As Ontario confirms its first coronavirus death and declares a state of emergency, health-care workers in Toronto and beyond are bracing for the next front in this rapidly-growing outbreak: intensive care units.

Doctors say COVID-19 patients are already being admitted to intensive care units across the Greater Toronto Area. Based on the pattern of the outbreak in other countries — which typically ticks along at low levels and then suddenly booms, with an associated increase in the severely ill — experts are bracing for a surge to begin in the next few days.

Canada’s top public health officer, Dr. Theresa Tam, said Tuesday that of Canada’s 440 cases the “most concerning” was the increase in Ontario, including three Toronto cases not linked to international travel. The city has now reported 108 cases, and Toronto medical officer of health Eileen de Villa said she expects to see more community transmission.

Doctors have expressed concern over whether Ontario has enough ventilators, a crucial medical device that can save the lives of patients suffering acute respiratory distress. As fears of global ventilator shortages grow, calls for a “wartime” effort have prompted factories to pivot toward producing parts.

The Ford government just spent $12.2 million to boost the province’s supply, anticipating a surge in demand, according to a Ministry of Health spokesperson.

But as hospitals await the promised reinforcements, doctors are already gearing up for what some describe as a “coming onslaught.”

“I don’t want this to sound too hyperbolic but it feels like we’re going into war and we’re just preparing ourselves for that,” said Dr. Michael Detsky, an intensive care physician at Mt. Sinai Hospital. “Like the people who were stationed in England before D-Day — that’s kind of the sense you have. You know this is coming and what to expect is hard to know.”

Among the many uncertainties now facing hospitals is how much of a surge to brace for.

In China, where the outbreak was first detected, data shows that 80 per cent of confirmed coronavirus cases are mild to moderate. The remaining 20 per cent were severely or critically ill, and a quarter of those required mechanical ventilation, according to a World Health Organization mission report co-led by Canadian Dr. Bruce Aylward. A recent study from China of 52 critically ill cases found that three patients spent 28 days on ventilation.

Italy had much higher intensive care rates. A recently published study found that 16 per cent of all confirmed COVID-19 cases were admitted to the ICU. A group of Italian doctors said that roughly 10 per cent of cases required mechanical ventilation.

It’s not clear why Italy experienced a higher proportion of severe cases than China, but it could be because its population skews significantly older, and older COVID-19 patients are more likely to suffer severe outcomes or die. Canada’s population is younger than Italy’s but older than China’s.

The availability of ventilators has been a particular source of anxiety for health-care workers bracing for the coronavirus’ arrival in Canadian ICUs. Federally, there is no single body tracking the number of ventilators available across the country.

But according to a 2015 study that surveyed acute care hospitals, Canadian hospitals had at least 4,982 ventilators at the time. Dr. Robert Fowler, an intensive care physician with Sunnybrook Hospital and lead author on the study, says he and his co-authors are now working on finding updated figures, an effort that began last week.

“We want to make sure that we have enough capacity to treat everybody to the best of our usual ability,” he says. The devices are needed not just for the sickest COVID-19 patients but also for people being treated for everything from chronic lung disease to opioid overdoses.

A spokesperson for Ontario’s Ministry of Health confirmed to the Star Tuesday that the province had just spent $12.2 million to obtain 300 new ventilators, and said the devices have already been delivered. That money is on top of the $304 million announced to address COVID-19 in the province, including $100 million to increase capacity in hospitals, including ICU treatment.

Ontario also has a ventilator stockpile, part of a provincial plan to deal with surges in critically ill patients — a plan developed after the 2003-04 SARS crisis, when Ontario’s health-care system buckled under the stress of a different coronavirus-caused respiratory illness.

The provincial stockpile counted 209 ventilators stored at 19 hospitals in 14 different regions as of last August. Hospitals in a crunch for ventilators can request one or more of these to be delivered through a series of protocols.

As for the availability of ventilators in regular use in Ontario, the province has yet to publicly confirm a number, though physicians like Isaac Bogoch, an infectious disease specialist at Toronto General Hospital and the University of Toronto, have called on officials to disclose this information.

“We’ve had two months to prepare for this,” he said. “So the Ministry of Health really needs to step up and ensure that we have the appropriate number of beds, the appropriate intensive care capacity … we need it now.”

But James Downar, secretary of the Canadian Critical Care Society, says when it comes to the province’s availability of ventilators, “the people who need to know these things, know them.”

Citing numbers provided by the ministry, Downar says he is aware of 1,700 ICU beds and ventilators currently available at hospitals across Ontario. He adds that hospitals also have the ability to “flex up,” for example by using resources in operating rooms to treat critical care patients.

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Detsky believes his own hospital has enough ventilators at the moment and his bigger short-term concern is keeping hospital workers healthy — patients on ventilation need the support of an entire team, everyone from nurses to respiratory therapists.

But like all ICU physicians, he has read disturbing accounts streaming out of Italy, where doctors have described ventilator shortages and heartwrenching decisions over which patients to save. He can’t help but worry about the prospect of a ventilator shortage.

He still believes Canada can avoid the worst-case scenarios currently playing out in countries like Italy and Spain, but everyone will have to play their part in controlling the spread.

As he awaits his first coronavirus patient — one he knows will soon be coming to his ICU — he can only hope Canadians are heeding advice to stay home and practise social distancing.

“It makes me sick just looking at these videos of people at concerts, at Disney World over the weekend … it’s stressful,” he says. “We’re going to be tested in ways we’ve never expected.”