Reflections of a Family Physician in a Long-Term Care facility
By Dr. Mark Karanofsky
March 13th marks the one-year anniversary of the lockdown here in Quebec that for me represents the beginning of the pandemic. For many I am aware that this was a time where life stood still for many months as the first wave took hold of our community. As a family physician leader responsible for the Herzl Family Practice Centre and at the Donald Berman Jewish Eldercare Centre, a long-term care facility (CHSLD), this was but beginning of an incredibly challenging period of time.
At the outset let me express my deepest condolences to those who lost loved ones over the course of this past year. COVID-19 has taken too many before their time and left others with significant disability. In addition, many others have suffered greatly from the inability to be in close contact with the ones they love, especially in times of great need, and their loss is significant as well.
There is so much that I have learned over the past year that reflects the evolution of how we have faced this pandemic head on.
The First Wave
In the first two weeks after the lockdown began, many changes, some say 5 years of changes happened. At Jewish Eldercare in the first few weeks life became very quiet in the building as only staff were allowed inside. There was a great fear initially that the loss of help from loved ones would prevent our residents from being able to be fed and engaged with on a personal level. At the time, the social distancing practices we have become so familiar with had not been imposed. It was during those first few weeks that I saw how dedicated the staff truly are. Anyone in the building went to the floors at mealtimes to help. I saw the dieticians, the cleaners and anyone who could come up to help feed residents. I saw staff making sure to engage with residents and speak with them during this difficult time.
In addition, I saw the iPads and online video platforms implemented to connect residents with their families. Late in March 2020 one of my residents was dying from a non-COVID-19 related illness. Due to the restrictions at the time, family members were not allowed in the building. The night before she passed, I arranged with Melody, our floor’s nurse to set up a Zoom call with her and her family. That night I witnessed 9 family members from across the world, Canada, the US and Australia, gather to have a meal together and to say goodbye. She passed away the following morning. Prior to the pandemic, I am not certain that this type of arrangement would have ever been considered.
Our First Case
On April 1st I received the dreaded phone call that our first resident and staff member had been diagnosed with COVID-19. Daniela Vrabie, the managing director of the building, had already formulated plans to isolate residents once they were diagnosed with COVID-19 in a separate area of the building. As was seen throughout the province, once inside the building, the virus spread extensively across the affected units. Keeping the staff separate seemed to be the most effective way of limiting the spread. Had we been as aware and as vigilant as we are now with PPE perhaps there would have been more limit of the spread.
The early spread and call for PPE brought the entire system of supply chain management into clear focus. In roughly 72 hours our long-term care centre was forced to become an acute care hospital. CHSLDs are not staffed or equipped for that. On one Saturday evening, one of my physicians, Dr. Adriana Decker drove to the ER at the Jewish General Hospital to pick up IV pumps as we had run out of our available supply. Having the equipment and systems in place to ensure that those at the bedside needed was vital.
My initial response when I got the call about our first person with COVID was fear. Especially that I understood that a physician would be required to go in and examine those who were ill. Who would go in? Could I go in and get sick, or worse, would I get sick and bring it home and infect my family? For the first few days my brave colleagues went in. However, after about 5 days, despite my fear, it became apparent that more help was needed and that I too would need to go in. My first foray into the hot zone, in full PPE, was a scary moment as I did not know what a COVID patient looked like. Once I got inside though, I started to understand that while sick, on the outside this appeared to be a bad influenza. That initial fear stayed, as people started to pass away, I saw how bad this could get. And yet those who had not experienced COVID in real life still only had an abstract perception of what this virus could do. Despite all of our best efforts 25-30% of those who caught the virus ultimately succumbed. Some institutions had rates of 50-60% but nothing had ever prepared me for the severity with which this virus claimed the lives I was tasked with caring for.
COVID-19 often presents with fever, cough, loss of smell or abdominal pain. In my experience in CHSLD residents, the first 5-7 days followed a typical flu pattern where for the most part people are sick, but manageable. The scariest part of COVID tended to be day 9-14 when those suffering from the virus would suddenly get very sick and require a lot of oxygen to stay alive. This inflammatory lung reaction was the scariest part of the illness that claimed many of the lives lost. Until people got to day 14 I was always very nervous.
Communications is Critical
The next 8 weeks became a continuous battle. 16–18-hour days became normal with never the thought of taking a day off. Beyond the physical exhaustion of being in full PPE in a hot zone taking care of patients, it was also clear that communication with families needed to be improved. Early in April, my team of physicians committed to trying to call the designated family member daily for those affected by COVID. We also learned that communicating with the entire building and their loved ones was vital to ensuring that they had accurate information that truly reflected what was going on inside. So, I began writing letters to the community updating them on the state of the situation. As a physician I had always been trained and endeavored to speak with my patients and their families one to one. Never had I needed to reach out in this way to the broader community. The paucity of information led to rumors that only seemed to make the situation worse. One of the greatest lessons I have learned from this pandemic is the need to communicate clearly and honestly. Information and facts have evolved throughout this past year. It is difficult at times to suggest that what I said before is no longer the “truth”. It is important that everyone understands that decisions are being made with the best information of the day but that as more information becomes available some of those decisions will change.
The True Heroes
The manpower issue cannot be forgotten. Transforming a CHSLD into a full-fledged hospital overnight is an impossible challenge. What had been a tenuous state prior to COVID-19 became even more challenging as staff became ill. Despite this, the emergence of the heroes of this pandemic came into greater focus. The nurses and PABs are the greatest heroes. Their work could not be done remotely at a safe distance from this virus. The men and women who put on scrubs, mask, face shield and gloves daily and who spent hours at the bedside are incredible human beings. As a physician, I spent a lot of time inside the hot zones, but my time spent at each bedside was limited. The nurses and PABs were and still are the front line. Their compassion, sense of duty and loyalty to those in their care in the face of personal danger, is nothing short of heroic. I am grateful to those who volunteered and came into our building to help take care of some of the most vulnerable people in our community. There are so many that deserve public recognition. There are too many to name here, and we all are forever in their debt.
At the end of the first wave in June, 169 residents out of 320 had contracted COVID-19 and 48 had passed away. In addition, over 100 staff members had contracted the virus as well.
The Human Cost
The isolation from family and loved ones due to the restrictions imposed on the facility has affected both residents and their loved ones. Many family members had previously come at least once per day to the building and could no longer spend time with their loved one. From the beginning we knew that connecting loved ones together would be a necessary and vital effort. During the first wave, residents were kept in the hot zone for 28 days. One 91-year-old resident missed his wife only slightly more than she missed him. In order to help them both, during his illness I would set up the iPad in the Hot Zone and they would Facetime to enjoy lunch together. Another gentleman had a birthday party with his children and grandchildren over Zoom from across Canada and the United States. Whatever bit of normalcy we could provide, we would aim to do.
Staffing
The first wave exposed a lot the vulnerabilities in a CHSLD. Staffing was the major concern before and continued throughout. The initiative by the Quebec Government to train and hire 10,000 PABs over the summer was an unmitigated success. By the fall, the strain that we had felt before for PABs had disappeared. That manpower support ensured a much-needed capacity to provide safe patient centered care. Other professionals take a lot longer to train. Front line nursing staff have become tired. It is hard to replace those that need to step back and with the second wave looming became one of the most challenging situations to resolve. Mobilizing the network is hard, and I believe one of the toughest negotiations to be had will be in demolishing the silos between the institutions of our health care system and allow for easier mobility of movement of staff to respond to a crisis. While the CIUSSS leadership structure has allowed for coordinated care across the region, the deployment of staff from one site to another remains a challenge to overcome. This was a situation I heard of regularly across the province.
The Second Wave
As the fall approached, we prepared ourselves for a second wave. Many of the procedures and lessons we had learned from the spring were applied, and we were much better prepared. At the end of October 2020 our second wave began. It is at this point that I too felt COVID-19 on a very personal level. On the evening of October 30th, I started coughing and put myself in immediate isolation. The next day I got tested, and on November 1st I found out that I had contracted the virus, likely from the CHSLD. My headache and cough were pretty tough, but thankfully never worse than that. It did take 2-3 months to regain my breath and wind fully, but thankfully I have recovered. The personal toll of the infection though was far greater as the fear of getting really ill, the guilt of bringing this virus home and the physical isolation from my family weighed heavy. In the spring, I had moved out of my bedroom to the basement to minimize the risk to my family. That was hard, this was much harder. My wife took care of me from afar and over Zoom. Words cannot express how thankful I am. In addition, the support I got from family, friends, acquaintances and strangers throughout my illness truly helped lift my spirits and get me through this difficult time. The physical and emotional impact of COVID is real. I believe it is because of the support from those around me that I got through this. The impact of the distancing, isolation and stress of the entire pandemic has weighed heavily on the entire community. As a family physician I see the effects of this daily in my patients and I see its effect on myself as well. This is a challenge that our community faces and by helping each other we can help lift spirits and help each other make it through these difficult times.
During the second wave at Jewish Eldercare, 31 residents became ill and 12 passed away. As people became ill, news that the vaccine was on its way brought a lot of hope. The holiday of Channukah, the festival of light, began on December 10th. During this week I was able to go into the hot unit and light the candles with our residents and their families. Despite all of the hardships of the past year, being able to celebrate inside the hot zone kept the hope and promise of the coming year at the forefront.
Reason for Optimism
The vaccine’s arrival marked a new chapter in this pandemic. On Tuesday January 5th, I was at the pharmacy when the box arrived with the doses of vaccines for the residents. 280 doses come in a package the size of a shoe box. Yet this package contained a ton of hope. Efficiency has become essential in everything we do. The team from the CIUSSS arrived and within hours, all of our residents that wanted the vaccine were vaccinated. Since the vaccination of our residents, none of them have gotten ill. A sign, I hope, that this year will be far better than the last.
The past year has been the most challenging I have had as a family physician. I have learnt that having a reliable supply chain, clear communication and flexibility are necessary tools to make it through a crisis. The most important factor is having a heroic, committed and selfless team that support their patients and each other no matter what. The kindness and generosity of strangers has brought us together as a family and community that I hope will be a silver lining legacy to the pandemic of COVID-19.