The Taut Front Lines

"There are places that have shortfalls, there are decisions being made because we don't have the supply, period. Nobody at the moment has an understanding, a full Canadian understanding of how much PPE [personal protection equipment] is in stock at each facility."
"For every one patient who is on a ventilator, for every single day, you're talking somewhere in the order of hundreds of pieces of PPE when you add up the gowns, the gloves, the masks."
"When the prime minister says they have all this supply coming, how is it going to be distributed? How are they going to figure out where the need is? they have no idea, because nobody has done that work."
"We've started that work here; we're working on that frantically to figure that out. We're all on edge. This feels like the Viking ships are on their way, we don't know how many ships there are, we know that when they arrive they're going to pillage, destroy. We don't know how much we're going to be able to fend them off."
"We're just hoping they're just sending one ship, and we've got enough people to battle them. We just don't know."
Dr.Andrew Morris, infectious diseases specialist,Sinai Health System/University Health Network, Toronto

Doctors treat COVID-19 patients in an intensive care unit in Rome, Italy. Antonio Masiello/Getty Images

The community is agitated and concerned; no one wants to become infected with the novel coronavirus and most everyone is following recommendations to self-isolate, to practise great caution, to maintain a two-metre distance from others, to religiously wash and soap their hands for a protracted scrub, to be vigilant about what they come in contact with. The news -- all the news, everywhere -- is suffused with updates on the lightning speed of infection and the number of hospitalizations, much less deaths from respiratory collapse.

And then there are the health professionals, both doctors and nurses and others, those engaged in cleaning the hospital environment to make every effort to reduce the chances of a silent, lurking virus invading the closest human body, to replicate and to re-infect endlessly in a spiral of mass infection. Medical staff are in close contact with the ill; their profession demands it of them to serve the needs of the sick, leaving medical personnel in a moral quandary; what about their personal obligation to their own longevity, to their families?

Everything is hugely complicated by the fact that hospitals have insufficient personal protection equipment for their staff, leaving them vulnerable to infection while they tend to the needs of those infected. The rate of death of clinicians, of attending physicians, of caring nurses, of paramedics has astonished and frightened everyone in the medical fraternity. They are more exposed, the viral load they may be infected with may account for their increased mortality. This is their profession, one they are proud of and protective of. At a new, harrowing cost.

"Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work."
"As always, members should document their rationale for decisions under crisis situations to assist in the event of medical-legal difficulties."
Canadian Medical Protective Association

"I think what [doctors are] really concerned about is, 'do I have the guidelines to make proper decisions and do I have the support structure to make an unthinkable rationing decision of two patients, and one ventilator."
"What they're looking for now is really some guidance, some standards on how to make those decisions should they be forced to do so."
"[Doctors] have questions about the reuse of protective gear, questions about what's appropriate with respect to the use of  homemade gear."
"Physicians can't refuse to see patients who are ill or who have an infection, but there would be some expectation that they would have the appropriate gear to be able to complete their task."
"And so that's what we're telling physicians, but that doesn't necessarily go far enough. Because at the end of the day, the building is still burning, patients are still sick and they need to be cared for and physicians feel that tremendous obligation to care for them."
"So it's really putting the doctors in a very difficult position, because they're concerned about their patients, they're concerned for their own health. They're concerned about transmitting the infection back to their family. And they're concerned about asymptomatic spread."

Dr.Todd Watkins, associate executive director, Canadian Medical Protective Association

Thanks to the new pestilence that is upon the world, and the many unknowns related to it, and its
virulence, medical professionals now have conversations with themselves that they never before contemplated having to indulge in, as introspection goes. How much exposure should they permit themselves given the very real risk of morbidity? Two nurses in New York City have died so far. "Doctors are getting sick everywhere", stated William P.Jaquis, president of the American College of Emergency Physicians.

Italy's experience has been telling. A first-world country with a first-rate medical system that has been overwhelmed by a firestorm of an infection rate that has exhausted them physically and psychologically, while taking a dreadful death toll of the medical community, on the verge of collapse. No fewer than 4,824 health-care workers were infected with the virus at last week's count, with 61 doctors having perished. That dread experience has informed Canadian doctors what the future may resemble for them, as well.

"My friends in Italy and Spain didn't seem to wrestle with it as much. We're a little less focused on the individual well-being here and more supportive of the social contract where we look out for each other."
"I just think Canadian doctors will be less likely to consider staying home if help is needed on the front lines of this battle."
Dr.Anand Kumar, critical care doctor, Winnipeg

A robot operated by medical teams helps treat patients suffering from COVID-19 in the Circolo hospital in Varese, Italy. Flavio Lo Scalzo/Reuters

In today's Canada where hospitals are concerned over their lack of equipment and doctors are exhausted before the real crush in intensive care units have even surfaced, doctors are isolating themselves, determined to avoid taking the novel coronavirus back to their families at home. The necessity of having to ration personal protective equipment places medical staff at higher risk of becoming infected themselves. And the scarcity of mechanical ventilators is the stuff of nightmares where doctors may be forced to make choices no one can morally contemplate.

To avoid over-use of PPEs, staff have begun using cellphones and baby monitors in communication with infected patients, hoping to limit face-to-face contact with the attendant need to fully suit up, using up scarce personal protective equipment. According to Public Services and Procurement, the federal government has placed on order 157 million surgical masks, 60 million N95 masks and 1,470 ventilators, while hoping to source even greater numbers.

Nightmare scenarios of having to decide in crisis situations whom to extend heroic care for, and whom to leave, haunts the medical profession, with the legal and ethical issues inherent in such dramatic decision-making. There's a brief window "during which they can be saved" reads an article published in the New England Journal of Medicine, when a patient's breathing deteriorates to the point where a ventilator is required. Should the ventilator be withdrawn the person will die within minutes.

"Unlike decisions regarding other forms of life-sustaining treatment, the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice." Should the  young leapfrog the old? How much time is given someone to recover before life support is removed? COVID-19 has become a global pandemic,"and the sad fact of the matter is that in most health systems around the world, physicians, nurses, health-care providers have limited-to-no access to personal protective equipment", noted Dr.Ross Upshur of the University of Toronto Joint Centre for Bioethics.