H1N1 and the surgeon
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* Edward J. Harvey

We all know the flu season is soon to be upon us. The main question is how serious will it be? The World Health Organization (WHO) has declared a pandemic already and expects an explosion in the number of deaths worldwide. The lay press is rife with concern. A Google search for swine and H1N1 flu results in about 200 million hits. PubMed and other databases with strictly medical interests show more than 800 references published this year. Google has actually partnered with the Public Library of Science to premiere a new website that will allow researchers to immediately share their findings and ideas about the H1N1 virus with the scientific community at large. Every day, I read an article in my newspaper at the breakfast table.

It was with great interest that last week I read an article in which my province’s health minister stated there was no need to worry about the health risk and that current measures in place were more than enough to deal with the new flu season. This worried me both as a physician and as a potential patient because I was aware that at one time this year, Quebec was actually the second most dangerous place in the world to catch the H1N1 flu, with a mortality rate second only to Mexico. Ours is not the only health minister facing a possible pandemic who may have difficulty both preparing the populace and ensuring health care delivery. No health minister in Canada has served a full term in the health post, and the longest serving health minister has been in the post for only 3 years. The federal health minister is also largely untested.

How is this going to affect the surgeon? Apparently it will touch us in many ways, particularly if the new season brings a more virulent strain, as the WHO expects. Currently, the replication and case fatality rate are lower than that of the Spanish flu of 1918, but we have no idea how changes in the virus will affect its behaviour in the coming year. Even slightly increased rates of either its ability to infect or kill are going to make this a difficult flu season.

Resources will be limited for surgeons for a number of reasons. Intensive care unit beds will be occupied with flu victims. Respirators will be at a premium as new strains are expected to attack mainly the respiratory system in young patients. Some provinces are trying to work out selection criteria for being on or staying on a respirator if we need to make room for the flu victims. This type of ethical decision process over who lives and dies would usually take months or years to determine; we need to figure it out in the next few weeks.

With the crush of patients in the emergency departments, there may be a shortage of hospital workers, including physicians and nurses. I assume most physicians with young children at home will not be going to work without some deep soul-searching. But of equal importance to patient care is the ancillary hospital staff. There will be little means for the hospital administration to force staff to stay on the job. Absenteeism in the whole health care sector will be difficult to correct. Not only will we lose the people who are worried about their families, those who are infected or those caring for a family member who is infected will also be missing in action. The provincial ministers have thought of ways to ensure care for the patients. Some have proposed reimbursement packages up to $500 per hour, whereas others are considering legislation resembling inscription.

All these factors will obviously put elective surgical procedures on the back burner for a number of months until immunization is prepared. Surgeons will obviously be hard-hit financially if no surgeries are being performed. However, there is still a need for surgeries to occur. There are the obligatory surgical cases that never go away: trauma, cancer, infection, acute abdomens and so on. What have the provincial mavens planned to ensure these patients continue to receive care? There seem to be no plans that designate surgical emergent hospitals to ensure that flu patients do not encroach on the treatment of other patients. By the time this edition goes to press, I hope the provincial ministers have proven me wrong.

## Footnotes

*   **Competing interests:** None declared.