It’s 8 a.m. and Dr. Garret Pulle has just completed a 12-hour shift in the intensive care unit at Humber River Hospital.
It’s the largest community hospital ICU in the Greater Toronto Area and lately the frontline health care workers there are dealing with many coronavirus patients.
“We had a few COVIDs come in overnight,” Pulle told the new team of doctors who will replace him.
After a brief rundown of the patients, Pulle leaves. There are 15 COVID-19-positive patients in the ICU on this day.
“These patients tend to be very sick … they tend to be intubated for a long, long time,” explained internal medicine specialist Dr. Jamie Spiegelman.
“We don’t know how long yet — we’re still early in the pandemic in Toronto.”
If there is one thing they know for sure, it is that the patients deteriorate quickly.
Spiegelman said many patients arrive in hospital after suffering at home for a week or two with flu-like symptoms, then shortness of breath sets in and they are rushed to the emergency room.
“A lot of them are intubated for weeks to months from experience in Italy, China … if they survive,” he said.
“We’re learning, we don’t know, we have never dealt with patients like this before. Their physiology is clearly different than any other physiology we’ve seen.”
There is no manual to follow, this is new to frontline healthcare workers, and yet they know lives depend on them.
“We don’t understand it yet and I’m not sure we’re going to understand it any time soon during this pandemic,” said Spiegelman.
Besides caring for the critically ill, the doctors and nurses need to practice self-care. Protecting themselves from COVID-19 is just as crucial.
“I’ve worked 31 days straight with ICU and ER and I’ve been in close contact with a COVID patient every day … we always have to be mindful and very alert and aware of the risks at hand and do everything by the book.”
There is a strict protocol to follow, noted critical care specialist Dr. Keren Mandelzweig, and that includes the mindset “you just have to assume that everything has COVID.”
“We are working in spaces where we cannot physically distance, we can’t just stay at home … we’re coming into work and we’re working in very close quarters with other people and we have to just assume that every piece of equipment and every other person has COVID,” she said.
At home, she said she and her partner stay as separate as possible to keep each other safe.
“We have our separate spaces just in case I get symptoms I don’t infect him. He’s still able to do all the grocery shopping, he makes all the food and he’s able to support me in that way,” she explained.
“It allows me to focus on just coming to the hospital and taking care of patients.”
Inside the ICU, the team decided a 62-year-old female patient who arrived in hospital just hours earlier needs to be intubated.
“She’s working way too hard, she needs too much oxygen (and) she’s not getting enough oxygen. I’m scared that she’s going to fatigue and stop breathing,” said Spiegelman.
The woman has diabetes, had a previous minor stroke and presented to hospital with flu-like symptoms and shortness of breath.
Within hours, her condition had deteriorated.
“I am concerned that if we don’t do it early we’re going to be doing CPR on her chest because she will go into respiratory arrest,” added Spiegelman.
Dr. Keren Mandelzweig spends time getting into the appropriate personal protective equipment, also known as PPE.
“Normally before the COVID era if someone had to be intubated we would put on our mask, but we would really all rush into the room and use the equipment that we are used to using and intubate a patient. Now we have to do things a lot differently,” she explained.
Registered nurse Julia Piekielko is a PPE marshall and watches doctors and nurses closely to ensure they use the proper PPE. She has a marker in one hand and a checklist in the other.
“My job is when they’re coming out and when they’re going in, we check and make sure that all the PPE is properly on. When they’re coming out, one by one we go through each step — the safest way we can to avoid any contamination,” she explained.
However, no one is taking chances.
“It is a higher risk procedure for the health care workers, but also to the patient because they could desaturate very quickly. We don’t have the same techniques necessarily that we are used to,” said Mandelzweig.
“The main thing that we need to do is prepare, be focused and make sure that everyone knows the plan going in beforehand.”
She then went directly to a patient.
Mandelzweig can be heard from a distance explaining calmly, and compassionately, “We are going to help you with the breathing. We are going to put you on a breathing machine to help you, OK? We are going to take good care of you.”
Minutes later, it became clear this would not be an easy intubation. CPR was performed and the team managed to save the woman’s life and attach her to a ventilator.
“I think that experience shows just how challenging and how high risk these intubations are. These patients are already so precarious in terms of their oxygenation and they desaturate so quickly,” explained Mandelzweig.
“If she didn’t have the support of the breathing machine, then her muscles would tire out, her oxygen level would drop and she would likely pass.”
These are difficult times for frontline health care workers balancing the need to protect themselves, but also care for critically ill patients.
“It is stressful because all you want to do is help these people, our patients, but just watching them desaturate so quickly and not being able to do everything that we can all the time to help them it is really frustrating, it is terrible,” said Mandelzweig.