Commentary by Dr. Desmond Colohan
The lead editorial in the Guardian on January 20 strongly supports the re-institution of vascular surgery services on Prince Edward Island, despite a recommendation from both the provincial Physician Resource Planning Committee and the provincial Medical Advisory Committee to the contrary.
Your editorialist seems to base his arguments primarily on comments in a recent opinion piece on the same subject. Your readers should be aware that neither of these committees is a bureaucratic puppet of government.
The PRPC is comprised primarily of physicians representing the P.E.I. Medical Society and Health P.E.I., as well as non-physician representatives from the Department of Health and the other two sponsoring organizations. The PMAC consists of 11 physicians, both elected and appointed, as well as three non-voting support staff from Health P.E.I. I can assure you, having served on PRPC and worked closely with this PMAC, that the members of these committees have the best interests of the patient at heart.
I was unable to find a position paper by the Canadian Vascular Society on the provision of vascular services, but did find a comprehensive document titled The Provision of Services for Patients with Vascular Disease, 2012 by the Vascular Society of Great Britain and Ireland. They recognize the challenge of providing vascular services to people living in smaller and more isolated communities and recommend the development of strong clinical networks, at the centre of which should be a major treatment centre, as exists in Halifax. Here are a few thoughts from that document.
1. Satisfactory provision of vascular services requires equitable patient access to both elective and emergency care. When emergency assessment and treatment are necessary, they should be available from a recognized vascular unit within one hour of travel. All elective management (for both arterial and venous disease) should be undertaken by vascular specialists.
2. Recent studies have shown that patients may suffer unnecessary strokes or amputations unless they have access to the full range of vascular services.
3. Hospitals having a single vascular surgeon cannot be supported as it is considered to disadvantage local patients. Single-handed surgeons have limited opportunities for peer-related development or team working, and the elective vascular service is suspended when the consultant is on leave.
4. Hospitals with 2-4 vascular surgeons should be part of a clinical network and designate a single high volume arterial centre as their referral centre (Halifax). Appropriate support must be available from interventional radiologists, vascular anesthetists and other support specialties.
5. It is recommended that hospitals undertaking fewer than 33 elective abdominal aortic aneurysm interventions per year should not offer these procedures.
6. At network hospitals not designated as the acute arterial centre, all elective and emergency arterial surgery should cease and patients should be referred to the designated arterial centre hospital. A daily vascular presence must be maintained at the referring hospital (QEH) to provide care to vascular patients with non-arterial disease, those rehabilitating from arterial surgery nearer to home, and for affiliated specialties who occasionally require vascular assistance, such as kidney disease.
It would be great if we could find two altruistic and dedicated vascular surgeons who would be prepared to be on call every other night and every other weekend and prepared to restrict their practice to non-acute venous disease, as recommended in the British report.
Given the limited number of qualified vascular surgeons in Canada, about 150, as near as I can gather, setting up a limited vascular program on the Island seems like wishful thinking. While it is difficult to find a recommended vascular surgeon-to-population ratio, it appears to be about one surgeon per 200,000 of population. In the situation of 24/7 care, internists and general surgeons end up taking most of the night calls and manage patients who, in larger medical centers, would be cared for by sub-specialists, such as cardiologists, endocrinologists, vascular surgeons and neurosurgeons.
That is the reality of living on a semi-isolated, predominantly rural island. Let’s do the best we can with what we’ve got, strive to improve where we can, and continue to seek help from our neighbours in our time of need.
Dr. Desmond Colohan is a P.E.I. physician and coroner with an interest in addictions and responsible public policy.