As Ontarians are starting to receive news that the hard work in flattening the COVID-19 pandemic curve is working, we check in with Dr. Phil Shin. The chief of medicine and medical director of critical care at one of the country’s top hospitals, North York General Hospital (NYGH), discusses what makes this virus such a moving target, why recommendations for treatment continue to evolve and what happens next.
Dr. Shin, how are things going?
Things are better than we thought. The ICU capacity is not overwhelmed. We are busy. Because of the public health measures we have taken, it seems like a plateauing of ICU admissions across city and province, and that’s been encouraging.
What has surprised you about this virus?
I think that what a lot of us are seeing is that patients are behaving differently than most patients who are presenting with pneumonia we are used to looking after. A lot of these patients, even those with oxygen levels that are very low, they are often very awake and alert, not even complaining about shortness of breath even though their oxygen level is getting to critical levels to the point where they are still able to talk to their families. They are able to communicate very clearly but are still requiring life support, so for sure that is something a lot of us are not used to seeing.
And those who are critically ill and on life support, several days into the illness, a lot are developing other kinds of organ failure — kidney failure, cardiovascular collapse. Some deteriorate very quickly four or five days into being sick. So there is not a step by step progression that we would normally see in other infections and viruses.
How does one decide what path the virus might take?
There has been some description in the medical literature about different phenotypes, but it is so difficult. There are different types of presentations of COVID-19, meaning that there are some patients that present as hyperacute where they deteriorate very quickly, 12 or 24 hours, and others who deteriorate more slowly. But the way their lungs are behaving may not be the same as most patients with severe respiratory failure. It is in some ways unpredictable. This is still such a new disease: what one group publishes in one country may not be the experience in another. The experience in China may not be totally borne out in Italy. Then there is what’s coming from the experience in the U.S., [an experience] which has been very informative and may be a little bit different in terms of mortality rates and how people are being treated. So things change very quickly in terms of recommended treatments.
And how has that been to balance?
We do have to balance. We do know how to treat a virus that is droplet spread, and we do know how to protect ourselves. We do know some basic principles in critical care that are known to be best practices in helping our patients, so you don’t want to throw those out. But you do have to balance that with the certain aspects of this infection that are unique and not really seen in other diseases, so it is really hard to know what practices we should be changing and what practices we should be adhering to.
What about the recent experiences in New York regarding how ventilators are used?
It’s interesting. Things evolved very quickly. The medical literature a few weeks ago, the recommendations were to put people on ventilators early, meaning don’t wait until they deteriorate, and to intubate. Then with the experience out of the United States, the pendulum shifted in the other direction. If we can avoid Intubating, don’t just rely on oxygen levels, that perhaps putting people on ventilators may be causing deterioration and may be harming people, so it really swung from one extreme to the other. And I think certainly that may be the right approach, but on the other hand, I also have some concerns about delaying and perhaps it has swung too much in the other direction. Meaning, if we delay intubating these patients, there is some thought that when patients are in respiratory distress for some time that they may be self-inflicting lung injury by not intubating them and resting them on the ventilator. And if we wait too long, then some of these patients may deteriorate to the point where intubating them can become very dangerous and high risk.
Where that settles out in the coming weeks, I think it is really unclear.
How is the ICU capacity there now and with regards to the peak?
The latest modelling I’ve seen is that we may still be a couple of weeks from a peak but a peak that is much less than what was feared a few weeks ago and our peak will be manageable within the existing provincial critical care resources.
My concern is that in the coming months ICU capacity will still be strained. When you see numbers that are flat, it doesn’t mean that there aren’t more patients coming in. Unfortunately, a lot of these patients are dying very quickly, so when you see provincial numbers that haven’t changed, ICUs are still admitting patients daily. There are just many who are unfortunately not surviving. There are some small numbers who are surviving as well. But what we are seeing is that, if they do survive, they are staying on ventilators for quite some time. At NYGH we have patients who have been on life support for over two weeks already, and that’s much longer than average. And if these patients are recovering much more slowly than the average patient, that means that their stay is going to be longer. So even if there is a smaller number of patients being admitted, if they are staying longer, then ICU resources can still be constrained.
So what is to be done?
It is tricky to know when the transition point is: that if the hospital starts to open up surgical services that they’ve had to ramp down or if people that have been avoiding the hospital start to come back, then even though we don’t have the tremendous peak that was predicted, I think the hospital’s resources will be strained for the foreseeable future.
So when will we see a return to some of the treatment and surgeries that were put off?
In the next number of weeks we will be entering a transitional phase where we start saying that our original pandemic planning may no longer apply but then going back to the previous normal is going to have to be done in a very staged manner. And to figure out the best way is really complicated because we want to treat the patients who still need to be treated. Patients with cancer will still need to have their surgeries, their chemotherapy. People with other medical diseases will still need to get the treatment that has been delayed. And there is that principle of proportionality that dictates the practices we have had to implement shouldn’t be harming more patients than we are helping, So at some point, we do need to open up, but we still don’t have enough data to know what additional capacity we are going to need in the coming months for patients with COVID-19 and how to balance that with the resources we need to open up for other patients who need it.
How is morale in the ICU?
There are a lot of mixed emotions. I think people are feeling exhausted. It’s been emotionally draining, as I mentioned. But our team has been amazing. We try to celebrate our successes and recognize when people are doing a great job. It has been really nice to get community support. It makes a really big difference in morale when we have messages that come through and when people are donating meals for our staff. And when we see things out in the media that are really portraying health-care workers in a positive light; it’s really important for us to see.
Have you ever experienced anything remotely like this?
What I’m not used to personally is patients feeling subjectively well and being able to talk to them and engage them in conversations right up to point where we are putting them on life support and being privy to these conversations that they are having very clearly with their families right before they are being put on ventilators only for them to die a number of days later. It is really emotionally draining and different than what I’ve experienced, and I think my experience is shared by a lot of my ICU colleagues here and more broadly.
What about having enough PPE?
There is a lot of fear that, even if we know we are using the proper equipment and even if we do have sufficient amounts of equipment, which we do here at our hospital, there are always slight changes to recommendations and protocols. People get very nervous, and it can be really tiring having to adjust to different recommendations that change slightly on a weekly basis.
I think we’ve been sprinting essentially for the last couple months to get ready, and I think now we are recognizing that it is going to be more of a marathon, and I think that’s still pretty daunting when you think about the coming months.
Do you see a light at the end of the tunnel?
If I was to predict based on what I’ve heard and read and think, I believe the strain on hospitals and critical care units is going to be for many months, not many weeks. As mentioned, until [there’s] a definitive vaccine, this virus will still be circulating in the community, and we will see smaller waves and smaller outbreaks throughout the city, and those patients will still be coming into the hospital. When we open up resources to other patients — and we really did ramp down to create as much capacity as possible — I still think it is going to be strained over many many months until there is a vaccine that is protecting a greater proportion of people in the community.