a memoir from the Covid ward at TGH

0
9



I’ve been practising internal medicine and infectious diseases for the better part of 20 years. I’ve been through the Ebola crisis, H1N1 and SARS, but none of those experiences prepared me for Covid. The scale of the whole SARS outbreak in 2002 pales in comparison to the current Covid-19 pandemic. It was still harrowing—I saw colleagues get sick and patients die—but that virus was somewhat more predictable. What differentiates Covid-19 is that it’s hidden, capricious. It’s also extensive in its reach and dangerously infectious, which makes it even more daunting and overwhelming compared to any outbreaks I’ve seen in the past.

I work at the University Hospital Network, and when the pandemic hit Toronto, there was an unspoken assumption in the medical community that internists like myself would be given the task of treating Covid patients. I would have volunteered anyway. Anyone with the requisite skills and knowledge has an obligation to contribute. When I was called upon in the spring, I was glad to do it.

But working in the Covid ward comes with a great deal of personal sacrifice. While on duty in the ward during the first wave, and for periods afterwards, I was sequestered from my wife and three kids (they’re nine, seven and four). I ate separately from them, slept in a different part of the house, and used my own bathroom. I wasn’t able to read my kids bedtime stories or tuck them in at night. I tried to tell them that I was protecting them from these little bugs and monsters at the hospital, that there were viruses that I needed to get rid of before I could get close to them again. It’s difficult to explain to a four-year-old that his father can’t give him a hug for weeks at a time. My older kids sort of understood. But that didn’t make it any easier for them to accept a lesser version of their father for long stretches.

Over the summer, when the city’s case numbers were down and patios were packed with people acting like they were on Rumspringa, I was filled with a sense of doom. I knew that the numbers were deceptive, that the seeds of the second—and much larger—wave were being sown. It was only a matter of time. Sure enough, by early October, the numbers caught up with us. The second wave hit Toronto hard and fast, as if we never saw it coming. But many of us did. The seemingly virus-free summer reprieve only increased people’s doubts and denial about the insidiousness of the pandemic. I knew that once people had a taste of freedom, it would be difficult to take it away from them—and that the second wave would be even more devastating than the first.

My parents immigrated from Egypt to Canada in the early 1970s. I’m the youngest of seven kids, and the only one born in Canada. I spent the first years of my life in Lac La Biche, a small town in Alberta, about a two-hour drive northeast of Edmonton, but our family moved all over the place, including Edmonton, Vancouver, Toronto and Princeton, New Jersey.

I got into medicine almost by accident. As an undergraduate at the University of Alberta, I wanted to explore my creative side and considered pursuing writing or broadcasting. But I was also drawn to science. There was something about the art of medicine that felt so inherently right to me. During undergrad, I volunteered at a dialysis unit at the University of Alberta Hospital in Edmonton. The patients came in for treatment two or three times a week, so I saw the same people regularly. Over those months, I realized that medicine was the perfect way for me to marry my interests in science and the humanities. As a physician, I could form meaningful personal relationships while discovering the miracle that was the human body.

From there, choosing my specialty was easy. Working in infectious diseases is like being a scientist, a detective and an advocate all in one. I get to see so many different aspects of a person’s life and how it shapes their health—their social situation, culture, lifestyle and profession all speak to their exposures. I get to appreciate the scope and complexity of a patient as a whole to determine how and why they have an infection, whether it’s HIV, tuberculosis or a travel-related disease.


Over the summer, when the city’s case numbers were down and patios were packed with people acting like they were on Rumspringa, I was filled with a sense of doom. I knew that the numbers were deceptive, that the seeds of the second—and much larger—wave were being sown

 

I’ve always been particularly interested in zoonotic diseases like Covid, which can pass from animals to humans. I think of them as puzzles I can solve by examining a patient’s habits, hobbies and interests. I don’t think there’s any other field in which you can figure out what’s wrong with someone’s heart or lungs by knowing whether they went swimming in the wrong lake, walked barefoot on the beach or were exposed to a pregnant sheep. I get to be a witness to my patients’ social and human conditions, and to be an artist in how I determine what’s wrong with them and develop a strategy to treat them.

But Covid is unlike any other disease I’ve encountered, and the ward is unlike any other medical ward in a hospital. In a typical medical ward, people are bustling around, there’s lots of talking and close interaction. There’s an almost musical quality, a chorus of voices, machines beeping, phones ringing and the rhythmic footsteps of people coming and going.

The Covid ward, by contrast, is an island, isolated and remote. This is where all non-ICU Covid patients are housed, and there are few people around by design and necessity. The patients are all isolated in single rooms. Only vitally important equipment is present—no extraneous computers on wheels or chart racks. There’s a nakedness to the Covid ward that creates a deep sense of loneliness for both patients and physicians.

We have a schedule of one-week rotations on the ward. My shift typically starts around 7:30 or 8 a.m. and ends around 5 p.m. But because of the complexity of these cases and the suddenness with which they evolve, I’ll often stay late to follow patients more closely or update family members on their condition.

During our shifts, we’re paired with one other person who acts as a spotter. It’s usually another physician, a nurse practitioner or a physician assistant. One person is designated to go in and out of the patient’s room, to minimize the risk of contamination and exposure, while the other person remains on the other side of the door, ensuring that PPE is correctly donned and doffed and inputting data into the patient’s chart. Over the course of the week, you forge a special relationship with your partner, even if you’ve never met them before. We keep patients’ doors open so they can see both of us. It’s a powerful experience to go through together. You can’t help but feel bonded to your partner.

On November 18, I started a week-long stint in the Covid ward at Toronto General—my first of the second wave. I normally work at Toronto Western Hospital, but our Covid ward was closed due to prior outbreaks, and I was redeployed to TGH. I was working with a physician’s assistant for the first part of the week and a nurse practitioner for the second part. From a morale standpoint, it was immeasurably helpful to have them in the ward with me. On the weekend, I was on my own. There were some nurses around, but the staffing typically thins out on those days. Seeing patients, entering notes and coping with any distressing outcomes is much harder to manage when you’re alone.

That week, I thought I was mentally prepared. After the first wave in the spring, I felt more committed and connected to my patients than ever before. I knew they needed my support, and the support of everyone in the health care system—more so because they were so isolated. Sometimes a patient’s only form of human contact all day is an orderly clearing away their half-eaten lunch tray.

We had 12 Covid patients at the start of the week. Some were very sick, a few others were slowly recovering and waiting to enter rehab, and a couple of patients were in relatively good shape. The sickest patients are frail and struggling for oxygen. By the time they get to that state, several therapies have failed, and even a stint in the ICU isn’t likely to save them. ICU intervention usually occurs when a patient is nearing respiratory extremis—when they’re maxed out on oxygen by face mask and they might have a fighting chance with additional ventilator support. Sadly, not many patients who move from the Covid ward to the ICU survive.

You might be fortunate enough to have an entirely uneventful shift in the Covid ward, where nothing drastic happens and you feel good at the end of the day. But the truth is, I haven’t had that experience very often during this pandemic. It’s been the rule rather than the exception that people will die on my watch. At least some of those deaths will be premature and unexpected. So I have to gather myself and anticipate that I’m going to be facing some difficult outcomes. I can’t let it crush my soul, because I have to go on for as long as the virus does.

On the first day of my stint in November, I took stock of my patients’ conditions, then spent a moment going over all their ethnicities and spoken languages. It’s a habit of mine, one I genuinely enjoy. I speak about 15 languages well enough to get by with pleasantries and basic medical questions. One of the privileges of working at UHN is the diversity of our community. It’s a welcome challenge to look around and say, “Okay, I don’t know enough of this language. Let’s see how far I can get.” Over the years, my interest in languages has helped me break down cultural barriers and forge connections with patients that would otherwise not have been possible. I felt pretty lucky that first day, when I looked around and saw Italian, Korean and Portuguese on the charts. We also had Russian, Polish and Cantonese. I speak almost all of those languages to varying degrees of proficiency. I figured my bumbling attempts to communicate would, at worst, provide some comic relief and maybe even distract my patients from their pain and discomfort, if only for a moment.

My excitement quickly dissipated. I had an elderly, Korean-speaking male patient who’d developed pneumonia as a complication of Covid, which is especially common in older patients. He was in poor shape when he arrived, but when I saw him, he was responsive and alert enough to know I was there. I took that as a hopeful sign. As I was assessing him, I smiled and said, “Hi, how are you?” in my rudimentary Korean. I talked about the foods I like to eat. He smiled back. He had these very gentle expressions of laughter. It’s a seemingly trivial gesture to say, “How are you?” in a patient’s native language, but I could tell he appreciated what I was trying to do. He was starting to experience respiratory fatigue, which can occur when the lungs become inflamed and stiff, and the muscles that help the lungs contract and expand eventually wear out.

Despite his prognosis, I wasn’t expecting him to deteriorate as quickly as he did. It happened in the span of a few hours. His respiratory fatigue turned into full-blown collapse. It was like a tidal wave that couldn’t be stopped, despite our best efforts. Two days into my rotation, I lost him. I’ll never forget the sense of loss I felt when I realized I wouldn’t be speaking any more Korean that day. It’s never a complete shock when you lose a patient in this situation—especially when the patient is older and has Covid. But it’s very hard. Once you start building a rapport, it’s human nature to want to fortify that and to make what is otherwise a very lonely, frightening and alienating experience for the patient manageable, maybe even gratifying.

In the Covid ward, a physician is one of the very few people who have contact with patients, who are privy to what they’re experiencing: their pain, fear, despair. The other kinds of interactions that happen routinely in a conventional medical ward are completely absent. This is by design, of course, but there’s an element of collateral damage. You feel like you’re carrying more on your back. You feel a heightened sense of pressure and responsibility.

As I was trying to gather myself in the aftermath of losing my Korean patient, a situation arose with an elderly female patient who, until that point, had been completely unresponsive when I spoke to her. She too had pneumonia and was in poor shape. Even when patients aren’t conscious, I talk to them. It’s something I was trained to do. And I’m glad to do it, because I’ve had experiences where patients have woken up and known that I’d been talking to them the whole time.

I held that woman’s hand and talked to her about her family. I mentioned her daughter’s name to see if that would trigger a response. Finally, on the third day of my rotation, she woke up while I was sitting by her bedside. She mumbled something I couldn’t quite understand, but it sounded purposeful. I thought she might be starting to turn the corner. Her vital signs were weak, but there was something in her demeanour that seemed to suggest she was holding on to some meagre but miraculous hope—that some ineffable force was going to get her through this.

I do not believe that we’re governed by biology alone. It’s not superstition or magical thinking, but there’s something to the idea that a person’s spirit and willpower can inexplicably change their condition. Maybe a part of me was hanging on to that. She looked at me with recognition and gratitude in her eyes. She grabbed my hand tightly—surprisingly so for someone who looked so frail. I got choked up. I thought, Oh my God, she knows who I am. She’s heard everything, and she’s fighting.

She smiled the most magnificent smile, just out of the side of her mouth. Her pulse weakened as I stroked her hair with my other hand. And then she died. Just like that.

Even after 20-plus years as a doctor, I’ve only rarely witnessed someone’s final breath. To have been present for this patient’s last moments, to have seen her smile, sobered and humbled me. I thought about how every small, chance encounter holds meaning. Instead of being surrounded by family, it was me, by some twist of fate, who’d had the privilege to stand in for her loved ones in her final farewell. She was the second patient I’d lost, the second courageous casualty of Covid, in 24 hours.

As an internist, I’m used to losing patients. But the Covid experience is different because it’s so alienating—that degree of vulnerability is unlike anything I’ve gone through as a physician. And it’s far, far worse for patients. I see it written on their faces. Their rooms are dark, there’s no music or light. When I speak to them, they respond with very little vigour in their voices. Their family members can’t visit them. Everything about the experience, especially the loss of a life, is amplified by the profound isolation that fills the air.


This was a guy who had his wits about him. He was gregarious, personable, charming. His death was one of the most devastating. I thought he had a real chance to dust this off and go back to a meaningful life and a loving family. Covid stole that from him

 

I had another patient, an elderly Italian gentleman, who looked the best out of all of my Covid patients. When I met him on my first day in the ward, I thought, Here’s a guy who’s going to walk out of here. He had mild heart failure, and I was fine-tuning his medications to get rid of the excess fluid in his lungs. I thought I’d be able to treat him quite effectively. We made fun of my Italian vocabulary. He told me it was good enough to order food but not to practise medicine. We had a good belly laugh over that. I performed a few physical exam manoeuvres that weren’t relevant to his condition, just to show off my Italian. We laughed about that, too. He looked good. He was sitting on the edge of the bed as we talked and joked around. I remember speaking to his daughter on the phone and saying, “I think he’s going to be okay.”

Three hours later, without warning, he had a massive stroke and lost all movement on the left side of his body. He deteriorated over the next three days. Despite all our interventions, he went into respiratory extremis. He died the morning after I lost my second patient.

In my clinical opinion, his stroke was 100 per cent due to Covid. There are a number of non-Covid-related stroke risk factors, like high blood pressure, high cholesterol and diabetes—he didn’t have any of them. This was a guy who had his wits about him. He was gregarious, personable, charming. His death was one of the most devastating. I thought he had a real chance to dust this off and go back to a meaningful life and a loving family. Covid stole that from him.

I called his daughter to tell her that her father had passed away. She’d tried to steel herself after the stroke, but still she was inconsolable. She told me how grateful she was for the care and compassion we’d shown her father. I said how painful it had been for me to see him take that turn, from being relatively well and in good spirits to being so swiftly ravaged by the virus. I wanted her to know that her father hadn’t been alone in his final moments. I wanted her to know that I was with him right until the end.

From the first wave to the second, I’ve noticed a shift in people’s attitudes toward the virus. There’s public doubt, a belief that the spring lockdown was an overreaction, that the first wave wasn’t really so bad. There’s an element of rebellion, and distrust in our public health officials, which is fuelling an anti-science sentiment. I think there’s even a growing resentment toward doctors and nurses and other front-line health care workers, because some people see us as reminders of the virus they don’t want to hear about anymore. Some people, mostly younger people, are thinking, Well, I’m young and healthy, so I’m going to be okay. Those people are trivializing the risks and consequences of the virus. That’s a punch in the gut to me, because I see the horror of those consequences up close on a daily basis. When I see a 60-year-old father or mother—someone who would have likely walked out of the hospital had they been sick with a conventional pneumonia—die on maximal therapy, without their family there to say goodbye to them, that’s a punch in the gut too. It pains and angers me to see people diminishing the threat of this disease.

By the end of that week, I felt engulfed in a cloud of tragedy. I struggled to find the words to express the frailty of the life in front of me and to honour the memory of every person who had been taken by this terrible virus. That’s when I wrote a poem called “This Is the Covid Ward,” describing the loss I had witnessed:

This is the Covid ward / The bed raised to its customary height once a patient has been “discharged,” bed sheets folded perfectly / A pillow untouched / Monitor blank / My skin tingles in a moment of sobriety / It’s over / Just like that.

The fear and trauma within the Covid ward are directly linked to what’s happening outside its walls. Some patients have died because someone else, possibly someone far removed from the patient’s social circle, didn’t act responsibly. And the consequences of those actions found their way to someone who was vulnerable and stole a life. It’s a difficult thing for people to wrap their heads around. But that’s exactly how this virus operates. Telling these stories, bringing some humanity to the numbers, is my attempt to bring that reality home.

In that week alone, I lost three patients in 36 hours. We ended up losing three more in the ICU the following week, all under the age of 65. One patient in the ICU was completely healthy before contracting Covid and didn’t have any risk factors. We lost another patient a few days after that. There are other patients who, as you read this, will die today, and tomorrow, and the day after.

I came out of my rotation in the Covid ward gutted and grief-stricken. I broke down several times—on the drive home and later, at home, with my wife. I slept very poorly, if at all. My appetite suffered. There’s no way around it other than through it. I had bouts of uncontrollable grief, the likes of which I hadn’t experienced since my mother died unexpectedly 10 years ago from metastatic lung cancer. She never smoked a cigarette in her life. It was eight weeks from her diagnosis to her death. It still haunts me.

Some of the grief over my mother’s death was rekindled by what I experienced in the Covid ward. I’d be lying if I said I wasn’t traumatized by it. The images I have in my mind will never leave me: the gentle Korean man who kept his composure in the face of death, the woman who slipped away with her hand in mine, the Italian gentleman who grasped my hand tightly after his stroke with his one good hand, when we’d been joking around like two old friends at a pub just two days before. The interactions I had with my patients who died are like jewels I’ll treasure for the rest of my life.

I hope some of those memories will help me build more empathy, more compassion, a greater obligation to establish trust with my patients. I’m off the Covid ward for several weeks until my next rotation, but I’ll never be completely out of it. I still keep tabs on the patients who survived. I check in from time to time. It’s not like Covid has disappeared from my daily life just because I’m not running the ward.

And I’m comforted by the fact that many people do go home. I had one Covid patient who had advanced cancer and came in with severe pneumonia. We had discussions about her philosophy of care, in case her condition declined catastrophically. It took a few days of oxygen and antibiotics, but she perked up nicely and regained a lot of her vigour. She ended up being discharged. I had another patient in the ICU, a young man, who was fortunate to avoid intubation. He responded well to steroid therapy and was able to walk out of there.

These cases are an ounce of redemption against the weight of what sometimes feels like a hopeless battle. The losses tax you, and you need to hold on to these moments of triumph when you get people back in their homes, back to their families, thinking about going back to work and being functional again. You’re helping people restore their humanity in the face of what would otherwise be an inhumane experience.

I had the option not to work that stint in November. Some would argue it was bad luck that I opted to go in. I wouldn’t have had it any other way. I’m glad I went through it. I’m glad I saw what I saw. I think it was meant to happen. All of it. And I would do it all again in a heartbeat.   —As told to Haley Steinberg


This story appears in the February 2021 issue of Toronto Life magazine. To subscribe for just $29.95 a year, click here.