‘I’m drained. I’m tired. I just want to be over with this’
Its hospitals strained by nearly two years of the COVID-19 pandemic, Ontario could take years to whip waiting lists for surgeries and other services that have grown since the virus struck. London hospitals have performed thousands fewer procedures than they normally would. Reporters Jennifer Bieman, Jonathan Juha and Norman De Bono examine the local fallout in five key areas.
Karen Koyounian began losing her voice in October 2020.
After the treatment her family doctor recommended didn’t bring her voice back, the 47-year-old mother of five asked her doctor to refer her to a specialist.
“I had never had this happen to me before,” the Cambridge resident said.
“I couldn’t talk. I couldn’t yell, so I said to him, ‘Can you please send me to a specialist because something is wrong.’”
Her doctor agreed, and he referred her in January 2021.
Due to pandemic delays, Koyounian didn’t get to see the throat specialist until July 2021. Months of tests, CT scans and ultrasounds later, she was diagnosed with thyroid cancer.
She had her thyroid removed Dec. 15, but cancer had spread to her vocal cords and surrounding nerves. Radiation would be needed.
Koyounian was told she should start cancer treatment a month after her surgery, and she was referred to London Health Sciences Centre (LHSC), one of Ontario’s 14 regional cancer centres.
At an appointment this week, Koyounian learned that her treatment won’t start until June 1 due to backlogs caused by the pandemic.
The wait for treatment, the fear her cancer may spread further and the financial strain of being out of work have been almost unbearable for Koyounian and her family, she said.
“I cry all the time,” she said. “It’s terrible. I’m drained. I’m tired. I just want to be over with this.”
Koyounian isn’t alone.
As potentially life-saving procedures, cancer surgeries were allowed to continue at Ontario hospitals while they battled a surge in patients caused by the Omicron wave.
But the reduction in surgical volumes has meant doctors have been put in the difficult position of having to prioritize which patients get care first, leaving others on an ever-growing waiting list.
Several factors play a role in deciding who goes to the top of the list, including the type of cancer a patient has and how aggressive or fast-growing it is believed to be.
For the most part, LHSC says it has managed to provide timely care – usually within days – to people whose cases are considered urgent, known in medical lingo as Priority 1 (P1) and 2 (P2) patients.
But that has meant those in the P3 and P4 categories have sometimes been left in limbo, knowing of their cancer diagnosis but without a set date for their procedure.
“The impact to patients has been significant,” said Dr. Patrick Colquhoun, chair and chief doctor of LHSC’s surgical oncology division.
“The goal of this approach is to serve patients in a very difficult circumstance; however, there are times when patients . . . are considered to have less aggressive forms of cancers (but) whose clinical course proves otherwise over time.”
Even before the pandemic hit, wait times for patients varied depending on their types of cancer.
Cancer Care Ontario, a provincial agency that sets care standards, said it was still too early to determine the fallout of the latest capacity restrictions on hospitals, which took effect Jan. 5.
But the expectation is the patient wait list only has grown, even as doctors do their best to work through procedures delayed by the pandemic.
“After each wave, there was a bit of an opening up for a little while, so we did try to catch up . . . but we never even completely recovered from the first wave,” said Dr. Joseph Chin, an oncologist and surgeon specializing in prostate cancer in LHSC’s urology department that specializes in prostate cancer.
“If we were given more operating time, we wouldn’t mind operating six days a week or on weekends. We’ve been working hard to try and cut back on the waiting list but there’s no question it has gotten bigger.”
Chin said in his practice, urgent surgeries are being performed.
But patients who ideally would be treated within 12 weeks of diagnosis “likely won’t have any prospects of being done for probably several months,” he said, adding some patients could miss the window during which surgery is a viable treatment.
Compounding the problem are pandemic delays in diagnostic exams, giuven the importance of early detection to cancer patient’s outcomes, Chin said.
“We are very concerned because when we do see (patients), they are further along, so they need more extensive treatment, maybe longer treatments,” he said.
There’s also the emotional impact of learning of a cancer diagnosis without having a date for treatment, said Tracey Jones, executive director of Wellspring London, a support agency for cancer patients.
Wellspring has seen a “huge increase” in the number of people seeking their services due to delayed cancer procedures, with many saying they are dealing with anxiety and depression.
“That feeling of being in limbo and almost of being lost in a system that is sort of crippled by a pandemic is really profound,” she said.
“They are feeling really uneasy because they don’t know what their next step is.”
Ontario’s fiscal watchdog, the Financial Accountability Office, estimated there was a backlog of nearly 2.5 million diagnostic procedures – from MRI and CT scans to mammograms and pap tests to screen for cervical cancer – as of late September.
Amid the pandemic, LHSC completed fewer colonoscopies, an outpatient colon cancer screening procedure often done under mild sedation.
At some points during the pandemic, staff typically assigned to diagnostics were reassigned to other units to help LHSC respond, chief medical officer Adam Dukelow said.
“Health care is not a single event. . . . Having a colonoscopy might lead to a diagnosis that requires surgery,” Dukelow said. “What I’m most concerned about is patients we may not know are out there that need help.”
The province’s directives to halt all non-urgent procedures at hospitals applied to diagnostic imaging, too, said Graham King, site chief of surgery at St. Joseph’s Health Care London.
Diagnostic services have had to prioritize referrals based on patient condition, but some delays are happening downstream from hospitals, King said.
“Some patients haven’t been seeing their family doctors. There’s a lot of patients that haven’t had their routine pap test or prostate examination. They’re not even getting as far as having a (hospital-based) test ordered,” he said.
“We’re all expecting a tsunami of referrals once patients are return to their doctors and doctors are able to see more patients in their offices.”
Orthopedic surgeries, specifically joint replacements, have been among the first on the chopping block during provincewide surgical shutdowns.
Such surgeries improve a patient’s quality of life, but generally aren’t urgent or emergent, said Vai Rajgopal, a Strathroy Middlesex General Hospital orthopedic surgeon who sits on the board of the Ontario Orthopedic Association.
As of November, patients in the London area could expect to wait two years from the time they’re approved for surgery to having a joint replaced, though the wait varies slightly between hospitals, he said.
The Omicron shutdown has only make that projected wait time worse, Rajgopal said.
“We’re still doing consults, at least trying to get patients seen to book them for surgeries,” he said. “We’ve been adding more patients to the wait list. It’s not just about the cancelled surgeries, we’ve added another month’s worth of patients.”
London area hospitals typically would do about 300 joint replacements a month pre-pandemic, Rajgopal said. The latest provincewide surgical shutdown has brought that number to near zero, he said.
“We’re only doing the occasional really urgent person who is disabled and wheelchair bound because of their pain,” he said. “Those are the people that we’re still trying to accommodate because, in my mind, if that’s not urgent, I don’t know what is.”
Pre-pandemic, Southwestern Ontario had some of the province’s longest waits for hip and knee replacements, prompting some patients to seek operations elsewhere.
Even if Ontario funds unlimited joint replacement surgeries to address the backlog, the health system is dealing with pre-pandemic constraints that have only worsened in the last two years, Rajgopal said.
“Even before COVID, there weren’t beds and we were seeing people in hallways,” he said.
“We’re so far behind now that I don’t see, in our current health-care system, how we will ever catch up. It will require staff and nurses and beds, which were already an issue.”
Brandy Robertson says her father just got “sicker and sicker” as he waited years for a liver transplant.
Then life-saving surgery was rescheduled three times last year due to the pandemic.
Finally, in July, Neil Reece received part of his daughter’s liver. Sadly, he never would leave London Health Sciences Centre, dying in November, a weeping Robertson recalled.
“He had issues with his liver for five years, he got sicker and sicker. The day before the pandemic he was on a transplant list, then COVID happened and it was shut down,” she said.
Robertson is not alone in feeling the pandemic’s impact on surgery in London. Critical transplant surgery at LHSC plunged 25 per cent amid the virus crisis, the hospital reported.
Surgery at LHSC’s multi-organ transplant program slowed as fewer surgeries were done and organ donations also declined, the hospital added.
Between April 2019 and the end of March 2020, the hospital did 240 transplant surgeries. Over the same period in 2021, the total nearloy 24 per cent to 183.
“By the time he had the surgery, I don’t think we knew how sick he was,” Robertson said of her father. “I don’t think he was strong enough, physically. It had been an exhausting year-and-a-half.”
Reece’s transplant was first set for January 2021, but was pushed to May by a COVID outbreak. It was then rescheduled for the first week of June but had to be cancelled because Robertson, the donor, wasn’t vaccinated – her age group wasn’t yet eligible for a shot.
The transplant was finally done July 28. Reece, 64, was in surgery for 12 hours and Robertson, 39, eight hours.
Robertson isn’t angry about the COVID delays.
“The transplant gave my dad 113 days he would not have had,” she said. “As we are dealing with our grief you can’t place blame, you can’t go down that rabbit hole.”
“We had an amazing team,” of doctors, nurses and support staff, she added. “I cannot find words to thank them. We had wonderful support. There are amazing people at the hospital.”
While some transplant surgeries were delayed amid the pandemic, “emergent” or critical transplant surgeries were not cancelled and no patient was denied life-saving transplant surgery, said Patrick Luke, co-director of LHSC’s multi-organ transplant program at LHSC.
While the hospital has prioritized “emergent” surgery, the delays still impact patient care, said Adam Kassam, president of the Ontario Medical Association.
“The impact on patient care has been significant. When we talk about non-emergent it does not mean it is not essential,” he said. “Any delays that happen for any reason can have substantial impact on quality of life for patients.”
The program, which performs liver, kidney, heart and pancreas transplants, did 17 heart, 123 kidney and 52 liver procedures in 2020. That dropped to 10 heart, 95 kidney and 46 liver transplants in 2021.
The program also saw a decrease in the number of organs donated, though it wouldn’t say how many were received in 2020 and ’21.
“Early in the pandemic, we did see a decrease in the number of available organs. This has been anecdotally attributed to factors surrounding the pandemic, including lockdowns,” Luke said. “We have since seen numbers return to where they were pre-pandemic.”
Andy Moncrieff, 66, had liver transplant surgery in 2016, but maintains ties to the program, working in fundraising and with various transplant groups advocating for care.
“It has been impacted, they have had to hold off on transplants. If it’s a life-saving transplant they do it but it is now on a priority basis,” he said.
“I can tell you they are overloaded right now. The docs are under . . . tremendous stress.”
Kassam agreed, saying about 75 per cent of Ontario’s 43,000 doctors have reported feeling burned out, up from 60 per cent in the pandemic’s first year.
“The impact of the pandemic on the profession has been substantial. We are seeing an escalation of burnout.”
John Korzec needed cataract surgery so badly, he could barely see out of one eye.
“It was impaired,” he said. “I did see with my other eye better, but my one eye was a lot worse.”
But the 52-year-old London manufacturing worker waited more than six months for surgery at St. Joseph’s Health Care London’s Ivey Eye Institute.
“It’s unfortunate, but I understand,” the COVID-driven surgical delays that have hit London’s medical community, he said. “. . . Obviously. I would have rather done it sooner. But if you have to wait, you wait.”
Korzec had his surgery in late November. Then about three weeks later, he suffered a retinal detachment.
“I notice my right eye had a significant blockage in my vision. I called my surgeon and he had me come in the next day. They sent me for immediate surgery,” he said.
The speedy response impressed Korzec. “I am very happy with that. I cannot complain,” he said.
The Ivey institute, London’s eye care centre, saw surgeries drop by 14 per cent – more than 1,030 procedures – amid the pandemic, St. Joseph’s reported.
The centre, which did 7,315 eye surgeries between April 1, 2019, and the end of January 2020, did 6,279 in the same period a year later.
The decrease was to pandemic delays in non-urgent work, said Michael Motolko, chairperson of ophthalmology at Ivey.
The institute was able to do urgent work despite COVID-19 thanks to extra resources from the hospital and Ontario’s Health Ministry, he added. Without that support and staff efforts, that 14 per cent drop could have been much worse.
“The ministry has an interest in making sure as many cataract procedures (as possible) could be done,” Motolko added. Ministry incentives and funding helped St. Joseph’s move from four days a week of cataract surgery to five.
Other urgent work done included retinal detachment, corneal transplant, glaucoma and surgery of the eyelids for cancerous growths, he said. “That has been going on since the beginning of the pandemic. Emergency work has not stopped.
Ivey has still been doing diagnostic work on patients required before surgery.
The province has made cataract surgeries a priority because visual impairments can lead to other, costly procedures snarling the health-care system, such as car accidents, falls, and “morbidity,” said Motolko.
“The cost to the health-care system of poor vision is much higher than paying for cataract surgery,” he said. “It is efficient and there is a high degree of success, it is good bang for our buck.
There are more cataract surgeries done in Ontario than any other type.
St. Joseph’s was doing 12 to 16 cataract surgeries a day amid the pandemic, down from 24 to 32 before the virus crisis.
“I think we are in pretty good shape and ready to ramp up (non-urgent surgical work) when we get the go-ahead from the province,” said Motolko.
HOW WE GOT HERE
- Ontario halted non-urgent surgeries provincewide three times amid the pandemic: during the first wave in March 2020, the third wave in April 2021 and this year’s Omicron-fuelled fifth wave.
- Cancelling non-emergency surgeries frees beds and staff to respond to surges of seriously ill COVID patients. It also ensures there’s capacity in the health-care system to transfer patients from hard-hit regions.
- During the second wave in December 2020 and January 2021, Ontario required hospitals to reserve 10 to 15 per cent capacity for pandemic response.
- With that restriction in place, LHSC changed its surgical formula to do more outpatient procedures and more judiciously schedule non-emergency surgeries requiring a hospital stay or intensive care bed.
- COVID outbreaks, like one that killed 26 at University Hospital in November 2020, also forced hospitals to postpone surgeries and outpatient appointments beyond what the province ordered.
CRUNCHING THE NUMBERS
- Calculating exactly how many London-area surgeries were delayed by the pandemic is difficult. Some people put off visits to family doctors, delaying being referred to specialists and joining a surgical wait list. Patients may have moved, sought their surgery elsewhere or no longer need an operation.
- What hospitals can do is compare the number surgeries they have completed during the pandemic to what they would have done pre-COVID.
- Since the pandemic began, London Health Sciences Centre has completed about 7,000 fewer surgeries than it would have before COVID. Gynecology, plastic surgery, orthopedics and general surgery have seen the largest reduction in surgical volumes.
- In its pre-pandemic 2019-20 budget year, LHSC completed about 27,000 inpatient and day surgeries at its two hospital sites.
- St. Joseph’s Health Care London has completed 4,300 fewer surgeries during the pandemic compared to pre-COVID levels. “We’ve been able to do tumour surgeries, people with infections, fractures and urgent eye conditions. We’re not behind in urgent and emergent work,” said Graham King, site chief of surgery at St. Joseph’s. “The group that has suffered the most are patients with less urgent surgery . . . Their wait times are well over what we would consider acceptable targets.”
- Both LHSC and St. Joseph’s have ramped up surgical volume as much as possible between waves to get through some of the postponed procedures, sometimes operating beyond the typical capacity of their operating rooms.
With the Omicron wave receding, the province has let hospitals gradually resume some non-urgent surgeries. Both St. Joseph’s and LHSC have begun ramping up their surgical volumes, but making a dent in the backlog won’t happen overnight, LHSC’s top doctor said.
“Our initial and medium to long-term constraint will be people,” said Adam Dukelow, chief medical officer at LHSC.
Retaining health-care workers is a priority, he said. And there’s a need to bring more staff into the system, either by accrediting people trained abroad or adding spots in the post-secondary programs.
The Ontario Medical Association estimated the pandemic had caused a provincewide backlog of 20 million health-care services, including surgeries, even before the Omicron wave struck.
Queen’s Park earmarked funding to address the backlog after the spring 2021 surgical shutdown and has made similar funding commitments moving forward, but money alone won’t solve the province’s backlog problem, said OMA president Adam Kassam.
“There are other ways that, as we start to think about the future, to reorganize our health-care system to get through the backlog in a timely and meaningful way,” he said.
Doing more surgeries and procedures in specialty settings outside hospitals, enhancing remote monitoring of patients before and after surgery and bolstering home care are ways to ease pressure on hospitals, Kassam said.
Some smaller surgeries can be moved to minor procedure rooms, “mini-ORs” in clinic spaces, to free up operating rooms, said Graham King, St. Joseph’s site chief of surgery.
“This is happening across our services, ENT (ears, nose and throat), urology, orthopedics and general surgery,” he said. “We have to . . . think in an innovative way to get more capacity in the system.”
In a bid to ease chronic staffing limits on care capacity, St. Joseph’s is working with area nursing schools to get nurses working in operating rooms early in their careers, he said.
“A lot of nurses don’t get trained in operating room work anymore,” King said. “We’re trying to get nurses into the OR to try surgical nursing so that they’ll choose to come and work in the operating room.”