COVID-19 became real to many British Columbians on March 12, just before the start of the spring break. That’s when B.C.’s medical officer of health warned against all non-essential travel outside of Canada and ordered large gatherings to be cancelled.
In the days that followed, Dr. Bonnie Henry’s orders tightened restrictions, including closing schools. These are the journal entries of some front-line health care workers in the weeks that followed.
- Dr. Cyrus McEachern, consultant anesthesiologist, Vancouver Acute Department of Anesthesiology, Vancouver General Hospital and UBC Hospital
- Jayne Hamilton, advanced care paramedic, Metro Vancouver
- Megan Lawrence, primary care paramedic, Metro Vancouver
- Moses Li, registered nurse/clinical nurse leader, emergency department, St. Paul’s Hospital
- Dr. Steve Reynolds, specialist in infectious diseases, internal medicine and critical care, ICU physician and site medical director at the Royal Columbian Hospital in New Westminster
- Dr. Daniel Kalla, department head of emergency medicine for St. Paul’s and Mount Saint Joseph hospitals, and practising emergency physician
Dr. Cyrus McEachern, March 14
I’m called to intubate my first patient with COVID-19 in the ICU. I don’t usually work in the ICU, but because of our expertise in airway management, the Department of Anesthesia at VGH has been tasked with this most dangerous procedure.
I gown, glove, mask and shield before speaking with the patient. I’m 35; he isn’t much older. His wife cries to him on speakerphone: “I love you …”
I run the checklist: personal protective equipment? Check. Drugs? Check. Intubation gear? Check. Contingency plans? Check.
I give him 100-per-cent oxygen and he coughs violently. I visualize the clouds of virus filling the room. We push the drugs and he’s unconscious. I secure the endotracheal tube. We can all breathe now.
I doff my protective equipment meticulously, terrified of contaminating myself. Still, I feel contaminated. I shower and change. I know I can’t see my family now. I’m alone. I hear the 7 p.m. cheer once I’m home, and I break down, sobbing.
Dr. McEachern, March 18
The March 14 intubation follows me for days. I’ve since debriefed with what feels like half the hospital, and it’s obvious just how stressed everyone is, and rightfully so. Intubating COVID-19 patients aerosolizes the virus, and fills the air with infectious contagion.
I feel that the best contribution I can make during this pandemic is to educate as many health care workers as possible about how to intubate these patients safely. This is a new and terrifying disease, and I want others to feel more prepared to manage it than I did. I set out to create a training video to illustrate COVID-19 intubation safety, and connected with a video producer through a friend.
We’ve been working intensely in the evenings after my 10-12 hour shifts. It’s coming along, but I’ve sacrificed a lot of sleep, and I am exhausted.
Dr. McEachern, March 20
My first case today is a seven-hour cardiac surgery: “Give heparin … lungs down … go on pump …” It’s a familiar dance, and I know all the steps.
The routine is soothing in the anxious atmosphere of COVID-19, where our policies and procedures change by the hour.
My second patient is old, frail, very sick and having major, high-risk surgery. Mid-operation, the patient goes into cardiac arrest. Code blue: push adrenaline, squeeze IV fluids, transfuse blood. We get him back.
I gather myself, stabilize his vitals and prepare for the most dangerous phase of the surgery.
He arrests again – more adrenaline, more blood. We resuscitate him and the dust finally settles; he survives.
As I open my locker to change, I notice my hands shaking. They never shake. I am maxed out.
Dr. McEachern, March 23
This week I’m acting director of the Cardiac Surgery ICU (CSICU) – one of my usual roles. I was shocked this morning to find that the CSICU has been repurposed into an enormous negative pressure unit exclusively for COVID-19 patients. The entire CSICU and its patients have been relocated to the back pod of the Post Anesthesia Care Unit.
This is wartime mobilization of resources. Such a move would usually have taken years of planning and approval processes. Instead, it happened over a weekend.
We’re able to care for the patients to our usual high standards, but it’s a new environment, in a dynamic climate, and people have so many reasonable questions. “How do we maintain social distancing on rounds?” “Should we extubate all patients in negative pressure isolation?” “Can we expedite COVID testing for cardiac surgery patients?” I feel underqualified to answer everything … but this is my role: to figure it out.
Dr. McEachern, March 31
I was anesthesiologist in charge overnight, and it was busy. Despite cancelling elective surgeries at VGH, we are not short of work in the OR. In fact, around 65 per cent of the surgeries we do are on an emergency basis. We had an aortic aneurysm, a hip fracture, a traumatic subdural hematoma (brain bleed), a subdural abscess (brain infection), an appendectomy and, finally, a stroke. The attending neurologist informs me that COVID-19 is associated with a high incidence of stroke.
We are now treating all patients as if they could have COVID-19. This means personal protective equipment and safety precautions for every operation.
As I sit there at 4 a.m., struggling to read the vital-sign monitor through the fog in my safety glasses, unable to readjust them for risk of contaminating my face, I reflect on how this pandemic affects all of health care.
Jayne Hamilton, April 1
If you asked any paramedic right now what the theme of the pandemic has been, I think many would answer “moral dilemma.” This concept means the treatment we must give does not match the treatment we want to give.
This disparity between what we can do and what we must do is well regarded to be a leading cause of mental-health injury among us.
Right now, we must take the time to don our PPE no matter what the emergency. We are limited in the treatments we can provide in the interest of keeping ourselves and those around us safe. And our sense of control in directing care has been stripped to the necessity of what must be done in the interest of the greater public good.
Today, someone filmed me on the street taking off all my PPE and I felt angry. I tried to remember people are just as scared as us. One colleague said to me today, “There must be such a thing as pretraumatic stress … we know exactly what’s coming.”
I told my partner today I felt bad that I might get sick and pass it on to my colleagues before I was symptomatic and she said, “I feel like if you have it, then so do I … so no hard feelings, okay?” Some small control. On the drive home from work, I felt tears streaming down my face with the distress of it all, and I allowed it because I know I won’t have the time later.
Megan Lawrence, April 1
I work a four-on-four-off pattern of two days and two nights in the Metro Vancouver area. I have been a paramedic for eight years now. When I decided this is what I wanted to be back when I was 15, I had an idea that it would be scary, that I would be exposing myself to unknown risks and dangers. I never thought I would be exposed to something like this, something I couldn’t control.
I have had to don and doff more personal protective equipment in three weeks than I have in my entire career so far. The feeling of donning your PPE on a street is scary, especially when I looked all around me and in all the homes’ windows all I could see was the neighbours staring at me, frightened. It made me feel like I was the plague doctor wearing the bird mask, the ones we learned about in history class. Never did I think I would be someone that would be associated with genuine fear.
Ms. Hamilton, April 2
Shortly after starting my shift tonight, myself and a few other medics were sitting in the day room of the station when we heard a strange clanking noise coming from outside. I got up and peeked out the window, and to all of our surprise there were several neighbours standing on the street with their families (socially distanced, of course) holding signs that read “Thank you,” honking horns and clacking noisemakers, their children holding up hand-drawn signs of ambulances.
We were speechless. Unsure of what else to do, I pulled the ambulance out of the bay and fired up the lights and sirens as I choked back tears. We still don’t know how to feel about the 7 o’clock cheer, maybe because we aren’t used to feeling this way at all while we’re at work – a chink in the armour.
Later in the evening, I responded to a call for a little old lady with fever and weakness, one of dozens this week, and when I noticed she was shivering I asked if she was cold. After a few seconds she responded quietly, “I’m scared,” and I realized she was shaking with fear. I remembered all the PPE I was wearing, and looked at her family all wearing masks, too – so many scared eyes.
I told them that the patient would have to go to the hospital alone and they wouldn’t be allowed to visit, and for the hundredth time this month felt my own chest hurt with their panic.
I remembered the families cheering on the street a few hours earlier.
Dr. Daniel Kalla, April 2
Every day starts with me desperately looking at the numbers to see how many more patients we have. I always look at the hospital admits to the ICU. But yesterday was a day of getting ready for contingency and creating more spaces where it’s safer for COVID patients.
I would say on a personal note, it continues to be a roller-coaster ride. I am so proud of my team and staff and believe we still have a lot of capacity at the hospital, but, as always, I am terrified by the reports we hear from New York now or wherever the latest hot spot is, trying not to imagine that we could be next.
Dr. McEachern, April 5
I’m a few days into a much-needed week off, but I can’t sleep. A stretch of night shifts usually throws me off a bit, but this is different.
Last night I lay in bed and waited all night to fall asleep, but simply did not. I feel a buzz in my chest like the hum of a fluorescent light tube.
My thoughts aren’t particularly fixed on any specific anxieties or worries, but I’m definitely burned out.
Ms. Lawrence, April 6
After finishing a set of four days off, I am preparing my mind emotionally and physically to head back to work. There have been significant changes since I was last in my ambulance. COVID-19 is constantly evolving and changing, and so do the practices that we have. The way we now treat our patients may leave me and my co-workers with a moral injury.
Ms. Hamilton, April 8
A few days ago I woke up after a shift feeling fatigued, with a headache and a sore throat, and thought, “Oh no.”
We take every precaution in this job, but we all have a secret place inside us where we are prepared to catch this thing. I felt sick more from the terror than my symptoms, so I called my partner, also a paramedic, to tell him I needed to get tested.
I made the tense trip to a testing centre and endured a Q-tip being swirled around in what I’m sure was my brain. Within 24 hours I had my result: negative. This time. My relief quickly gave way to the realization that I could still catch COVID. It’s not over.
My days off aren’t rest any more with the thought of this, and by the time I got to work this morning I felt my feet dragging like I’d worked a week of nights.
Dr. Kalla, April 9
Yesterday we were running a simulation in our outdoor resuscitation zone. In these ultrarealistic scenarios, we run through what would happen if paramedics brought in a patient in cardiac arrest who may have COVID, and how we would manage the patient’s airway with intubation.
The zone is a makeshift space created inside the paved, tiny courtyard behind the ambulance bay, with tarps up and lights for nighttime use. There’s a vulnerability to the whole thing. Normally, when we do simulations, they can be nerve-racking and exciting. With COVID, not only are you training to do the procedure to resuscitate and ideally save a patient’s life, but you’re also training to protect yourself and ensure the neither you nor your colleagues get infected.
It adds a whole level of vulnerability to the procedure that I have never experienced.
Dr. McEachern, April 10
I finally feel back to baseline. In a week off, I exercised, slept in, spring cleaned, caught up with friends over the phone, photographed the full moon, watched terribly entertaining TV (Tiger King) and even bought a motorcycle out of hedonistic impulsiveness. Normal human-being stuff. I’m ready to go back to work.
Ms. Hamilton, April 11
To say that the difference between the outside world and inside the hospitals is jarring would be an understatement.
Outside, it’s spring – tulips and cherry blossoms, sun blazing, and despite all of the physical distancing and closed businesses, Vancouver is still managing to be oh so beautiful. It’s crisp and fresh outside. When I look around me, it doesn’t match the reality in my head, or the visual of walking into any hospital in the Lower Mainland. All staff there – all of them – covered head to toe in PPE: surgical bonnets, goggles, masks, gowns, gloves, booties.
There are no familiar faces in here any more as we wheel our sickest patients into a negative pressure room to be intubated. Removing PPE is painstaking and my hands sting and burn red from the hand sanitizer.
To leave this area requires passing through an airlock door, where as one door closes behind you the air is sucked out before the door in front will open. A faceless doctor waves and says “Thank you EMS!” and I wave back sadly, wondering “for what?” as I step back outside, out of the stench of sanitizer and hospital and into spring.
Moses Li, April 11
I scrambled to get my belongings together so I could get going for the weekend. Then the page rang out: “CODE 19.” Someone sick was arriving imminently. The team scrambled. The clunk and complexity of donning PPE made a normally calm and collected process into a heated sprint to prepare for receiving the patient. ETA five minutes, but it felt more like seconds. We received the patient. It looked grim. The team did what they could – CPR, intubating. In the end we “called it.” We took a quiet moment for the patient, now passed. Afterward, I stood there with each team member, coaching them to meticulously doff equipment piece by piece, being assertive (herein lies the greatest likelihood of exposure), but also trying to bring down anxiety (my own included).
Dr. McEachern, April 14
I’ve been redeployed to the main ICU this week. This is not my usual role, but I’m being oriented in case there’s a tsunami of COVID-19 patients around the corner, or the main ICU doctors fall ill.
Minutes into my first day I’m handed a patient list. My stomach sinks immediately. One of my patients is an old friend, and she’s about to be intubated by my teammate for a life-threatening emergency.
We get a quick hello in before she’s put to sleep: “Hi Cy. It’s nice to see you. How are you?” It always throws me off when patients on their deathbeds ask how I’m doing.
As I leave the room to catch up with my team rounding on the other 13 patients, I duck into a supply closet to cry for 30 seconds. I need to be human after that.
I hope the week gets easier.
Ms. Hamilton, April 15
The experience of wearing personal protective equipment, or PPE, is unpleasant in any setting, but especially so in homes, workplaces, public buildings and spaces and even the back of ambulances where paramedics work before arriving at hospital. Before every call, we must don an N95 respirator that clings to our face and is akin to breathing through a duvet. The first one I wore this morning stayed on my face for hours as I went from one call to the next, and it was completely toast by the time I finished working a cardiac arrest shortly before noon.
Over the mask we wear a face shield to protect and extend the life of our precious N95s. These shields fog up and warp our field of vision. Next comes the droplet gown, with all the breathability of a garbage bag, then finally our gloves. Breathing while standing still is difficult and you’re immediately trapped with your own breath and humidity. By the time you walk up one flight of stairs carrying all the gear, it’s enough to double you over gasping for air. The sweat drips in every spot you can’t do anything about, and the heat is quickly nauseating.
There’s no subtle talking in an N95. If you don’t yell, you aren’t heard. This makes communication during a medical crisis difficult at best. Giving a death notification while your face is so hidden seems obscene, and even worse when the recipients of such terrible news consider English their second language. What must we look like to them?
We struggle to convey our humanity through the very equipment meant to preserve us and suffer physically so that we might not succumb to something worse than sweat and angry red creases etched into our faces for hours afterward.
Mr. Li, April 17
A sudden flurry of sick patients showed up during the afternoon. Beds were filling up fast and our nurses were busy, yet working well together. But we needed to make room. And so I did my best to be useful. What this looked like: helping one of our discharged and now-sober patients get himself out of bed and dressed. I had to negotiate with and remind him that we did not actually lose all his belongings but that rather he was found with nothing on him but his soiled clothes and some change. And so I got him a sweater and a pair of shoes, a sandwich and a juice for the road. Relieved the interaction went smoothly, I wished him the best as he reluctantly moved on from the hospital. All the while dodging his cough.
Dr. Kalla, April 17
I returned with a vengeance to clinical work this week, doing four shifts in the five days. One thing I have noticed: I only saw a handful of patients whom I suspected might have had COVID, and I swabbed and tested them. But I saw even more patients convinced they had COVID, although I was certain they did not. Understandably, there’s a COVID paranoia going on, often among younger and healthy people. There’s so much fear, uncertainty and anxiety out there. I’m even seeing some people return multiple times despite having previous negative tests and symptoms that aren’t really compatible with COVID. It makes me worry about people’s mental health after this COVID pandemic is finally over. I wonder whether we will face an epidemic of people scarred by post-traumatic stress disorder and psychological damage from the physical distancing, isolation and fears we have lived with for the past month or two.
Dr. Steve Reynolds, April 18
Recently, one of the resident physicians arrived in the ICU, and he seemed angry.
With his shoulders slumped and without making eye contact, he announced that he’d been redeployed to the ICU.
During the regular medical banter of rounds, he was conspicuously silent.
He wasn’t angry. He was scared.
Ultimately, I signed up for this. Not explicitly. No one asked if I wanted to be on the front line during a pandemic, but it came with the territory. I chose this with the implicit knowledge that one day this might well happen.
But he didn’t. He was in the midst of years of gruelling training, constant evaluation. With little control or say, he was plucked from a rotation and dropped unceremoniously into the ICU.
I have the privilege of leading a team in this. I have some control over my small sphere of influence. Surely not over the terrible consequences of this disease, but I do get to exercise even a small bit of control over how I will engage with the challenge. The unknowns of this disease, although significant, are only a small part of the thousands of hours of experience that I have gained through my career.
Even that small amount of control, that familiarity with parts of this work that I know, grounds me.
He has no such control and no such leverage. He doesn’t know the nurses, the hospital layout or our little rituals. He was stepping into the fray with the unknown all around him. He never signed up for this.
I resolved to approach him when we could have a quiet moment together and thank him for stepping forward, and perhaps share my own fears that my skills and knowledge may not be up to this new task.
Maybe that will help, but I suspect the barrier of hierarchy and the expectations of suffering silently will eclipse those efforts.
Mr. Li, April 20
I entered the room, doing my best to smile with my eyes behind the mask. I was asked by a colleague to help insert an IV in a patient who was here for non-COVID issues. They had already been poked multiple times. They did not have great veins, but they needed a big one in case we needed to give large amounts of blood or fluid. I looked and felt. Just a small one over the wrist. The patient commented on how they probably should have come sooner before they felt so ill. They were worried about coming to the hospital due to fears of COVID. I reassured them they did the right thing, but I also wondered how many other people were waiting too long to come to hospital. I poked, and a flash of red appeared. Nailed it.
Dr. Kalla, April 23
Working another night shift this week, I noticed a new phenomenon in the evolution of this pandemic: a form of COVID fatigue.
In the first weeks to month, there was so much adrenaline coursing through us and such a sense of urgency and purpose to our approach. We were learning on the fly how to cope with this unexpected disaster.
But now that in B.C. the curve has flattened and the number of hospital visits have decreased, there’s a kind of exhaustion creeping into our world. The pandemic has created this cognitive load for all of us in the emergency department. We’ve had to learn so much to prepare and respond. And COVID remains this unseen but omnipresent threat, not only to our patients, but for the staff as well. It’s always there. It’s always discussed. Even though our visits are fewer, it’s more exhausting to work a shift and manage all of the extra steps that are so vital to keep us safe. It’s beginning to catch up with me, anyway. Even though our curve has flattened and our numbers have trended in a positive way, it’s hard to see the light at the end of the tunnel now that we’ve entered the chronic stages of this disease.
Dr. Reynolds, April 24
An experience from a few weeks ago still stays with me.
I remember her image coming up on the FaceTime call.
I could see her in her living room. A picture of her and her husband during happier times over her left shoulder.
I could also see my face in the top corner. I was hidden behind my mask. Almost anonymous, impossible to build rapport and trust.
I gently started the conversation and probed her knowledge of the situation and preparedness for what I would tell her next.
Her husband, who a few weeks ago was vibrant and healthy, would die soon. He had a sudden complication of COVID, something we didn’t expect and couldn’t fix.
There was no chance he would survive.
I waited as she cried.
I watched her on that odd FaceTime angle.
I wanted to be there with her in her grief, but I was only a small image behind a white mask in the corner of the screen. What she needed was a human beside her.
We planned for her to come to the hospital. The social worker who was with me on the call arranged a cab, planned to meet her at the door and would wear a mask and gown.
I remember standing up. I turned to leave, mostly unsatisfied with the limited compassion I could provide over a screen.
I am quietly haunted by the fact that he was almost my age.
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