The doctor’s diary: Coronavirus dispatches from an ER physician in Toronto

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About the doctor

James Maskalyk is an author and emergency physician. His books include Six Months in Sudan: A Young Doctor in a War-Torn Village and Life on the Ground Floor: Letters from the Edge of Emergency Medicine, which won the Hilary Weston Writers’ Trust Prize for Non-Fiction. Dr. Maskalyk works at St. Michael’s Hospital in downtown Toronto, and he’ll be filing regular dispatches from the front lines of the COVID-19 pandemic.

Latest entry: May 1

16,608 CASES IN ONTARIO, 1,121 DEATHS

My hands are raw. I’ve washed them a thousand times, rinsed them in alcohol a thousand more. I’ve always done this, of course, but it’s become compulsive. They sting up to the wrist.

We’ve seen so many other changes. Few of us carry our stethoscopes anymore because of possible contamination. I can’t remember the last time I heard the clear, sweet sound of a free breath from a maskless face. We try to touch people as infrequently as possible. Some doctors are even calling patients on their cellphones, from behind the glass, moving to the bedside only if necessary.

This is how my mom died not too long ago. She had been placed in isolation, possibly infected with a resistant bacteria she ended up not having. She stumbled out of bed unobserved, confused from a fever, then fell to the floor. “The nurses are afraid to come into my room,” she said the day before the fall. Afterwards, she never spoke another word. My father, brother and I sat by her bed for days, until her look of surprise faded to nothing.

At least we could see her face and show her ours. We haven’t been allowing visitors in the ER since this all started. The other day, I walked to the ambulance bay to tell a waiting mom her son would get to keep his hand after running it through a table saw. At least it was good news. All of us have delivered worse over the phone to a person idling in her car, a block away.

A fellow ER doctor in New York City died by suicide a few days ago. More than one nurse has told me they go home after their shift and cry. It’s harder for those of us who are alone – just flashes of masks and stinging hands, with no end in sight. There are reports from all over the world of health care workers being targeted, hurt or ostracized because of our contact with the virus. Our world will be the last to return to normal.

We’re all lost in this new one. I can place the voice and posture of people I know in the ER, but anyone new, patient or staff, something human remains forever unseen. You can’t smile from far away or mirror an expression to let them know they’re understood. The medicine that passes unspoken between people, the kind that depends on neither surgery nor drugs, has all but disappeared. How many people we can’t fully see are falling? Who will catch them?

Previous entries

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April 6 (4,347 CASES IN ONTARIO, 132 DEATHS)

The ceiling: I stared at mine last night after I read in bed a notice from Alberta of a woman in her 20s, dead from COVID-19 – their youngest yet. When this all started, a few of my fellow emergency physicians said quietly to each other, “Maybe we should just get it and have it over with.” Now, we’re not so sure.

The numbers are growing every day, and no one, no matter their credentials, can say how high they’ll climb. We only know that there will be more tomorrow than today. The last time I saw something like this was in 2007, when I was working in Sudan with Médecins sans frontières. The ceiling then was also unknown, but the question was different: how could we get the measles vaccine into as many arms as possible as quickly as possible? It took days to arrive, and the infected filled our wards, then the yard.

There were no e-mails about the dead. I could hear the wails, though, through my hut’s thatched roof. I still can. Eventually I stopped going to the hospital when I heard them. There was nothing more to be done. I’d just tuck my mosquito net in more tightly, turn over and wait for them to quell.

I’m back in the ER tomorrow after eight days off. We try to space our shifts far apart so that if we get infected at work (where the risk is highest), we’ll get feverish at home rather than in the hospital, where we might spread the virus around.

There’s no vaccine for us yet. The best we can do is wrap our bodies tightly in gown, goggles, gloves and bonnet.

On today’s daily Zoom call, 20 of us talked about hand signals we could use when inside isolation rooms, intubating the sick COVID patients who are starting to arrive – how we could gesture for more equipment or drugs without having to step outside. One finger: difficult-airway kit. Two: ultrasound. It feels good to be so prepared, yet sleep is still slow to come.

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April 8 (5,276 CASES IN ONTARIO, 174 DEATHS)

People line my street in Kensington Market, spaced six feet from one another. A woman scowls at me as I move past. Gone are the smiles from the early days. I walk through Baldwin Village, listening to voices from New York talk about a COVID patient’s hurt lungs. At the corner of Yonge and Dundas, a man plays three pails as drums, a big smile on his face. Masked people pass.

“Do you work here?” a security guard asks me outside the hospital door.

“Yes,” I answer

“Badge?”

“It’s in my locker.”

He opens the door. No one is trying to sneak into this place – not since it’s become a place where COVID lives.

A person inside passes me two masks in a plastic zip-lock bag. I can ask for more, of course. There’s no shortage so far, but they’re keeping track. It feels good. For years I’ve thrown away trays of metal tools after a single stitch, and no one knows how many patients will line these halls.

I relieve Brian in the “moderate-risk” zone. There’s no such thing as “low-risk” these days – only this and “high.” We look through a list of patients, breath steaming our protective visors. There are two patients who need to be seen, fewer than usual. Before, there were heart attacks, strokes and other ailments. Not just here, but all over the world, people are staying at home, holding their chests.

A man has cut himself. A woman has a headache. I discharge them both. They’re grateful to leave.

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April 15 (8,447 cases in Ontario, 385 deaths)

There’s a moment in the trauma room, after you’ve received word of an injured person on the way and you’re gathered with the team to plan for the worst. I want you over here, you might say, to open the left chest. You cut a hole in their right ribs, let the trapped air out. If she’s pregnant and dying, I’ll cut to the baby.

You wait in heavy lead vests, gloved hands folded, lost in images of what you might see, your heart in your ears. Every minute feels like 10.

Sometimes, it’s a woman sitting up on a stretcher, chatting with the medics, eyes above the oxygen mask crinkling from a smile. Other times, the doors swing open and it’s the medic’s wide eyes you see, frantic, one hand pumping up and down on a dead chest.

We watch New York and Italy – health care workers dying from COVID, bodies left in buildings for days. The patients moving toward us have the most viruses cascading in their blood, and from there, into their breath. We hypothesize that the doctors who died received a fatal dose, so we’re changing what we do. No compressions. No oxygen above six litres, no matter what. These aerosolize the breath into mist, and on that mist, a virus can float into your hair and down the hall. If they aren’t breathing, don’t help them with a bag, not even once. Put a tube through their vocal cords, attach it to a filter, from there to a machine.

Andrew, an ER doctor waiting for the sickest to arrive in acute care, messages me. “You busy?”

I’m not. The ambulatory part of our emergency department is empty. People are afraid to come near the place where COVID lives.

“Let’s do a simulation,” he writes back. Practise while we still have the time.

In an empty room, over a rubber body, we talk through the steps again and again – the list of what’s necessary to don before you step into a patient’s room. We describe it, but we don’t do it, because every piece of PPE counts. “Wash hands," I say. "Hold N95 against face. Bottom strap. Top strap. Mould nosepiece. Breathe hard, feel for air. Gown. Neck tie. Front tie. Goggles. Visor. Cap. Shoe covers. Long gloves. Short gloves.”

The order isn’t so important for donning as doffing, when you’re covered with viruses. You move from dirtiest to cleanest: “Long gloves, wash, gown tie, wash, short gloves.…” You approach your face last. “Sniffing position, cap, wash, visor…” You throw the soiled material in the garbage before stepping out of the room. We watch each other through both stages for exposure or missteps.

“What about here,” I say, gesturing to the part of my neck that’s exposed between shield and gown. “Maybe a sterile towel? Clip it in the back?”

Andrew wheels the video laryngoscope into the room. It’s a curved plastic tongue depressor with a camera on the end. We’re using it for our first attempt at intubation. Normally, I’d use a blind metal device – a “direct” laryngoscope – held in my left hand to pull the tongue aside. Then I’d place my eyes just over a person’s mouth, where I can see the V of their vocal cords before passing a breathing tube between them and connecting it to a ventilator. The camera offers distance, but the angle is different. The tool feels more clumsy, the view less literal.

I pass the video blade beyond the mannequin’s pale rubber lips. Andrew and I watch the screen. “You’re too far,” he says as the vocal cords loom into full view. ”Pull back," he says. "The cords should be about one-third of the screen for the tube to pass easily... Good.”

The tube slides through, plastic on rubber, and I repeat the move with my hand a dozen times until it feels natural, then pass the blade on.

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April 16 (8,961 CASES IN ONTARIO, 423 DEATHS)

Patients sit in chairs two metres apart, eyes darting above their masks. The nurses and I are gathered in long yellow gowns a few paces away, behind a rolling steel wall.

That wall once protected us from radiation, back when we used this room for x-rays. But in February, just before COVID-19 landed, our new trauma room opened, airy and bright, and we moved the x-rays there. We’ve turned this space, windowless and dank, into a COVID clinic, where people with symptoms requiring more than a swab – people breathless or in pain – are sent from an assessment centre across the street. The wall reminds us where the “uncontaminated” area starts. We use only clean gloves and wipe the counter several times per day. We’ve argued about the language to use, not wanting to call one side of the wall “clean” and the other “dirty,” because one side isn’t better than another – it’s just different.

We also avoid the word “negative,” even after a patient’s swab comes back finding no viral particles. Instead, we prefer “low-risk” or “medium risk,“ depending on the symptoms. If they have cough, fever and the aches of a flu, we’re inclined to disregard the negative. The nasal swab isn’t perfect – some say the false negatives are as high as 30 per cent, and we’ve all heard of patients who swab negative again and again, until you reach into their lungs. We don’t know if it’s the test itself that’s to blame or the virus’s behaviour, or if it’s because a patient flinches as the nurse tries to scrape the back of the nose. Staying vigilant is the best way to keep spaces safe.

“Ms. X,” I call out, and a young woman raises her hand, her purse crumpled by her feet in one of the clear plastic bags we hand out at the door. We consider everything contaminated.

I stand six feet from her, straining to hear her muffled voice. No fever, no travel, no cough. A bit of a sore throat.

I ask the nurse beside me to repeat her vitals. After touching the patient, he’ll need to change his gown, gloves and face shield. We try to stay unexposed as long as possible to conserve personal protective equipment and save time disinfecting equipment.

“Temp, 36.6 C. Sat, 99%. Heart rate, 75. Blood pressure is 110 over 70,” the nurse says, the sphygmomanometer cuff hissing flat. Normal. She must’ve been refused a swab at the centre. But my sense is the patient needs some reassurance, as do I – I’m still learning about this disease.

I explain that we’re saving the tests, at least for now, for people who need to be admitted to hospital and for front line workers who have to get back to work. I tell her it’s unlikely she has COVID, and even if she did, her healthy body has all the tools it needs to fight the virus. She just needs to isolate until she feels better, but if she gets worried again – about anything – she can come see us, even in the middle of the night.

She can’t see my face, nor those of the nurses, to see how much we mean it – we’re covered head to toe in a second skin. She starts to cry. “Can we talk alone?” she asks.

In a quiet room, she tells me her boyfriend is hurting her. She has nowhere to go.

“Not even a friend?”

“No.”

She’s met at the doors to the ER by Jen, a nurse whose smile is so wide not even a mask can hold it back.

“Come with me, darling,” Jen says, and they disappear down the hall, the woman’s plastic bag dangling between them, to find a chair where she can wait until we find her a safe bed.

I watch them disappear. I know Jen’s hand wants to be on this woman’s shoulder, and that this woman’s shoulder wants a hand. So much is lost to keep them both safe.

April 22 (12,245 CASES IN ONTARIO, 659 DEATHS)

“Next weekend, for sure,” says my colleague Emily at shift change, trying to predict when our hallways would fill with COVID patients and we'd we start getting sick ourselves. We’ve been repeating the same prediction for three weekends, though. When the first wave of community transmission didn’t get us, we thought it'd be the people returning from spring break – rolling into grocery stores, unmasked and chatty – who'd get us. Now we talk about the homeless, the inevitable outbreaks in prisons and care facilities. This virus doesn’t just exploit weaknesses in the body, but in society, too. I’m standing at triage with two nurses. We’re glancing back and forth between the ambulance ramp and a plexiglass-wrapped triage desk, imagining ways to make the route safer. The swinging doors at the bottom of the ambulance bay open and a young woman, mask dangling from one ear, lurches up the gentle slope. Her breath is shallow and fast. She grasps the grey railing.

“Help,” she says and falls to the ground. It’s here, I think. Hands rush toward her, as they have for decades. “Nononononono,” I shout, pulling yellow gowns and gloves from boxes by the door. “These first.” The woman lies on her side, face on the cool cement, panting, while we wrap ourselves. A stretcher appears at the top of the ramp. John and I hook our newly covered arms under hers. Candice pulls the mask across the woman’s face. “One, two, three,” we say in unison, pulling her onto the bed. “You’re going to be okay – you’re safe now,” Candice whispers as we angle her around corners, toward an acute bay. The nurses fit oxygen prongs into her nostrils, careful to keep the flow as low as possible, so we don’t transform droplets to aerosol and send COVID spinning into the air. I stand beside her, asking questions. She has no pain, cough or fever. She hasn't travelled. No asthma, no risk for clots in her legs or lungs. Her breathing slows as the nurses finish hooking the EKG leads to her chest. Her heart rate is a bit fast, but her oxygen is normal. It doesn’t sound like COVID, but I’m still learning.

We run more tests. Her blood is normal, both her hemoglobin and white count, and the gases in it show low carbon-dioxide, the opposite of what we'd expect of lungs filled with fluid. Her x-ray is normal. When I return to the room, her heart rate is too. “Before you fell on the ramp, were your fingers tingling?” I ask. Yes, she says. It seems it's worry that had clamped so viciously onto her chest. I explain that we’ll swab her just in case. By the time she leaves, her breathing is easy. I mention the case to another ER doctor. He nods. “You remember that guy the other night, who came in with medics just as you were leaving?” “Yup. He looked terrible. His feet were gray.” “That’s him. Everyone was freaking out, getting the intubation tray, but I said ‘Slow down.'" They gave him oxygen and narcan, and he came right out of it.

“Opiates,” I say. “Yup. But everything’s COVID these days, even when it’s not.” It’s become a state of mind.

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April 25, part 1 (13,995 CASES IN ONTARIO, 811 DEATHS)

“Do you want us to take him?” Mackinnon asks, looking at the clock. “Your shift is just about over.”

“No, we’ll do it,” I say. “Right, Dave?”

“Definitely,” Dave answers, and pulls the difficult-airway cart toward the negative pressure room. We've received word of a man who's feverish, coughing and confused being brought toward us by medics. COVID-like for sure. It will be my first case.

He'd been sick for a week, but yesterday, he stopped answering the phone. A superintendent found him confused in bed. From what the medics described, he'd need a ventilator, and if he has COVID, we have to ensure during the process of putting a tube into his trachea that we don't expose ourselves or send the virus spinning into the air. The hypothesis is that in the sickest, the ones with many viruses in their blood, the inflamed skin in the lungs is stretched one cell thin, and they're most likely to have viruses in their breath, saliva, stool, even their tears. We need to be as covered as possible and spend as little time as possible in the room.

“Want to watch me?” Dave asks, as he starts to unfurl his protective blue gown, the pores on it so small, not even water can seep through. We each make sure we don’t miss a step.

Dave is a senior resident, in the last of his five years of training. At the end of it, he'll be working night shifts alone. We want to him to learn as much as possible from all of us and help him prepare him for his exam – which, like everything else, has been cancelled.

“Your bonnet – pull it over your ears,” I tell him. He spins in a circle. “Let’s get a towel for around your neck.” A nurse unfurls one from the top of a red cart and clips it behind his head.

We’ve gathered a crowd. Everyone is keen to watch and learn.

I copy the routine: mask, goggles, visor, bonnet, gown, neck towel, long gloves, booties, short gloves. Once I’m covered in virus, I'll. need to reverse it, approaching my face last, with hands and arms as clean as possible. Someone I can’t see clips a towel behind my neck.

My temperature has risen. I breathe hard through my mask. A film of fog rises and disappears from my goggles. That’s not good.

I call out the plan: The nurse, Frank, goes in first, and then the respiratory tech to get the ventilator set up. Then we list off the meds so we can get them all in the room to minimize ins and outs: ketamine to make the patient unconscious, rocuronium to paralyze the muscles, an adrenalin-like drug in case the blood pressure falls toward zero. Finally, sedation, so the patient doesn’t wake up, ventilator huffing into his throat, unable to move.

Behind the glass, the respiratory tech, in blue from head to toe, is opening up oxygen spigots, connecting the rolling ventilator.

Frank follows, a whiteboard in his hands so we can write messages about what we need to those on the outside. We’ve tried speaker phones and baby monitors, but this works the best.

“Here he comes,” someone says. A stretcher holding a thin, frail man with an oxygen mask over his face turns the corner. The glass doors slide open, and the medics move him in.

“Alright, let’s go,” I say. Dave steps in beside me, and the glass slides shut.

April 25, Part 2

Frank bends over the man’s elbow, looking for a vein below a blue tourniquet. The patient is so thin, I can see the pale rope of one from where I’m standing. With six people in the room – including the paramedics, wearing goggles and gas masks, canisters jutting from each side – it’s hard to move. No one wants to touch anyone or anything.

A respiratory technician is punching parameters into a ventilator. We’ve all learned the different physics of sick COVID lungs, shared from Wuhan, then Bergamo, now New York. Podcasts, Twitter, phone calls – I’ve never seen anything like it, not even during SARS.

“We’re set,” the tech says. I can’t tell if I know her, since she's clad in blue from head to toe.

He’s still relatively young – in his early 60s. His eyes are closed, and his shallow breaths are the kind that turn to last gasps. Frank pulls off the tourniquet with a snap. Clear beads of saline patter from the bag into the line, then into the man’s arm. On his other arm, the blood-pressure cuff hums fat, then deflates with a click, hums again. It can’t find a pressure, which means it’s far too low.

We’re hoping the saline helps – that part of his low pressure is from dehydration. But half the saline is already gone. Someone suggests a norepinephrine infusion – an adrenalin-like drug used to squeeze sick vessels tight and get blood to the brain and kidneys.

Frank uses a red marker to write "Norepi infusion" on a whiteboard and holds it up to the window. The runner nurse outside nods and pushes her way through the half-dozen people watching us from outside.

The RT stands by the ventilator we plan to attach to the gasping man, so his diaphragm and chest can rest. She’s put a filter through the tube we hope to slide smoothly into his trachea, to catch all the viral particles. So once he’s connected, he’ll stop blowing them into the air.

His oxygen-saturation level – already low at 88 per cent, despite the oxygen pouring into his nose – disappears, replaced with three dashes. The probe on his finger is still in position. The oxygen tank is still pumping four litres per minutes (we don’t go much higher, for fear that a rush of air will send viruses into aerosols that will hang in the room, instead of falling to the ground like dew). I follow the tubing to his nose. One of the nasal prongs has become displaced.

Should I touch it? So many viruses. Gently, I reposition the prong into his nose, then put my gloved hand under the automatic sanitizer. It whirrs a dab of disinfectant onto my hand.

The saturation is still blank. I move the probe to another finger, and “90%” appears for a brief second, then nothing.

The anteroom door opens, and a gloved hand reaches in. The norepi. It’s so powerful, we dose him with just 10 micrograms. A single bubble traces the norepinephrine into his arm to disappear into a million pieces in his hurt lung. As it reaches his arm, his vessels tighten up, and with more blood going to his brain, his eyelids flutter. He lets out a moan.

“Sir?” I say loudly. “You’re at the hospital. You’re very sick. We’re going to put you on a breathing machine, okay?”

He makes a slow nod. His breath comes fast. His eyelids close again. A rattling cough.

“Seems like it could be sepsis,” I say to Dave, describing an overwhelming bacterial infection that can lower your blood pressure. “Maybe not the virus.”

He shrugs. Doesn’t matter. That’s emergency medicine. We decide to give antibiotics, just to be safe.

The intubation goes smoothly. We drip in ketamine to make the man unaware, then a paralytic. When his jaw goes slack and his breathing stops, we use the video laryngoscope – a curved tongue depressor with a camera on its end – to see his vocal cords. Then we pass the tube through them without administering a single breath. If it’s COVID-19, we don’t want to use the breathing bag if we can avoid it – aerosols.

“OK, let’s recap. We’ve managed his airway. He’s protected, we’re protected. Oxygen is 94 per cent. Pressure is 120. He’s had a litre of saline and more going in. He is on norepi. Antibiotics are on the way. We’ve been in here for ... 25 minutes. I suggest we swap out. Are we missing anything?”

Silence.

“Let’s get the hell out of here.”

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