Around 400 patients a day make their way into the emergency room at Humber River Hospital in northwest Toronto.
The hospital was designed and built after the SARS outbreak of 2002 and was at the epicentre of Ontario’s fight against the novel coronavirus last spring.
“We are seeing almost the same volume of patients that we’ve been seeing prior to the start of coronavirus,” said Dr. Leon Rivlin, the chief and medical director of emergency medicine at the hospital.
It may appear to be business as usual in the ER, but many changes have taken place over the last few months.
“It’s a whole new world in emergency medicine,” Dr. Rivlin said.
“We’re taking all of our PPE (personal protective equipment) precautions. … If I were to be clinically seeing patients, I would have a mask and either a facial shield or goggles on. Sometimes I would have a gown. … We have a designated area for patients who come in with high-risk coronavirus exposure, which we didn’t have in the past.”
On this day, the emergency room is calm.
Dr. Rivlin walks through the halls and explains: “When we do our resuscitations and our codes, we’ve gone through rehearsal training and simulations in order to appropriately manage those codes and get all of our garb on in order to protect ourselves and safely remove it. So whole different world.”
Like SARS, Rivlin once again found himself on the front line of the fight against COVID-19.
Back in March, Global News spoke with him, in a busy ambulance bay, as the number of cases of COVID-19 and deaths resulting from the virus was increasing rapidly.
“We’ve never seen a virus like this before because it’s spreading without people even having symptoms… it’s not like our experience with SARS,” he said at the time.
All these months later, he points out, his team is feeling far more at ease and comfortable dealing with patients who present with the virus.
“If this were a battle, then in March, we got ambushed and we really didn’t have a great idea of what we’re up against and how to fight the disease and we were learning as we were doing it and there are some days where we had to retreat and then there are other days where we sort of forged forward,” he said.
He recalls shortages of personal protective equipment, which was a major issue for health-care workers across Canada, who were putting their own lives in danger to save others.
“Physicians and nurses had anxiety around what kind of exposure they could have that would actually put them at risk because we were looking to New York, we were looking at Italy, we were looking at China and we were concerned, as we saw our professional peers… dropping and dying,” he said.
But that was then and this is now.
“We are prepared so there’s no ambush… like I said, if this were a battle, then we would be very firm and strong and we would stand our ground and I think that we’ll make a lot of progress. We have all of our PPE. We know how the virus is transmitted. We know how to set up operations within the emergency department and in the community in order to take on whatever comes our way,” he said.
Last week, Ontario Premier Doug Ford said the province is experiencing a second wave of COVID-19 and that it may be worse than the first.
In response to that, Dr. Rivlin pointed out his team is ready for it.
“I’m very confident that the way that we’re going to manage the second wave is completely different and way better than the way that we managed the first wave,” he said.
In the spring, vulnerable, elderly people suffered the most from the virus.
Long-term care homes bore the brunt of the first wave across Canada, with more than 70 per cent of deaths from COVID-19 occurring in people aged 80 and over.
That is not what doctors and nurses are expecting in the second wave.
“This is a 44-year-old landscaper who came in about a week ago with respiratory failure, really requiring a lot of oxygen,” said Dr. Jamie Spiegelman, internal medicine and critical specialist, as he points to one of his patients in the ICU.
The patient is quite sick but Spiegelman is confident he will pull through.
“If it was the first wave, if this was March or April, I’d be like, ‘I have no idea which direction he’s going to go in,’ but I have a feeling that he has almost 100 per cent survival rate at this point just based on previous patients similar to him,” Spiegelman said.
Another COVID-19-positive patient he is caring for in the ICU is a grocery store employee who also presented with respiratory issues.
“They’re younger this time. They’re not the nursing home patients or the older patients. They are still in their 40s and 50s … and they still need a lot of oxygen and we have an intubated person so they’re still pretty sick from respiratory failure, but in general, they’re not that sick,” he explained.
The portrait of a COVID-19 patient is changing.
“Nursing homes are being much more careful, although there are occasional outbreaks so I think it’s a younger population that are not as careful. They’re eating out in restaurants or going to bars. They’re going to gyms. Those are the people that we’re seeing coming in,” said Dr. Spiegelman, adding, “a lot of them with the current therapy, including steroids really as a mainstay right now, we’re finding that they don’t progress as quickly or as commonly as the first wave.”
His team learned a lot from the first wave about treating critically ill COVID-19 patients.
“What we know now compared to the first wave is the one treatment that has good evidence for this is steroids. We’re giving patients steroids really early on. And I do think it is having an effect on the outcomes of these patients, where they’re improving, where they don’t progress to intubation,” he explained.
Registered nurse Sugandha Pandya is the team leader of a general medicine unit she pointed out was at “the epicentre” of most of the COVID-19 cases at the hospital during the first wave hit.
“We do notice that with the staff, the anxiety has gone down, because now we are well equipped with the knowledge and the PPE to deal with the second wave. I think we’re better prepared and I hope everyone out there is also, because wave one was about understanding and learning about the illness. Hopefully wave two is about how we can plan better and tackle it in a more informed manner,” she said.
One of the COVID-19 patients in her unit is a 73-year-old woman whose symptoms first presented as a common cold but then became more serious with weakness and difficult breathing.
“It was an effort to lift an arm, to lift a leg, to lift myself up… so that’s the most disconcerting,” said Carol-Ann Doyle. “You’re scared in the beginning. You’re scared when you feel so low because you think, Oh my God, am I going to be one of those statistics? I don’t think I’m old enough yet to go.”
Back in the ER, Dr. Rivlin puts his team through regularly scheduled rehearsal training and simulations to ensure everyone is ready and properly protected for whatever is to come.
“We have almost an algorithm in our minds as to how we’re going to approach, assess and ultimately treat patients who present this way,” he said.
Rivlin noted the so-called calm before the storm has now passed and the reality of the second wave is setting in.
“Historically, when you look at epidemiological data for pandemics in the past, you will often have a second wave and it makes sense that that’s going to happen because as we’re trying to reopen and restart the system we are going to see more transmission of the virus,” he said.
The difference, Dr. Rivlin added, is the confidence level of health-care providers as they take on this next phase of the battle with COVID-19.
“I don’t have a crystal ball, but I’m hoping that what we’re going to do is maintain regular community activities, we’ll definitely maintain all of our medical activities in the emergency department in order to deliver care the way that we need to because of all of the precautions that we have learned for phase one,” he said.