6 days Ago By [email protected] (Bruce Arthur)
The casualties kept coming — burn victims, patients with drug-resistant infections or traumatic brain injuries, patients with amputated limbs and heavy trauma — and none of the health-care luminaries in the room were truly ready. They couldn’t be. This is Canada, after all.
Still, the men and women around the table worked on the unfamiliar scenario of handling Canadian casualties coming home from a major ground war in Europe. Belatedly, the men and women moved faster. They learned from mistakes, and their horizons expanded.
They failed, because that was the only real option in this tabletop war game. If anything, it was too easy. But it was an extraordinary meeting of remarkable people from some of our nation’s worn institutions; the kind who want to help.
It was, in Canada, something close to unprecedented. “I don’t want to get into is a situation where we have to decide between military patients and civilian patients, and that’s one of our concerns in setting up the exercise,” said Dr. Andrew Beckett, the medical director of trauma at St.
Michael’s Hospital, the chair of NATO’s blood panel, and the Canadian Armed Forces’ chief of general surgery, in his 27th year of military service. “The last time we did something like this was probably 1939.” *** They called it : Trillium for Ontario, and Cura is Latin for care or concern.
It was a war game based on the idea of a protracted ground war in Europe that involves NATO countries, and therefore Canada, based on the war in Ukraine. Ukraine has lost at least 43,000 troops in the war. So in early November, a group of almost 50 people met in downtown Toronto, with another 27 watching virtually: health-care leaders from Ontario, Alberta, Quebec and B.
C.; emergency preparedness and health-care officials from the Ontario government; and almost a dozen officials from the CAF, including two brigadier-generals from its medical wing. The game was designed by retired Canadian combat engineer Anthony Robb and former British officer David Redpath, who are contracted to design and run war games for CAF and other NATO countries.
In the World Wars, the dead stayed in Europe and casualties came home: Sunnybrook Health Sciences Centre, for instance, started as the largest veterans’ hospital in the country. Post-war Canada has not had to plan for military patients in a public hospital system, and however many troops Canada could muster for a theoretical conflict — and based on our acknowledged capacity, it’s limited — that number could expand over time. It may seem far away, but the CAF is worried.
Beckett notes the Canadian instinct in the 1920s under prime minister William Lyon Mackenzie King was, as Canadian senator and cabinet stalwart Raoul Dandurand said in 1924, to make Canada “a fireproof house, far from inflammable materials.” “The inflammable materials are starting to move closer to Canada,” said Beckett, on the phone from a war and disaster medicine conference in Tartu, Estonia. “And I think COVID-19 showed that we’re not fireproof, and bad things can happen at home, too.
” That’s a relatively new idea. Canada sent almost one in 10 Canadians overseas in the Second World War, lost 44,090 men and women in the effort, and has been underfunding our military for decades while under the protective American umbrella, based on a multi-party assumption that nothing too bad would happen in any particular mandate. Canada remobilized for the Korean War, but the largest military operation in the last seven decades by troop volume sent about 40,000 Canadians to Afghanistan between 2001 and 2014; 158 died there, along with 2,000 casualties, through 2012.
It did not disrupt Canada’s health-care system. “We’ve had a really stable society in Canada,” said Dr. Andrew Baker, the chief of critical care and anesthesia at St.
Michael’s Hospital, and a key member of Ontario’s COVID-19 response. “We haven’t had national disasters, and we are a trusting group as well. And there’s a downside that we sort of even trust in our own future.
” More and more, that feels dangerously true. Donald Trump could ransack the international order, including NATO; if anything, that could mean Canada must be prepared for more potential crises. This summer, Gen.
Jennie Carignan, Canada’s chief of the defence staff, that the military needed to be ready to face potential threats to its territory within five years. NATO has been eyeing Ukraine carefully, and asking member states how they might handle large-scale combat operations. And as former surgeon general Colin MacKay notes, Canada eliminated its military hospitals following the fall of the Berlin Wall, on the assumption that large-scale ground warfare wasn’t a priority anymore.
But, as he says, “Ukraine has made us think differently again.” Those conversations reached , the dean of the Dalla Lana School of Public Health at the University of Toronto, and former co-chair of Ontario’s COVID-19 science table. After conversations with Beckett and others, he decided that even if Canada didn’t go to war in Europe, another multi-casualty event — another genuine crisis in Canada — is possible.
He worked to put a group together. “I want us to be much better prepared than we were the last time,” said Brown. “Warm hands just allows us to start faster.
” *** The game randomly generated a range of casualties modelled after those in Ukraine coming into Ontario’s current health-care system, between seven and 122 per week. Each had their own injuries, hometown, story. In this scenario, five per cent of Ontario’s health-care human resources — doctors, nurses, and more — were deployed to Europe to aid in wartime medicine.
It’s a stunning idea on its own, but also: that number was generous. It was a slow start. The 16 main participants didn’t all know one another, and first steps were modelled on the COVID-19 response because, as one participant said regarding systemic health-care crises, “that’s all we got.
” (The exercise was conducted under Chatham House Rules: the list of participants is in the report, including this reporter, but nobody was quoted by name for this story unless they were interviewed afterwards.) The main participants had to balance factors including existing capacity, specific care needs, logistics and communications. But the complexity was new.
Should they send wounded soldiers to their home provinces, where family members could visit them and help with their care? Shuffle them between hospitals in Ontario? How many ambulances do we have? ( , CEO of the Ornge air ambulance service and a decorated CAF veteran, was at the table.) The first patients sat on the tarmac at Pearson airport for some time. Trauma units were not all put on an emergency contingency status.
It started slow. Pressure was added; chaos multiplied. At one point, one leading participant said, “Some decisions will be wrong, but a decision is better than no decision.
” There were unexpected events: an attempted cyberattack, public protests (the stated reason was societal unhappiness with reduced health care, rather than misinformation-based anti-Ukraine protests that would mirror ). Other possibilities included a blackout, a COVID or seasonal respiratory virus surge that floods a hospital with patients, a sudden influx of malnourished prisoners of war, foreign or domestic. Decision-making sped up.
At one point, an emergency alarm in the building blared for 10 minutes. After every round, a member of the media — this reporter — grilled one randomly selected member of the decision-making team. Someone pointed out that land near Pearson airport could be quickly repurposed for a temporary first-contact hospital, triage point and security centre; that changed the game.
Someone pointed out there were only four or five burn surgeons in the entire province, and that only 10 per cent of skin grafts originate in Canada; in wartime, both could become huge problems. Gradually, they realized this was not a COVID problem: there was no pending relief from levers like public health measures or vaccines, and the longer-term horizon of the patients — requiring specialized care and then rehabilitation, with patients from across the country — was a totally different problem to solve. Burn patients piled up.
Hard choices had to be made. Rehab capacity was another choke point. As one participant said, “We need to triage differently.
Either we stop doing some care or change the way we do.” In a real crisis, transport would be harder to master than hospital beds. And if a more realistic number of 25 to 30 per cent of health-care workers were deployed from Canada to Europe to support a war effort — with more following as some doctors or nurses died or were injured — that could strain Canadian health care to a breaking point.
That would be a true, shared societal sacrifice. The group failed: the burn patients overwhelmed capacity. It was reiterated: This was easiest possible scenario.
*** The role of federal command and control was missing here, and the hope is this exercise will be repeated and expanded. But based on the reaction from those in the room — the level of confidence in health care’s ability to handle a crisis rose in a post-exercise survey — this was a constructive first step. “Being a military guy, I thought some of the civilians would be .
.. you know, there would be a lot more hesitation,” said Beckett.
“I was actually reassured by the level of commitment and the flexibility of people to understand, and to come up with creative solutions, how we would deal with this. “There are gaps, but I think they found strengths in each other’s organizations that could bridge these gaps.” The gaps could, of course, be chasms: Canada’s institutions are partly explained by the old Vonnegut line about how everyone wants to build and nobody wants to do maintenance.
How could you ask health-care workers to sacrifice further after COVID-19 pushed to their limits? How do you assemble the overlapping agencies at each level of government, with federalism baked in? As McKay notes, the Constitution Act and the Canada Health Act means provinces have no legislated responsibility to look after military casualties, and that would have to be worked out. If this country has living memory of large-scale war, it is largely confined to our few remaining Second World War veterans, some historians and museums, and a Canadian Armed Forces that, as McKay put it, “does so much with so little for so long.” How could it be reconnected to systems it has been siloed from, with a health-care system already under enormous strain? It may not be possible on a short timeline, and the report shows how much work there is to do.
It recommends working groups to delineate agency and government responsibilities, for logistical planning, to secure data sharing and resource maximization — blood stocks, skin graft stocks, equipment — and so much more. The good news is that with commitment and political will, most of those are fixable problems, and more, specific ones, versus reports that deliver a vague fog of principles without prescriptions. “The type of conflicts we’re seeing isn’t simply about bullets and shells,” said Dr.
Colleen Forestier, a brigadier-general in the Canadian Forces Health Services and a signatory to the report. “It’s also about undermining institutions, about eroding the institutional framework that create strong societies. We know it’s being deliberately targeted — with cyberattacks, with erosion of trust — and building resilience in the health care system, in institutions, is a form of deterrence.
” Right now, Canada would be terribly unready if world events drag us into a mass casualty war, because Canada has spent much of eight decades deciding it did not have to be ready. *** If anything, though, it was the people in the room who fended off that fatalism. There was an instant level of trust, and of shared purpose; there was a flurry of knowledge-sharing, of critical relationship-building, of co-operation, of creativity.
It was a reminder that while Canada has not tended to its institutions, those institutions have often been kept afloat by the quality and dedication of the people in them. “For me, it was so great to see so many people sitting around a table trying to help with something the CAF might have to deal with,” said McKay. “It was inspiring to see,” said Beckett.
“Because I have a lot of faith in, you know, Canadians and our ability to solve these problems, as we did this during the First World War and Second World War. I think we can do it again.” During the COVID-19 emergency, Baker was the incident commander of Ontario’s critical care COVID command centre, which worked to keep Ontario’s hospitals from boiling over.
It was hard work, under huge pressure. “Sometimes people ask me about my own personal experience, and it’s hard for me to hide the fact that there was an aspect of the experience which I really enjoyed,” he said. “And that’s sort of a bit weird, because a lot of people were dying, and it was a very terrible situation, and a lot of people felt burnt out by it.
But the redeeming quality that I experienced was a sense of shared mission and purpose, and a sense of trust in teamwork. “It had a positive effect on me. And then I felt that again during this session.
” People holding up sagging institutions is not the most comforting thing to have to rely on, but as with COVID, it’s something; in a more dangerous world, it’s a start. Maybe this report will be received with seriousness by decision-makers; maybe it is the beginning of a more cohesive Canadian ability to ready for crises. Ideally, we won’t have to find out if we need it.
But we may not get to choose..
