The call arrived one afternoon in March: a patient at a Vancouver medical clinic complained of chest pain.
Paramedic Jeffrey Booton watched the details flash on the screen as he and his partner made their way to the clinic.
It was his first potential case of COVID-19 and he felt both apprehension and a sense of duty.
“I see this work as working for people. And to do it in the context of a pandemic is obviously caused by fear and apprehension on certain days, but it is a job that still resonates in me, “he said.
When Booton arrived, he put on protective gloves, a water-repellent robe, an N-95 mask and a face shield over his freshly buzzed black hair – a haircut at home that turned out to be shorter than expected.
After a physical exam, they returned to the ambulance and Booton did what he was still trying to do: comfort the patient. Paramedics see people during what can be critical personal moments, and Booton has felt the weight of the patient’s worry. As they traveled together to St. Paul’s hospital, he told the patient what to expect in the ER and what types of tests he could have.
“I can only imagine what he was feeling at the time, but it must have looked like a real feeling of vulnerability in the face of the uncertainty ahead,” said Booton.
Booton was one of at least 125 health workers, ranging from dispatchers and nurses to the hospital’s housekeepers, who cared for the patient.
On that day, the patient was one of 55 cases identified by dispatchers as possible cases of COVID-19 in Vancouver.
Since the start of the pandemic, more than 50,000 people in Canada have tested positive for the new coronavirus, and federal government figures indicate that at least 2,900 people have been hospitalized.
This is the story of those who dealt with only one case in St. Paul’s.
Dr. Shannon O’Donnell knew that she only had a few minutes to prepare after paramedics called the hospital to warn that a suspected COVID-19 case was en route.
“I was a little anxious,” she said. “We don’t know what we are getting, how much distress a patient will feel, or how sick they will be. And you know, you also worry about being exposed to an infection. “
The department was strangely silent after the beds were released and the workflow was revised to make room for a possible increase in COVID-19 cases, said O’Donnell. Provincial health worker Dr. Bonnie Henry recently announced that the province is able to control the spread of the virus, but the workload increased further when the patient arrived.
The paramedics brought the patient directly to a negative pressure room for high-risk cases. The glass walls allow filtration changes to reduce the risk of the virus spreading through the air.
Like everyone else the patient would interact with, O’Donnell examined him with heavy armor of personal protective equipment. He was one of the sickest patients she had seen.
“What struck me most was that he needed oxygen, but he also had a very high respiratory rate. He was breathing 30 breaths per minute, while you or I were breathing 15 or 16 breaths per minute, ”she said.
COVID-19 has transformed not only the hospital but also O’Donnell’s family life. She and her husband, also an emergency room doctor, have juggled the full-time care of their three children at home since the schools closed.
Together, they decided that if there was a major epidemic, one would work in the hospital and isolate themselves from the family, while the other would take care of the children.
“My husband compared him to the two of us running around in a burning building at the same time. “
O’Donnell ordered blood tests, chest X-rays and an electrocardiography, and performed a chest ultrasound with the help of RN RN Rachel Mrdeza.
For Mrdeza, some of the most difficult cases have been the older patients who are incredibly short of breath, with fever and chest tightness. Emergency workers generally do not learn if patients have COVID-19 because test results come back after they leave their care, but there may be solid evidence of the virus.
“You know they are in the vulnerability window to have a pretty disastrous result from COVID. It’s really hard to see, “she said.
Under normal circumstances, the emergency doctor would work with several nurses, but only one is allowed at a time in the isolation room to protect against contagion.
When QianQian Wu started her night shift, she was only the third nurse to see the patient.
Despite the numbers of promising cases in British Columbia, Wu said that staff did not feel able to relax. St. Paul’s Hospital is the primary treatment center for vulnerable residents in the city’s Downtown Eastside, a neighborhood facing another public health emergency related to the overdose crisis.
Wu started her shift by putting on the uncomfortable protective gear she would wear all night. She tries to stay hydrated before work because she knows she can’t drink water with the mask.
“It’s sometimes a bit difficult to breathe,” she said. “And sometimes you’re sleepy for a long time, it’s very hot.” “
Wu took the patient’s vital signs and told him about his family and friends. She also noticed his labored breathing.
The testing process
While the patient was waiting in the ER, blood samples and swabs were sent to the hospital laboratory.
Dr. Marc Romney, medical director of medical microbiology and virology, said manual molecular testing for COVID-19 typically requires five to ten laboratory workers.
“It’s not like a pregnancy test you get from London Drugs, it’s much more complicated,” said Romney.
A carrier carries the sample, a technologist checks if it has been ordered and labeled correctly, then two or three technologists perform a multi-step process involving the extraction, purification, amplification and detection of genetic material from the virus . A senior technologist and one or two physicians review the results before sending them back to the treating physician and the infection control team.
But the virology lab has been transformed by the arrival of a machine in March that automates part of the process.
The Roche Cobas 6800 system has been adapted from HIV testing and has increased the theoretical capacity of the laboratory up to 2,000 tests per day, in combination with manual testing.
Romney enthusiastically talks about the changes and ideas they have proposed to deal with the pandemic.
“One of the machines called an extractor, we had to be creative to introduce it into the laboratory because we didn’t have a lot of capital money to do it, so we bought it on the Internet second-hand, “he said. .
“We are under enormous pressure to deliver, it was a difficult time. But we are delighted. “
She was also paid personally.
A technologist lived mainly in the laboratory and only slept five hours a night.
Romney spent weeks without a day off and saw no one in person beyond his immediate family and colleagues.
When 19 positive tests returned in a single day, another doctor “basically ran from his home” to the hospital to start communicating the results to doctors, public health officials, and others who needed of that information, said Romney.
“The front line workers are amazing, and we are here to support them, but I think it’s good for people to know that there are also a lot of people behind the scenes working on this too,” said he declared.
“It’s not just the machines that are plugged into the walls, it’s very human what we’re doing here. “
Romney said laboratory staff are aware that time is of the essence in fighting the virus.
“It is a sacrifice, but we understand the importance of what we do and there is a kind of window of opportunity to try to contain the virus. Part of it is testing. “
The transition team
More serious suspected COVID-19 cases are sent to the intensive care unit for isolation. Back at the emergency department, Dr. O’Donnell called Dr. Mathieu Surprenant for an assessment pending the test results.
The 29-year-old clinical associate suspended plans to return to Montreal when the pandemic broke out. Moving in with other doctors seemed too risky, so Surprenant stayed in his nearly empty apartment in British Columbia. on an extended lease.
“I sleep on my air mattress and try not to see anyone,” he said with a laugh.
“It was very lonely because when I don’t work, I don’t do anything. “
When he received the emergency call, Surprenant went downstairs with resident Dr. Charles Yang.
It was not the first suspected case of COVID-19 from the hospital and Yang wondered if he would follow the same path as the others.
“In my mind, I was wondering, OK, what precautions do I need to take to protect myself and other patients while maintaining the level of care I generally provide to a patient,” said Yang.
He thought of his fiancée at home and if he was going to endanger her.
The team examined the patient to develop their care plan. They examined his oxygen levels and also the patient himself. Did he look comfortable? Was he struggling?
“What we are sort of afraid of is that they reach a point where they are able to compensate with their own physiology and ultimately fall back and decline at a rapid rate,” said Yang.
Accidental intubation would be risky for personnel due to the time required to put on protective equipment, and a chaotic rush in an isolation room could spread the infection. A care plan puts everything in place for controlled intubation, if a patient seems likely to decline.
The team talked about it and the patient was transferred to intensive care for overnight monitoring.
But it wasn’t long before her oxygen levels started to worry Surprising.
Best practices are rapidly changing as new information becomes available on the new coronavirus, the doctor said.
Initially, for example, the idea was to intubate as early as possible because if a patient becomes too ill, their chances of dying with a ventilator increase. But intubation is also more invasive than other procedures and risky for health workers because it pushes droplets of virus into the air.
Since the start of the pandemic, recommendations have been relaxed to allow for other treatments first, but it is a constantly evolving target, said Surprenant.
He believed that the patient had reached the stage where intubation was his best chance of survival.
Making that call meant calling a group known as the COVID Airways team. At the start of the pandemic, experts in respiratory and port management and the removal of specialized protective equipment waited on call at a hotel across the street.
“The simple act of dressing takes between five and 10 minutes,” said Surprenant. “They look like astronauts with all layers. “
The COVID airway team
Anesthesiologist Dr. Shannon Lockhart was part of the planning group that designed the COVID airway team.
The cancellation of elective surgeries meant that the traditional workload for Lockhart and his colleagues would be lighter. Their idea was to form teams with respiratory therapists to perform intubations so that emergency and intensive care physicians would not be exposed to the high-risk procedure.
The anesthesiologists self-selected from one of three groups: the first wave was ready to start joining the COVID airway team immediately. The second would occur if the first wave fell ill. And the third would not participate because they or their loved ones were at risk of serious illness if they were exposed to the virus.
For Lockhart, the decision to join the first group, known as the “green team,” was easy. The hardest part was creating a plan that would invite others to face the same risk.
“I’m 35, I’m young and healthy. I have a family that is young and healthy, so the personal risk was quite low for me, “she said.
“The hardest part for me was identifying this as a useful role model for our group, who are my colleagues and friends, and therefore potentially offering the services of people and putting them at greater risk.”
The absorption was however good. She was one of 16 people who volunteered for the Green Team, which made it viable.
When Lockhart was called to intubate the patient, she was ready.
“It was the story of what you hear about COVID patients who look really good at the bedside, but their numbers are not all that good,” she said.
Putting a breathing tube into a patient’s throat under normal circumstances takes between five and six minutes, she said.
That time went up from 60 to 90 minutes to process the extra protective gear, prepare all of the possible materials you might need in isolation, and clean up or dispose of everything in the room.
Dressing up is like running when someone has trouble breathing. Once inside, the urgency to clear the airways is heightened by the heat produced by the suit.
“The longer we stay in the room, the warmer we get and the more foggy our eye protection is,” said Lockhart.
Lockhart and a respiratory therapist gave the patient a sedative and a paralytic, and inserted the breathing tube while another anesthesiologist was waiting outside for help.
Working with different colleagues in an unfamiliar environment wearing bulky new equipment is stressful, said Lockhart. But she was encouraged to see hospital staff react quickly and break down the elevators in which they typically operate.
After intubating the patient, the riskiest part of Lockhart’s new job is to remove her equipment.
Since the patient relies on strangers for care, Lockhart also depends on someone she barely knows for her own protection. She and the respiratory therapist look at each other carefully as they remove the equipment piece by piece, watching for any slippage that could allow contamination.
“It’s kind of an interesting job to have when you trust this person for this very important task, but you may have never met him before. “
Inside the intensive care unit
When Dr. Gavin Tansley met the patient, he was already sedated and breathing on a ventilator.
Tansley had given the green light for intubation when Surprenant woke him up with a phone call. He already knew the patient’s case.
Where possible, intensive care staff keep an eye out for patients they may inherit from other services, said Tansley, a general surgeon in training in intensive care. They wonder, if things get worse, what would we do?
In the ICU, the focus on ventilation is focused on more holistic care of all of the patient’s major organ systems.
“Critical illness is a bit of a funny thing where you really recognize how intertwined all these organ systems are,” said Tansley.
“With COVID in particular, we see very familiar patterns where often the kidneys don’t work 100%, sometimes the heart doesn’t work 100%. So we have to support these organs with other drugs or sometimes we have to add dialysis or additional interventions to optimize things as best we can while the body tries to cope with this virus. “
When Tansley decided to become a doctor, he wanted to help people heal. He did not realize that at the ICU, he would not know his patients very well.
“Very often when I meet patients, they are already sedated or aerated or so sick that they cannot speak to you. So your relationship becomes with the family and you develop incredible relationships, ”he said.
Reflecting on the case, Tansley said it reinforces some recent thoughts he had on the serious illness that are not discussed. The focus is on the patients, but their families are often traumatized.
“The conversations we had with this particular family reinforced the fact that he was very, very taken care of within this family and they struggled a lot with the fact that he was not well. “
The inability to visit loved ones during the pandemic added an additional layer of grief, he said.
It has been difficult for staff to keep families of loved ones, but they find ways to help them connect. Tansley has set aside time to phone them with updates. Nurses hold iPads in front of patients so their families can at least see them on video.
Whatever they try, it’s not the same as being able to hold a loved one or even sit with them. Grief can also add an additional layer of emotional stress to health workers.
“This is just one of the many ways in which the coronavirus has changed the way we practice medicine. “
A look at the recovery
By the time the patient arrived in the ICU, about 25 health workers had already played a role in his case. Some interacted directly with him, while others played an important but indirect role in his care, ranging from housekeepers in the hospital to radiology technologists.
About 90 ICU staff saw him and from there he was transferred to a general medicine team.
Recovery is a long road that involves a vast network of specialists, from dietitians to speech-language pathologists and social workers. Behind the scenes, hospital administrators, education and awareness teams are also doing their part.
Kevin Novakowski is a respiratory therapist and, during his 28 years of work, he has never felt an illness create such a constant psychological burden.
“It changed me in a way,” he said. “It’s always on my mind. “
In recovery, a patient begins physiotherapy to develop strength. Novakowski is watching how it affects his breathing.
It can take weeks or even months, and some never fully recover. Between 30 and 60 percent of survivors of serious illness have ongoing medical or mental health issues, said Dr. Del Dorscheid, who oversees intensive care as a treating physician. This can mean residual lung disease for COVID-19 survivors, who he says could receive intensive care for a week or more than a month.
But the first important step toward independence is weaning a patient from the ventilator.
While Novakowski was monitoring the patient, he began to reduce the power of the ventilator and gave him short trials without it.
“You watch their breathing, you watch them and you focus on the appearance of their muscles. Do they have trouble breathing, do they breathe deeply, do they breathe quickly, do they breathe shallowly? ” he said.
Weaning is a gradual process, like a ebb tide. Outside the ventilator, a patient’s breathing vibrates.
“They cough and spit,” he said.
The rattle may disappear and then come back when it rises for the first time or when it starts walking.
It is a stressful process for patients. If they don’t cough to clear their airways, the infections can come back.
During these first tests, Novakowski waits and listens.
“You listen to them breathe,” he said. “And then all of a sudden it’s just a little bit very calm and their breathing sounds just like our normal breathing.
“And you think, OK. Its good. “
Amy Smart, the Canadian press
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