Hospitals across the country are bracing for what’s expected to be a rush of new coronavirus cases in the coming weeks.
With the numbers steadily rising in Canada – the latest official tally is more than 11,000 – staff at many hospitals are already treating every patient as though they carry the deadly virus, which can hide itself in a human host without causing symptoms. But as it spreads more widely in the community, a sudden surge of new cases – a pattern seen in other countries – threatens to swamp Canada’s health-care system.
To prepare, doctors, nurses and hospital administrators are redeploying medical staff and providing additional training for how to cope with the looming increase in COVID-19 cases. Masks, ventilators and face shields are being counted and carefully rationed, or desperately sought.
Tim Rutledge, the president and CEO of Unity Health Toronto, estimates the network’s current stockpile of masks will run out in a matter of weeks. “And this is not going to be a few weeks – this is going to be a few months,” he says. “I don’t think we can rely on importing masks from other places.” (This was on Thursday, before news broke that the Trump administration had ordered medical manufacturer 3M to stop shipping N95 respirator masks to Canada.)
Intensive-care units are hastily being expanded, with staff reorganizing into new posts. Professional bodies are putting out calls to retired doctors and nurses to see who’s willing to help. Beds have been emptied of patients well enough to go home.
Non-essential surgeries – and even cancer treatments – have been cancelled, and families and friends have been ordered to stay away, leaving many hospitals more silent than they’ve ever been.
In the calm before the storm, medical workers are trying to adjust to the new reality, running simulations to prepare them for fixing broken legs and delivering babies and shocking stalled hearts while a cunning, deadly virus lurks in the room. They’re rehearsing how to do intubations on potential COVID-19 patients not only to save lives, but so that in the chaos they don’t accidentally waste the limited supply of protective gear that will keep them safe.
So much is still uncertain – how hard we’ll be hit, how long it will last, how many lives will be taken. But the stories coming out of countries already devastated by the virus make it clear the toll on health-care workers will be dire. Early research suggests high rates of depression, anxiety and burnout. More troubling, the statistics indicate health-care workers are among the most likely to catch the virus themselves – especially when shifts run long and protective gear runs out.
Medical workers are the storm watchers – they’ll know first if, when, the virus finally falls upon us in earnest, because the beds will begin to fill, the lineups for ventilators will quickly grow and their own colleagues will begin to get sick. Yet, for all the frustration they expressed over equipment shortages and the worry they’re feeling for their families and for themselves, not one of the more than two dozen health-care workers who spoke to The Globe and Mail – doctors, nurses, respiratory therapists and hospital cleaners, in cities big and small – mentioned wanting to stay home with the rest of the country.
“We prepare for pandemics, and all that preparation does help," says Mark Joffe, the vice-president and medical director of Alberta Health Services. “But there’s no question this is an extraordinary time that surpasses anything any of us have ever worked through before.”
ER doctor in Toronto
By 7:45 most nights – back when things were normal – Kanna Vela and her husband would snuggle up on the couch with their two young daughters, reading stories the girls had chosen from a basket of books nearby. (One of their favourites is about a doctor dog that fixes up storybook characters.) Next, they’d have some milk – a glass at the table for the five-year-old and a bottle for the toddler – and brush their teeth. Then Dr. Vela and her husband would read them a few final stories before lights out.
This bedtime ritual still happens each night. It’s just that Dr. Vela isn’t there. Instead, the 37-year-old emergency-room physician is sitting alone at the kitchen table in her parents’ vacated home, many blocks away. She has been working on the front lines of the COVID-19 crisis (she splits her time between three hospitals in the GTA), directly interacting with sick patients on a daily basis as the number of infections continues to climb. One of the most recent patients she admitted to the ICU was an otherwise heathy fortysomething man. “That could have been my husband,” she says.
She decided that the safest option was to swap homes with her parents, both of whom are in their 60s. And so, while her husband and parents tuck the girls into bed, she performs a new, solitary nighttime routine – scanning through medical journals, taking stock of her hospital’s inventory of protective gear, and preparing for a nightly COVID-19 planning meeting on Zoom. She hasn’t seen her children in person – even at a distance – since she moved out a week and a half ago. “I think my five-year-old could understand the rules, but the two-year-old can’t be expected to,” she says. “Her physically seeing me – she wouldn’t understand why she couldn’t run into my arms.” She has no idea how long it might be before they’re reunited.
Earlier this week, Dr. Vela and some colleagues drove around to Canadian Tire stores in the GTA, buying up face-shield masks more typically used by people who work with industrial chemicals; she found 33. An online town hall for ER doctors this week included suggestions for how they could make their own cloth masks if the official supply runs out, as many doctors believe it will.
“We are all walking around with this knot in our chest. There are times when I rehearse letters that I am going to write to my loved ones if I get sick,“ Dr. Vela says. “People ask me what they can do to help. Stay home. That’s the gist of it. The sooner everyone does this, the sooner this will be over, and the sooner I can see my kids again.”
Chief of emergency services at Lake of the Woods District Hospital in Kenora, Ont.
It hit Sean Moore unexpectedly hard when he learned Wednesday night about the first emergency room doctor in the United States to die from COVID-19.
When Dr. Moore shares the news over the phone, his voice cracks. Health-care workers have been dying in devastating numbers in China and across Europe for months, but Dr. Frank Gabrin’s death feels closer, more specific. The 60-year-old ER doctor in New York had gone home with a suspected case of COVID-19; a week later, he reportedly died in the arms of his husband while waiting for an ambulance.
Because of an underlying health condition, Dr. Moore and his team decided this week that he couldn’t risk working in the emergency department. The danger to health-care workers is serious and well documented, with some studies suggesting doctors and nurses on the front lines might get sicker because they’re exposed to a bigger “load” of the virus. A paper published in the Lancet in March found that in Lombardy, the Italian region hardest hit by the coronavirus, 20 per cent of health-care workers were infected; as of March 30, 61 doctors had died, according to the Italian Association of Doctors. Spain suggested late last month that nearly 15 per cent of confirmed cases in that country involved health-care workers. The numbers are rising here in Canada, too. Montreal’s public-health authority has reported 121 confirmed cases among medical workers (but no deaths).
Instead of working on the front lines, Dr. Moore will focus on the complicated logistics of keeping his colleagues safe and his small hospital running smoothly in unpredictable times. That has meant advocating for more protective gear and better testing, as well as publicly urging cottagers from just across the border in Manitoba to stay home so they don’t increase demand on limited health-care resources. Lake of the Woods Hospital treats 30,000 people a year, but it has just four ICU beds. It’s already facing a staff shortage, since many of the doctors who travel in from other centres temporarily to take shifts now have to stay home.
About two weeks ago, five local doctors who work at Lake of the Woods had to be quarantined because they developed colds. They were tested for COVID-19, but because the tests had to be sent away, it took 10 to 14 days for results to come back – all negative. In the meantime, however, with the doctors in quarantine, colleagues had to cover their shifts. It was a stark lesson in what could happen if just a few doctors were taken out of the picture.
So far, Kenora has no known cases of the virus. But Dr. Moore – and his colleagues across the country – are having grim discussions about possible shortages of protective gear and what will happen if there are too many patients who need care. Either scenario could force them to make the kinds of heartbreaking decisions doctors in Italy and elsewhere have already been forced to make. How many times can an N95 respirator mask be reused before it no longer keeps the wearer safe? And if you only have so many ventilators – and so many staff to operate them – which patients take priority?
On Wednesday evening, Dr. Moore participated in an online town hall for Canadian emergency doctors that explored some of these questions. Laurie Mzaurik, a critical-care transport physician in Toronto, showed pictures of the full gear worn by doctors in Wuhan and compared it with the typical garb in North America, where medical staff can’t count on having hoods or neck protection. She urged those listening to tie their gowns tight, and to sanitize their necks and faces, not just their hands, when they doff them. The sicker the patient, the higher the viral load, she warned, so be quick around them and keep your distance.
In another presentation, bioethicist David Migneault discussed the kinds of decisions that could become necessary if pandemic cases surge dramatically and equipment is in short supply. Age can’t be the only factor in deciding who gets care, Dr. Migneault explained; doctors have to assess healthy-life years – does a physically fit 50-year-old get treated before a fortysomething smoker with a chronic condition? Another session explored whether doctors have an ethical responsibility to identify patients who might be willing to forgo care so someone with a better chance could have a ventilator.
These collaborative discussions help prepare doctors for what’s coming – but there are always more questions than answers. “It’s a very different space right now,” Dr. Moore says. “The norm in most places in Canada is we’re going to take care of everyone who is sick. These are not conversations I have ever had in my career.”
Cleaner at St. Paul’s Hospital in Vancouver
Precy Miguel works evenings cleaning rooms in the emergency department at St. Paul’s – washing floors, changing beds and wiping down railings. She cleans carefully and wears goggles and a mask at all times, adding more protection – including an N95 respirator mask – depending on the seriousness of the coronavirus warning on the door. When she leaves the hospital late at night, she carries a sanitizer wipe to scrub down railings, elevator buttons and door handles.
She lives with her elderly parents and two brothers, but since COVID-19 arrived, she has kept her distance, sleeping in the living room behind a partition and storing her clothes in plastic bags in her car. When she gets home, her parents open the door and then dash away, so she can hop in the shower without touching anything. Sometimes, paranoia sets in, and she double and triple cleans. Not working is not an option. “Then,” she says, “the next problem would be financial.”
But she wouldn’t abandon the hospital anyway: “I am there for a reason. How will COVID end if we aren’t on the front line?”
As the chair of her union local, that’s a message she also delivers to co-workers worried about bringing the infection home to their families and wondering if they should keep coming to work. “We are all family now,” she tells them. If the cleaners don’t sanitize the rooms, how can the nurses and doctors keep working to save lives? “It is hard,” she tells them, “but we need to be strong.”
The stress is getting to them all, she says. With so much uncertainty, and in the face of a stealthy villain, “it is tough to give hope.”
Obstetrician at the Ottawa Hospital in Ottawa
Glenn Posner is medical director of the hospital’s simulation patient safety program. He’s been overseeing regular dry runs at the General and Civic campuses to test standard procedures in a world where every patient – even the pregnant women whose babies Dr. Posner now delivers in full protective gear – must be assumed to be infected with a highly contagious, deadly virus.
Dr. Posner says the simulations have revealed important gaps in protocol. In one surprise test to determine how to safely transfer an infected patient from the ER to the ICU, the orderly who showed up had a beard, meaning his mask wouldn’t seal properly. Staff now know to ask for a “fit-tested transport.” In another simulation, a chest X-ray was ordered for a patient with COVID-19. Usually, the doctor and nurse would step outside the room while the X-ray is being taken, but that could spread the infection to other parts of the hospital. So the radiology technician learned she’ll need to bring in three lead vests, not just the usual one for herself.
Doctors and nurses use high-tech mannequins to practise administering medications and taking vitals. They’ve also been focusing on how to avoid removing protective gear unnecessarily, which increases the risk of heath-care workers infecting themselves and wastes limited supplies.
Dr. Posner recently oversaw a cardiac-arrest scenario. “A ‘code blue’ is a crowd-control nightmare,” he says. “Everyone naturally wants to help.” Typically, there could be 20 people in a room during a code blue, but that can’t happen in a COVID-19 scenario – it puts too many people at risk and requires too much gear. A key goal of the scenario was to figure out which medical personnel were absolutely essential.
One of the big questions, Dr. Posner says, is deciding when to start CPR. In normal times, a nurse would start right away, but that’s no longer safe. Stepping in to shock a patient with a defibrillator is usually the next step, which is safer, since it doesn’t require such close contact. In the end, the team decided the nurse would hold off on CPR until she had donned all the necessary protective gear, a process that would reduce her risk but delay patient care for a few minutes. These are the choices hospitals are having to make now, Dr. Posner says. During a pandemic, they can’t risk losing vital staff or wasting precious protective gear.
ER nurse in Edmonton
Lisa Watt and her husband wrote out their wills a few days ago. It seemed like something the couple should do, given Ms. Watt started treating possible COVID-19 patients – anyone who showed up at the hospital with fever and respiratory issues – a month ago. The volume has been climbing every week, and the mother of two knows the situation will only going to get worse.
“A lot of my colleagues and I have described it as standing on the edge of a cliff and looking down, but not knowing how far it is to the bottom or when you’re going to fall,” says the 36-year-old. “The waiting is hard because you have no control over the situation.”
Ms. Watt says that as of right now, the two hospitals she works at are pretty quiet. People seem to be staying home and using telehealth services (a trend half a dozen other health-care workers who spoke to The Globe this week also reported).
Her workplaces are using the time to prepare staff. On Friday, Ms. Watt ran through her first simulation. The scenario was a suspected COVID patient in need of intubation. It’s a dangerous procedure, since intubating can generate what’s called “aerosol” – small airborne particles.
”I’m not exactly scared,” Ms. Watt says. “Not yet. I have anxiety, but I’m not necessarily afraid.” The anxiety centres on the lack of available protective gear. She’s also nervous about what would happen at home if she or her husband, a firefighter, get sick. “The plan is one of us would move into the basement.”
It’d be hard to be separated from the kids, who are just 3 and 4, but they have a sense of what’s happening. They know they can’t see their grandparents. They know school and daycare is closed. They know it’s not okay to play with their friends.
And no one knows when any of that is going to change.
Respirologist and ICU doctor at Charles-Le Moyne Hospital in Longueuil, Que.
Saving lives during the pandemic will be a family business for Antoine Delage. His wife, Dominik Cyr, is a family physician on standby in case she’s needed for COVID-19 patients. His cardiologist father, François Delage, has gotten his licence renewed after two years of retirement so he can handle routine cardiac matters for his colleagues on the front lines.
“There’s a lot of solidarity across the system,” says the younger Dr. Delage. “People are raising their hands to volunteer. Everyone wants to help.”
Dr. Delage and Dr. Cyr have three children, ages 4, 5 and 6. “It’s a busy household,” he says. The family has found a nanny to take care of the kids. As soon as they get home, Dr. Delage and his wife both scrub down as though they were entering an operating room. Their clothes are bagged and washed. Shoes stay at work. Jewellery stays at home. “We’re actually lucky the kids aren’t in school or daycare any more. Hopefully we can keep them together so they don’t bring in anything,” he says. “That’s when you lose control – when the kids bring it into your house.”
Meanwhile, workers at Charles-Le Moyne have transformed a new wing dedicated to short-term stays into an ICU, adding 23 beds to the 17 the hospital had already. In addition to installing all the necessary equipment, they’ve also overhauled the ventilation system to create “negative pressure” – which means contagion is sucked up rather than spread throughout the wing.
To help prepare staff to work with critical COVID-19 patients, the hospital is “cloning” ICU nurses, physicians and respiratory therapists – giving professionals from other specialties a crash course in the specific needs of virus patients, such as managing intubation and oxygen flow. “It’s a hard thing to do,” says Dr. Delage, “and we’re doing it very fast.”
ANDY BLACKADAR and MARY MACDONNELL
Family doctor and ER nurse supervisor at Queens General Hospital in Liverpool, N.S.
On Wednesday morning, at this small-town hospital 155 kilometres from Halifax, Mary MacDonnell is calling out directions at the doorway of Exam Room 1. “Remove outer gloves,” she tells Andy Blackadar and the two nurses who have just finished a blocked-airways simulation and are sweating under all their protective equipment. “Grasp headband of face shield and pull forward. Roll gown inward on itself.”
Removing gear after treating a patient with COVID-19 is one the likeliest ways for health-care workers to become infected – hence Ms. MacDonnell’s careful instructions. “It’s like a one-act play,” she says. “We have our set and our script.” Like every other medical facility in the country, the doctors and nurses at Queens General are choreographing how they’ll manage when the first known case strikes someone in their town of 2,600.
For now, the place is unusually quiet, absent the family and friends who bend the rules around visiting hours to sit long spells with their loved ones. Yesterday, staff stumbled on a treasure: a set of hoods stuffed in a cupboard, left over from another anxious time, when there was worry about Ebola spreading up from the United States.
That threat didn’t materialize, though this time they don’t expect to get so lucky. Staff here are acutely aware of the town’s large senior population, the most likely demographic to be struck down by COVID-19. In the winter, the nursing home was hit hard by the flu, and a few residents died. That was tough on the doctors who knew their patients well. And even if it stays away, the virus has already stolen community connections. The last time Dr. Blackadar made his routine rounds at the nursing home, elderly parents were chatting with sons and daughters divided by windows, like a scene from a jail. This week, during a phone call to one of his older patients, who’s isolated at home, she told him, “It is so nice to hear your voice. I think I am going to have a little cry when we hang up.”
Dr. Blackadar worries about how lonely isolated seniors are feeling and the risk that some may die alone. “That is the hardest thing for me to think about,” he says.
He’s already made plans to retreat to the “teen room” in his basement should he catch COVID-19 himself. “If I do become mildly ill,” he says, “I can hole up there, and crawl out of bed to talk to patients on the phone.”
Ms. MacDonnell, meanwhile, is due to retire in June after three decades of nursing. But she’s not going far: She’ll return for casual shifts and to fill in should the worst-case scenario happen. “It’s very uncertain times,” she says. “We have to think about what we can do today to look after our people and to look after each other.”
Vice-chair of family medicine at McMaster University in Hamilton
Cathy Risdon sent her staff a sombre email: Use this time to get your affairs in order. “Based on the experiences of other countries, we need to be prepared for the possibility that some very hard, sad things will happen to people in our work circles and our family circles,” Dr. Risdon wrote. “If we reach a point that our hospitals are overwhelmed, there may also be more deaths because people can’t receive the care that might have typically saved their life. A lot may happen without our ability to prevent or control it.”
What health professionals can do is prepare for the worst-case scenario and encourage everyone in their circles to do the same. “Do you have a will? Powers of attorney for finance and personal care? Are all your insurance policies and financial documents organized and easy to find?... Next is the conversation about the kind of death you might want for yourself or your loved ones.” The harsh reality is that the most gravely ill COVID-19 patients require ventilation, which could mean dying alone in a hospital, unable to communicate. That might not be the kind of death someone wants, particularly if they’re elderly or have underlying health issues that could limit their chances of survival.
Dr. Risdon knows her email might have been tough to read, but it’s important that everyone – not just health care workers – have these difficult conversations. “I was looking for a message that was honest and that would focus people’s attention on something that might be very important to consider. Everyone should be making these plans. Ninety-nine per cent of us will never have to use them.”
Lori Regenstreif, a Hamilton doctor who works primarily with vulnerable inner-city populations and an assistant clinical professor at McMaster, was one of the physicians who received Dr. Risdon’s email. She said it prompted her to have a conversation with her husband and sister to make sure they knew where they could find her account passwords.
“It’s moving so fast. I think it’s hard for people to grasp,” she says. “I have colleagues in other cities who are losing colleagues. It certainly feels like it’s getting closer and closer – like a horror movie.”
A song for the front lines
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