‘I have seen a tremendous amount of tragedy’: Hamilton doctors speak about the toll of COVID’s fourth wave

Dr. Erick Duan can finally see the light at the end of the tunnel after more than 18 months of caring almost exclusively for COVID patients at St. Joseph's Healthcare.

I have seen a tremendous amount of tragedy that is indeed very real," said the intensivist who specializes in the care of critically ill patients on the COVID ward and the intensive care unit.

This is affecting people from all walks of life, of all ages and of all circumstances," said Duan. The stories that we've seen in the last two years are something that we've never seen before in terms of the amount of suffering, isolation and tragedy. People are dying, entire families are getting sick, people are alone in hospital and we see the effects on the entire health care system."

The finish line is painfully close for exhausted and burnt out health care workers - all it will take is for enough people to get vaccinated.

Hamilton is more than three-quarters of the way there, but the last mile is proving to be all uphill to the despair of doctors like Duan who have seen the COVID ward fill with the unvaccinated during the fourth wave.

COVID-19 will find the unvaccinated," said Duan. If you're hesitant or unsure or unclear, this is the time to talk to someone - your doctor, your nurse practitioner, your neighbour who's working in the ICU. I would rather have people have those conversations early when they can get vaccinated before it's in a hospital bed with oxygen on your face or a ventilator being wheeled into the room. Now's the time."

The toll of what has become a pandemic of the unvaccinated is starkly described in their own words by four Hamilton doctors who share the same overall message.

We are urging people to be vaccinated and to look out for one another through public health measures," said Duan. We see a way forward. The vaccine is effective and safe and is really going to be key to get us through this pandemic and to move on with our lives."

The following interviews have been edited.

Dr. Kuldeep Sidhu - chief of emergency medicine for Hamilton Health Sciences

In the fourth wave of this pandemic the patients who are presenting are quite a bit younger and I mean there are pediatric patients as well as people in their 20s, 30s and 40s," said Sidhu. I would say the bulk of the admissions now are all unvaccinated individuals who are quite a bit younger."

It's distressing especially with many of the staff being in that same age bracket," he said. Seeing a young patient coming in struggling to breathe and needing all sorts of assistance. For many of them, this is probably their first major medical illness and you can see the anxiety and the fear and the unknown."

I think many of them are regretful," said Sidhu. They're asking, Can I get a vaccine now.' It's even more saddening when I tell them the time for vaccination has passed and right now all we have to do is identify and treat. Then they're usually asking, What sorts of treatments are available.' Quite literally it's still at this point supportive care, supportive ventilation and oxygenation."

On denial and disbelief:

Those individuals who come in later because they were in denial or they thought this was not true, you'll admit to hospital because they need oxygen, they need high-flow oxygenation, sometimes they need pressure support ventilation where you have to push oxygen into their lungs," said Sidhu. They're still in disbelief that this is happening to them."

You do come across people who will say, It's a hoax and that this is not true'," he said. You'll show them their lung pictures and they'll say, No it can't be COVID, it's got to be my asthma.'"

I think that mostly health care providers are saddened and some are frustrated that still at this point the person still does not believe," he said. What I tell our staff ... is have that empathy and that compassion because they still require that."

On backlogged care:

The suffering is widespread - all the people who needed cardiac surgery, hip replacements, hernia replacements, people who have needed hysterectomies. This has been terrible," said Sidhu. You're going to see advanced cancers show up ... because there hasn't been the regular surveillance. On top of that people who have been delaying surgeries - gall stones and hernias - you are going to get more complications and we've seen that. We've seen people who have mild to moderate angina symptoms who weren't worked up and they are coming in with more serious heart attacks and illnesses. Most certainly we're seeing chronic disease management at a worse level."

That's what a lot of the fourth wave has been - increased congestion in the department because of all of those other illnesses on top of COVID," he said.

On bedside conversations:

When people were coming in with other illnesses or injuries, it was an opportunity to have a conversation with them to say, Have you been vaccinated?What are your concerns?' and to be able to dispel some of the mistruths," said Sidhu. I let them know, I've seen too much of young people, old people getting ill now with a disease you can ... avoid serious illness with vaccination.' I think the majority of people are open to at least having a dialogue."

As a society as a whole we're all tired of this," he said. This is the only way out for us. Let's get over this. Let's move back to our lives, let's achieve a 90 per cent vaccination rate and let's get back to normalcy."

The suffering is too great and we can do something about it just by getting vaccinated."

Dr. Alim Pardhan - emergency medicine site lead at Hamilton General Hospital

The hospitals are pretty full - we're pretty close to capacity right now," said Pardhan. We're struggling to keep up both the COVID and non COVID fronts."

Our teams are tired," he said. It's been a long 18 months for us. I think people need to see how busy it is in the emergency department, in our intensive care units, on our wards. Look outside Hamilton Health Sciences at the ambulances that are parked there ... None of us want people to be languishing on ambulance stretchers or languishing in the hallways in the emergency department because we have no in-patient beds to send them to ... Get vaccinated. This is a huge tool to prevent serious illness and frankly deaths."

I do feel a bit frustrated that a lot of the patients that we're caring for are patients where this could have been avoided had they gotten what is a life-saving vaccine," he said. But there's a lot of reasons why patients have not been vaccinated. I think there is definitely the group who don't believe in vaccines or who don't believe in this vaccine ... A fairly large percentage ... had trouble accessing it or are socio-economically disadvantaged."

There's a fair amount of misinformation or disinformation that some patients have," said Pardhan. Sometimes opening up that conversation can be the wedge that you need."

That face to face contact, the ability to be there and say, This is a safe vaccine. I've gotten it, all my colleagues have gotten it," he said. Those who do get sick despite being vaccinated ... have lower hospitalization rates, much, much lower rates of needing to go to the ICU and the rates of death are vanishingly small once you've been vaccinated."

On angry patients:

A lot of what I've heard is regrets particularly when they're more unwell, requiring hospitalization or when it's looking like we're going down the pathway toward critical care," said Pardhan. I have gotten the, Can I get it now' question."

I've absolutely had patients get angry at me when you tell them that they have COVID," said Pardhan. The answer is, I don't believe in that. You're making that up.'"

We've definitely seen the age of the sicker patients drop," said Pardhan. Mid 30s to mid 40s, otherwise healthy, non vaccinated, no medical comorbidities and they're coming in very unwell, requiring admission or critical care."

It's definitely hard for people to see patients come in with what is ultimately a preventable disease," he said You know, the long-term outcomes for these patients are potentially bad if they're angling toward critical care."

On staff burnout:

With numbers climbing, I think people are like, Here it comes again.'" said Pardhan. The degree of fatigue is palpable ... Everyone is frankly, a little bit burned out."

We're being hit on a number of different fronts," he said. One front is definitely the COVID patients. But then the other fronts are patients who have had delayed care that are now coming in with worsening complications."

We've had to cancel cardiac surgical procedures, there are other procedures or interventions that have been delayed and so patients wait at home and in some cases they're getting worse," said Pardhan. When they are no longer able to tolerate their symptoms they come into hospital. Had we had the opportunity to intervene sooner, we could have prevented a hospitalization or an emergency department visit."

The hope is that if we can get the majority of the population vaccinated, we can not have as many patients with COVID," he said. We can start ramping up our elective surgical procedures ... we can start opening our clinics back up. We can go back to a certain amount of face-to-face care."

Dr. Jill Rudkowski - head of critical care and ICU at St. Joseph's Healthcare

With Delta, it's so contagious - especially among the unvaccinated - compared to previous variants so it's not unusual for multiple members of two generations of a family to be admitted to hospital or ICU, which is always extremely stressful for the families," said Rudkowski. It's just so tragic."

Adding to the distress is that, we can't allow them into the room," she said about visitors. We do sometimes allow visits outside the room ... But, of course, it's totally suboptimal to not be able to sit beside your loved one and hold their hands."

I think the statistics bear out that the people that are getting sick during this wave - as in need to be hospitalized or receive critical care - are unvaccinated primarily," said Rudkowski. If they're fully vaccinated, they haven't developed a good immune response and they're more vulnerable because of underlying conditions or their age or both."

I think that for most of the unvaccinated people that end up getting very sick, many of them feel regretful that they didn't find a way to get vaccinated earlier," she said. When you have planted your flag, so to speak, it's very hard to say, Actually, I feel like I want to move it.'"

On shaming and blaming:

When we start to shame and blame people, it all unravels extremely quickly," said Rudkowski. There is no shame in asking questions. There's no shame in wanting to assess your own risk. And there's no shame in trying to seek information to make you feel confident ... I've talked to lots of people that have the information they need to make the decision about taking the vaccine, they're looking for the ways that they can save face with their friends and family."

Rudkowski often tells patients about New Zealand's swiss cheese model for managing COVID.

You have a whole stack of slices of cheese between the virus and an individual and with every slice of cheese there's a hole in it so no one thing is perfect to protect us from COVID," she said. It's up to each of us to choose how many and what kind of slices of cheese we can put between us and COVID - things like wearing masks (and) making a dedicated decision about who you spend your time with when your masks are off. The vaccine is a really important one because that piece of cheese has only a tiny hole in it - it's a great deal of protection, particularly, against being hospitalized or being put in ICU."

We've given vaccines across the world to over six billion people and data is flowing in literally daily," she said.

On resignation and resilience:

There is a sense of resignation that there's not an end to the pandemic as many people had hoped," said Rudkowski.

Many health care providers feel anger toward those ... who perpetuate the misinformation," she said.

I don't think people have the same amount of resilience that they did at the beginning of the third wave," said Rudkowski. We have never had a lot of wiggle room and the pandemic has certainly made us even thinner."

We have had deaths in excess of what's expected even outside of those who have COVID - those are people that had their surgeries delayed, couldn't get their kidney transplants, didn't get a colonoscopy so ended up with later stage cancer," she said. I think there's a lot we still have to find out about when the dust settles and ... we're going to be blown away."

Dr. Erick Duan - intensivist in the COVID ward and intensive care unit at St. Joseph's Healthcare

I think that many people just have not seen COVID in such close proximity as we have," said Duan. When they see COVID with such a first hand experience, it really changes them."

I am struck by how many people as soon as they're in hospital and have an opportunity to talk to us or see the ramifications of COVID and how devastating it is, how their minds can be changed," said Duan. Many families, while their loved one was in hospital, would get vaccinated as a result of seeing how it really affects people and seeing how terrible it is on their family member or their friend."

On strong beliefs and division:

I'm talking to them at a very vulnerable time - they're ill," said Duan. The first moment in which I'm meeting you is not the right time to talk about a vaccine ... I try to build rapport ... understand their values, their beliefs, their fears, their goals ... and build some trust and confidence ... They can see that we come from a place of caring and compassion ... The stories that we hear really are quite diverse. And everybody has their own reasons."

It's such a divisive issue where people are telling us they hold very strong beliefs about vaccination and it's really affecting them in a very profound way," he said. This is an opportunity to connect with people about something that has become so political and heated."

I'm struck by the human conversations," said Duan. In social media and online, you hear ... a lot of vitriol and divisiveness ... People have hot takes and are very angry ... I think that it's more important that we come together and talk to people ... and rely upon human interaction and not just those angry and mean spirited interactions we have in 140 characters or less or on Facebook comments."

A lot of people just don't have the information," he said. They've told me about things they read on social media or their own online media sources. They tell me about family members who hold strong opinions. Some of them ... just weren't sure what to trust ... There are a lot of people out there who just didn't have the right sources and are still very humble and open minded when given the opportunity to really consider information and talk to an expert."

On the tragic toll:

What stood out to me is this moment in the ICU when I recall looking around and seeing in every room there was so much tragedy related to COVID," said Duan. Families that have been ripped apart by this disease and people who are dying alone and separated from their loved ones. People who don't have COVID whose diseases progressed because they couldn't access the care as timely as they would in a non-pandemic time."

Through that tragedy, that hardship and the really daunting task of how difficult it is to care for this many patients who are critically ill, looking around and seeing the dutiful nurses, doctors, respiratory therapists from all over the hospital - people who are redeployed, called for, volunteered to work in the ICU," he said. In those moments of despair, seeing so many people come together to be able to look after so many critically ill patients, that was really inspiring. It gave me hope ... that through our advocacy, people will be able to avoid unnecessary tragedy."

Joanna Frketich is a Hamilton-based reporter covering health for The Spectator. Reach her via email: jfrketich@thespec.com