Patches on X-rays, breathing troubles, and ‘odd presentations.’ What COVID-19 looks like to Ontario hospitals
As an emergency room doctor in Ottawa, Dr. Rohit Gandhi is used to seeing people in serious distress. They usually fit the profile of someone at risk of becoming extremely ill - maybe they're elderly or live rough on the streets, or suffer from a serious medical condition.
But last week, he saw a case that just looked wrong. The patient was young and fit, a man in his 40s with no prior medical history. He was gasping for air but there were no other red flags - until Gandhi saw his X-ray.
There they were: hazy white patches on both lungs. This is a terrible X-ray, Gandhi thought. "You're like, wow, I don't even need to test this person," he said.
"They have it."
The "it" Gandhi is referring to is COVID-19, a disease that started popping up in Ontario in January and is now threatening to overwhelm hospitals across the country. Only about five per cent of COVID-19 patients become critically ill but in many cities around the world, their numbers have become extreme enough to cripple health-care systems and force doctors into making unprecedented medical decisions.
Gandhi is among a growing number of hospital physicians who are witnessing the first ripples of the coming tidal wave of patients with severe COVID-19 in Ontario, many of whom arrive in emergency departments scared and struggling to breathe.
"This feels like the beginning of the crisis," said Dr. Andrew Healey, chair of the COVID Clinical Response Committee at William Osler Health System. "We are now seeing the sickest patients first hand."
The Star spoke with nine hospital physicians across the province who have now seen COVID-19 to get a sense of who these patients are, the havoc this virus can cause, the difficult realities of critical care - and the strain COVID-19 is already placing on hospitals, even before the outbreak hits its peak.
Ontario doctors are also learning first hand how much they still don't know: the varied symptoms of this disease, who will crash and become critically ill, and why a surprising number of younger people are winding up in ICUs.
"This is a new virus which we don't completely understand," said Dr. Michael Warner, medical director of critical care at Michael Garron Hospital. "There could be a 40-year-old who has the sniffles, and there could be a 40-year-old who requires life support."
"Many of the patients who've landed in our intensive care units so far would have been very healthy at baseline. We are not talking about all elderly, frail people," said Dr. Brooks Fallis, division head and medical director of critical care at William Osler.
"As we look across the GTA, we're seeing patients in their 20s, 30s, 40s, 50s, who are healthy prior to contracting COVID (and) are now fighting for their lives on life support."
When Gandhi went back to work after March Break, he found himself experiencing an unusual emotion: fear.
"I've never really been scared to go to work," he says. "That was a really weird feeling."
He was called in on his day off, so he expected to see the ER slammed. But he arrived to find a relatively quiet department, with a fraction of its usual caseload. Gandhi briefly wondered why he was called to work but was then directed to his first task: intubating an elderly patient suspected of having COVID-19.
"I've never gone into a shift and gone right in to help intubate someone," he said. "There were one or two patches (of patients) coming for shortness of breath, fever; shortness of breath, fever. I realized they (called me in because they) were nervous to have more acuity building up with the same staffing."
In the pre-COVID era, a typical day in an ER would involve toggling between patients who are seriously sick and less urgent cases, like cat bites and broken fingers. Gandhi said there are now fewer people coming in for more minor ailments but the patients they see tend to be sicker.
And everyone now needs to be treated as a potential COVID-19 case - even the cat bite patients. "You're scared that everyone has it," he said. "You're putting on equipment and taking it off for every patient, every broken knee or laceration. So it's really changed the game for us."
Doctors across the country are now on high alert for symptoms like fever, cough and shortness of breath but there is a growing recognition that front-line health workers need to keep an open mind - there are still a lot of unknowns around what a potential COVID-19 patient might look like.
At Trillium Health Partners, roughly a quarter of cases seen so far by Dr. Shaan Chugh have had "odd presentations" - an elderly man who passed out and later tested positive for COVID-19, for example. "We're extrapolating a lot from SARS," he said. "I think that there's a lot we don't know."
Chugh said front-line doctors like him have been tracking the scientific literature now being published at a furious pace, but for more practical advice, he's looked to a made-for-Ontario website providing clinical guidance on treating COVID-19.
Created in a two-week span in March, the site is streamlined to offer clear answers to common COVID-19 questions for those on the front lines of the illness, said Healey, one of its co-authors and a critical care physician at Brampton Civic Hospital, part of William Osler Health System.
It lays out how to screen patients for COVID-19 in clinics and emergency departments, when to admit them to hospital and how to care for those who are severely ill in the ICU, including safe procedures for intubation and what to do during cardiac arrest, said Healey, who worked with Fallis, his ICU colleague, on the site.
Based on medical literature from other jurisdictions, the guidance is also being updated in real time from first-hand accounts in local hospitals and critical care units. As the pandemic progresses, for example, it will include guidance on how to safely divert some critical care patients in case units become overwhelmed.
"As we have our own experiences, we will learn from them and modify our answers," said Healey, adding their site was intentionally designed to be easily read by a physician, nurse or respiratory therapist on a smartphone at a patient's bedside. "People who are managing on the front line, they just want to quickly know an answer to a question and how to proceed safely."
For Dr. Erin O'Connor, the patients she's seen at Toronto Western Hospital and Toronto General Hospital have generally described an unrelenting fatigue, painful muscle aches and an inability to catch their breath.
They are often deeply worried when they learn they have COVID-19 but for the most part, their symptoms are mild enough to warrant sending them home.
"I often get a sense of relief when I say your symptoms are mild, your oxygen saturation is good, the other tests we've done are OK," said O'Connor, deputy medical director of emergency departments at Toronto's University Health Network. There's "definitely a palpable sense of relief. Everyone is afraid of the worst-case scenario."
But O'Connor acknowledges it can be difficult to determine who can recover at home and who needs to be admitted; people have wildly different responses to the infection. Patients who do get admitted - but are not yet sick enough for the ICU - are often those who have oxygen levels that are below a safe threshold and will be given IV fluids and supplemental oxygen into their nose.
Their vital signs are closely monitored and when there are signals a patient can no longer get enough oxygen into their bloodstream, even with the help of supplemental oxygen, that's when they will be rushed to the ICU.
But another challenge for physicians has been determining which hospitalized patients will improve with a hit of oxygen - and which ones will start suddenly crashing.
"That's the challenge with this disease. Patients can be walking around on the wards at five o'clock in the afternoon and then two hours later they can be on the ventilator," Warner said. "The deterioration can be that fast in some patients."
In an ideal world, patients are intubated pre-emptively in a calm and controlled way, well before their illness becomes imminently life-threatening. At Warner's hospital, patients are brought to the ICU well before "the wheels start falling off" so doctors can monitor them closely.
If it becomes clear that they will soon need intubation, the patient is moved to a negative-pressure room and a team of airway experts will assemble to plan the procedure and prepare the equipment. They will then dress carefully in personal protective gear and get to work inserting the breathing tube - a process that should be calm and controlled but take 30 seconds or less.
But if the outbreak begins to overwhelm hospitals, as it has in other COVID-19 hotspots around the world, "we may not have the luxury to watch patients" in this controlled way, Warner said. "We may just have to take the risk of having them in a less monitored environment and hope they get better."
Once on ventilation, a COVID-19 patient's prognosis becomes considerably more grim. The current numbers show that only about 30 per cent of COVID-19 patients who go on a ventilator will survive. "Those are not great odds," O'Connor acknowledges.
At this stage, patients typically have Acute Respiratory Distress Syndrome (ARDS), a catch-all term for severe lung disease. "It's like being in a sprint you haven't trained for," Warner explains. "Your body needs you to breathe faster but you get so tired you can't keep up with the demand."
All sorts of patients can develop ARDS - everyone from car accident victims to patients with bacterial pneumonia - but early reports suggest that COVID-19 patients who require mechanical ventilation have higher mortality rates than the general ARDS patient population.
The lungs have a thin membrane that facilitates oxygen exchange, allowing red blood cells to carry oxygen to the rest of the body. When a coronavirus infection takes hold, this membrane can fill up with proteins and cellular debris, stiffening the lungs and making it harder for them to expand.
Inflammation also cause the lungs to become swollen and "flooded with liquid," according to Dr. Laurent Brochard, a critical care doctor and researcher with the Keenan Research Centre for Biomedical Science at St. Michael's Hospital, specializing in ARDS and mechanical ventilation.
"It becomes very, very difficult to breathe," Brochard explains. "Because the lung is so heavy and so inflamed, the lung becomes very difficult to open. It's like a very stiff lung."
When this is the case, mechanical ventilators do the hard work of breathing for the patient. A tube is inserted into the airway and connected to the ventilator, which pushes oxygen in and carries carbon dioxide out.
But mechanical ventilation requires "careful fine-tuning," Brochard says. Not enough positive pressure and you can't properly ventilate; too much pressure and you risk causing more damage. "It's like if you are ventilating an adult patient who has a small lung like a child or a baby - we often call that the baby lung," he said. "Because it's so small, it's easy to over-ventilate."
Keeping patients on mechanical ventilation is extraordinarily resource-intensive, but jurisdictions already hard hit by COVID-19 have seen ICU patients on ventilators for as long as four weeks.
Even young patients are sometimes spending weeks in the ICU; in Seattle, a 20-year-old patient was on mechanical ventilation for two weeks, said Dr. Pavan Bhatraju, an intensivist who recently published a study of critically-ill COVID-19 patients in the New England Journal of Medicine.
Another technique that appears to be helpful for COVID-19 patients is called "proning" - basically, flipping them onto their stomach, allowing better oxygenation. "You flip them over and it's like magic in some patients," Warner said.
But this, too, requires considerable resources because patients need to be flipped twice a day and each time it might require six hospital workers, all in full protective gear.
A major difference now compared to the "pre-COVID era" is that most hospitals are restricting families from visiting in intensive care, Warner said. Thoughtful and contemplative conversations around the realities of providing life support will become harder to have with patients and their families, especially if ICUs start to overflow.
This is why people need to start discussions now with their loved ones about what they might want, should they find themselves critically ill, he said.
"We're making a contract with the patient that we're going to subject them to suffering and loss of dignity for the chance that they're going to come out on the other side," Warner said. But "there's no guarantee once you go on life support that you ever return to the life you had before."
Are you a COVID-19 patient or front-line health worker who would like to share your story? Contact us at jyang@thestar.ca and mogilvie@thestar.ca