Dr. Shajan Ahmed says he always thought of triage training as something needed in other countries or in war zones, where doctors must decide who gets potentially life-saving care and who doesn’t.
So when the emergency room physician with Toronto’s University Health Network found himself watching a webinar about it to help prepare doctors for the third wave of COVID-19, he says he was in a bit of shock.
“To come to grips with this being right at our [doorsteps] here in Toronto, a place where we have all kinds of resources, it was really bizarre, it was surreal,” he told CBC Toronto.
“None of us had trained for it before and none of us really signed up for this, to be honest with you.”
Ahmed was among a group of around 60 physicians who received the training earlier this year. It included running through mock cases, reading material and referencing online resources. The virtual sessions were conducted over Zoom with experts in simulation, ethics and palliative care.
The province says no triage model has been activated in Ontario at this time, and although the overall number of ICU admissions climbed to 900 for the first time last Saturday, the rate of increase appears to have started to slow down. In a memo obtained by CBC News directed to hospital CEOs, Andrew Baker, the incident commander of the province’s critical-care COVID-19 command centre, says projections remained “very concerning.” But the memo also adds they are “increasingly confident” that they will not need to recommend the use of the triage protocol.
But the prospect still weighs on the minds of some doctors, and for Ahmed, the training made the situation feel “very real.”
“You read about it and you think it may come, but until you are actually doing the training it doesn’t feel real until that point,” he said, adding the sessions were more challenging than he anticipated.
“We would debrief after the sessions to talk about how it felt, and what was going through our minds and collectively everyone had to take a deep breath and, I guess, also a bit of a sigh of relief because we aren’t actually in this situation.”
Despite describing the current situation in GTA hospitals as “bursting at the seams,” Ahmed wants people to know if the triage model is activated, patients will still be cared for. The decision is not whether someone lives or dies but whether the person would be offered ICU level care.
“It’s very complex and there’s a lot of logistics involved but I don’t want the public to think we’re making decisions as to booting people to the street without providing care,” he said.
“We absolutely will provide care.”
Compassionate conversations part of the training
Dr. Erin O’ Connor, the deputy medical director of the University Health Network’s emergency departments, was part of the team that led the training.
“There’s a lot of emotion around this and this isn’t something any physician or any health-care provider wants to do, but when we were getting ever closer to it we realized we needed to prepare ourselves,” she said.
She adds that conversations with patients and their families were a big part of it.
“It helped people find the right way to say this kindly and empathetically and to also recognize and process their own emotions around it.”
O’Connor describes the process as an application of tools to help determine how likely someone is to survive and their likelihood of survival after a year of any acute illness, not just COVID-19. She says the team looked at five cases that represented typical situations in the emergency department and had participants evaluate the patients’ chances of survival.
“It was a little bit of how you would apply the tools to different cases, so it wasn’t so abstract,” she explained. She says the whole point of developing the short term mortality risk tools was to remove any bias from the system.
“It was very clearly laid out that decisions cannot be made based on race, gender, economic status, disability, or age. This is really looking at as much as possible the medical factors that contribute to whether someone has a high chance of survival at a year,” she said.
Resources have been expanded through bringing health-care workers from other parts of the country, redeploying and retraining health-care workers, cancelling surgeries, bringing in more ventilators and transferring patients from hot-spot areas, among other measures. The Ministry of Health says the province continues to create additional hospital beds in the province, including the creation of two mobile health units.
“The logistics have been massive. But all of these things are being done to prevent us from getting into a position where we have to triage resources,” O’Connor said.
She says she’s feeling cautiously optimistic given the recent trends.
“We’re not out of the woods yet because we know patients stay in the ICU for a long time but we are slightly backing away from the need to use this.”
But Ahmed still thinks about it, and is still concerned about the current state of ICUs. He’s encouraging people to have conversations with loved ones about their goals of care.
“A lot of us lose sleep over it.”