Doctors in rural and northern Ontario hospitals are working flat out to prepare for the arrival of COVID-19 in their communities, with many worried just one or two critically ill patients will overwhelm their hospitals.

The new coronavirus has not yet taken hold in most of the province’s remote and rural regions, but doctors know it could soon arrive in force. And, when it does, it will test hospitals and clinics already running near their limits.

“Many are barely holding on at the best of times,” said Dr. Sarah Newbery, a family physician and chief of staff of two hospitals in Marathon, a town of 3,300 located 300 kilometres east of Thunder Bay along the Trans-Canada Highway.

“When COVID-19 comes, we could keep things going for a little while, but we are preparing to be clinically overrun with sick patients with no other local resources to turn to.”

In small communities, family doctors are overseeing all aspects of coronavirus plans, from setting up assessment centres to counting emergency medical supplies, finding space for more hospital beds to drafting backup solutions for when colleagues get sick — all while taking care of their usual patients.

Among the biggest fears is that small hospitals, which sometimes only have a single ventilator on site, won’t be able to treat all the sickest patients with COVID-19. There are also concerns Ontario’s air ambulance service, used to transport critically ill patients to larger hospitals, won’t be able to keep up with demand.

Rural hospitals, too, don’t have the same staffing levels as larger, urban centres. Already stretched thin, and with no in-house specialists to call on, a hospital will struggle to care for its patients even if one doctor or nurse falls ill with COVID-19. Some hospital chiefs of staff even now feel isolated from public health officials in southern Ontario and say they are exhausted from preparing for the virus, knowing the real fight hasn’t yet begun.

But more than all the practical concerns, rural physicians fear the emotional toll the virus will take should it sweep through their community. They know their patients intimately, often treating entire families during their careers, standing at bedsides for births, deaths and every medical concern in between.

“I feel like all of these people are my family and friends, and what worries me the most is that some of these people are going to die and that’s going to be really, really hard,” said Dr. Sara Van Der Loo, chief of staff at Atikokan General Hospital, which serves a community of about 2,000 people in and around the town of Atikokan, 200 kilometres northwest of Thunder Bay.

In a joint statement released Saturday, the Society of Rural Physicians of Canada and the Canadian Association of Emergency Physicians asked for more support during the outbreak. Among their requests are more personal protective equipment and testing supplies, setting up rural laboratories for COVID-19 testing and creating “rapid rural relief teams” of medical specialists, such as respiratory therapists, that could be deployed to remote communities as needed.

Atikokan’s hospital has 15 in-patient beds, a small emergency department and an attached 26-bed long-term care home. A single family physician is responsible for all the patients and residents during a 24-hour shift.

Van Der Loo, who has lived in Atikokan for 15 years, said providing medical care in a remote region in some ways has prepared rural physicians for COVID-19. By necessity, they problem solve difficult cases on their own, can quickly co-ordinate care between clinics and hospitals as unforeseen issues arise, and already rely on each another for advice and support.

But no matter how well they plan for COVID-19, Van Der Loo said rural hospitals will struggle more than those in larger Ontario cities.

Her hospital, for example, has just one transport ventilator used temporarily until an air ambulance can transport the sick patient to a larger hospital. Still, Van Der Loo and her colleagues hope to figure out how to make it work for two patients at once, and even then she still worries that won’t be enough.

She’s also concerned there will come a time in the outbreak when her hospital won’t have enough doctors to treat all those with COVID-19.

“It’s fine most of the time. But if COVID-19 becomes a big issue, if patient volumes go up dramatically, it’s not going to be fine.”

In Marathon, Newbery has many of the same worries.

As chief of staff at North of Superior Healthcare Group, Newbery has spent two weeks overseeing COVID-19 preparations for its two hospitals, various health clinics and staff.

Among her many concerns is the limited number of COVID-19 testing swabs available for Marathon. Currently, there are 50 swabs for a region of about 3,800 people. Newbery said they are carefully watching their supplies and prioritizing how they are used, with a focus on health care workers.

With little guidance from Public Health Ontario for rural and remote regions, Newbery has become one of the few people in her community who colleagues can turn to for any COVID-19 questions.

“I’m fielding phone calls from physicians in communities across northern Ontario and from industries,” she said, adding that Marathon has a construction camp of 300 workers who live in shared barracks, where COVID-19 could easily spread. “They tell me: ‘We don’t know what to do and we can’t get through to public health.’”

A few days ago, while working on pressing COVID-19 preparations, Newbery couldn’t immediately help some of her patients, including someone in palliative care and a woman who had a miscarriage the previous evening.

“I missed those calls. Babies will still be born, miscarriages will still happen, people will still need their cancer treatment. And this is all also our responsibility as rural family physicians. There is no one else to do that work.”

From Kenora, about 500 kilometres northwest of Thunder Bay, Dr. Sven Pedersen will watch for the potential spread of COVID-19 through the remote and northern parts of the province.

The family physician and president of medical staff at Lake of the Woods District Hospital said his colleagues across the north are in constant contact, and will help each other if the new coronavirus affects just a handful of communities.

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But those plans will fall away if every community gets hit hard, he said.

“That’s one of the things we are most anxious about in the north — not having enough doctors or nurses to help all the sick patients.”

In general, Ontario’s remote and northern communities have populations that skew older with a higher burden of chronic disease, which puts them at greater risk of death or suffering severe symptoms of COVID-19, said Pedersen. Indigenous communities, too, are at higher risk of severe illness with the virus, he said.

Despite these risks, it’s currently difficult to get COVID-19 test results in Ontario’s north, with lab-confirmed answers taking 10 days or longer, Pedersen said. The lag in testing is partly due to a provincial backlog, but also because it takes between three and five days for a patient’s test swab to reach Toronto from Kenora.

“Clinically on the front line, it’s almost useless to get a test result nine or 10 days later,” he said.

Lake of the Woods District Hospital, which serves Kenora, the surrounding area and several Indigenous communities, has about 55 in-patient beds and a four-bed Intensive Care Unit (ICU). Currently, the hospital has two ventilators for its ICU and three ventilators in its surgical suites.

Pedersen said the hospital is looking ahead for how to care for COVID-19 patients who need specialized breathing and, like other northern and remote communities, is planning to airlift critically ill patients to Thunder Bay. He’s worried that city’s hospital will quickly be overwhelmed by COVID-19 patients from the north.

“We really won’t know what it will look like until it hits. But we’re ready to roll with the punches. We have the attitude of: ‘Whatever you need me to do, we’ll get it done together.’”

Dr. Stewart Kennedy, executive vice president of regional programs and clinical support and medical affairs at Thunder Bay Regional Health Sciences Centre, said the hospital is well-prepared for the expected surge of COVID-19 patients from the north.

The hospital, like many others in Ontario, has cancelled elective surgeries, one of several measures that will help free up 200 in-patient beds within its 389-bed hospital, Kennedy said. It’s also initiated its pandemic plan, asking the Ministry of Health for 20 to 30 ventilators to add to its current stock of 25 breathing machines, he said.

Ontario’s air ambulance service — known as ORNGE — is ramping up its capacity to transport critically ill patients in the province’s north and has a number of plans in place to meet demand, said CEO and president Dr. Homer Tien.

These include hiring additional qualified pilots, expanding its 24/7 telemedicine service to support rural doctors who need assistance with patients on ventilators, and having the option of using one critical care paramedic work in the back of ambulances for appropriate patients, he said.

On Manitoulin Island, Dr. Maurianne Reade and her colleagues at the Island’s health centres and two hospitals are readying for COVID-19.

Their assessment centres are up and running, including one in a garage behind the Manitoulin Health Centre in Mindemoya. They will be receiving virtual training on how to safely intubate patients with COVID-19 from colleagues at Sudbury’s Health Sciences North. And, like other hospitals across Ontario, they are making space for more beds in anticipation of what’s to come.

Among the island’s biggest challenges is its chronic shortage of physicians, a problem now made worse by locum doctors from southern Ontario, who had signed up to work on the Island, no longer being able to help. Their own hospitals and clinics can’t spare them during the outbreak, said Reade, a family doctor and physician representative on Manitoulin Health Centre’s emergency preparedness committee.

“That puts a bigger strain on an already strained system,” she said, adding virtual help from colleagues is always welcome. The Society of Rural Physicians of Canada hosts an online forum where doctors ask questions, trade advice and offer emotional support, a crucial service during this pandemic, said Reade.

As she watches hospitals in other parts of the world collapse under the huge burden of COVID-19 patients Reade is concerned about what might come to her part of Ontario.

But Reade also believes the hard-earned resiliency of rural and remote health care workers is what will see them through the coronavirus pandemic.

“We do know we are all in this together.”