Maurice A. Bent, M.D., FRCSC
North York General Hospital
Toronto, ON

The following is my experience, as an orthopaedic surgeon practising in a community hospital, which was the epicenter of the second outbreak of SARS in Toronto. This period of time has been both frightening and surreal in its effects.  

During the first outbreak, which came to be called "SARS I", in late March and April, the hospital established a SARS unit and cared for a large number of patients who had acquired the illness in other health care institutions. Due to the closure of the Emergency Department in those hospitals, our emergency was particularly busy with an extra load of the usual emergency cases, but at the same time seeing patients with SARS. Visiting emergency meant entering only through one access point and wearing a gown, gloves, hat, mask (N-95) and goggles while seeing each patient.

As a result of one ice storm, during this time, there were 70 fracture patients requiring orthopaedic care in one 24-hour period. We were able to manage this only because the operating rooms were closed for elective surgery, and we ran three orthopaedic rooms for three days to treat all these cases.

During that first outbreak, the impact on orthopaedics was mainly loss of all elective operating time, the need to wear N-95 masks full time, and the use of gowns and gloves when making rounds. As SARS I came under control, Public Health allowed us to discontinue the use of masks and gowns on the inpatient rounds, but their use was continued in the Emergency Department and the Fracture Clinic. We gradually returned to doing elective surgery.

In the week of May 19, 2003, new cases of SARS were identified and this new outbreak, which came to be called "SARS 2", was traced directly to our orthopaedic ward. On May 23, 2003 the hospital was placed on Level 3 status. This meant that all elective surgery was cancelled, the emergency was closed except for the admission of staff or their relatives with SARS, no investigative services were open and all staff were placed on 10 days of home quarantine or work quarantine.

The orthopaedic ward was designated a SARS unit. Public Health directed that only one orthopaedic surgeon, out of the six on staff, was to visit the ward and he would be responsible for all of the patients on the floor from May 23, 2003 forward. I took on that responsibility and it was an interesting few weeks, as several of the patients on the floor were not orthopaedic cases. I upgraded my knowledge of medicine and general surgery during those weeks.
Entering the floor meant wearing "greens", then at the entrance putting on a gown, gloves, hat, shoe covers and goggles. To visit each patient, a second gown, mask face shield, gloves and boot covers were worn and discarded in each patient’s room as well as hand washing with alcohol after each change. Making rounds occupied the whole day as this ritual was followed for each patient. To leave the floor for any reason, hat, goggles, gown and any other protective gear were discarded with frequent hand washing and greens were changed for a clean set and a new mask before exiting.

For those patients still requiring surgery for fractured hips etc., the ritual involved in getting them to the operating room and into the operating room was even more complicated. Every procedure required two to three times the usual time while all the appropriate protective suits for surgeon, nurses and anaesthetists were donned, and all equipment was passed into the room only as needed. No personnel were allowed in or out of the room without putting on or removing protective suits. The patients then had to be "recovered" in the O.R. until stable to return to the unit. All of this was hugely time consuming.

Several postoperative patients on the floor developed SARS and were transferred to one of the SARS units in the hospital, where there was negative pressure, or to I.C.U. if needed. During this time I had great support from our infectious disease specialists in reviewing patients suspected of SARS and transferring them when the diagnosis was probable.

During the first 10 days, I was on "work quarantine". I was allowed to go home and to the hospital with no stops in between. During this time the hospital arranged for cans of gas to be supplied at the hospital, for staff that needed gas for their car.

At home I was required to sleep in a separate room from my wife and to wear an N-95 mask on a full time basis. I ate my meals at a different table and no family or visitors were allowed in the house for 10 days. This was a difficult and frightening time. Several physician colleagues were admitted with SARS, acquired from seeing patients on the orthopaedic floor, before the outbreak was recognized. One of our colleagues was in the I.C.U. I knew that I had had unprotected contact with some of these patients who developed SARS, as had all but one of the other orthopaedic surgeons (who was on vacation). In the end, none of us became sick, but it was an anxious period of time for us and for our spouses and families. E-mails were sent by the hospital several times a day, for those on home quarantine, updating them on the number of staff who were ill and outlining measures being taken to control the outbreak as well as to advise them about procedures regarding the maintenance of proper quarantine.

Being at the hospital was, at times, a surreal experience. All of the nurses and staff from the orthopaedic floor were on home quarantine. Twenty-five members of the nursing and support staff from the floor became ill with SARS and were admitted to the SARS ward. For this reason, all of the nurses I was working with were from outside agencies or from another floor in the hospital. They were masked throughout this time and I never saw their faces nor did they see mine. There was an unspoken anxiety for our own health working in this environment, but I have to say that it brought out the very best in people. The quality of concern and care for these patients was exemplary.

During the first two weeks of hospital closure, the remaining patients on other floors were discharged, leaving only the SARS floors occupied. The usual hustle and bustle of hospital activity disappeared. In the cafeteria, the staff still working had to sit at least two meters from each other while eating. In all, it was an isolating and disquieting experience.

All appointments scheduled at our offices and fracture clinics had to be cancelled for the quarantine period and for a period after. This caused a large amount of work and frustration for our office staff. Our waiting lists for surgery and for the office extended even further. In total, at the time of writing, the hospital will likely be closed for elective surgery and emergency work for at least eight weeks. Orthopaedic care of our patients will be greatly compromised.

The decision to cancel the COA Annual Meeting in Toronto was a disappointment for me. While I, personally, would not have been able to attend while still working at the hospital, there was never any evidence that SARS was spreading in the community. SARS has been confined to the hospital setting. I think the meeting could have continued by just restricting the attendance of the orthopaedic surgeons working at the affected hospitals. The continuation of the meeting would have provided a message of support for the health care workers at the front-line and the community in general, by saying that a large group of physicians were not afraid to have their conference in Toronto.

As it happened, orthopaedic surgery was particularly affected by SARS at North York Hospital, but it could just as easily have been any of the other services and in the future, other services may well be affected. We have learned from this experience, and we must not fail to put these lessons into practise as we go forward. SARS may well reappear and other infections such as Vancomycin-resistant enterococci (VRE) and Methicillin Resistant Staphylococcus Aureus (MRSA) are becoming more common in hospitals worldwide. We must be diligent with respect to early diagnosis and isolation of suspected cases and observe careful personal hand washing and aseptic technique between patients.

Our orthopaedic service has been decimated by this latest outbreak. We have had more than 25 nurses and support staff ill with SARS and one nurse has died. Many of our staff are seriously concerned about ever returning to work, and several will not. It will be a long time before we are able to handle our normal volume of orthopaedic patients.

We must do our utmost to be certain that an outbreak of SARS or other infectious disease does not happen to another group of heath care workers. It is too easy to become complacent.