At Markham Stouffville Hospital, intensive care physicians and cleaners are part of a team who must work more closely than ever
Intubation is the most high-risk procedure for hospital staff in the battle against COVID-19.
In the intensive care unit (ICU), a patient who can’t breathe on their own gets a tube inserted into their mouth, connecting them to a ventilator that gives the lungs a chance to relax and heal while they are put on life support. During the procedure, there is a lot of coughing into the faces of the medical team, which spreads COVID-19-positive droplets everywhere. To carry out a single procedure safely, Markham Stouffville Hospital puts together a crew at least 12 deep, half of whom are decked out in full personal protective equipment (PPE).
“We’re all small cogs in a giant wheel,” says Dr. Subarna Thirugnanam, the lead ICU physician at Markham Stouffville, who performs her duties flanked by fellow doctors, nurses, technicians and hospital staff. “None of us would survive without the other.”
When on duty, Thirugnanam oversees the intubation procedure, managing medication and anesthesia. The anesthetist inserts the tube. An ICU nurse handles the drugs. The respiratory therapist manages the ventilator – and that ventilator must be covered with cellophane so it doesn’t get contaminated, adding half an hour to the prep time.
As the team of four operates within a negative-pressure room – where air flows in but is sucked out by ventilation so as not to spread to other rooms – another respiratory therapist and ICU nurse stand by in the adjacent anteroom to assist in case the patient goes into cardiac arrest. Everyone inside the negative-pressure room and anteroom are in full PPE, which takes five to 10 minutes to put on under close personal supervision. Taking the protective gear off is even more time consuming since, after entering a patient’s room, it is contaminated. Hand washing after removing each piece, slowly and mindfully, is mandatory.
Outside the anteroom, there’s another nurse managing the pumps that flow medicine and IV fluids to the patient. Pre-COVID, these pumps would be situated inside the patient’s room. But to minimize the need for nurses to enter a patient’s room when managing or refilling the pumps, they have been moved outside with extension cords and long IV tubing that regularly needs untangling. Just preparing the pumps takes an hour.
Another nurse will be standing by outside on the phone with Thirugnanam, relaying instructions for the nurse managing the pumps or to another nurse who records necessary drug information. Two more respiratory therapists act as runners, and even more nurses stand by to assist.
A single intubation takes more than two hours. The required planning, staff and time for each patient is the reason coronavirus is such a drain on hospital resources, leaving the health-care system in critical condition when more than a handful of patients show up at emergency.
Only a month ago, Thirugnanam over saw her first COVID-19 intubation, an emotional, high-pressure ordeal that took almost four hours because the familiar procedure was now saddled with entirely new stakes and protocols.
“As the ICU physician my responsibility is to my patient to make sure my patient is safe and we do everything possible,” says Thirugnanam. “But I’m also responsible to my team, to make sure that we do everything that we can to mitigate their risk of being exposed. It was very stressful. I was very scared. I was even more scared knowing that, that night, I was going to have to do a few more.”
The first intubation took place around 6 pm on March 26, when the ICU department was slammed with six COVID-19 patients at once. Markham Stouffville was essentially ground zero for Ontario’s coronavirus outbreak.
“It came very quickly for us,” says Thirugnanam. “There was no trickle effect. It was like ‘BANG! Here you go! Here are your COVID patients!’”
Thirugnanam has been on-call for the better part of last month. Markham Stouffville has a single ICU and at one point the unit had 19 patients on life support. To put that into context, Toronto General, Sunnybrook and St. Michael’s hospitals have three or four intensive care units. At their peak (as of this writing), Toronto General had 20 patients in ICU.
But Markham Stouffville managed with an Avengers Assemble mentality shared by the entire hospital and provincial health-care system. When it was slammed, Toronto General and St. Michaels took on some of their patients. Staff from surgical departments at Markham Stouffville that were freed up – since procedures have been reduced to only the essential – have been re-deployed as PPE experts, watching through a window as every doctor, nurse, technician or sanitation crew member follows a checklist to safely put on and discard gear.
While the ICU ward copes with the most severe patients, Thirugnanam points out that’s not the only unit drastically overwhelmed. The internal medicine doctors, or internists, whose wards are the go-between for emergency and ICU, are managing many more COVID-19 patients at any given hospital.
“For every patient that I bring to the ICU, they’re managing five patients,” says Thirugnanam. She explains that those doctors, who have vast training in all areas, and their team of nurses, treat patients who have been admitted because they need oxygen, are worn down from the illness, are too weak to get out of bed and can’t be cared for at home.
The patients are given supportive treatment and fluids. Doctors also use a technique called proning, which means flipping patients onto their stomachs to aerate different parts of their lungs. The goal is to improve lung oxygenation as a whole and minimize the need for ventilator support.
“[Internists are] the gatekeepers to the ICU, managing their patients appropriately so that they don’t deteriorate,” Thirugnanam explains. “If internal medicine don’t do their jobs properly, all of these patients would end up in the ICU and the system would already be crippled.”
Thirugnanam also points to one more crucial player on her team: Environmental services attendant Carmela Yambao, who immigrated to Canada from the Philippines in 2008. Yambao has more humble terms for her job.
“I’m the housekeeper in ICU,” she says, downplaying how intensive and crucial her job is. Her regular duties in the ward include changing sheets and clearing out trash, but also doing terminal cleans. When a patient in ICU is discharged, the environmental services attendants patiently and painstakingly clean every crevice, corner and the walls from top to bottom with bleach. They do that twice so that a room is ready for new patients, and must change their PPE each time they exit a potentially contaminated area.
“Environmental services has the highest risk of getting contaminated and infected,” says Thirugnanam. “Because cleaning of these rooms is very detail oriented and finicky.
“That is a crucial part of what we do,” Thirugnanam adds, explaining that the faster Yambao effectively performs her duties, deep cleaning six or seven rooms in a day, the sooner patients can be admitted for care.
There’s another reason Thirugnanam singles out Yambao from the environmental services team. Not only does she take on her intensive duties without complaint – despite the risk of bringing COVID-19 home to her 65-year-old husband – Yambao is also a maternal figure in the unit, looking after the doctors and nurses who often forget to look after themselves. On the day that Thirugnanam performed her first intubation, with more to come that night, Yambao sought her out to make sure the ICU physician was staying healthy.
“Doc, you need to eat,” Thirugnanam remembers Yambao warmly reminding as she urged the physician to take a break.
“We are all motivated to support one another,” Thirugnanam adds. “If there’s a crack in the team, then everything gets screwed up.”