Omicron in Ontario, Part 3: A hospital chief of staff on ICU overload

TVO.org speaks with the critical-care physician from Sarnia's Bluewater Health about isolation protocols, cancelling services, and staff exhaustion
By Matt Gurney - Published on Dec 16, 2021
Michel Haddad was appointed as Bluewater Health’s chief of professional staff in December 2015. (Communications Bluewater Health/YouTube)

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This is the final instalment in a three-part series looking at what we do and don’t know about the Omicron variant. Read Part 1 here and Part 2 here.

In just a few short weeks, the so-called Omicron variant of COVID-19 has swept the globe at a remarkable pace. The virus seems to be extremely contagious. We will have large outbreaks all over the world, including in Canada and in Ontario, specifically, before medical experts and scientists have a good understanding of how lethal it will prove for both the unvaccinated and the vaccinated, whose doses may not fully work against the new, highly mutated variant.

Early indications from South Africa, where Omicron was first identified, do not yet show a clear signal that Omicron is producing serious illness at the same rate it’s producing infections. But it’s far too soon to say anything with confidence. In the coming days, TVO.org will speak with experts about what we know about Omicron and what kind of shape we are in to combat it.

Today, we speak with Michel Haddad, a critical-care physician and chief of staff of Bluewater Health, a hospital in Sarnia.

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Matt Gurney: Omicron is moving incredibly quickly — I began interviews for this series two days ago, and it feels like a lot has changed already. But though there’s a lot we don’t know, what is your sense of the latest in our understanding?

Michel Haddad: I was actually on a World Health Organization briefing this morning with some of the experts doing the analysis and modelling. I already summarized some of what they said on my Twitter account. But the sense is, two doses will not be as effective at preventing infections. Infections, I stress. There are fewer neutralizing antibodies. It does go up with a booster to almost the same level two shots gave you against Delta. But the one thing that is likely more important is the fact that what they found is the T cells, which is another arm of immune protection, seem to actually be intact. The T cells seem to recognize the new variant, which means that you might get that initial infection, because your antibodies are lower if you’re not boosted, but the T cells that take couple of days to kick in will actually recognize this as being COVID and will protect you from ending up with me as an ICU doc, which is very important. That’s good news. It means that a lot of infections won’t necessarily progress into serious illness, once the T cells kick in. 

There is also bad news. In the old days — like, last month! — double vaccination protected us from infection by about 80 per cent, and 90 per cent for severe disease. Omicron is different: two doses only give you 30 per cent protection against infection. For severe disease, it used to be 90 per cent or more. Now we’re looking at about 80 per cent. That’s still very good. But it’s not 100 per cent, obviously. And it’s less than before.

People are very upset. There’s a lot of doom out there on the news and on social media. People are saying, well, we’re back to the beginning. Listen: we’re not. This is not March 2020. It’s December 2021. Almost 80 per cent of us are double vaccinated. Boosters work. In March 2020, we didn’t know how the virus spreads or how lethal it is. We had no vaccines; we didn’t even know we were going to have a vaccine. We had no medications to treat it. It was like all completely new. So we’re further ahead.

A new variant is disappointing. It is. It’s not surprising, though. I was actually looking at the Greek alphabet recently. Pi is next. And this is something we need to talk about. What’s our target? What’s our goal? Variants are going to keep coming up. Are we going to react strongly each time, to close the borders? Or do we find a way to live with this, knowing that it’s more or less endemic, as part of the repertoire of viruses we’re going to get? 

I completely agree that you have to control an endemic virus — you can’t have it going to 10,000 a day. You have to bring it down to some acceptable level. But you also want to decouple that number from the impact on the hospital system. We can’t just be focused on hospitalization, as important as that is. If we decouple this from hospitalization, where cases mean fewer people showing up for me to care for, that’s the goal. If you’re running a business, and your staff is always isolating after exposure, then you can’t run your business. Factories, restaurants, whatever. And schools. 

So what is a “case” now? How important is it? I’ve lived this for two years now, since March 2020. Then, when you had, say, a long-term-care resident who became infected at 85 years old, they’d come here, and I’d think, well, shoot, there’s a good chance you might die. This was always very age-related, and that’s why we put the vaccines into the long-term-care homes first, and the nursing ones, to decouple cases from hospitalizations and death. We protected the most vulnerable first, then the 60s and the 50s and so on. Obviously, there are exceptions. We’ve lost people in their 20s. It’s rare, but it happens. But, today, if I hear about someone in their 40s with two vaccines testing positive, I’m not as worried for their health outcome. We need to get the clinical context. We had, what, 1,500 cases in Ontario today, but if half of them are under 10, I will not see them in the hospital. 

This is not about denying the challenge or the danger. Omicron is real. We can’t minimize this. But purely from a health perspective, I’m not as worried about a double-vaccinated 40-year-old as I am an unvaccinated 80-year-old ... or a transplant patient who’s 60, and we’ll see breakthroughs there because of compromised immune systems. But we need to think about what cases mean. We don’t count each case of rhinovirus, and I think we need to be courageous enough to talk about this. Omicron is real, but we’ll have to live with it.

Gurney: Infection-disease expert Zain Chagla told me something similar just a few days ago: it’s loose and here to stay. Something you said above tracks with what I’ve been feeling in recent days. You said we need to view this clinically and scientifically. And you also talked about the doom. There’s a lot of that. I think some of that is exhaustion and fatigue. Trauma, even, on a collective scale. But I also think a lot of this is just now getting folded into our existing political views. If you dislike Doug Ford or Justin Trudeau, it’s their fault. If you like them, they’re doing their best. And we have people taking sides or supporting an action or opposing an action or demanding something based more on their political affiliation than on the science and the medicine. That ain’t helpful.

Haddad: You’re right. It’s not helpful at all. I’m apolitical. I’m very apolitical. I’m into the science. I go by data. I did epidemiology as my master’s training. I think our patients don’t care what colour government we have. So we have to decouple politics from medicine and health care in general, just like we have to decouple case numbers from hospitalizations. That is a goal for the vaccine. 

So the message has to be clear from leaders. What are we doing? What’s the goal? Are we going to just do our best to save lives and reduce the impact on the health-care system? 

Vaccines do that. We are not going down to zero cases. This is not going to go away. Realistically, to achieve the initial goal of fewer people in the hospital, you have to have enough people vaccinated, a high number of vaccinated people. This keeps a lid on the number of cases and helps prevent even the unvaccinated from becoming sick. Hospitals are the last line of defence. I’m not in public health, but I’m a stakeholder in what’s happening in my community — a portion of the people who get sick, I end up seeing. And as a hospital administrator, being the chief of staff, I have to worry about my staffing, both medical and overall. So please get your vaccine; get your booster if you qualify. 

I know people need to live their lives. I’m realistic. I am realistic about that, but I’m also realistic about this: it’s here to stay. We have strep, we have pneumonia, we have influenza, and now we have COVID. Decoupling it from severe disease should be our main goal. We have to control the endemic virus load, yes, absolutely, and be smart about it. But we also need to make good personal choices. If I’m a transplant patient, I’m not going to the office Christmas party. But if I’m 40 and fully vaccinated — with two or now three doses, I guess — and cases are low? Yeah, I’ll go to the barbecue at my neighbour’s in the summer.

Gurney: Yeah. That’s how I feel. Once I was fully vaccinated in June — well, fully vaccinated as we thought of it then — I had a pretty normal summer. But Omicron has bad timing, if nothing else. It’s right at a time of year when we’ll be travelling and mingling.

Haddad: I don’t think it’s fair to tell people after two years of this, and being double vaccinated, and now we’re telling them to get a third, I just don’t think it’s fair to tell them what we told them last year. That’s my personal opinion. I can’t tell someone to keep grandkids away from grandparents or siblings not to meet up or children and parents. Keep it small. Keep it close. Keep it with family. And I definitely don’t think people should go to large office parties — and that’s not just because of the health part. If you run a business, and you have one case at your party, do you want to isolate your entire workforce? 

A month ago, if we’d been talking, I might have been more ambivalent about parties. I’d have said, well, if you’re young, if you’re vaccinated, yeah, maybe you can go. With every patient, I discuss their personal risks, their conditions, their vaccination status, and we come up with personal conclusions. But now? It’s different. Omicron is going to change things. It’s going to go up. It’s going up in the United Kingdom, and it’s going to go up here. We’re not different; we’re just behind. 

This is still some guesswork. We don’t have enough data. I’m still trusting that double vaccination will reduce the impact from a hospital standpoint, but I think the hospitals will be very busy. I was just saying to the hospital CEO today, it’s winter. People are indoors. We were going to get busier even just from Delta. Now with Omicron, we just don’t know how busy we will get. 

Gurney: I know that this is all still emerging and developing, but as a chief of staff at a hospital, as a critical-care doc, when you don’t know what’s coming, how do you prepare? How are you preparing?

Haddad: Yeah. We will be busier, for sure. The statistics show us what the experience of the last three waves was. The first wave — the “wild wave,” and then Alpha, the second wave, and now Delta, the third and start of the fourth. In those waves, about 7 per cent of cases in the community wound up in the hospital. This is what I’m reminding my staff. So if I see 100 in the community, we’re going to get seven of them. That’s a rough guesstimate, right? It changes a lot based on age and vaccination status, but it’s a rough guide. A third of those seven, so about two, will end up in the ICU. Half of those will die. That’s our 1 per cent mortality statistic for COVID-19. So, with Omicron, we’re hearing it’s milder. And that would be wonderful. And there is emerging evidence of that. I’m seeing the signs. That’s very rough and preliminary. South Africa is younger than us, as a population, and they’ve had three waves rip through them. They don’t test as aggressively, but, in some areas, maybe 80 per cent of the population has some immunity. We have an older population, but we’re more vaccinated. I don’t know what that will mean, how it will play out here. I just don’t know.

But let’s do some statistical guesswork. If Omicron is milder, maybe we don’t get seven out of 100 in the community. Maybe we get three. And then a third of those go into the ICU, so one, and there’s a 50 per cent chance of death. So that’s, just statistically, less than one death for every 100 cases. Which is good. But Omicron is more contagious, and if we have 200 cases in the community, not 100 ... well, do the math.

Gurney: Half lethality and double the cases is a break-even. You end up with your ICU as full and the same number of deaths. You just make it up on volume.

Haddad: Yep. That’s exactly it. Exactly. So, on an individual basis, this could be a much milder illness. But if it rips? Well, it could be like last year, every day — the TV telling you there are no beds. But I don’t know. I’m just playing the odds. Like, I’m sitting here just like everybody else. 

Add to it the fact that December is always busy. So, today, our occupancy is not horrible. [He checks something offscreen.] Yeah. It’s, like, 85 per cent. Our ICU is more than 90 per cent. We have 14 beds in our ICU. We have 14 beds, and 13 are filled now. Give me five more COVID patients from the community, and we’re plugged up pretty bad. You have to cancel big procedures that will end up in ICU. And you’ll still have traumas coming from the ER. Staffing becomes a big issue now, and that’s going to affect someone’s health care if we start to quarantine and isolate staff. Today, I have 14 people quarantined because of some exposure. That’s the issue right now. And that’s not going to be limited to health care. 

Gurney: If Omicron really rips, as I was told just a few days ago, even people with mild symptoms or no symptoms will end up home in isolation, and you’ll show up to buy food at the grocery store or to fill your tank at the gas station, and they’ll be closed because the whole workforce is in isolation.

Haddad: Exactly. So the government has to think about these things. It’s complicated. I’m still hopeful. We do have 80 per cent double-vaccinated. But, nevertheless, if we truly have fewer neutralizing antibodies, that means more will be infected. Maybe fewer will come to the hospital. Great, but if we’re isolating a lot of people, our society will be paralyzed. One more thing. I don’t know how fast we’ll get those boosters. Omicron is fast. And it’s going to take us time to organize that campaign and do the shots, and then it’s two weeks to get full protection from the shot. This might rip through before we can boost a lot of people.

Gurney: I was thinking about that earlier. We aren’t fast, Canadians. So we have delays in political decisions. Then we’ll have organizational delays. And then we’ll have execution delays. And, then, as you say, we’ll have to wait two weeks. I look at what Omicron will do if it keeps doubling every two or three days and how long we’ll need to boost everyone, and Omicron wins that race.

Haddad: And now that we’re opening it up, we’re going to have 18-year-olds competing for boosters with 60-year-olds. From a hospital standpoint, I’m worried about the 60-year-old. So it will be weeks before many of us get boosted and then two weeks after that for protection. 

Gurney: Let’s talk about that, then. The speed of Omicron. This is going to unfold over days, not weeks, and most of our reactions will take weeks. You’re a hospital administrator, a doctor — what can we do now to help you? What will be fast enough to matter?

Haddad: We have been working to give our own staff third doses. As soon as we were able to do that, we began working on that to minimize the chances of a breakthrough infection. We’ve also been getting bombarded with new information and new protocols for isolation. If we have exposure, we’ll have to send workers home. We can’t afford that. 

So I’m trying to advocate for changes. Maybe if someone has three doses and was in PPE — we’re always in PPE — we don’t have to send someone home? One hundred per cent of our staff is vaccinated here. We have a vaccine mandate; many hospitals do. We will work with family docs and other organizations in the city to get boosters out to the public, though I still think that should be in descending order of vulnerability. We had an infection-control meeting just this morning. We had another meeting to talk about mitigating the impact of staffing shortfalls from isolation orders on clinical services, because we don’t want to be cancelling services. 

So what are we doing now? More robust planning meetings, keeping up with changing directives, advocating for changing isolation rules, and doing our best to boost the community. Because it’s all out there. Whatever happens in the community is what’s going to end up coming to the hospital. People need to help themselves. We have maybe 10 per cent, 15 per cent of people who are refusing to get vaccinated. Some of them are going to come here. And there are people who are doing their best and did get vaccinated, but maybe they have a health condition or are immunocompromised, and some of them are going to come here, too. People are going to get sick and need a hospital. 

Gurney: But, in the meantime, you’re just waiting, I guess. You don’t really know what’s coming, so you’re just preparing as best you can.

Haddad: We haven’t had any Omicron in our community yet that we know of. If you look at the U.K. data, many of the cases are milder. Is it because they’re vaccinated? I don’t know. I don’t have the breakdown. Omicron is still COVID, though. So, to plan, we assume, say, an unvaccinated 60-year-old before would be in trouble and an unvaccinated 60-year-old now will still be in trouble. There’s some data now emerging that I saw, maybe Omicron is 29 per cent less severe. That’s good, but that’s still not zero. So an unvaccinated 25-year-old gets it, that risk is probably mild — it’s not zero, because we have had people die in their 20s, but most likely, that’s a few days of illness and then a recovery. This is still a disease that is highly correlated with age, and most of the deaths are over 50. Maybe it’s a bit milder, but, in general, I’d still worry about the same people as with Delta — older and unvaccinated or immunocompromised. And remember, even with a “milder” disease, if you’re the unlucky one and need a ventilator for two or three weeks, that’s still bad for you.

Gurney: One of the reasons I wanted to do this series was to inform myself. I don’t know what’s coming. I honestly have no idea what’s coming, and I wanted to talk to smart people who maybe would. But let’s talk about a hypothetical. And I want to stress that this isn’t a prediction. But during the third wave, we had about 900 people with COVID in our ICUs, and that seems to have pushed the system to the very brink. Let’s say Omicron is mild, but we have so many cases that we end up with, say, 1,200 COVID patients in our ICU. I know that that might not happen, and I don’t want to sound alarmist, but just even from a planning standpoint, what can you and your hospital do in that situation?

Haddad: Right. During the third wave, actually, we were receiving patients from Toronto. Quite a few.

Gurney: I live near Sunnybrook Health Sciences Centre. Very close. There were a lot of helicopters in and out in the spring and early summer.

Haddad: Yeah, right. We had to actually expand; we went to 18 beds, I think, and we could go to 22. But we did that by stealing staff from the operating rooms and cancelling procedures. If something like that happens again, we’ll have to ramp down everything elective, everything but emergencies that present to our trauma wards, and direct everything to the frontlines of COVID. 

But, at some point, you also break. You can’t go anymore. We have physical beds, and we have extra ventilators than the 14. But we need staff. So I think once we get to 18 or 19, that will be really up there at our limit. 

The province does try to share capacity by moving patients around. But not every ICU can handle a COVID patient. They’re very high-demand patients; they need a lot of staffing and ventilators with very advanced settings. You’re not going to send them to a small town with a couple of ICU beds. They can’t handle those. 

So, last year, we added beds everywhere. We were at, like, 2,200 ICU beds in the province and 900 COVID. Today, we have 1,800 beds and about 150 COVID. The projections by the science table, as you know, is for 250 to 400 COVID in ICU, but that’s mostly Delta. So if we go back up to 900, I think it’ll be awful. But we can handle it just like we did last time, though it won’t be fun at all. 

The one thing that I worry about is that it’s like charging a battery — with time, you get your charge back, and then you use it up, run it down. Our staff is exhausted. We are not charging the battery fast enough. In the old days, people would jump into overtime, for example; now you have to beg people to take on overtime. We have people who were close to retirement and chose to retire and say, I’m done with this. So we have to replenish them with fresh ones who are less experienced. We are training them, but that takes time. So even at 900 people, it would be really tight. The battery just isn’t as juiced up. At 1,200 or 1,500, well, I’m not going to lie to you. Some people would die.

Gurney: Yeah. No one likes to hear that. But that’s what I’ve concluded, too.

Haddad: No, no one likes hearing that. But people would die for lack of care or delayed care. We didn’t have to implement the triage protocol last time. No one even likes the word. But at 1,200, we would need to. I hope we don’t have to.

Gurney: Last December, I knew three people who all needed urgent care. Different scenarios. All bad luck; none had any warning. And they’re all okay today because there was a hospital bed for them, and a doctor and a nurse. At 1,200 patients, at least two of those people are probably dead today. They’re alive today because, in December 2020, there was a system for them. A few weeks from now? I don’t know. How much training time for the new staff? Like, Omicron is moving fast. It’s going to pop in days. You can’t train staff in days.

Haddad: It depends on the specialty. But, also, there’s this. There’s mandatory training time, right? And then there’s hands-on training, getting a chance to use the equipment and learn. But there’s also the training for some very emotional stuff. It’s hard when you’re with someone and they’re dying without their loved ones. I don’t want to relive those days. We had people crying on iPads because they couldn’t be with their family member as they died. Or we, a doctor or a nurse, would hold someone’s hand, so they didn’t die alone. That was awful. We don’t want to do that again. 

You can’t prepare for something like that. You train and train and train, but we’re humans. And something I want to say: most people who get COVID don’t come into hospital, but some do, and this is a terrible disease. It’s terrible. We have seen dozens and dozens of patients with it. We’ve seen people die from it. And we remember their faces, because they spend weeks with us, sometimes, and we care for them, and sometimes they die. And then we leave the hospital, with these faces in our minds, and we see someone on TV or on Twitter saying it’s a hoax? That COVID isn’t real? It’s insulting to the families that just lost a loved one, whose faces are imprinted on our brains. All of our staff — the doctors and nurses and respiratory therapists and physiotherapists and OCTs and support staff — we were heroes. Now people protest us while we work. We get yelled at as we try to save lives. It’s hard. It adds a lot of stress. 

I understand the frustration of the community. We live in the community. We go to restaurants, and we want sports games, too. We get it. We want to move on. We don’t want to go through this again either, believe me. We want to see our families. So we also care about our freedoms. But we know what’s coming. So do you. I don’t like rollercoasters. But I feel like I’m on one again. The fourth time.

Gurney: What should we do right now to get you off that rollercoaster?

Haddad: I’m not calling for a lockdown. At all. But we can do some smart things. Don’t go to a small indoor space with 50 people in. Just don’t. Masks? Wear your mask. It’s not being adhered to enough. People aren’t doing it. It’s a basic courtesy. I’m young. I’m triple-vaxxed. I’m not wearing my mask to protect me, I’m wearing it to protect you, and you can wear it to protect others. 

Reduce your social interactions down to what you need — family, the people at work. Testing. Just random screening might not work so much, but we’re sending rapid-testing kits home with all school kids. That’s a great idea. I’m totally for that. But I was just talking to my wife about this. Imagine a classroom where half the kids took their rapid tests, but the other half didn’t bother. What’s the point of that? It’s voluntary! That doesn’t make sense. We have tools. We have to use them in a smart way. I live in a border town. I see trucks going over the bridge every day, and they’re all essential, in theory, but come on. We have families that are split by the border. People couldn’t care for their loved ones in a nursing home or visit dying relatives, because that wasn’t essential. Come on. We’ve got the tools. Let’s be smart.

Oh, and if you aren’t vaccinated? It’s a bit late, but it’s never too late. One is better than none. Two and three are even better, but it’s not too late to start even now. Vaccination, limiting gatherings, indoor masking. A combination of these things can break transmission chains and slow even Omicron down. We need to use science and be realistic, because COVID is going to be here a long time. It’s with us now.

This interview has been condensed and edited for length and clarity.


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