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(L to R) Dr. Shaf Keshavjee, Dr. Fayez Quereshy, Dr. Barry Rubin, Terri Stuart-McEwan, Dr. Tom Waddell, Donna Williams
An inside look at how UHN’s surgeons are dealing with the novel coronavirus
In early March, Dr. Fayez Quereshy, Clinical Vice-President at University Health Network (UHN) and a surgical oncologist in the Sprott Department of Surgery, received a flurry of texts from colleagues in Italy and Spain warning him about COVID-19. At the time, the Canadian public wasn’t sure what to make of the novel coronavirus, especially with cases still in the single digits, but Dr. Quereshy’s European colleagues knew what was coming. “This is very real, and it’s scary,” the texts read. “We don’t have enough ventilators. Patients are coming to our emergency departments, and they’re super sick.”
Those reports from abroad motivated Dr. Quereshy to organize an emergency meeting with leaders at the Sprott Department of Surgery, including Dr. Shaf Keshavjee, Surgeon-in-Chief and the James Wallace McCutcheon Chair in Surgery; Terri Stuart-McEwan, Executive Director, Surgical Services in the Sprott Department of Surgery; Dr. Barry Rubin, Medical Director of the Peter Munk Cardiac Centre at UHN, Peter Munk Cardiac Centre Medical Director Chair and vascular surgeon in the Sprott Department of Surgery; and Dr. Tom Waddell, Head of the Division of Thoracic Surgery in the Sprott Department of Surgery, the F.G. Pearson-R.J. Ginsberg Chair in Thoracic Surgery, the Richard and Heather Thomson Chair in Thoracic Translational Research, and the pandemic lead for Sprott Surgery.
For hours, the group sat together, creating a plan to keep surgery patients safe – an Italian study found that 40 per cent of post-surgery patients who had the coronavirus didn’t survive. Plus, the Sprott Surgery team realized they had to start conserving drugs and personal protective equipment (PPE). “Countries were facing shortages of masks and gloves, and the same drugs that were helping keep COVID-19 patients alive in other places were also the drugs we needed to anesthetize patients for an operation,” recalls Stuart-McEwan. “We were scared.”
At that meeting, the group decided to operate on only those who required emergency care or would be at a risk of significant harm if they weren’t operated on in the next two weeks. “It was pretty bold to say an organization that does upwards of 2,000 surgeries per month would go down to double digits. But all of us felt that by doing this, we could save Ontarians’ lives,” explains Dr. Quereshy. “We knew we had to act quickly,” adds Dr. Keshavjee. “If we didn’t do something radical, we were facing the potential of overwhelming the entire healthcare system.”
Sorting out staff
There was also immense pressure on human resources. By late March, OR nurses were being pulled into the intensive care unit (ICU) to prepare for the expected surge. Hospital projections estimated that by mid-April, 240 patients would require ICU beds, but the ICU only had 90 beds, says Dr. Rubin. The group was also aware that, as Dr. Rubin puts it, “the sickest COVID patients from all over Ontario … they’re coming here.” That’s because UHN is the only hospital network in Ontario that provides Extracorporeal Lung Support (ECLS), a state-of-the-art machine, reserved for life-and-death situations, which keeps people with severe lung failure alive. ECLS pumps blood with oxygen through a patient’s body and can take over the work of the heart and the lungs if they both fail.
Once Sprott Surgery’s leadership knew they would only operate on the most at-risk patients, they had to figure out who those patients were. Dr. Keshavjee gathered the heads of Sprott Surgery’s 13 divisions to create categories of urgency for surgery cases. They also organized surgical teams to be “on” and “off” to ensure surgeons wouldn’t all get sick at once if COVID-19 swept through the hospital.
March was one of the more challenging months – physically and emotionally – in the leadership team’s careers. Everyone put in 12-plus-hour weekdays and often worked on weekends. Dr. Quereshy found himself frequently unsure what day of the week it was, while Dr. Rubin moved into his daughter’s condo (and she moved in with her mom) so he wouldn’t expose his family to the virus. When Stuart-McEwan developed and communicated the new protocols to teams, she’d take the time to listen to their fears – knowing her own nurse daughter was among those at work in the ICU. There were also urgent 11 p.m. meetings where many medical issues were discussed. “We’d often have to say, ‘There isn’t a randomized trial for this. We’re just doing the best we can with the best information we have.’ People understood. We were in it together,” says Dr. Keshavjee.
The shutdown required close communication between surgeons and their divisions. Before the pandemic, each surgeon scheduled their patients within their individual allotted time slots. Because of COVID-19, they had to schedule surgeries in coordination with the entire Sprott Surgery team to ensure a less urgent case wasn’t scheduled before a more urgent one, says Stuart-McEwan.
The decisions weren’t always easy. Dr. Quereshy recalls a patient with rapidly spreading cancer. The operation to save their life would be done in two stages, by two separate surgeons. Dr. Quereshy and the other surgeon were worried about how long the patient would have to stay at the hospital afterwards, where they might be exposed to COVID-19. They knew the patient had a young family at home. “I remember standing in the hallway, feeling really conflicted about what decision we should make,” he recalls. “But we went ahead, and they’re now cancer-free.”
Patients with COVID-19 treated with Extracorporeal Lung Support at UHN
The hardest part was calling patients and letting them know their scheduled surgeries wouldn’t go ahead as planned. “What’s amazing is no one pushed back,” says Dr. Quereshy. “Certainly, our frontline care providers are heroes, but patients are amazing and heroes as well.” While patients waited, doctors continued to monitor their health through tests and imaging. In some cases, they called patients multiple times a week to ensure their conditions weren’t worsening.
Donna Williams and Rose Puopolo, Nurse Managers of Perioperative Services in the Sprott Department of Surgery, were involved in scheduling patients. Surgeons went from having operations back to back to coming in for just one or two procedures, often on short notice. As leaders, Williams and Puopolo were present for many of the surgeries, where they would make sure staff were carefully donning their protective equipment in the right order and the right way. “Everyone was nervous. The information about what kind of PPE staff should be wearing, and when, was changing frequently,” says Williams.
In a fortunate coincidence, Sprott surgeons had a tool to help them prioritize and schedule patients. For the past year, Stuart-McEwan and Dr. Waddell had been collaborating with Boston’s Institute of Health Care Optimization to fine-tune operating room scheduling according to urgency. With models based on previous patient volumes and a dashboard of available resources, from hospital beds to anesthesia to nurses, staff could schedule surgeries in order of urgency with little risk of cancellation. This tool turned out to be extremely helpful during the pandemic, when operating rooms went down to four from more than 30. “We could make much more calculated, granular decisions about scheduling,” explains Dr. Waddell.
Preparing for the new normal
All the measures they put in place were working, but by May the backlog began to grow to worrying levels. “We felt the pressure,” says Dr. Rubin. Fortunately, some restrictions were lifted that month, and they were allowed to increase their case load. As of August, Sprott surgeons were doing about 80 per cent of the operations they had been performing before the pandemic. Doctors continue to work in close coordination to ensure the most urgent patients are operated on first.
If there’s one silver lining to COVID-19, it’s that Sprott Surgery’s leadership team has had to reimagine patient care. In this “new normal,” as Dr. Quereshy calls it, minimally invasive technologies will be used more frequently to reduce hospital stays. Virtual visits, in which doctors can walk their patient through an upcoming procedure or answer any post-surgery questions, will also become the norm. “Patients will get even better care,” says Dr. Keshavjee. “Instead of someone having to travel far to see me for 15 minutes, we can talk on video. It’s better for everybody.” Clearly, the pandemic has tested the limits of modern-day medicine, but Sprott Surgery was ready to take on the challenge.
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