honourably because they did not expect to live long enough to enjoy the rewards of a good reputation. The pre-pandemic Athenians who were sure of their moral grit and virtue came to face a different reality and abandoned the values that had been at the heart of their civilization. Ultimately, it was not only lives that were lost but eventually democracy as well.
As historian Katherine Kelaidis put it, “For Thucydides, the death and suffering of a great epidemic (just like war) test the moral health of individuals and of societies. And a people who are not morally strong, when they become afraid, quickly slip into lawlessness and sacrilege.”
Thucydides saw the collapse into immorality as being latent and only exposed by the plague, “Men who had hitherto concealed what they took pleasure in, now grew bolder.”
This sounds all too familiar today. The great toilet paper wars, the gun-toting demonstrations in support of re-opening and the betrayal of our seniors in long-term care are all signs of character gaps made manifest by this pandemic, not created by it.
Crises and situational pressures don’t only unmask the character of societies but of leaders as well. Athens had Pericles, who despite horrifying conditions commanded the people’s trust. When they lost their character, Pericles helped them regain perspective. He implored Athenians to reaffirm their values and rise above their selfishness: “You must therefore put aside your private sorrows and concentrate on securing our common safety. Hatred is short-lived but the brilliance of present deeds shines on to be remembered in everlasting glory.”
Thucydides reports that Pericles was an effective leader because he resisted giving in to the base desires and fears of people and instead inspired (at least some of) his followers to a more noble vision. Pericles himself was to die of the plague the following year.
Photo by Charles Deluvio on Unsplash
Today, we have leaders in health care and politics who have modeled the very best in character and have inspired their followers to rise to the challenge. And we have others who have chosen to stoke anxieties and fears and encourage racism and xenophobia. The pandemic did not create those leaders, it merely revealed them more plainly for everyone to see.
So what are we to learn from all this? We as a society, our leaders, and our educational institutions have focused our efforts on competence, science and technology and have lost sight of the importance of developing character. This neglect may go without consequences for some time but eventually a situational pressure, a crisis, will come along to reveal the gaps. A circumstance will inevitably arise for all leaders in which their characters are tested, and if left wanting, will undermine their ability to lead. The work of protecting our nations from the ravages of the pandemic begins, but does not end, with material readiness.
We must refocus our energies on the importance of nurturing character once again. The last decade has seen significant movement on this front, notably the Ivey Business School’s Character-Based Leadership model. A group at the Schulich School of Medicine at Western University is adapting this model to medical education.
Through a renewed sense of importance of this topic, a future generation of leaders can emerge understanding the importance of character and, more importantly, manifesting character so that instead of future crises revealing disgraceful gaps, they will reveal a depth of character of which we can be proud.
Nabil Sultan is an associate professor of Medicine, medical educator and former Program Director of Nephrology at the Schulich school of Medicine & Dentistry. He is a researcher in the Centre for Education Research & Innovation at Western University.
Wael Haddara is an associate professor of Medicine, medical educator and Chair of Critical Care Medicine at the Schulich school of Medicine & Dentistry. He is a researcher in the Centre for Education Research & Innovation at Western University.
I wrote this back in 2004 and published in the London Free Press in response to a columnist’s suggestion that Doctors are “milking the system”… It has some relevance now with the unilateral moves by the Ontario Government to decrease doctors’ fees. I should state that I am in support of some fees being reduced in light of technical advances made that have enabled physicians to treat more patients. Having said that, it is abundantly clear that the Ontario government pays physicians considerably less than what individual patients would be willing to pay if this was a free market economy.
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[…] thinks I am overpaid. Well, he did not mention me specifically, but he thinks physicians’ incomes represent an enormous burden to the taxpayers.
Funny that. While few physicians I know are poor, most are not exactly wallowing in cash. The point most physicians take issue with when we read criticisms of this sort is the value people seem to attach to their health compared to other commodities.
The present set up – where the government is the single payer tends to ensure that physicians are paid less that what the population at large would be willing to pay. Consider the following example: A physician is on call at a hospital. At 3am, a 58 year old male patient experiences what the Government of Ontario’s Ministry of Health and Long Term Care euphemistically calls a “Life Threatening Emergency Situation.” In lay terms, that means that his heart or his breathing have stopped. (We used to call this death until we realized that it could be reversible and death was supposed to be irreversible). A sequence of events is activated, culminating in a number of overpaid health care professionals, including the physician, responding to this emergency in an attempt to resuscitate the patient.
It is difficult to explain what it really means to be at a dying person’s bedside at 3 in the morning, knowing that you have only a few minutes to take very specific actions that may mean the difference between life and death. We break down the process into individual components to which we give sanitized terms like “securing the airway” or “obtaining intravenous access.” In the meantime, you’re furiously drawing upon every last bit of knowledge and experience you have accumulated to understand why this man is dying and how to stop this from becoming permanent. When it’s all over, someone has either just died in front you, or, if they have survived, you’re still going over the events in your mind hours and days later.
The big question, of course, is how much […] would pay for the performance of this service. I haven’t asked him, but I am certain that most people would pay more than what the government pays. The “system that has paid off handsomely for health care workers”; the government that has “caved in” to the demands of physicians will pay roughly $120 for an average resuscitation attempt.
If the physician attending to the patient is the intensive care physician and the patient actually survives, that physician receives no remuneration for his or her efforts.
What else can you get for $120 these days? Ironically enough, two tickets to the upcoming Melissa Etheridge concert at the John Labatt Center cost $122. The concert could very well sell out. Some people may complain, but most understand that this is the cost of bringing a big ticket item to town.
As I mentioned in the beginning, most physicians are hardly poor. However, the vast majority of physicians I know are not practising their profession for the money either. For the same amount of training and education – the current minimum is 8 years, the average is closer to 12 years – most would make more money doing other things. Many consider their practice of medicine to be a privilege – the privilege of being able to attend at a sick person’s side and provide help in their time of need.
And if you are the person dying in a hospital bed at 3am you had better hope that the physician resuscitating you is not doing it for the money, because, frankly, the money is not worth it.
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Addendum: Since 2004, the amount paid for an average resuscitation attempt is around $165.75 – this represents an increase of $25 dollars in real terms (after adjusting for inflation) ie a raise of ~2% per year. The question does remain, though: in 2012: What can you buy for $165.75?
