In the first weeks of COVID-19, fear came first. Fear is still there, but now it is addressed with courage and resilience.

This is the story of ICU, a critical focal point in the effort to save lives and battle a disease that the scientific community still doesn’t know much about.

Dr. Iyengar is the Department Chief of Critical Care Medicine at the Queensway Carleton Hospital. If there was any doubt as to the intensity in the ICU and seriousness of COVID-19, he dispelled it quickly, “The first COVID-19 week was one of the toughest as an ICU doctor.”

He describes it like this:

If you are an intensive care provider, you face difficult situation every day – and a certain level of fear every day. Normally the fear is balanced by knowledge, experience, courage and resilience.

But recently fear took over.

Fear of getting infected. Fear of PPE shortages.

Fear of wearing the right PPE.

Fear of not knowing enough about the disease. Fear of not providing adequate care.

Dr. Iyengar expressed, “what I see happening now, is that those fears are being addressed with courage and resilience. That’s something I’m very proud of our staff for doing. The way we’ve approached every situation, it’s just been a complete team effort both within our unit and within the hospital.”

Over the past month, the emergence of the COVID-19 novel coronavirus has drastically changed almost every part of our day to day life. While Canada was fortunate to have time to react, dramatic decisions still needed to be made quickly.

ICU preparations started in early March at both the regional and hospital level. At QCH, it was decided that the hospital’s existing ICU would be dedicated to COVID-19 patients. At the same time, a secondary ICU would be opened for non-COVID-19 patients in what is normally the Post-anesthesia care unit, known as PACU.

Everyone in the hospital was mobilized to assist with the response to the virus. ICU physicians took on additional roles managing schedules, human resources, and virus education. Nurses with previous critical care experience were brought in from different departments while other nurses received additional training. There was expanded training for respiratory technicians, with new ones being hired. Mock Intubations and Code Blues were run in order to train staff on what would be needed to support an incoming patient, start to finish, while also keeping staff safe.

The challenges hospitals expected to face were clearly daunting. Countries such as Italy, Spain, and France had seen their COVID-19 infection numbers skyrocket in a matter of days and their health care systems became completely overwhelmed. Their experiences taught staff in Canada of the very difficult road ahead. Staff and logistical preparations were going to be key, as both could become overwhelmed very quickly.

“All those countries that suffered, and are still suffering in many ways, published a lot of information that guided us in how to prepare for this. At the same time, we also knew that while a lot of preparation goes into this, you never really know what to expect and that preparation only goes so far.”

Even in normal times, the ICU is a challenging unit to work in. Now, being on the front line of a global pandemic with the first patients starting to arrive at the Emergency Department, the preparation stops and training kicks in. “I think these are challenges that often appear to be theoretical talk, in that it’s never going to happen. Well it’s happening and that’s something that our team has approached head on,” said Dr. Iyengar.

In the early stages of the virus’ presence in Ottawa, QCH had more COVID-19 positive patients in their ICU than anywhere in the entire region, which stretched from Cornwall to Scarborough. What makes the novel coronavirus so challenging, is how it acts very heterogeneously, expressed Dr. Iyengar. “Even in the patients that we’ve had, it’s a different pattern in virtually every patient […] It does not behave like other viral pneumonia.”

For people who are not in ICU seeing the impacts of COVID-19, it can be difficult to grasp the intensity of the virus on the body. “What we know about these COVID-19 patients, worldwide mortality rate is above 50% once they reach the stage of mechanical ventilation and require ICU care,” said Dr. Iyengar. Even with the best equipment and the best staff taking care of patients, recovery is not guaranteed when a patient gets to ICU. “So far, although several patients have survived, unfortu- nately, we’ve also had several deaths in our unit, […] This is a bad disease. Just in the patients that we’ve seen in the last 2-plus weeks in the intensive care unit on full life supportive measures – we see that it does not discriminate with age, it does not discriminate necessary with pre-existing health issues, or functional state before getting sick.”

The teams that work in the ICU are composed of many different hospital staff. Shawna Nicholl is the ICU Nurse Manager, as such she oversees all the nurses in intensive care. When COVID-19 positive patients began arriving into the ICU, Ms. Nicholl knew that there would be some anxiety amongst the staff, “There’s obviously fear among staff. You expect that, that’s normal.” However, the way the ICU and hospital staff have stepped up to help one another in response to the pandemic is what helps them get the job done. “Staff have pulled together 130%. There’s not one staff member, from the physicians, to the ACC, to the EVS, to the nurses, to our NPP team that are not doing an extra task.”

The team has had to significantly change the way care is provided to patients, and how they communicate with families. “Now that families have had to step back with the visitations, sometimes you question the care you’re providing.” She continues. “Since you’re talking to the families through email and on the telephone, you’ve lost that face to face connection, you wonder how that is being perceived and that kind of plays on you a little bit.”

Despite the uncertainty in providing patient care in this new setting, QCH staff have a tradition of working to provide excellent support to patients and families. So, Ms. Nicholl was relieved when she received a note from a patient’s family. “Recently we had a lovely thank you letter from a family,

saying even though times are tough and you’re doing things differently, you’re still doing it very well. It was nice to have that reconfirmation and for the staff to know that we’re still providing that quality care we’re known for and that we love to give.”

Overcoming the fear and continuing to provide care to patients, and their families, speaks to the resilience of staff in the ICU. “We got hit pretty hard in the beginning. In that time, we had to rely on our critical care trained nurses, but also on nurses who came in from other parts of the hospital […] When I saw staff rally to support these nurses, bring them up to par, and everybody working together for the greater good of the patient, that was pivotal for me.” Ms. Nicholl expressed. Even with the challenges and uncertainty of the pandemic, staff continued to do their jobs. They stayed focused on treating patients, learning about the virus and supported one another.

“There will be tough times, so we’ll work together. We will get through this! We’re going to help each other, and we’ll be okay in the end,” said Dr. Iyengar. “That’s the message that we’ve been stressing right from the beginning, despite all the fears and other stresses that everybody has. That is how we’re going to get through it.”

Ms. Nicholl reminds us to stay positive and is hopeful that things will improve “People have said this is our new normal. But I recently heard someone say, ‘No, it’s not the new normal. It’s a moment in time and it will pass.’ I try to keep this in mind during difficult times.”