Impeded Access to Emergency Stroke Care in Ontario — Hamilton Health Sciences Centre And Elsewhere

What follows is my letter to the Premier and the Minister of Health on a personal family experience, trying to access emergency care for stroke symptoms. I raise the issues contributing to the present crisis in Ontario health care. Underfunding of our health care system (10% per capita below other provinces) and a very poor public health response to the COVID19 pandemic in 2022 have exacerbated existing deficiencies in stroke management as identified by the Auditor General in December 2021. I have no doubt people are dying or suffering permanent disability because of inadequate resources. COVID19 related stroke syndromes may be contributing — I don’t know? What I do know, I summarized in a letter below:

July 28, 2022

TO: Premier of Ontario, Honourable Douglas Ford

Honourable Sylvia Jones MPP, Minister of Health

Dr. Kieran Moore, Chief Medical Officer of Health

Dr. Wajid Ahmed, Associate Chief Medical Officer of Health

CC: Andrea Horwath, MPP Hamilton-Centre

Anthony Leardi MPP, Essex

Dr. Fahad Razak, Scientific Director, COVID19 Advisory Science Table; Assistant Professor, University of Toronto

RE: Impeded Access to Emergency Stroke Care in Ontario — Hamilton Health Sciences Centre — Hamilton General, And Elsewhere

Dear Premier Ford and Minister Jones,

I am writing to report a most serious lapse in the access to emergency services at the Hamilton Health Sciences Centre, and indeed, in multiple communities across Ontario.

On July 19th, my 58 year old my partner was working in Ancaster. He felt strange and video called me. He was complaining of a tingling face and tripping a bit more. When I saw him, the left side of his face was drooping. I had him stick his tongue out straight at me and it would only deviate to the far right. These are classic warning signs of a pending stroke (TIA — transient ischemic attack), or a stroke in evolution (has already occurred). A stroke is normally caused by a clot in smaller vessel coming off the large artery in the neck, the carotid artery.

I had him rush to the nearest emergency department which was Hamilton General. I had called the ER physician just minutes before his arrival and provided a history. He was placed in the general waiting room and his initial vitals did not include neurological vitals, which would be standard for all possible stroke patients. Minutes normally matter for stroke.

My partner waited for 3 hours in the Emergency Department without any assessment whatsoever beyond triage. I called the Emergency Triage desk again to speak to the charge nurse about him. They said it would hours, possibly five, before he was assessed. They had traumas etc which took precedence and I was not able to speak to the triage nurse. He went back to his hotel exhausted against my advice. He slept and I did not. The next day he was assessed at the Windsor Regional Hospital Emergency Department. Within 30 minutes of registration, he was triaged, provided a room, had bloodwork drawn, and was assessed by a talented nurse who completed a thorough neurological evaluation (which I taught in medical school). We were so fortunate that some of his deficits (neurological problems) had started to improve. His CT showed no evidence of stroke though IV contrast is being rationed presently, because it is in short supply as it was described to me. This makes smaller strokes possible to miss. He continued to improve over a few days. He’s waiting for a neurology consult and some additional tests including MRI. Waits for neurological consultations are often greater than a year in my region.

I do not know what caused my partner’s neurologic problems. It may have been temporary ischemic event (reduced blood flow) event or something else. What I have since learned is that 15% to 25% of “stroke patients” actually have a “Stroke Mimic” syndrome, where something other than a clot causes the brain symptoms/brain injury. Many receive clot busting drugs urgently because it is difficult to know for sure what is happening, other than stroke, especially in the first hours; and to miss a stroke can be disastrous. My partner was extremely lucky. What is the average experience of a stroke patient in Ontario? How long do they wait? How many have been or will be left with permanent paralysis or an inability to speak/understand language because of inappropriate delays?

The Auditor General issued a media release on December 21, 2021, titled: “Stroke and Cardiac Emergency Treatment in Ontario Should be Faster and Better: Auditor General”. It leads with: “Ontario is not doing enough to make sure people know where they should seek treatment for a stroke.” Fifteen recommendations for improvement were provided. I knew the Hamilton General campus was a designated stroke centre and I spoke to the physician on duty. It didn’t matter. COVID19 causes a propensity to clot among some individuals. Stroke is a well documented complication. Hospitals should have streamlined stroke assessment and treatment by now. What are the barriers? Which of these fifteen recommendations has your government acted upon six months later?

https://www.auditor.on.ca/en/content/news/21_newsreleases/2021_news_AR_Cardiac.pdf

https://www.auditor.on.ca/en/content/annualreports/arreports/en21/AR_Cardiac_en21.pdf

We are already seeing reports of stroke patients being left unattended in hallways. Deaths in ER waiting rooms (various causes) have been reported across Canada. Paramedics cannot always offload their patients because the ERs are full. I saw a report of one woman with an acute stroke, who was stuck in an ambulance for 45 minutes before being seen in the ER at Windsor Regional. Ambulance shortages in Ottawa were reported by CBC News today. The crisis befalling emergency and urgent care is none like I have witnessed in my 30 year career as a physician. ER departments have closed in some communities. My colleagues in Oncology are feeling burnout. So many workplaces are short staffed because of illness: It doesn’t matter if it is a hospital, restaurant, or a grocery store. This past week, I have received apologies from all three sites in Windsor because so many staff had recently called in sick. And all employees said so while not wearing a mask.

The Importance of Mask Mandates in Preserving Health care

Ontario’s physicians and nurses provided you a means to help prevent these problems before they occurred: Encouraging vaccinations and requiring mask mandates indoors, in public buildings. The Chief Medical Officer of Health denied requests from three regional Medical Officers of Health for mask mandates. Mask wearing in Windsor-Essex is less than 1% and vaccine hesitancy, especially among children, has been a serious problem. Meanwhile Dr. Moore has publicly urged all Ontarians to mask indoors. There is a glaring disregard for public health recommendations among Ontarians in my region. It is one reason our regional Windsor-Essex MOH, Dr. Nesthurai requested a mask order in May. Windsor-Essex hospitalizations are now increasing in both ICU and acute care beds, where occupancy often exceeds 100% for the latter. Ontario wide, hospitalizations are doubling every 12.6 days according to the COVID19 Science Table Dashboard. Deaths are also increasing, presently 9 Ontarians per day on average are dying from COVID19. Why did three regional MOHs feel it necessary to publicize a request for a local mask order, when they clearly had the power to enact those orders without approval from the Chief Medical Officer of Health, according to the Health Promotion and Protection Act? Had they received directions that are contrary to existing law?

Mask wearing may not be popular but governing should never be a popularity contest. One role of government is promoting and protecting the health of its people. Mortality must never be the only yardstick used in deciding public health measures. Nevertheless, approximately one third of COVID19 deaths in Canada have occurred in 2022. COVID19 is airborne. Successive infections can lessen immunity especially among some vulnerable persons. It is not known if vaccination fully protects against this documented problem with COVID19. Illness from BA5, the current circulating variant, may be prolonged even among the 4x vaccinated. Temporary, indoor mask mandates even excluding restaurants, would be extremely helpful. At least you would have immensely reduced circulating virus in the community for the vulnerable. More importantly, it will help to reduce those requiring COVID19 care in emergency departments and hospitals, allowing for more timely care for stroke and heart attack patients. Without testing, tracing, or isolating for the average infectious period of the Omicron variant, masks remain a vital public health tool.

I would also like to emphasize that a non-fit tested N95 mask, should a vulnerable person be able to afford one, provides much less protection than one would believe in a crowded public space where others are unmasked. The longer the exposure, the greater the risk. Telling vulnerable persons to assess their own risk is frankly not their job and unconscionable. Severely disabled ODSP recipients, some living on $1169/month, cannot even afford cloth masks. The pandemic has been especially hard on the impoverished and the disabled. They must have high quality masks provided.

The problem facing our hospitals is not all related to acute COVID19 infections. Years of pandemic life and periodic closures have relegated some to postpone seeking help for underlying serious illnesses. Simultaneously, some physicians have retired early because of their own health risks. Emergency care should never be rationed. Masking is necessary now.

Investing in Health Care

I have come to know and and admire a number of accomplished, hardworking physicians and researchers throughout the pandemic. These include renown ER doctors, paediatricians, infectious disease specialists, virologists, immunologists, public health officials, and family physicians. It is clear from their reports that Ontario is experiencing a healthcare crisis. The Independent Financial Accountability Office (FA) found that 2020 health care spending per person in Ontario was the lowest in Canada, 10% below the average of other provinces. This must change.

In the short term, I would recommend:

1-An urgent solution to improve triage in emergency departments. Hire physicians (retired and physicians-in-training) and nurses to perform stroke assessments, angina assessments etc. Use these same individuals to monitor patients waiting for ER assessment.Identify when hospitals should be put on redirect.

2-Urgent meeting of Ontario Surgeons to develop strategies to expedite all surgery, including adding OR teams on the weekends. Provide additional funding to physicians to assist surgeons.

3-Urgent influx of money to hospitals, to expand ORs and emergency departments and/or to add temporary beds, physicians, and nurses.

4-Urgent improvement to home care nursing and to the coverage of PSWs and homemakers. We will need to rely on them for post-surgical care.

5-Do not limit nursing income or over-time. Provide quarterly retention bonuses especially to all nurses working in critical care, ORs, and emergency rooms.

6-Develop a system with the College of Physicians and Surgeons [and the Registered Nurses College of Ontario] to rapidly approve and train credentialed nurses and physicians from other countries.

7-Launch a concerted effort to vaccinate children especially in low income neighbourhoods. Use financial inducements. Television and social media should be flooded with advertisements. Parents must be reassured about vaccine safety. There is clear evidence that unvaccinated children are strong contributors to community spread of the virus. September is approaching.

These are only some recommendations that should be considered. Your government responded to the advice of Ontarian physicians like myself in early 2020, and again in 2021. Together, we have minimized poor outcomes before and I believe we can do so again. I remain grateful for your review of my correspondence.

These comments are my own.

Most Sincerely,

Christopher Leighton MD, FRCPC

Radiation Oncologist (ret)