Death, pain and soaring wait lists: How surgery backlogs have become pandemic’s lingering collateral damage

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Dr. Harindra Wijeysundera is not an infectious-disease specialist or an ICU physician.

But COVID-19 has still had a profound impact on his practice — and on the people he treats with angioplasties and other heart procedures.

The pandemic forced the cancellation of many of those operations, causing backlogs and wait times to soar. And as the delays grew, patients with cardiovascular conditions suffered, or worse.

“I have lost a lot of patients on the wait list,” said Wijeysundera, an interventional cardiologist who also heads cardiac care at Toronto’s Sunnybrook Health Sciences Centre. “Patients have died because we’ve had to make decisions about who is the person we have to treat first … Those patients and their families deserve recognition that they are victims of this pandemic, too.”

In fact, soon-to-be-published data indicates that twice as many Ontarians with heart ailments passed away waiting for surgery during the pandemic than before COVID-19 hit, he said.

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The nightmare scenario for doctors and nurses treating coronavirus sufferers has been having to triage, to make excruciating decisions about who gets life-saving care and who does not. They’ve so far avoided such dilemmas.

But in cardiac care, said Wijeysundera, triaging has been a reality for a year now.

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I believe we’re at a tipping point

And that’s just one facet of an often-overlooked side effect of the pandemic: the logjam across the country of hundreds of thousands of surgeries that grew as hospitals freed up space for COVID sufferers.

Authorities often call the delayed treatments “elective.” But patients are now waiting much longer than normal for eye procedures needed to stave off vision loss, orthopedic operations that address debilitating joint pain and surgery to remove cancerous tumours.

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Clearing the backlog is expected to cost billions, take years and keep operating rooms open evenings and weekends. For-profit clinics are playing a part — to the chagrin of some critics — in the epic catch up.

And COVID’s third wave is continuing to add to the problem, delaying more operations.

Dani Alexandria, a Toronto musician, was supposed to undergo surgery last week to fix problems caused by a ligament tear in 2017. The 24-year-old has been unable to straighten one leg, suffered pain that keeps her awake at night and been prevented from working ever since.

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But just before her OR date, she learned the operation had been cancelled.

“This was supposed to be the restart of my life,” said Alexandria. “My whole life has been put back on hold, with zero word on when this is going to take place.”

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British Columbia has reported exceptional success in reducing its backlog. But in many other parts of Canada, getting people like Alexandria back under the knife seems like a daunting challenge.

The number of patients waiting more than a year for surgery has increased five-fold in Quebec; a new paper by opthalmologists estimates that wait times for eye surgery will more than double, without factoring in the most recent cancellations. In Alberta, the government has committed $ 1.25 billion to return to pre-pandemic conditions.

Getting caught up will likely take “several years,” says Dr. Colin Mann, a Bridgewater, N.S.-based ophthalmologist and president of the Canadian Ophthalmological Society.

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“It’s a big, big hill to climb,” echoed Dr. Mohit Bhandari, president of the Canadian Orthopedic Association.

To push the issue, his association has even set up a web-based program to help patients lobby their local politicians for more orthopedics resources, including making use of the specialty’s more than 100 out-of-work or underemployed surgeons.

The problems began last March as every province cancelled “elective” surgeries for what turned out to be about three months. With an eye to northern Italy and New York City — where hospitals and intensive-care units were overwhelmed by COVID patients — health-care officials decided that non-emergency surgeries should be put on hold to prepare for a possible flood of coronavirus cases.

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The system began ramping up again last May, but in some places never reached pre-COVID surgery volumes. Then the third wave hit, and Ontario, Alberta and Manitoba put new restrictions in place.

Even freestanding clinics that do medicare-funded procedures in Ontario, like the famed Shouldice Hospital for hernia repair and the Kensington Eye Institute, were shut down for reasons that are not totally clear.

The province did announce Wednesday that hospitals could begin ramping up procedures again slowly.

According to Ontario’s Financial Accountability Office, the province’s surgical backlog will have reached 419,000 by September. Erasing that deficit will take $ 1.1 billion and three and a half years, the office estimated in a recent report.

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Patients have died because we’ve had to make decisions about who is the person we have to treat first

In Quebec, the number of patients waiting more than a year for surgery had climbed to 17,600 by the end of April, 4.7 times the pre-pandemic number, according to Health Ministry figures. Alberta had an estimated backlog of 36,000 operations as of March, before elective surgeries were again scaled back in April.

Specialists say the term elective belies the very necessary nature of much of the treatment.

As a surgeon who works on skin-cancer patients in the Toronto area, Dr. Michael Brandt said he’s seen a clear fallout from both the surgery waits and delays in patients getting diagnosed in the first place.

“Without question, we’re seeing a higher severity of disease,” he said.

Increased wait times for ophthalmological procedures could mean more vision loss, warned a recent paper by researchers from the University of Toronto and Queen’s University.

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A modeling study looking only at cancellations during the first wave suggested that waits for orthopedic surgery like hip and knee replacements would increase 3.4 fold on average, turning a half-year wait into 21 months.

Leaders in some of the most-affected specialties say they are loath to second-guess decisions made during COVID’s first wave, when no one knew exactly what to expect.

But they say lessons were learned and more effort made to keep offering surgeries amid the ongoing pandemic.

Some physicians still scratch their heads, though, about how the system has been managed. Dr. Vaishnav Rajgopal, an orthopedic surgeon in the southwestern Ontario town of Strathroy, said he sees little reason to cancel surgeries in communities like his with scant COVID cases, especially now.

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“Our hospital could have kept going and I without a doubt could have kept operating,” he said. “It’s very frustrating when I’m trying to understand and piece together the logic.”

Meanwhile, plans are underway to make up for the lost time.

B.C. may become a model of sorts. The province said in March it had cleared 95 per cent of its backlog, opening new and unused ORs, adding hours throughout the week and hiring more surgeons, nurses and anesthetists.

Some specialties have been experimenting with shorter hospital stays. That includes “same-day admissions” for knee and hip replacements, where the patient is sent home after the surgery, said Bhandari.

Even certain patients who have had major heart procedures are being discharged within a day to streamline use of hospital resources, said Wijeysundera.

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Some provinces, such as Alberta, Quebec and B.C., have already been using private clinics to provide government-funded procedures. In Quebec, 38,000 patients have received their surgery in such facilities to help fix the backlog, said a Health Ministry spokesman Tuesday.

Drawing on private, for-profit clinics is being discussed for low-risk cataract surgery from Newfoundland to B.C., said Mann.

One other tactic seems inevitable: offering surgery at unaccustomed times — on weekends and after hours.

But specialists also worry about the impact of that overtime on nurses already exhausted by the pandemic, and their own work-life balance.

“There are groups of surgeons who are saying ‘I believe we’re at a tipping point where I don’t believe I can ever get caught up,’ ” said Bhandari of the orthopedics association. “ ‘I can’t get caught up (they say) because I can’t possibly work every weekend. Even if they gave it to me.’ ”