COVID-19: Are rural regions in our blind spot?
Last Tuesday at the Hôtel-Dieu de Lévis, our group of doctors and nurses were preparing for the worst scenarios. The news from Italy and New York is clear, we may have to deal with a wave of patients large enough to activate our “mass casualties” protocol, which will potentially force us to make heartbreaking choices to target who has the best chance of surviving in intensive care. We are one of the best performing emergencies in the province and we are afraid. Fear of running out of material for patients and of protective equipment for ourselves. Fear that too many staff will fall into battle and not be able to do what they have always done: care for people.
And there, it strikes me: the regions; are they ready? I have been studying these small emergencies for ten years which treat more than 400,000 patients per year in Quebec and 3 million in Canada. These emergencies are the safety net for 20% of the population. Already, in a context where no pandemic is raging, there is a higher mortality for rural patients for several medical conditions. The regions are vulnerable.
Rural emergencies have access to few specialists on site 24/7. The shortage of staff (nurses, psychosocial services, etc.) rages in rural areas even more than elsewhere. In addition, more than half of rural emergencies rely on convenience store doctors (volunteers who come from large centers) to insure up to more than half of their guards. Will these doctors still be there if they are retained in their community?
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In addition to staff, material resources and infrastructure are minimal in rural areas. For example, do distant hospitals with only a few intensive care beds have enough ventilators? Certainly not to deal with this crisis.
The remoteness of rural areas also makes them very vulnerable. Thus, almost 60% of rural hospitals are more than 150 km from a secondary or tertiary trauma center. One hundred and fifty kilometers to transfer a patient. It is 300 km round trip for limited ambulance resources. All this if we assume that the receiving centers have the space and the staff to receive these patients.
In response to these concerns, we convene a pan-Canadian think tank, the “Blind Spot Think Tank,” an initiative inspired by the International Masters in Health Leadership from McGill University.
From these discussions emerged a finding: not all rural emergencies are as ready to face the wave. Some regions with strong local leadership have been able to organize themselves quickly, while others seem disoriented without knowing where to start. In the best organized regions, doctors can count on the versatility and generalism inherent in practicing in rural areas, while other areas do not seem to have understood the gravity of the situation.
Here are some areas of priority solutions that could be implemented right now, in addition to the closure of the regions announced, which is an excellent measure, in order to maximize the little time we have to minimize the vulnerability of the environment:
1. Attitude and leadership
A) We must first trust the leadership of rural leaders recognized for their willingness to act and their proactive, unifying and positive attitude. We must ensure that experts who are aware of the multiple realities of rural and remote areas are included on the various provincial decision-making tables. The Association of Emergency Physicians of Quebec, the Association of Specialists in Emergency Medicine of Quebec and the Association of Emergency Physicians of Canada must be able to enlighten decision-makers. Nurses associations or other professionals can also help.
B) Academic circles and regions must freely share their training, knowledge, concerns, protocols and local innovations documented via a platform accessible to all circles in the regions.
2. Human resources
A) Favor rural regions for the deployment of graduates in the field. These young nurses, doctors, specialists could help local doctors. They must be deployed on the ground urgently. Graduates: are you ready to pack your bags? You will be welcomed with open arms by a population who will be forever grateful to you.
B) Mandate the provincial payday bank to cover the breakdown of services in the regions. Many small emergencies may lack doctors when they get sick. There needs to be a rapid deployment mechanism and a sufficient number of convenience store doctors ready to be deployed in the short term.
C) Create a critical care center in support of the regions via telemedicine, taking the example of British Columbia. The isolation professionals could then be recovered to support the regions.
3. Optimizing patient transfer
We must ensure that the pre-hospital system is ready for the regions. These regions have access to a limited number of ambulances and paramedics who may also fall ill. Transfers to major centers were already complicated before the crisis. It’s time to create links with airlines and helicopters to optimize patient transportation. It’s time to build a sturdy plane / helicopter-ambulance system forever.
4. Prepare for the worst
Many believe that the current system will not be able to meet the needs of the population. Regions should lead by example and prepare for the worst. This includes a concrete plan for mass casualties to maximize resources in the event that this approach becomes the only one possible.
Let us hope that this blind spot of the regions returns to our field of vision before it is too late.
Richard Fleet, MD, PhD, Emergency physician CISSS Chaudière-Appalaches; Psychologist; Professor Department of Family Medicine and Emergency Medicine Université Laval; Holder of the Research Chair in Emergency Medicine; IMHL student 2019-2021. www.medecineurgence.ca; FB: rural emergencies 360.
In collaboration with “Blind Spot”: the creative unit inspired by IMHL (International Masters for Health Leadership, McGill University)
Jean-Simon Létourneau, MD, Emergency physician CISSS Chaudière-Appalaches; IMHL student 2019-2021
Simon-Pierre Landry, MD, doctor in the emergency department of Ste-Agathe and columnist on health issues
Bernard Mathieu, MD, emergency physician. President of the Association of Emergency Physicians of Quebec
Henry Mintzberg, PhD., Professor Management Studies McGill University; Faculty Director IMHL
Leslie Breitner, PhD., Senior Faculty Lecturer Faculty of Management McGill University, IMHL Academic Director
Mike Ross, MA, M.BA, Founder Juniper – Strategy, Culture and Innovation Consulting
Mylaine Breton, PhD., Commonwealth Fund Harkness Fellowship 2019-2020, Harvard Medical School, Canada Research Chair in Clinical Governance of Primary Care; University of Sherbrooke
Hassane Alami, PhD., Postdoctoral fellow, Center for Research in Public Health. Montreal university
Emanuel, EJ, et al. (2020). “Fair Allocation of Scarce Medical Resources in the Time of Covid-19.” New England Journal of Medicine . March 23, 2020. DOI: 10.1056 / NEJMsb2005114; Truog, RD, et al. (2020). “The Toughest Triage – Allocating Ventilators in a Pandemic.” New England Journal of Medicine. March 23, 2020. DOI: 10.1056 / NEJMp2 005 689
Fleet, R., et al. (2019). “Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centers in Quebec: a population-based, retrospective cohort study.” BMJ Open 9 (6): e028 512; Fleet, Richard, et al. (2018). “Rural versus urban academic hospital mortality following stroke in Canada.” PloS one 13.1.
This pragmatic list is in addition to that issued by the Society of Rural Physicians of Canada .