Inside the ICU: What staff at a Toronto hospital have learned about COVID-19

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Jeff Semple takes us inside one hospital and meets a doctor whose family constantly confronts life and death questions – May 3, 2020

Ray Gentle was feeling ill and resting at home when he collapsed.

“I stood up, I tried to walk,” he said.

But he wasn’t going anywhere.

“Shortage of breath, my lungs just collapsed on me. And I basically dropped back down where I was,” he added.

His wife called 911 and an ambulance rushed him to Toronto’s Humber River Hospital. Based on his symptoms — shortness of breath and a fever — staff immediately suspected COVID-19, and they were right.

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Coronavirus around the world: May 3, 2020 – May 3, 2020

“I have no idea how I came in contact with this virus,” the 55-year-old father of three told Global News from his hospital bed, where he was laid up and on oxygen for over a week.

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“I’d been indoors, I wasn’t out in the public or anything at all. I couldn’t believe it.”

As cities and provinces begin lifting restrictions aimed at slowing the spread of the new coronavirus, front-line hospital staff say their fight is far from over — battling an invisible enemy they still don’t fully understand.

“This is a very smart virus,” said Dr. Jamie Spiegelman, an internal medicine and critical care specialist. “We don’t know exactly how it works, where it goes, the way it infests our body. It’s unpredictable.”

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The Toronto hospital where Gentle found himself was literally made for this — its construction and design inspired by the SARS epidemic in 2003.

“As we were building it, we were very conscious of SARS and very conscious of the kinds of things that you might be able to do to make it a healthier, safer environment, should there be a pandemic,” said the hospital’s president and CEO Barbara Collins.

The 656-bed hospital boasts a state-of-the-art ventilation system with “100 per cent fresh air” (no recirculation). 85 per cent of its rooms are single patient with private bathrooms and 80 are equipped with negative pressure.

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“Our hallways are wider, our doorways are wider, our building is larger square footage (167,225-square-metres), all of which allows ‘social distancing,’ which isn’t something we knew about when we designed this building,” Collins said.

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But even armed with those advantages, the hospital’s front-line staff are anxious. Over the past seven weeks, they’ve seen firsthand what COVID-19 can do.

“Older people definitely get sicker than younger people, but we’ve seen random younger people get really sick: a 23-year-old woman, we have a couple of guys upstairs in their 40s who are critically ill on ventilators,” Dr. Spiegelman said.

“This does not discriminate, whether you’re rich or poor, old or young — if you get this disease, it’s a bad disease if your body responds poorly to it.”

In the hospital’s emergency department, we meet our guide for the day.

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Dr. Susan Tory is an internal medicine physician and a “hospitalist” — a relatively new and little-known position in some hospitals, responsible for caring for in-patients who are sick but in stable condition. That includes most of the hospital’s approximately 80 COVID-19 patients.

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“On an average day shift, we have maybe 14 to 16 referrals from an emergency doctor; I’d say at least half of those are suspected COVID,” she said.

Dr. Susan Tory prepares to enter the hospital room of a patient with COVID-19. Jeff Semple / Global News

Dr. Tory’s first stop: checking in on a newly-admitted COVID-19 patient — a man in his 60s who recently tested positive and was self-isolating at home until he started having trouble breathing. He was found passed out on his apartment floor.

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“It sounds like the patient is a pretty stoic guy and was trying to avoid coming into hospital as much as possible,” she said after speaking with his daughter by phone. “But his family then really urged him to come and get some help.”

Now that he’s been admitted to hospital, those concerned family members can’t see him. In this pandemic, they’re not allowed to visit.

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“It’s difficult. There are patients going through a lot of very severe illnesses. And in those moments where there’s high stress, every family member just wants to be there holding their hand. And they can’t.”

In their absence, Dr. Tory takes his hand and spends time talking with him, while keeping a close eye on his condition. She and her colleagues have seen how quickly COVID-19 can take a turn for the worse. “The thing with these patients that’s been very tricky is that things can evolve very rapidly.”

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Dr. Susan Tory speaks with a COVID-19 patient at Toronto’s Humber river Hospital. Jeff Semple / Global News

Just down the hall, that’s exactly what’s happening: A 62-year-old woman, who arrived hours ago feeling unwell, is now struggling to breathe.

Dr. Spiegelman said it’s fast become a familiar pattern: patients suffer flu-like symptoms for up to 10 days before their lungs rapidly become inflamed and filled with fluid.

“This is quite consistent and actually quite scary,” he said. “The virus gives itself nine days to be able to be contagious to other people before a person gets really, really sick.”

READ MORE: How the City of Toronto responded to the Spanish Flu in 1918

To save the really sick, doctors perform a high-risk procedure. The team is preparing to intubate the 62-year-old who’s struggling to breathe.

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Doctors intubate a patient with COVID-19 at Humber River Hospital on April 24, 2020. Jeff Semple / Global News

“She’s not getting enough oxygen. I’m scared that she’s going to fatigue and stop breathing,” said Dr. Spiegelman.

Intubation involves inserting a ventilator tube through a patient’s mouth and into the airway leading to the lungs. It carries risks both for the patient and medical staff; while COVID-19 is spreading through respiratory droplets, typically when an infected person coughs or sneezes, intubation generates contaminated aerosol particles. Following the procedure, doctors assume the virus is airborne inside the room for 30 minutes.

“Normally, before the COVID era, if someone had to be intubated, we’d put on our masks and we’d all rush into the room,” said critical care specialist Dr. Keren Mandelzweig.

“Now, we have to do things a lot differently.”

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For their own safety, hospital staff have redrawn the playbook — deploying extra layers of PPE (personal protective equipment).

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“It takes double the time to do anything because we have to put on all of the protective equipment,” Dr. Spiegelman said, his voice muffled by his N95 mask and plastic face shield.

Dr. Jamie Spiegelman says it takes twice as long to prepare for an intubation procedure due to the extra layers of personal protective equipment. Jeff Semple / Global News

Fewer staff are allowed inside the patient’s room, while others stand watch outside in case anything goes wrong. And this time, something did.

A few minutes into the procedure, one of the doctors started shouting for back-up: “Guys, we need a crash cart!” A crash cart is basically a shelving unit on wheels, which typically contains equipment needed to treat a person in cardiac arrest.

Fewer staff are allowed inside the patient’s room, while others stand watch outside in case anything goes wrong. Jeff Semple / Global News

In this case, the ventilator tube wasn’t fitting properly into the patient’s airway. Her oxygen levels plummetted. And, for about 10 seconds, her heart stopped.

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A staff member came racing down the hallway with the crash cart, which was rushed inside. An alarm started blaring. A small crowd of medical staff gathered outside the room, peering anxiously through the door window. The doctors inside performed chest compressions. And, in the end, they saved her life.

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“I’ve probably intubated thousands of patients. With COVID-19, it’s a completely different kind of intubation,” said Dr. Spiegelman, explaining that COVID-19 patients have an unusually low “reserve” of oxygen. Once doctors remove a patient’s oxygen mask to insert the intubation tube, they have to move fast.

“Most patients, if you give them oxygen, they’re good for at least a couple of minutes, and their oxygen saturation doesn’t go down. These COVID-19 patients, within a second or two or after taking them off oxygen, their oxygen saturation will go from about 90 per cent, down to 30 or 20 per cent within seconds.

“That makes it much more difficult to intubate these patients. You have to get the breathing tube in as quickly as possible.”

The 62-year-old patient remains in critical condition. Studies from other countries with COVID-19 suggest most patients placed on a ventilator don’t survive. But hospital staff have given her a fighting chance.

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“All you want to do is help these people, our patients,” said  critical care specialist Dr. Keren Mandelzweig. “But just watching them desaturate so quickly, and not be able to do everything that we can all the time to help them, it is really frustrating. It’s terrible.”

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Dr. Tory is done for the day and invites us to come home and meet her family: her husband Jamie and two daughters, six-year-old Piper and three-year-old Reese.

When the pandemic started, the family debated whether she should live somewhere else for a while. “People are worried about getting sick and they’re worried about bringing it home to their families,” she said. “It’s constantly on my mind, just in terms of being as careful as I can.”

She also worries about carrying the emotional weight of the pandemic through her front door. “You have to just find a way to try and let go of it when you come home. It’s not always possible.”

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It helps, she said, to talk about it with her friends and family, including her dad: John Tory, the Mayor of Toronto.

“I am proud of what Susan does, and I’m proud of who she is,” Mayor Tory told Global News over Skype. “And who she is is much more important: she’s a compassionate, caring, loving individual, who is applying those attributes of her personality to looking after people as a doctor.”

Dr. Susan Tory is the daughter of John Tory, the Mayor of Toronto. Susan Tory

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Over the past six weeks, Mayor Tory has spoken regularly with his family over FaceTime video. Once a week, he stands on the curb in front of their house and delivers treats for his granddaughters.

“I can tell you this much: I can’t wait for the day when I come and visit my grandchildren,” he said. “I do this thing where I stand on the porch like 10 feet away from them and talk to them, but I can’t give them a hug. I just feel a little hollow from the visit.”

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“So I’m waiting for the day – which I will have a hand, with others, in hopefully making come as soon as possible – when we can give people a hug.”

Toronto Mayor John Tory practices ‘social distancing’ by standing outside his daughter’s home to deliver treats for his granddaughters. Susan Tory

But while he misses his grandchildren, he worries about his daughter.

“I mostly think about her because she’s in an environment where she’s exposed to this virus all the time, and I worry about that,” he said. “The fact that my daughter’s on the front-line as a doctor is also just helpful to me in the context that I can turn to her, ask her a few questions about all of this.”

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Both the Mayor and Dr. Tory are fighting the same battle from different front-lines — Dr. Tory caring for Toronto’s sick, while her father tries to prevent others from becoming infected. The city has closed parks and issued fines to those who ignore the province’s ban on gatherings larger than five people.

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Dr. Tory is now seeing firsthand the results of her father’s lockdown: a surprising number of empty hospital beds with far fewer COVID-19 patients than they’d feared.

They’re also seeing a sharp drop in the number of other non-COVID patients. Traffic to the emergency ward is down 40 per cent.

“It’s this eerie quiet that exists where we have lots of capacity,” she said. “You’re not seeing the same volume, which leads you to wonder: what’s going on outside of these doors?”

One likely explanation is that people are driving less — Toronto’s traffic volumes as of May 1 were down 45-65 per cent. But hospital officials also worry that the sick are simply staying home.

“People might have worrisome symptoms and they’re just sitting on it because they don’t want to go to the hospital, because the hospital’s a place where all the COVID patients are,” said Dr. Michael Gardam, chief of staff at Humber River Hospital. “And so they’re avoiding it. And that’s going to catch up to us. That’s going to catch up to them.”

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They’re already seeing examples. During our visit to Humber River Hospital, an elderly woman was admitted. She told Dr. Tory she’d been feeling “rotten” — with aches and pains — for weeks, but she was reluctant to come to the hospital.

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Her test results revealed she didn’t have COVID-19. But she tested positive for acute leukemia.

Dr. Tory checks-in on an elderly patient at Humber River Hospital. Doctors discovered she had acute leukaemia. Jeff Semple / Global News

“That case weighed on me, because this was a woman who was of an advanced stage – she was 90 – but she was living independently and suddenly has this illness,” Dr. Tory said.

With the visitor restrictions, Dr. Tory had to break the news to her family by phone. She brought the patient a glass of water, held her hand and listened as she spoke about her beloved dogs.

The next day, she died.

“Myself, and every other front-line provider have come home and cried,” Dr. Tory said. “We’re human, at the end of the day. We’re emotional and it’s OK. I’m lucky I have the support of my family.”

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Families around the world have been forced apart by this virus. And a brave few are fighting, risking their own health, to help ensure we can all be safely reunited soon.

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