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Ontario hospitals under strain, and a premier under siege

An operating room nurse at Humber River Hospital in Toronto takes a moment last week to look out a window while redeployed to help covid-19 patients in the intensive care unit. (Carlos Osorio/Reuters)
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TORONTO — Children’s hospitals caring for adults. All but emergency medical services canceled. Patients transferred from overrun intensive care units to sites hundreds of miles away, sometimes without their consent.

Severely strained hospitals in Ontario, Canada’s most populous province, are undertaking unprecedented measures to cope as a variant-driven resurgence of the coronavirus tears through much of the country.

There were a record 851 adult patients with coronavirus-related critical illnesses in Ontario ICUs on Sunday, up 156 percent from a month ago, according to the provincial Health Ministry. Nearly 600 were on ventilators.

But critical-care physicians say those numbers don’t fully capture the number of severely ill covid-19 patients. ICUs are so taxed that many patients who would normally be treated in one, including those on high-flow oxygen, are being cared for in hospital wards.

“There’s no other way to put it other than to say that the virus is trying to bring Ontario’s hospitals to their knees,” said Anthony Dale, president of the Ontario Hospital Association.

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Ontario Premier Doug Ford has come under fire for failing to heed warnings that predicted such a scenario, ignoring the advice of scientific advisers and presiding over a clumsy inoculation drive that has failed to get doses to those most at risk of infection. Opposition lawmakers have called on the Progressive Conservative premier to resign.

The Liberal federal government has also drawn criticism from premiers, health experts and political opponents for failing to get vaccines into the country fast enough and for not doing enough to protect the country’s international borders. Amid pressure, it banned flights from India and Pakistan for 30 days last week.

Health-care workers say emergency rooms are swelling with patients who are sicker and younger than during previous surges. Many require oxygen and deteriorate rapidly. They include a number of pregnant women.

“I’ve seen people with no past medical history go to the ICU with an acute respiratory illness at an alarming rate,” said Andrew Healey, chief of emergency medicine at the William Osler Health System, a network of hospitals in Toronto’s hard-hit suburbs.

On Wednesday, Healey was working to match 23 acutely ill patients to hospitals with beds elsewhere in Ontario.

“We’re transferring patients out of the emergency department almost as fast as we’re bringing them in,” he said.

Of the more than 1,200 patients transferred by the air ambulance service Ornge since January, the organization says, roughly half have been moved in April alone. Bruce Sawadsky, Ornge’s chief medical officer, said patients are being dispatched from the Toronto area to as far away as North Bay and Sudbury, several hundred miles away.

Health-care workers on the front lines are taking to social media to share alarming stories.

“Man in 20s with life threatening brain hemorrhage, the most urgent of urgent cases. Can’t take to OR, they’re full of patients waiting for ICU bed,” Nir Lipsman, a neurosurgeon at a Toronto hospital, wrote on Twitter. “Meanwhile, pressure grows, life slipping away.”

Ontario has the fewest acute-care hospital beds per capita of any province in Canada, according to data from the Organization for Economic Cooperation and Development. Officials say they’re trying to increase the number of beds, but health-care workers fear there aren’t enough people to staff them.

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Prime Minister Justin Trudeau said last week that he was working with the provinces and territories to send health-care workers to Ontario. Ford declined Trudeau’s offer to send Canadian Red Cross staff to help with vaccination efforts, saying the province needs more vaccines, not people to administer them.

“If we had tightened our borders, if we had ample vaccines … we wouldn’t be in this position right now,” Ford said at a virtual news conference outside his mother’s house on Thursday, where he is in isolation after an aide tested positive for the coronavirus.

But critics say the province made critical missteps and failed to learn the lessons of previous surges, including the need to act quickly and decisively before case numbers hit a level that could stretch a health-care system.

In February, the Ontario covid-19 Science Advisory Table, an independent panel of scientists tasked with providing advice to the provincial government, unveiled its latest pandemic modeling.

At the time, cases, hospitalizations and deaths in long-term-care homes had fallen. That was evidence, panel co-chair Adalsteinn Brown said, that vaccinating nursing home residents and public health measures including a stay-at-home order were working.

But with more transmissible variants spreading, warned Brown, dean of the University of Toronto’s Dalla Lana School of Public Health, lifting those measures could cause cases and ICU admissions to “rise dramatically.”

“Am I missing something here,” a reporter asked, “or is this presentation actually predicting a disaster?”

“No, I don’t think you’re missing anything,” Brown said.

But days later, Ford lifted the stay-at-home order in much of the province. Some nonessential businesses reopened. Hard-hit areas, including Toronto, followed in early March.

Andrew Morris, a member of the advisory panel, said that while there have been many missteps, that one was “pivotal.” By April 1, indicators were blinking red. Cases had jumped 150 percent in one month. Hospitalizations had risen 40 percent over two weeks. There were a record number of covid-19 patients in ICUs.

Over the next several weeks, Ford made multiple announcements of new restrictions. Critics cast some as half-measures that lagged the virus’ trajectory.

Ford pulled an “emergency brake” one week, imposing capacity limits on businesses and closing indoor and outdoor dining. ICUs continued to swell.

A week later, nonessential businesses were closed and Ford imposed a stay-at-home order. Schools also were closed, one day after officials said they would stay open.

Solicitor General Sylvia Jones, pressed on why the province didn’t act sooner, said officials “wanted to make sure” that “the modeling was actually showing up in our hospitals.”

This month, during another bleak modeling presentation, Brown was asked whether the situation facing hospitals was the “disaster” his modeling predicted in February.

“This is what we were expecting moving forward if we relaxed public health measures,” he agreed.

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Ford then announced new measures, including the closure of playgrounds and other outdoor amenities. Vaccine supply to hot spots would increase. Police would be given authority to stop people on the street to check whether their trips were essential and ticket them for noncompliance.

The province erupted. Dozens of police forces said they wouldn’t conduct random stops. Infectious-disease experts and weary parents asked why playgrounds were being closed despite a dearth of evidence that they’re driving transmission, while few measures targeted workplaces that have been the site of large outbreaks.

The University of Toronto’s Dalla Lana School of Public Health, as if at a loss for words, weighed in on Twitter: “ …”

“I was so angry. I was furious. I was shocked,” said Lisa Salamon, an emergency room physician with the Scarborough Health Network. “ … I felt the patients that I care for in my community got spit on.”

The next day, the Ford government reversed its decision on playgrounds and backed off some of its police enforcement measures. But the damage had been done. Members of the science panel said they had never recommended those measures. Opposition leaders called for Ford’s resignation.

Ford finally apologized last week for some of his enforcement measures, including expanding police powers, saying they “went too far.”

He said he was “working on our solution” to a paid sick-leave program, but offered few details. That’s a measure front-line health-care workers have long urged, as their hospitals filled with infected essential workers, many of them from low-income multigenerational households who said they had feared losing paychecks if they stayed home.

Health experts say the federal government is not without blame.

“The federal government has largely become a procurer of drugs and vaccines and other supplies, but they haven’t led strategically,” Morris said. “They have halfheartedly tackled the importation of cases by travel in a manner that has substantially increased risk.”

Healey said provisions for an emergency standard of care, in which health-care workers would make decisions about who gets potentially lifesaving treatment and who doesn’t, have been readied for use but not yet activated.

“The fact that we’re starting to have to review these things and that this is even in discussion and that we’re even scared that it’s going to come to that — never in my career would I think I would be in this position in Canada,” Salamon said.

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