“Early on in this wave, we had 1,000 staff members off work every day”: UHN’s head of critical care on how ICUs are coping with the hospital crisis
Niall Ferguson is the head of critical care medicine at Toronto Western Hospital, Mount Sinai Hospital and Toronto General Hospital. Here, he talks about why the Omicron-induced wave is unlike anything he’s seen, how hospitals are preparing for a jump in cases and his family’s own brush with Covid over the holidays.
When did you first start to notice the effects of Omicron in your ICUs?
It’s come quite recently. Doctors in Ontario have been following Omicron cases in the community since early December. But predictably, we’ve seen a huge spike in hospitalizations over the last two or three weeks. And now those are translating into ICU admissions. There’s usually a week’s lag between symptoms and hospitalization and another week’s lag between hospitalizations and an ICU stay. We usually had about 130 Covid patients in ICU in Ontario between October to December. This week there are about 600 Covid patients in ICUs provincially.
How is the current wave different from the ones we’ve already experienced?
It’s extra challenging because everybody’s exhausted. People are occasionally breaking down in the middle of their shifts. We’ve had people in tears. It’s been hard. And the fact that some vaccinated people are still getting mild illness has put a lot of strain on our human resources. We’ve had lots of staff members who have had Covid. Normally in most ICUs in Ontario, if a patient is on a ventilator, there is one patient to one nurse. Now, we routinely have two patients on ventilators to every nurse, unless the patient is quite unstable. We also have nurse-led critical response care teams that can be dispatched for emergencies elsewhere in the hospital. But several times we’ve had to send a message out saying there’s no critical care response team nurse available. Many other people have had exposures, often through family members, like unvaccinated children at home. That puts them out of commission for a while, because obviously, they want to avoid spreading Covid in the hospital.
What’s different about the patients you’ve been seeing in the ICUs lately?
Ever since we’ve had a wide rollout of vaccines, the patients we’re seeing are heavily over-represented by unvaccinated people. At Toronto General, we’re seeing the sickest Covid patients because we’re the regional centre for extracorporeal life support—the artificial lung machine that we use when ventilators aren’t working. Like in other waves, some of our patients are older with significant chronic disease or immunosuppression from things like organ transplants. But now we’re also seeing young unvaccinated people, who end up getting very sick. These are healthy people in their 20s, 30s and 40s who didn’t have medical problems before. Some of them are getting severe Covid and are on ventilators for weeks. They think, I’m well and I have a good immune system. Maybe I don’t need to get vaccinated. My chances of getting sick are small. All those facts may be true, but they’re forgetting that they still might be the one in 100 who do get sick. And even if they don’t get super sick themselves, they’re still contributing to the spread of Covid in the community and its effect on other people.
Level with me here: is it at all frustrating to be treating unvaccinated patients nowadays?
It’s frustrating and sad. I think that most people who haven’t been vaccinated are scared, misinformed or don’t have all the facts. And I think that many of them, when they get sick, end up regretting it. They’ve made some miscalculations about what the relative risks of getting Covid are versus the vaccines. Very often, we’ll see that the whole family has made a group decision to remain unvaccinated. The good thing is that once a relative gets Covid, their family members often get vaccinated.
How are staff coping with the surge?
They’re distressed about deciding who to admit when the ICUs are full. We’re delaying fairly urgent surgeries because we don’t have any nurses or space to put people. We might have a patient in the ER who has low blood pressure and is hypotensive who in normal times we would have admitted to the ICU. But now we’re trying to avoid ICU admissions by keeping more patients in the ER and hoping they’ll respond to medications and recover enough to be sent to the medical floor instead.
Physicians usually work a week in the ICU at a time—to do more than that is pretty taxing. But when our regular attendings go into isolation or develop Covid, we have to put a physician on backup call. Everybody’s doing more clinical work because there’s more demand.
At the hospital level, at the beginning of this wave, we had 1,000 staff members at UHN off work every day, half being infected and half being exposed. If you get unlucky and have 30 nurses scheduled to work and suddenly 10 of them are not able to, that’s a one-third reduction in our workforce for the next 12 hours. Our nurse managers are doing a huge amount of work trying to balance out the staff who are available to work at our ICUs. Every day, there’s a request for them to work overtime. Nurses will finish a 12-hour shift and be asked if they can stay for an extra four hours because they’re short-staffed.
Have you started redeploying doctors from other departments?
Yes. So far we’ve welcomed some residents and anaesthetists. Going forward, we’ll be bringing in people who don’t normally do general medicine, like surgeons, endocrinologists and nephrologists, to come to work on the Covid wards or to help in the emergency departments because there are so many visits. Last week, we had nurses normally in cardiac ICU in Toronto General going to the medical-surgical-neuro ICU at Toronto Western. The idea is that redeployed physicians will be working in a similar way that many of our trainee physicians work, under the supervision of an attending physician, since they’d be using skills that they learned during their training but might not have used for five, 10 or 20 years, like putting central lines into veins in the neck or groin or figuring out what are the right settings to use on a mechanical ventilator.
There must be some challenges to that.
There’s some adaptability and training that’s happening there. Some nurses who come from other areas have core skills so ICU nurses can offload some of their tasks. But at times they’ve been overwhelmed by all the new technology that they wouldn’t see on a daily basis, like mechanical ventilation and continuous infusions of medications, or the challenges of looking after patients on extracorporeal life support. Over the course of the pandemic, we have expanded the number of ICU beds, and we’re trying to hire new ICU nurses like crazy. There are lots of relatively junior nurses working in the ICU these days. The nurse administrative team used to be quite demanding about having a certain number of years of experience as a floor nurse before you could even think about applying to the ICU. We’ve had to let those requirements slide a little bit just to have people available to work. And even then we’re still struggling to fill vacancies.
How close are you to capacity within your ICUs?
In our medical surgical ICU at Toronto General, we’re full, but we are not yet into a massive surge. I would characterize what we did in the third wave, in the spring, as a massive surge. Patients were routinely being cared for in non-traditional areas, like the recovery room, or medical bay units that normally wouldn’t have intensive care patients.
And how far away are you from opening up those additional spaces?
That depends on where things go. The thing with Omicron is that the pace of change is much faster than we saw in previous waves. So that slope is much higher. We’re hopeful that this is gonna be a quick up and down scenario, like we’ve seen in some other geographic areas. But we don’t know that for sure, and we don’t know when that’s going to start happening.
How are you coping through all of this?
Well, we had Covid in my house over Christmas. My two-year-old and my almost-six-year-old got it. So we did a lot of outbreak control and N95 mask–wearing at home for a couple of weeks over Christmas. We’re just emerging from that now.
What was it like having Covid in your house after treating it at work for so long?
It made me feel pretty good about my immunity to Covid. Obviously, we were trying to minimize exposure, but I’m sure I had a lot of Covid coughed on me. It’s pretty hard to isolate from your two-year-old. But, touch wood, nobody in my house who had three shots got sick, including my two older teenagers and my wife.
People are reaching their breaking point. How are you feeling about the state of things now?
I actually feel better than I did a year ago. We have effective vaccines. We have a highly vaccinated population. And most of the people who contract Covid, thanks to their vaccinations, are not going to get extremely sick. We know how to manage the disease better than we did a year ago. And the new Pfizer antiviral pill was just approved in Canada. That won’t be helpful for this wave. But maybe it’ll blunt any future peaks that we might see. I’m hopeful that this wave will rise quickly and fall quickly. In another month or two, we might not be out of the pandemic, but we’ll be in a better spot. We’re not going to have a “victory day” of Covid being finished. It’s going to gradually fade into relatively more normal life.
The government plans to reopen gyms, restaurants and movie theatres at the end of the month. Is that a good idea?
I think that’s still time for lots of people to get boosters. But it has to be a combination of having three shots and having the rate in the community come down somewhat. Between Christmas and New Year’s, it seemed like everybody had Covid. When the community rates are that high, even if you’re fully vaccinated, you should still be a little bit worried. I’m hoping they extend the vaccine passport to cover three shots.
This interview has been edited for length and clarity.