When you think about how COVID-19 has impacted the health of people living in Ontario, it’s natural that your mind goes first to the more than 500,000 who have already been infected, the tragedy in long term care, the plight of essential workers and the uneven burden this pandemic has placed on lower socioeconomic and racialized communities. How to care for those with COVID-19 and protect those most at risk has rightly been top of mind for health care practitioners and public health experts for almost fourteen months.

However, there is a side to the pandemic that has not received the attention it deserves – the impacts on people accessing other kinds of care, in particular, for time-sensitive conditions such as heart disease and stroke. These are the untold victims of the COVID-19 pandemic. Untold, because so many of these patients have disappeared from hospitals, clinics and doctors’ offices, and even emergency departments. Today we, and on behalf of our health-care colleagues, are writing to them: Ontario’s missing patients.

To you, the missing patient, we want to say this: we’re worried about you.

We are worried you might be ignoring changes to your health because you don’t want to place additional burden on a system that you keep hearing is overwhelmed. Perhaps you feel you would not receive the quality of care you normally would. Or you might be concerned about contracting COVID-19 in our hospitals and clinics.

We understand your concerns, but we want to reassure you; while our health care system is very stretched, it is not broken. We want you to know that more than a year into this, we have learned a lot and we have applied what we have learned, including how to protect and care for you when you come to see us.

If you experience signs of a medical emergency like a heart attack or stroke, you should call 9-1-1 immediately. For heart attack, these signs include chest or upper body discomfort, sweating, and nausea. In the case of stroke, watch for weakness on one side of your body, changes to speech or drooping of the face.

But even if it’s not an emergency, let us assess you and determine if it is something that can be safely postponed. Changes to your health including increased lightheadedness, shortness of breath, tightness in the chest or jaw are all reasons to reach out.

The bottom line is simple: please don’t triage yourself. Let your health care provider do that – that’s our job and we are here for you. If we can assess you virtually, we will. If we need to see you in person, we will make sure that it’s done safely. And if your symptoms change, our approach will adapt.

But we can’t help you if you stay silent. The nature of cardiovascular disease is that your symptoms may be stable for a time, but then change very suddenly. In our world, days, hours, and even minutes can make a difference. The longer you wait, the more difficult your recovery will be – if you survive. So please don’t wait.

The consequences of COVID-19 on the health of Ontario’s missing patients are not hypothetical. Delaying heart and stroke care has very real and very serious consequences. Our health care system and the people who work in it have been challenged by COVID-19, but we are still here and ready to help you. Please let us.

This article was published first on healthing.ca, operated by Postmedia.

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“My 86-year-old husband is in a nursing home…one long-time friend has died of the virus, and another was diagnosed and recovered,” she says. “It hits very close to home. I know I’m vulnerable and I’m taking it very seriously.”

A former nurse and clinical researcher, Mary remembers the “old days” when she was caring for a patient with tuberculosis.

“I still remember him saying, ‘If I’ve got it, you’re going to have it too,’ then he coughed right in my face,” says Mary, who is now retired. “You get some takeaway memories. I’ve become overly critical of the techniques being used to keep people safe.”

Mary admits she was worried she’d be disappointed at the hospital when she had to go to Sunnybrook Health Sciences Centre for an echocardiogram and visit with her cardiologist.

“It was a very anxious thing, and that made me even more impressed with how well they did,” she says. “You couldn’t get in without being screened – there was no way around it. It was very reassuring.”

Toronto-area hospitals have been taking extra precautions to reduce the risk of the novel coronavirus being spread from person-to-person, from entrance screening to personal protective equipment in clinical and high-traffic common areas.

Robert Kates, a seventy-seven-year-old grandfather of six (soon to be seven), says he too is “a little paranoid” about contracting COVID-19.

“At my age and with my prior history of infections, I’m overly cautious,” he says. “I wear a mask. I carry sanitizer in both my pockets. The only time I leave my house is to go out for groceries, and that’s about twice a week. I even sanitize my own car inside.”

Over the past three months, Robert has been to Sunnybrook three times to undergo tests to evaluate possible heart problems. On visiting the hospital, he says he wasn’t overly concerned: “I wondered what they were going to do. I knew they’d be taking precautions, and I was very relaxed and calm going in there.”

If you are going to hospital or out in public, infection control experts at Sunnybrook recommend you wash or sanitize your hands frequently, keep your hands away from your face, practice physical distancing, and make sure to wear your mask properly.

“Take precautions and trust in the hospital and the doctors,” advises Robert. “If you need to visit the hospital, do it. Don’t wait. It’s your life.”

Heart attacks don’t stop during a pandemic

Don’t ignore the signs of serious heart problems, especially if you have a heart condition. Call 911 if you think you are having a heart attack. Symptoms include:

• Chest pain
• Difficulty breathing
• Discomfort in your chest, arms, back, neck, shoulder or jaw

If you have questions about COVID-19 and your heart condition, or need a health visit, speak to your cardiologist or other health-care provider.

Source: Canadian Cardiovascular Society

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The Answer: You are correct to want to seek a geriatric psychiatrist but typically, they are in short supply and are most likely found in large, urban Canadian cities. There is a very good chance, however, that a general psychiatrist may also do a perfectly good job of treating your symptoms so you may want to consider being open to that possibility, particularly if the wait to see one is long.

“It sounds like the right thing was done,” said Nathan Herrmann, head of the division of geriatric psychiatry at Sunnybrook. “She has seen her physician and had a good medical checkup to rule out any obvious medical problem.” He suggested a geriatric psychiatrist would be ideal, though most psychiatrists would be able to treat your symptoms.

You also raise a very important issue that has been studied since the dawn of psychiatry: Do physical symptoms cause psychiatric disturbances or is it the other way around?

It turns out there it’s a bit of both. There are psychiatric disorders can cause physical symptoms and medical illnesses that can cause psychiatric symptoms. Patients who have suffered a stroke, for example, run a “high risk of developing clinical depression that can be due to biological reasons as well as psychological and social reasons,” Dr. Hermann said in an interview.

Psychiatric disorders, in turn, can cause physical symptoms, often amplifying aches and pains that many may live with but not feel as intensely. There are also medications to treat a physical symptom that cause depression and mania.

“There is a whole category of somatic illnesses that are actually psychiatric disturbances that present with medical complaints,” he said, noting that pain syndromes, neurological symptoms that are a direct manifestation of psychiatric illness.

Sometimes, the psychiatric label is placed on patients when doctors cannot determine the cause of their symptoms.

“Patients with Multiple Sclerosis are notorious for presenting with vague physical complaints that are never diagnosed and thought to be psychiatric in nature,” said Dr. Herrmann.

There is one other group that has both – psychiatric and medical illnesses that have a tendency to accentuate the negative. “People who have coronary artery disease and depression are more likely to drop out of their cardiac rehabilitation,” said Dr. Herrmann, who is also a professor in the department of psychiatry at the University of Toronto.

Typically, most patients go to their primary care physician with symptoms of palpitations, dizziness, fainting, nausea, weakness or vague pains. Some have premature ventricular beats that are within normal limits but because of an underlying psychiatric condition, they are hyper focused on it.

And then there is aging itself when many changes occur: children are leaving home – or coming back when their parents are living on a fixed income. Friends are dying; chronic medical illnesses – diabetes and heart disease for example – are more common.

You had mentioned that you are the child of a Holocaust survivor. There is a huge amount of literature on this very issue and “whether they are truly different is not clear,” said Dr. Herrmann, noting that the parents sometimes have post traumatic stress disorder.

“The children of Holocaust survivors are a different story,” he said. “They can be burdened by their parents guilt and emotional problems. The emotional distance can affect their psychological development.”

However, it would be incorrect to assume, he said, that there is a specific symptoms or cluster of symptoms that is associated with being a child of a Holocaust survivor.

“What a psychiatrist would do is include that knowledge in her information and how it might relate,” said Dr. Herrmann.

I suggest you return to your family physician and request a consultation with a geriatric psychiatrist and if not possible, a general psychiatrist who can treat your problem.

If you go to this link https://sunnybrook.ca/integration/# and search under “geriatric psychiatry” in the clinical focus section, you will find a number of Sunnybrook psychiatrists who specialize in the area who may be taking referrals.

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The Answer: A leading cause of emergency department visits is due to abdominal pain. At Sunnybrook, it represents about 10 per cent of visits, according to Dr. Jeffrey Tyberg, Chief of the Department of Emergency Services. Abdominal pain is a “perfectly legitimate” reason to go to emergency and in fact, he sounded concerned your sister’s symptoms were such that she went to three walk-in clinics for help – all to no avail.

“Abdominal pain – especially in a woman – can be a serious problem,” Dr. Tyberg said in an interview. “You have to decide if it’s worth the wait. She was concerned enough that she went to three walk-in clinics.”

In your sister’s case, the cause of her abdominal pain could have been due to medical emergencies that could pose serious threats to her health and potentially threaten her fertility. They include conditions such as ectopic pregnancy, appendicitis, ruptured ovarian cysts and ovarian torsion.

“It can be something benign,” pointed out Dr. Tyberg. “But it can be something serious. Acute, severe, abdominal pain in a young woman is certainly a medical emergency and requires urgent assessment.”

Canadians make close to 16 million visits to emergency departments (EDs) each year, according to the Canadian Institute for Health Information. With abdominal pain being one of the leading causes – no precise figure is available – it constitutes a challenging component of emergency medicine.

Diagnosis is not easy and typically involves physical examination, internal examinations and an array of diagnostic tests. That’s largely because the causes of belly pain can be due to referred pain due as there are many different organs within the peritoneal cavity. Some causes include peptic disease, pancreatic, inflammatory bowel disease, gastroenteritis, biliary colic, myocardial infarction and a ruptured spleen.

Tools for examining abdominal pain are far from perfect. Though CT scans can rule out many life-threatening causes of abdominal pain and reduce the need for exploratory surgery, they sometimes don’t lead to a definitive diagnosis. They also expose patients to significant doses of radiation. Ultrasound, both at the bedside and in the diagnostic imaging department, can help determine or rule out important causes of abdominal pain, said Dr. Tyberg.

Many patients who go to Canadian emergency departments with abdominal pain leave with the comfort of knowing the cause is not life threatening but without knowing precisely what precipitated it.

While your sister was trying to be a responsible user of health services, if she visited three walk-in clinics, that was probably a sign the pain was severe enough to warrant a visit to emergency.

It would have been best if your sister had a family doctor who could have quickly seen her. Below is a link to Health Care Connect, which helps Ontarians without a family health care provider find one. http://www.health.gov.on.ca/en/ms/healthcareconnect/public/

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The Answer: This is the kind of question doctors hear all the time and highlights some of the dangers of being on multiple drugs, particularly from multiple doctors and especially multiple pharmacists. There is no guarantee any of these health professionals are talking to each other and the risk of a dangerous drug interaction – when one drug changes the response to another medication – is high.

“There are literally thousands of drug interactions out there,” said David Juurlink, head, division of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre. “If I have a patient in the emergency department on 8, 10 drugs, there’s a very good chance we will find at least one, and possibly several, potentially dangerous interactions.”

According to Dr. Juurlink, “drug interactions are largely predictable and, as a result, largely avoidable.”

Some drugs are particularly prone to interactions. They include common cholesterol drugs (statins), antibiotics, anticoagulants and lithium – all of which, when taken with other medications, can cause potentially dangerous reactions.

Though it is rather well known, it is worth repeating that taking grapefruit juice can amplify the effect of certain drugs because more drug is absorbed from the gut. This is particularly true with statins – lovastatin, simvastatin and atorvastatin – used for the treatment of high cholesterol. Grapefruit juice taken with those drugs will cause too much of the active ingredient to enter the blood stream, resulting in side effects such as muscle damage.

The post Dangerous Drug Interactions and How to Stop Them appeared first on Your Health Matters.

The Answer: The “wait and see” surgical list is ubiquitous to Canadian hospitals. That’s because a hospital, with finite resources, must operate at or near occupancy to be efficient in the public health care system. This is in stark contrast to the United States, which has the ability to treat a paying patient more quickly in a private system where hospitals, in some cases, are only half full and are looking for business.

Since your father came through emergency department, he did not have a booked operation. He was deemed clinically stable, put on an intravenous fluid to keep him hydrated, then placed in a queue for the operating room. This is probably the most frustrating part for patients. He will wait for some time – hours, sometimes several days – to move up the queue, knowing that as a trauma hospital, a more injured person coming here will be jettisoned to the top of the list. Conversely, a booked surgery may be cancelled, and your father may quickly be seen.

Still, your point is a good one: you simply want to know why he wasn’t fed and when a surgeon makes “the call” to say your father can now eat, then try the next day to get into the operating room.

“On the acute units, we depend on the call from the surgical team for further information about the planned surgery,” said Smitha Casper-DeSouza, patient care manager. “As soon as we know, we inform the patients/families.”

Patients on the “wait and see list” include those with fractures, diverticulitis, gallbladder issues or bowel obstructions.

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The Answer: Some patients in Sunnybrook’s emergency department are just like you: they have a medical issue they want solved, be it abdominal pain, the long wait to see a specialist or the need for a second opinion. Most physicians empathize with what prompted you to come here – in some cases, difficulty accessing timely specialty care – but that is rarely an emergency.

“Patients are doing what they are legitimately allowed to do,” said Dr. Jeffrey Tyberg, Chief of the Department of Emergency Services at Sunnybrook Health Sciences Centre. “You understand why people are doing it.”

Canada has one of the worst rates of access to specialty services. A Commonwealth Fund study of 11 countries found specialist queues particularly worrisome, with 41 per cent of patients waiting two months or more. That lack of access is partly responsible for driving up emergency visits in hospitals across the country.

“The emergency department is the only place where you can walk in and say, ‘I’m here, I’ve been to four other hospitals and I want you figure out what happened to me,’” said Dr. Tyberg.

For physicians trying to manage a limited resource of health services, it represents inefficiency to the system. If a patient has already seen a specialist and received an answer, repeating a series of tests and imaging studies will rarely yield a new insight into their medical condition.

It can be frustrating for patients, who have waited many hours in emergency, after having driven long distances – Vaughan, Barrie, Woodbridge and Peterborough – in the hope of achieving a definitive diagnosis at a top teaching hospital.

Some patients come for severe head pain, other times, they come, after having seen three other neurosurgeons for back pain for which there is no surgical remedy. Even more are stuck in long queues, waiting to see a specialist.

“They can’t work, they say it’s 14 months to see the spine surgeon in Scarborough,” said Dr. Tyberg. “What’s the guy supposed to do? You understand why people do that. It’s the only door open to a lot of people.”

To in answer to your question, you do have the right to go to any emergency department you want if you think you are experiencing a medical emergency.

To go to emergency for a second opinion or specialist consultation, while understandable due to a problem with accessing care, is not necessarily going to yield that definitive diagnosis you were seeking.

“Maybe we need to manage expectations,” said Dr. Tyberg. “People think they can come for any problem at any time. Sometimes we have to say ‘This isn’t the time or the place.’”

The post A Second Opinion or an Emergency? appeared first on Your Health Matters.

Good thing he did. Arnold was having a TIA, short for transient ischemic attack. TIA’s are like mini-strokes, and put people at serious risk of having a full-blown stroke, often within hours or days. If Arnold had ignored his symptoms, and not received care at Sunnybrook’s High-Risk TIA Unit with its dream team of experts, he likely wouldn’t be golfing three times a week like he does now. Doctors found a major blockage in the carotid artery in his neck, which is a serious red flag. Surgery is usually the fix, but the trick is getting it done quickly if you are having symptoms.

Outside Sunnybrook, it’s been found that not all symptomatic patients receive this procedure within the recommended time frame of two weeks, something Sunnybrook experts are working with the Ontario Stroke Network to change. As the saying goes, time is brain.

Remember that if you are having symptoms of a TIA, including sudden trouble speaking, seeing or moving, call 911 right away. There are protocols in place to direct patients with TIA or stroke symptoms to a designated Regional Stroke Centre like Sunnybrook. Or, like Arnold, listen when a loved one tells you it’s time to go to the hospital.

“It’s a very strange phenomenon that happens to your body that you don’t know what is going on,” he recounted. “For whatever reasons, I didn’t know what I was going through until my wife told me. If the worst had happened, I would have had a major stroke within the hours afterwards.”

Thankfully, that wasn’t the case, but the shot of Arnold’s arteries in my video clearly illustrates how dire his situation was. It all goes to show that what you can’t see can hurt you. So if your body is trying to tell you something, make sure to listen.

Watch this week’s video on YouTube

The post Symptoms of a mini-stroke or TIA appeared first on Your Health Matters.

Everywhere you look, there is chaos. Some people have severe burns, and other clutch at deep wounds on their arms and legs. Dozens more wander around in shock, disoriented and withdrawn. Even some first responders have been injured by the intensity of the blast, which has rocked a 25-story apartment building and everyone in it. It’s hard to know where to begin to help, but luckily, that’s exactly the reason for this mock disaster.

Welcome to Sunnybrook’s mass exercise, which this year recreated the Wellesley Fire, a massive 6-alarm blaze that gutted a Toronto highrise in 2010. Several Ontario hospitals, and a wide array of health care disciplines came together to play out the horrifying scenes on a cool Saturday in March. “SARS really put emergency preparedness on the forefront of our minds,” says Dr. Laurie Mazurik, the grand maestro of this event (known officially as the Strategic Lead of Sunnybrook’s Disaster Emergency Preparedness). “It made me and others think we certainly need to prepare for future events, as this wouldn’t be the last.”

So, as if in a Hollywood movie set, the cast was prepared well in advance. Actors were given their roles, and played them out on a specially designated floor at Centennial College. This giant disaster playhouse was mocked up to include an emergency room, critical care unit, mini operating room, family information area and command centre. And let me tell you, with people screaming, crying and made up to look truly injured, it was easy to forget this was just a training exercise. But that’s a good thing. When preparing for the worst-case scenario, after all, you want to bring out the best in people.

The idea of disaster training was born here at Sunnybrook in 2004, and started out as an engaging simulation exercise for medical residents. But as the popularity of the event grew, so did the realization this was a great way to prioritize speedy care and smooth patient flow. It has since grown to include preparation for terrorist attacks, mass pandemics, school shootings and even the G8 Summit, and will be used in advance of the 2015 Pan Am Games.

Pardon the pun, but it all goes to show that practice makes perfect, even in the most imperfect of circumstances.

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Brandon Quigley was enjoying a game of volleyball three years ago when an ordinary day suddenly turned south. He felt a tearing sensation in his chest, and overwhelmingly unwell. He had the good sense to sit out the rest of the game, and follow up on his wife’s advice to see a doctor right away. Good thing he did. No one at the beach that sunny day could have predicted what this 32-year-old-father was up against. After extensive testing at Sunnybrook, a big problem was detected. Brandon had an aortic dissection, a tear in the big vessel coming off his heart and supplying blood to his entire body. It kills some instantly, and most within two weeks.

Brandon’s surgery was done by heart surgeon Dr. Gideon Cohen, who says aortic dissections, dangerously, are commonly missed or misdiagnosed. Because this condition causes chest pain, it can be easily mistaken for a heart attack, which is treated with blood thinners. But that’s the worst thing you can do for an aortic dissection, as the risk for bleeding is already through the roof. He says an astute medical team and CAT scan are essential to pinpointing the problem.

But there are many things you can do, like knowing the risk factors and red flags. Symptoms of aortic dissection include a tearing feeling or pain in your chest, abdominal discomfort, back pain or even paralysis. Conditions like high blood pressure, pregnancy, male gender, angiograms and even acute trauma, like a fall, can cause a tear. You’re also at higher risk if a blood relative has had the condition, meaning you should talk to your doctor about being screened with a chest MRI.

I met Brandon at his home after work a few weeks ago, where the success of his treatment became even more apparent. 4-year-old Emma happily leapt on her daddy’s back for a piggyback ride and he tossed her playfully around the living room. She was only a year old when her father was rushed to Sunnybrook, and will have no memory of this close call. Neither will 2-year-old Sara, whose life was made possible thanks to the saving of her father’s.

Brandon has been through cardiac rehab, which is recommended for all patients who have experienced an aortic dissection. After his own experience, and losing his mother to an aortic dissection, he’s now being proactive about screening his daughters. He’s also hopeful that others will learn about his story and come away knowing more. That includes recognizing the signs of trouble, and of course, how important is always is to take your wife’s advice.

Learn about Sunnybrook’s Schulich Heart Centre

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