“We’re beyond capacity, and I expect it will only get worse”: A Scarborough ICU director on what it’s like at hospitals hit hardest by Covid
As medical director of the critical-care program at the Scarborough Health Network, Martin Betts oversees one of the largest ICUs in Canada. It’s also one of the hardest hit: in October 2020, the program was treating roughly a third of Ontario’s critically ill Covid-19 patients. Betts describes what it’s like to run an ICU inside a hotspot as the second wave rages.
—As told to Luc Rinaldi
“I grew up in Coquitlam, B.C., and came to Toronto for medical school. I never left. After I graduated in 2013, I joined Scarborough General Hospital. It was clear every decision they made was about what was best for their patients. Many organizations say they do that, but in Scarborough, it actually happened. We were the first critical-care program to have a physician present in the ICU 24 hours a day. Other hospitals have since followed our lead.
“Now, as ICU chief, I oversee a team of 250 people that includes physicians, nurses, respiratory therapists, physiotherapists, occupational therapists, social workers, pharmacists, dieticians, and speech and language pathologists.
“During the early stages of the pandemic, we didn’t know what we were dealing with. No one had ever cared for Covid patients or knew how to manage the disease. I got in touch with colleagues around the world—from England, Italy, France, New York—to learn from their experiences. And with my critical-care colleagues across the province, I helped create treatment guidelines to ensure every patient in Ontario receives the absolute best care.
“Pre-pandemic, I usually worked one one week on, one week off. During on-weeks, there’d be nothing but the patients. I’d be at the hospital for 36 hours and then take 12 hours to go home, see my family, eat and sleep before returning for another 36 hours. In total, I might work 100 to 120 hours straight before getting a week off. During the pandemic, however, there’s no such thing as a week off. The other critical-care physicians and I can go two or three weeks in a row before getting even a free day or two.”The other critical-care physicians and I can go two or three weeks in a row before getting even a day or two off. We’re not the only ones. Most hospital staff have worked every single day since last February to make sure our community gets through this pandemic.
“We’ve made it this far, but we’ve now tipped into a frightening new phase of Covid. Cases are spiking, and things are heating up inside the ICU. Normally, we have 62 critical-care beds across our three sites: Scarborough General, Birchmount and Centenary. Last month, we had to open up another 18 beds: eight in a room just down the hall from one of our ICUs, and the other 10 in a medical ward that has special isolation features because it was built just after SARS. We use Bluetooth to monitor those patients’ breathing and oxygen levels remotely from the ICU.
“Still, we’re officially beyond capacity now—and I expect it will only get worse. Physicians throughout the hospital are trying to help, telling us when they have open beds that can take certain types of critical-care patients. But we’re limited by the fact that our hospital is from an older generation of health care. Although our ICUs have negative-pressure rooms that keep Covid patients isolated, not every room in the hospital has the required ventilation or technology.
“We knew the second wave was coming, so we made sure to secure all the PPE, ventilators and medication we’d need. Staffing is more difficult. It takes at least six months to train an ICU nurse, and even longer for a doctor. So we’re deploying nurses from other programs across the hospital and partnering them with critical-care nurses. The problem with stealing other staff, though, is that it prevents us from doing non-Covid surgeries that need to happen.
“Ultimately, there’s only so much we can do with the staff and beds we have. So we recently started transferring patients to other hospitals, including in Oshawa and Peterborough, that have available critical-care beds. I’m in touch with my colleagues inside the hospital and across the province on a minute-by-minute basis. Around 3 a.m. the other day, as I was waiting for an X-ray of a recently intubated patient, I tallied up all the communications I’d sent and received that day: 92 calls and more than 250 texts to 42 different people or groups.
“As busy as our ICUs have been during the pandemic, they’re much quieter. There are no families or visitors, and many patients can’t talk because they’re on ventilators. Most days, I check in with our ICU physicians at 7 a.m. At 8, I have another meeting to discuss what’s going on in the hospital at large. After that, I meet with the full ICU team to review our plan for the day. Then I don my full PPE—an N95 mask, a face shield, a fluid-resistant gown, extended gloves and a surgical cap—and go into the ICU to do bedside rounds where we examine patients and put a plan in place to advance their care. I spend the afternoon doing procedures and investigations, and connecting with patients’ families to update them on how their loved one is doing before we wrap up the day with another operational meeting. Superimposed on all of this are all those calls and text messages, as well as seeing patients throughout the hospital who may need to come to the ICU.
“Part of what makes my job so demanding is that Scarborough has been hit particularly hard by the pandemic. Scarborough makes up about five per cent of Ontario’s population, but at times our ICUs have treated more than 30 per cent of the province’s critically ill Covid-19 patients. Many of our patients are essential workers. A lot of them are first-generation Canadians. Our community has heightened levels of existing medical conditions—diabetes, hypertension, chronic kidney disease—that predispose them to develop severe Covid-related illnesses. And our hospital also supports 24 long-term care homes, a number of which have had outbreaks.
“A lot of our critically ill patients come from multi-generational homes. I’ve heard so many stories about entire households getting infected. One couple developed Covid-related critical illnesses and entered the ICU, leaving their 18-year-old son at home to look after his 10-year-old sister. Our nursing team and social workers talked to the kids every day to make sure there was food on the table, that they were going to school, that they knew how their parents were doing. It wasn’t looking good. Both mom and dad developed lung injuries so severe that we had to send them to Toronto General Hospital for extracorporeal life support—that is, replacing their lung function with a machine. They were in hospital for three months. But it’s a good news story: both of them survived.
“Many of our patients don’t. A lot of the care we provide ultimately becomes end-of-life care. In the spring, a single father was admitted to our ICU. His wife had died six years earlier from another illness, and he acquired Covid working double-time to pay for his 18-year-old daughter’s university tuition. As his health deteriorated, I called his daughter regularly to update her on his condition, and I could tell she carried some guilt because she knew her father had gotten sick working for her future. It was heartbreaking when we realized he wouldn’t make it and she would become an orphan. Before he passed away, we were able to arrange an in-person meeting between them, so she could say goodbye.
“In the ICU, we’re constantly surrounded by death, grief and trauma. But we take great pride in supporting patients as they’re dying. One of the ways we cope with it all is by thinking less of the loss and more about what we’re able to do for these people in their time of need, whether that’s a final meeting—or, in many cases, video chat—with loved ones or doing something positive for the people they leave behind. We see a lot of tragedy, but it’s balanced with successes. We just try to focus on the positives.
“The last year has been one of the most challenging periods I’ve ever experienced as a healthcare provider. My wife is also a physician, but luckily, she has a community practice, so she doesn’t see Covid patients herself. We had our first child, a little boy, in November 2019. Our families live out west, and they haven’t seen him since Christmas of that year, and we haven’t seen our nieces and nephews either. We knew Christmas 2020 would be different, too. My wife and I celebrated with just our son. I’ve seen too many people admitted to the ICU who got Covid from what they felt was an innocent visit with a loved one.
“My biggest fear is that we will let our guard down too early. We have to keep wearing masks and distancing. I know people are suffering in many ways because of this pandemic. It’s not just illness. The public health restrictions are impacting people’s businesses and their ability to maintain their livelihoods and pay their mortgages. I don’t want to make light of that, but when I hear people talking about the frustrations of being in lockdown, well, I think most health care providers can’t wait for all of this to be over so they can lock themselves down.”