The reality of COVID inside an ICU

Edmonton doctor Darren Markland describes ventilating people unlikely to survive, intubating friends and separating patients with different variants to try to prevent a new one

Dr. Darren Markland is an intensive care physician and nephrologist who works at Royal Alexandra Hospital in Edmonton. Throughout the pandemic, he’s been sharing stories on Twitter of his life as an ICU doctor at an inner-city hospital in a city hit hard by multiple waves of COVID.

This interview has been edited for length and clarity.

 What’s the situation now in your ICU?

We are technically full but we have expansion capacity. There’s a lot of anticipation. We are admitting one or two COVID patients a day. We’re still able to manage things right now. But every night, when I get ready to go on call, I’m just so worried that that’s the night when it’s going to hit. We’re having trouble filling shifts with people to work. We lost a fair number of people to burnout. To bring the people back that we had during the second wave is proving to be a challenge. 

In terms of active cases per capita, Alberta is in a worse state than Ontario. Yet, we do not have the same immediate crisis in our ICUs. What’s going on?

I think there are three things. Now that we have our fragile or at-risk population vaccinated, we have to get to higher numbers [of infection] before we cross these thresholds to admission and then to ICU. A percentage of people will get sick enough to come into hospital, but the absolute numbers have to be larger because now the [number of] people at risk is smaller. We also have a younger population in Alberta. And we have a lower density population. COVID spreads a little less quickly [here]. That being said, it is an eventuality if we don’t increase our restrictions. But the nature of our restrictions is that the alarm bells go off once the ICU is full. That’s far too late.

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Who are the patients coming into the ICU with COVID now?

Our patients, for the most part, are racialized, indentured workers who have no choice but to be out there. They come from multi-generational homes. We see entire families coming. They are younger than the first wave. That gives us a little more hope. There’s a new medication that has recently been approved called tocilizumab, which seems to provide us a little advantage, too. We’re seeing more of a conventional pneumonia: Patients come in, they get sick, but after a week and a half on the ventilator, we get them off, unless they have significant other co-morbidities. COVID really attacks, for lack of a better word, our overweight population. And these patients are more challenging to look after. 

How is the pandemic affecting non-COVID patients in the ICU?

The reason we’re full now is all of the unmanaged chronic diseases that were neglected during the second wave, and the mental health disorders and addiction disorders that spiralled out of control. We’re an inner-city hospital with a very marginalized population. We see so much trauma from addictions and crime, and that’s what we’re full of right now. There are also a lot of surgeries that the surgical teams were trying to catch up on, and we’re seeing late presentations of cancer in our hospital as a result of COVID.  As COVID patients come in, it’s not like these problems in the community go away. 

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Have you had any severely ill pregnant patients with COVID?

We’ve had a few. Physiologically, pregnancy is a terrifying thing. The ante is so much higher. 

We’re waiting for this onslaught of pregnant women which we’re hearing [about] from [Toronto’s] Mount Sinai. My centre is the maternal health centre, so when it happens, it’ll involve us. Dealing with pregnant women adds another level of emotional entanglement. You’re now dealing with two people. You’re constantly making choices about mom versus baby. If there’s a point where you have to sacrifice the baby, that weighs heavily. 

Can you describe some of the difficult triage decisions you’ve made over the pandemic?

In a way, we triage people all the time. We just don’t use that word. You’re always trying to figure out who’s going to benefit from therapy—it’s not right to throw people into unwinnable situations. Very early on in this, we realized that there was a strong age cutoff to COVID where you didn’t survive if you got put on a ventilator. The studies made it clear that if you’re over 80 on a vent, you would die. 

My most challenging case was a couple who were in their 80s. They were incredible people. They got sick despite doing all the right things. And when his wife couldn’t breathe, he called the ambulance. And when [the paramedics] got there, they realized he was far sicker than she. He was transported to our ICU directly, followed five minutes later by another ambulance for her. Our nurses put them side-by-side. Despite being so short of breath, they were chatting and cheering each other on through the windows. I knew that they wouldn’t survive if we had to proceed to ventilation. We did everything we could to prevent it. You turn them, you flip them, you feed them, you make sure that they get the antibiotics. But both were going in the wrong direction. In the end, I could not not do the next step, even though I knew it was going to lead to death. 

When he finally needed the tube, she wanted to watch. And I couldn’t deny her. She eventually got to the point where she needed it too. And she knew exactly what was going to happen. When it was clear that we just couldn’t support him any further, we rolled them into the same room. And she held his hand. We took the tube out. As he passed away, she grabbed her own tube and pulled it out. And, of course, this was horrific to the nurses. The natural response is to grab someone and stop them from doing this. But everybody was transfixed. Nurses looked at me as if to say “Should we put this tube back in?” I didn’t. They died within half an hour. We spent two and a half weeks with this family. We knew them. We learned how they met, how he proposed. And that gutted us. 

Knowing they were going to die, but doing all the things; knowing that it was futile, but knowing that it had to be done; it was this bizarre, prolonged grieving process in real time that had to play out. It taught me so many valuable lessons. It also left an indelible scar. I will do everything I can to avoid those situations.

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Have you looked after any of your co-workers?

I’ve intubated friends. I usually don’t shake but when it’s somebody you know, it’s really hard. I’m a dialysis doctor. You look after dialysis patients for years. Some of these people are my friends, even if you’re not supposed to say that. COVID affects everyone. This is why we’re all so burnt out. 

On April 12, Alberta Premier Jason Kenney said the province is on track to hit 2,000 cases per day and predicted that would equate to about 500 to 700 people in hospital. What will that mean for your ICU?

We will be running our surge wards again. They are converted recovery rooms for barrack-style care. All beds are in the open. All the nurses wear their PPE all day and they go from one bed to another, looking after patients sequentially. It’s a very efficient way to look after people, but it’s a very undignified way to be a patient. At this point, we’ve become proficient at proning—when you turn a patient on their stomach and then on their back to expose an infected lung to blood. It allows us to use less ventilator pressure. Proning used to be a big deal for us. We’d get six people, a doctor and respiratory therapist, and use special equipment. And now we literally just go from one person to another. There are four people and a respiratory therapist, and they just go flip. And flip. And flip. There’s no pomp and circumstance. We’ll see a kind of mass delivery of care. 

The one hiccup now is that we have variants. We can’t put patients together because there’s the potential that you can be reinfected with variants. So that’s thrown a bit of a loop in it. We may have to take over other spaces for patients with P.1 versus B.1.1.7 versus the wild type [the original strain with no major variants]. 

Are other ICUs in Canada cohorting by variant?

Yes, it’s infection control. The big deal is the P.1, the one in Brazil where we saw a lot of reinfection for people who had the wild type. We think that the immunity from vaccination is more robust. But the worst-case scenario for us is to have somebody who’s already sick get a super infection. Then, the two viruses can kind of hang out. Then you can get a new variant. 

RELATED: The P.1 variant is spreading in Canada. What do we know about it?

Do you have anyone with the P.1 variant in the ICU right now?

I haven’t seen it yet. I just was reading today that we have 134 P.1 cases now in Alberta. So that’s a substantial jump. Public health’s goal has been to suppress P.1 because they can’t suppress B.1.1.7 anymore. The fact that it’s getting away from them is not a good sign.

What do you want people to know about this stage in the pandemic?

We have this false belief that the vaccines are going to save us, but they won’t. They’ll dampen it down. I honestly believe that we have got to push for COVID Zero. COVID Zero is no more radical than triage protocol. It’s a far less radical idea than letting people of a certain age die. And that’s how we’re going to do it. It’ll be an absolute [age] cutoff. But with vaccine hesitancy, we’re not going to get the number of people we need vaccinated. And I fear that we will literally have variants that have some ability to get around the vaccine. I foresee a fourth and a fifth wave. Not bigger ones, and the people who behave will be safer. But life won’t be normal for a long time.

What’s been the hardest part of this for you?

It’s unrelenting. You have to be very positive because people look to you for leadership. That’s hard because our political structure here in Alberta hasn’t supported us. We started this off with our government tearing up our contracts and basically going to war with physicians. And then the pandemic happens and you’re expected to step up. And of course, you do it because you love it. I’ve watched colleagues not crumble, but quiver. But it’s harder now and there’s more fatigue. And you realize that it’s not just the words you say, but the way that you hold yourself that makes other people stronger. To do that all the time, when you’re not exactly sure that you believe it, that’s extra work. That’s the fatigue.

What are long-term consequences that worry you?

I think we’re really harming people. My wife is a developmental paediatrician. She’s terrified that we’re raising a generation of children who have not had the socialization they need to connect. And I think it makes a recipe for a very disconnected civilization. And if you follow me on Twitter, one of the things that I keep coming back to is the concept of civility—there are rules we need to function well together. COVID is kind of destroying everything I believe in: community connection, coming together. That’s going to scar us. 

I know physiologically this virus scars, too. There’s evidence that it will age us and damage our blood vessels. It will lead to premature heart disease and lung disease and kidney disease and high blood pressure. We’ll all be 20 years older than we wanted to be. Granted, we all feel 20 years older in the pandemic.

This is a pivotal moment for society. This was when we realized that there were boundaries between us and nature. With eight billion people on the planet, we better start being more respectful of the planet. The things we learn from this pandemic have to be applied to the next one because there will be another one. And we can do a lot better next time.