After seven weeks, one of Ontario’s first COVID-19 patients to be intubated leaves the ICU, to applause
At first, Linda Lam explained away the deep fatigue that left her feeling weak and worn out.
The 70-year-old from Richmond Hill had just returned on Feb. 20 from a two-week sightseeing cruise on the Nile River and it would take time, she reasoned, to shake the jet lag and recover her usual energy.
But a few days later, after she woke up with a constant cough that left her breathless, Lam began to worry she had COVID-19, even though Egypt had yet to become a hotspot for the virus.
Then, on March 2 - one day after finding out she tested positive - Lam's cough worsened, and soon she was struggling to breathe. Her son, Kevin, rushed her to Mackenzie Richmond Hill Hospital, where she was quickly escorted to the intensive care unit.
"That was it. I haven't seen her since."
Lam spent more than seven weeks in the ICU before she was finally discharged Wednesday to a medical ward amid cheers and applause from hospital staff, who were among the first in the province to treat a critically ill patient with COVID-19 and who took extraordinary steps to keep their patient alive.
Doctors at Mackenzie Health believe Lam is one of the first patients in Ontario with COVID-19 to be intubated. She is also among the few people worldwide to have received an experimental drug, remdesivir, which is being tested as a potential treatment for COVID-19. And in this ICU, Lam is - so far - the only patient with COVID-19 to leave the unit alive.
"It was the best day, the best day ever," said Samantha McLachlan, the ICU's patient care manager.
"Our whole team, we were outside her room when she came to get picked up. We lined the hallway and we were clapping, and she was clapping along with us and smiling up at us. It was such a beautiful moment."
Lam came close to dying several times during the nearly five weeks she was sedated and connected to a ventilator. Her kidneys failed, her liver function was dangerously compromised and, at one point, the ventilator was pushing 100 per cent oxygen into her lungs.
On March 2 - nine days before the NBA suspended its season due to the virus, and 15 days before Ontario declared a provincial emergency - few critical care physicians in the province had cared for a patient with COVID-19. Like hospital staff across the country, physicians and nurses at Mackenzie Health had been preparing for the arrival of COVID-19 patients, they had just not expected to see one so soon.
"When we intubated her, it was a frightening moment; I've never before been frightened in my career," said Dr. Ali Ghafouri, a critical care physician at Mackenzie Health. "But everything went smoothly, and we got her initiated on life support. That's when the journey started."
Lam had counted down the days to her February trip to Egypt, never expecting COVID-19 would find her while she admired the views and visited historical sites along the Nile River.
In mid-February, according to the World Health Organization, there were about 50,000 lab-confirmed COVID-19 cases worldwide, with only about 500 cases outside China.
"We were watching all the news reports and knew what was going on with the virus; she really thought she'd be OK in Egypt," said Kevin, recalling how his mother reported feeling unusually tired after her return on Feb. 20. "She told me 'I think I'm too old for travel; this might be my last trip.'
"That seemed strange; she's always been a go-getter, very active and the centre of her social scene."
Six days later, when her fatigue hadn't lessened, Kevin took Lam to the emergency department at Mackenzie Richmond Hill Hospital, where doctors prescribed a new blood pressure medication, hoping that would boost her energy. Since Lam had, as yet, no other flu-like symptoms, hospital staff did not suspect COVID-19. On Feb. 26, there were only five lab-confirmed COVID-19 cases in Ontario.
But on Feb. 29, after Lam started to cough and feel pressure in her chest, she went back to the emergency department. This time, physicians tested for the virus and sent Lam home, where she lives alone, to self-isolate and monitor her symptoms. Kevin, who lives in the same neighbourhood as his mother, also went into self-isolation with his wife and two young children.
"That's when it began to feel real for us," he said. "But we were always more worried for her."
The next day, Lam found out she had COVID-19. Still, she was hopeful she would recover on her own.
"She kept telling me, it felt like a severe cold and that she didn't feel like she was in danger," Kevin said.
On Monday, symptoms worsening, Lam called Kevin, telling him she could barely breathe and asked to go back to Mackenzie Richmond Hill Hospital.
"When I dropped her off, I wasn't thinking that far ahead " I didn't know that would be the last time I'd see her for a long time or maybe even never again."
Kevin and his family did not, to their knowledge, get the virus, though they've remained in self-isolation since the beginning of March. Of the five friends who travelled with Lam to Egypt, three others tested positive for COVID-19, though none has needed hospital care.
McLachlan was in the ICU that Monday when the hospital's emergency department alerted the critical care team that a COVID-positive patient with respiratory concerns was being brought up to the ICU.
"I can remember standing outside her room, helping get her off the stretcher and watching her walk into her room," said McLachlan, also a registered nurse. "She was scared. I also remember how scared everyone else was. It was all so new, this virus. It was just the beginning of COVID-19 in Toronto. But she walked into her room and thanked us and the glass door slid behind her."
For the first two days in the ICU, Lam was stable, able to call her family and browse the news on her phone. But then her breathing grew increasingly laboured, her blood oxygen levels dropped, and the ICU team prepared to intubate her.
"She knew we were doing it," McLachlan said. "We talked to her and reassured her. I remember her being scared. I remember her asking us to help her stay alive."
Dr. Danny Chen, physician lead in infection prevention and control at Mackenzie Health, knew almost immediately Lam could die of the virus. She was older with underlying health conditions, including high blood pressure and diabetes, and she quickly deteriorated during her first few days in hospital.
"She had these strikes against her; that's what prompted us to see if there were any treatments out there in clinical trial, knowing nothing had yet been proven. She was our patient, getting worse in front of us. We wanted to see what we could do for her and her family."
Chen applied to Gilead Sciences for compassionate use of remdesivir, an antiviral drug developed as a potential treatment for Ebola. Though the drug failed for that deadly virus, it's among the leading contenders for a potential COVID-19 treatment, and a number of clinical trials are underway worldwide.
Four days after contacting the drugmaker - and two days after Lam was intubated - Chen had the medication in hand and was speaking with her two sons about the potential benefits and risks of giving it to their mom.
"We signed off on my mother's behalf," said Kevin. "We felt like we didn't have any other choice; it sounded like she was going to die. What other chance did she have to get better?"
The study, the results of which were published on April 10, described the outcomes of 61 patients from the United States, Europe, Canada and Japan. The study could not determine whether it is an effective treatment; those trials are ongoing.
Chen said Lam tolerated the drug well, but it is impossible to know whether it made a difference in her care.
"We do know that the odds were stacked against her," said Chen, noting published data suggest that about 70 per cent of patients with COVID-19 who are intubated will not survive. "From our hospital standpoint, what we feel is that we gave her every chance we could to get better."
Seven weeks into treating patients with COVID-19, Ghafouri and the ICU team have learned much about the complex disease. The fear is gone, though some of the uncertainty about how to care for patients remains.
"It's very unpredictable," said Ghafouri, who has not hugged his children since March 2 - the day Lam came to hospital - for fear of transmitting the virus. "I've learned that if a patient survives the first seven or eight days, they could possibly survive longer. So far, most of my patients have passed away within the first week. And the ones who survive, it takes four, five or six weeks to heal."
In Lam's case, Ghafouri and the ICU team drew on their previous critical care experience to manage the new disease even as they learned about its unpredictability.
"We just kept at it. We tried to fix whatever was fixable, troubleshoot whatever we can, and fine-tune all the medications. We were supporting all her organs - her kidneys, her liver, her heart - until her body started the process of healing itself."
So far, Lam is doing well on the medical ward. She is sitting up and wearing her glasses and visiting with her two sons' families by video conference.
She can't yet speak because a tracheotomy tube remains in her throat. But Lam can wave to her family from her hospital bed and nod along with her grandchildren's stories. Kevin said they all can't wait to give her a hug.
Chen said Lam's recovery will be long, with many ups and downs, as her body heals after so many weeks in the ICU. Her muscles are weak, and she'll need to practise walking, talking and other daily activities. But there appears to be no lasting organ damage, and Chen said her body is no longer fighting the virus. Though she is likely not infectious, Chen said Lam is not officially virus-free as she has not yet had two negative COVID-19 lab tests, taken 24 hours apart.
McLachlan knows there will be many more difficult days in the ICU. The COVID-19 pandemic is far from over.
But seeing Lam leave the ICU, smiling and waving at her care team, has given staff some hope that there will be more patients who survive the disease.
"There is light at the end of this tunnel. With perseverance and with faith, we will see positive outcomes. And now that we've seen it, we will do everything in our power for our other patients because we want to have more of these moments."
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie