The Cambie Surgery Centre is now recommending patients scheduled for surgery at the private clinic get a COVID-19 test before their operations.

Dr. Brian Day, co-owner of the Vancouver centre, said although the test has been shown to have a false negative rate as high as 30%, “even a 70% rate of knowing is better than ignorance.

“Some knowledge is better than no knowledge and, as you know, some of the health workers (anesthesiologists) dealing with airways are at higher risk than others. For our purposes, testing is best done within a few days of surgery.”

Anesthesiologists and general surgeons have been some of the most vocal physician groups advocating for routine testing. But in B.C., where the testing rate is about half the national rate, health authorities are not asking patients to routinely get pre-operative tests although experts who drafted guidelines have wisely allowed surgeons to use their clinical discretion. Patients are, however, screened through questionnaires meant to identify risks. Those who are high risk because of contact with individuals infected by COVID-19, or who test positive themselves will have their operations delayed.

While surgeons, nurses and other health care professionals are protected in operating and recovery rooms with personal protective equipment (masks, goggles, gloves, gowns, face shields) some patients will undoubtedly have some anxiety about contracting COVID-19 from other patients unless they can be reassured by the knowledge that all patients have been tested.

Health Minister Adrian Dix said today that the B.C. government now has a large stockpile of PPE to protect health care workers – more than 4.8-million N95 respirator masks, five million surgical masks, two million pieces of eye protection and 30 million pairs of gloves. It’s estimated that the catchup for all surgical cases delayed by the pandemic will take two years.

Linda Lupini. an executive with the Provincial Health Services Authority, showed a photo on Twitter of the Langley warehouse where the PPE is stored:

The B.C. government has not disclosed how many patient-to-patient transmissions have occurred in hospitals. But in cities like Montreal, pre-surgery COVID-19 testing is now routine because of such transmissions.

The Cambie Surgery Centre is not one of the eight clinics the government and health authorities have contracts with to help clear the backlog of operations that were cancelled or delayed when the pandemic began.  The Cambie centre is involved in litigation against the government over the matter of patients using their money to get expedited treatment.

The plaintiffs in the long-running litigation maintain that patients have the right, under the Canadian Charter of Rights and Freedoms, to use their money for such purposes.

A decision in the matter is expected sometime in the next six months.

Here’s one of the dozens of stories I’ve written about the case:

https://vancouversun.com/news/staff-blogs/dr-brian-day-1-everything-you-need-to-know-about-him-and-his-legal-case-against-the-government-health-care-monopoly 

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Dr. Patty Daly and Dr. Eric Grafstein have been leaders in B.C. healthcare for a few decades now. The married physicians are intrepid leaders and during the COVID-19 pandemic, they’ve piloted their colleagues gallantly.

Daly is the Vice President, Public Health, and Chief Medical Health Officer for Vancouver Coastal Health. Grafstein is the regional head of emergency medicine for Vancouver Coastal Health and Providence Health Care. There have been 899 cases of COVID-19 in the Vancouver Coastal Health region (population 1.5 million) and 2,550 across the whole province.

They’re members of the reform synagogue called Temple Sholom in Vancouver so when Rabbi Dan Moskovitz convened a webinar for congregants and the community at large, he naturally tapped them.

I’ve watched the session that took place earlier this month and it was surprisingly reassuring in tone. Grafstein and Daly are about as well suited for a pandemic as anyone since they embody logic and calmness under pressure.

Grafstein debunks the need to wear gloves at all times (they may give a false sense of confidence; handwashing and sanitizer are the best modes of hygiene). He’s meticulous but not obsessively so. I watched a video of CNN’s Dr. Sanjay Gupta wiping down every product in his grocery bag; Grafstein said he doesn’t clean packages of products he buys at the grocery store but he does wash produce before it’s used and he cleans his hands incessantly.

Referring to the resumption of activities like canceled or delayed surgeries, Daly said:

“We’ve significantly bent the curve, so we can begin to lift some public health measures.” She also spoke about children who have a much lower risk of infection for inexplicable reasons, and that’s why daycares and day camps can likely re-open this summer, with some restrictions. Thousands of children have been tested for COVID-19 in B.C. and less than one percent have been confirmed to have had COVID-19.

Daly spoke to the anxieties people have about even going outside.

“It’s quite safe to be in parks, exercising outdoors. I’m not aware of any transmissions through casual exposures outdoors. People can be reassured that there isn’t a risk when someone passes them on the street.  We shouldn’t fear that passersby will infect us as long as they aren’t coughing or spitting directly in our faces.”

Asked by Rabbi Moskovitz about COVID-19 transmission to doctors, Grafstein said he knows of only one medical colleague at St. Paul’s who got the virus and he is “positive he didn’t get it in the hospital.” (Nearly a quarter of COVID-19 cases have been among health care workers, mostly those who work in long term care facilities).

But Grafstein acknowledged that the shortage of personal protective equipment for healthcare professionals and workers has been an ongoing issue requiring “shepherding logistics and procurement.

“At various times there’s been a concern on whether we’d run out. I wear a mask and a face shield but I keep it on throughout my shift.”

Daly said every positive case is followed up and “Eric is right, this is different than SARS, almost every health care worker transmission has occurred in the community,” she said, noting the community-acquired cases are what led to outbreaks in long term care facilities.

Not surprisingly, the rabbi asked about when houses of worship might be allowed to reopen. Daly said she can’t predict when that might happen:

“Gatherings over 50 will be the last thing we lift. Houses of worship have to protect older people…” she said.

In the fall, she expects university classes might be a combination of virtual and in-class teaching.

Asked at the end of the hour-long sessions about any blessings or silver linings that have come from the pandemic, Grafstein said the uptake of virtual health care technology is one. Apart from the utilization of technology, he cited the fact that the pandemic has led to “people coming together to sort out problems, to tackle it, and that gives me great confidence.

“Canada has done better (than many other nations),” he said, before giving a shout-out to his wife and other public health officials.

Daly echoed her husband’s comments about the use of technology.

“Like in any war, there is innovation,” she said, adding that governments have “come together to do the right thing.”

Rabbi Moskovitz got the last word in, praising the two for being the kind of “heroes we clang and bang pots for, and who we pray for.”

Watch the session on Youtube here.

Email me here: [email protected]

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I know of a West Vancouver resident who this week tested positive for COVID19, six days after she was released from Lion’s Gate Hospital where she had surgery.

The elderly woman is isolating in her apartment and receiving home care services from Vancouver Coastal Health. I am told she had COVID-19 testing in the hospital while she was an inpatient; Lion’s Gate has had COVID-19 outbreaks on patient wards. It would seem she could have acquired COVID in the hospital. Are the risks of contracting COVID-19 higher in hospitals than in communities? We don’t know. The government hasn’t given us that information.

In my last article, I drew attention to the fact that B.C. guidelines do not call for mandatory pre-operative testing for scheduled operations. And I have since heard from surgeons and anesthesiologists who are concerned about this. I asked Dr. Kathleen Ross, president of Doctors of BC, about the organization’s stance on this. She acknowledged some of the concerns and hinted at some flexibility as well as possible changes in the future if patients bring COVID-19 infections into hospitals or if hospital-acquired COVID cases spike:

“The guideline is not ‘no testing.’ It suggests testing based on screening for wide-ranging clinical symptoms, travel, and possible exposure. From a public health point of view, with the very low incidence of disease now, a positive test is not as accurate as we would like, though a negative test is reassuring. And a negative test 24 to 72 hours pre-surgery would not guarantee that the patient is asymptomatic on the day of surgery. We think the guidelines are flexible enough to allow testing if needed…”

Dr. Kathleen Ross, President, Doctors of BC

“We have heard of some concerns regarding universal laboratory screening of elective surgery patients as we prepare to increase the number of outpatient surgeries we are conducting. We do understand the concern of those on the front line of clinical care and also realize the PHO/BCCDC recommendations are based on the most up to date science relating to SARS-CoV2 disease incidence in the population, droplet precautions, aerosol-generating procedures, the effectiveness of PPE, and appropriate donning and doffing procedures. With the disease incidence being low in the community, the positive predictive value of a test is not as useful as the predictive value of a negative test.

“The critical piece is the entire surgical team will decide together which risk category the patient is assigned to prior to the patient entering the surgical suite and which PPE protocols will apply to the individual patient for any given surgery. This will optimally protect patients and providers.

“I personally trust in our protocols and recommend PPE when I am assessing, treating, and operating on patients in my own practice settings. We are currently rigorously applying procedures relating to the handling of all patients, including PPE equipment, to protect patients, healthcare providers, and support workers. Doctors of BC will continue to work closely with all our partners to monitor SARS-CoV2 incidence and COVID-19 cases as these screening and PPE processes expand to include elective surgeries and investigations over the next several weeks.”

As you can see from the comments by Dr. Ross (a general practitioner), experts have a lot of faith in personal protective equipment, perhaps more trust in PPE than in testing which may explain B.C.’s relatively low rate of testing. Indeed, B.C. is such a laggard in testing that just over 1,000 tests were done yesterday while the province has the capacity for seven times that number.

If hospital-acquired COVID infections – in patients and health care workers – spike, then I would assume the guidelines will change and testing before operations will become the norm.

I also heard from a patient whose surgeon has asked her to get a COVID-19 test 48 hours before her surgery. Her age, (co-morbidities (diabetes and heart disease), and a previous “indeterminate” COVID test, may all be contributing factors. But she’s reassured that her specialist has exercised his discretion and ordered a test.

In some other jurisdictions, pre-op COVID testing is routine because of studies showing that more patients die or suffer through long recoveries after surgery if they have COVID-19.

A surgical oncologist posted this on Twitter after she read my previous article:

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