Monday, March 23
Sarah says it feels like I’m going off to war. A week ago, my boss, Steve, called to tell me it was official: for the next two weeks, I will be the ward physician for every Covid patient at the hospital outside of the intensive care unit. The situation feels especially grave today, with the number of Covid cases in Canada now over 2,000 and the premier shutting down all non-essential businesses. I’ve spent the week reviewing all the Covid materials I can find, watching and rewatching videos of how to don and doff the mask, gloves and gown, and when I force myself to pause, I’ve been taking deep breaths. But I am so nervous and have no idea what to expect. My colleagues are all anxious about the anticipated surge. The hospital has only a few confirmed Covid patients right now, but there may be a rapid influx over the next two weeks. I hope we’ll be ready. My friends have been reaching out to thank me for my service and wish me good health, which makes me feel even more like I’m shipping out tomorrow. I’ve never before feared for my life going to work. But I am afraid.
Every night, Etai, like most toddlers, asks us to read him a different book before bed, but for the past week he has chosen the same one before every nap and sleep. It’s called When You Are Brave, and it’s all about summoning courage when the world feels bleak and scary and overwhelming. When Sarah and I read it to him, neither of us can fully hold back tears, since it’s all too on the nose. Etai happily points out the cars and the little girl moving to a new city, and at the end of the book, the three of us feel so much catharsis that he never asks to read a second book. He’s two years old, so maybe he just likes the pretty pictures, but maybe he also knows exactly what I need.
Sarah is helping me prepare. I shaved off my beard so an N95 will make a tight seal on my face. We’ve put hand sanitizer by the door for when I come home, and I’ll zip straight to the basement to launder all my clothes and even my backpack before I get into the shower. In the morning, I’m going to bike to the hospital in a pair of scrubs, then change into a fresh set when I arrive. I’m going to wipe down my entire office before putting anything down. I’m going to put my cellphone in a clear plastic bag. I’m going to wear my dad’s old surgical scrub cap. I’m going to change my shoes. I’m going to put on a mask, a face shield, a gown and gloves, and then I’m going to see the most feared patients in the entire world.
Tuesday, March 24
“Just speak to the patients like humans,” Steve advised me this morning. “Don’t use your stethoscope—it’s of little diagnostic value and will put you at higher risk of getting infected. Don’t go too close if you don’t have to. You don’t even need to spend that much time with them. They don’t want to infect you. These people are scared, and they’re lonely, and isolated, and we don’t have any proven treatments for them. The best thing you can do for them is speak like a human and show you care.”
Steve attended on the ward for the week before me, and his advice was exactly right. One of my patients, a young man in his 30s, had just been diagnosed with Covid, and he was trembling with fear. Originally from Ecuador, he was struggling using only English. I could tell he was terrified he might misunderstand the information he needed to get better. When I switched into Spanish, he almost wept with gratitude. His wife is six months pregnant with their first child, and he told me that all he wants is to be able to be there when his son is born—then I almost wept, too.
The nurse called me about another patient, a rabbi in his 50s, who had a low oxygen saturation. I rushed to his bedside. “How are you feeling?” I asked. “Fine,” he shrugged. “Any shortness of breath?” “No,” he replied. His long beard made it hard to assess his neck veins and respiratory muscles, but besides looking weak, he appeared to have no trouble breathing. Yet no matter how much we increased his oxygen, he still had a low saturation. Despite him feeling and looking well, I worried he was in fact rapidly getting worse. I called the ICU and they agreed. They intubated him, put him on a ventilator and spirited him away. Two more of my patients also went into respiratory failure and needed to go to the ICU today. This disease is tricky and deadly and I am filled with frustration. Too many of my patients are young, and I want so badly to make them better. But with no specific treatment for Covid, all I have to give is compassion.
Even though I have some very sick patients on my ward, I feel a lot better than I did yesterday. The anticipation is always worse than the actual thing. I hope the same is true with the dreaded Covid surge.
Wednesday, March 25
The hospital feels toxic. I love the hospital and I love my work, but now, every surface and space feels radioactive. I am so tense, every moment. On the ward, I am neurotically careful, constantly aware of what has touched what. If I get a phone call or want to read a text, I leap up and wash my hands before touching my phone. Each patient I visit, I perform the ritual: get a squeeze of hand sanitizer, carefully carry out the nine steps of handwashing, put the mask on, then the face shield, then wash my hands again. Then put the gown on, then the gloves. See the patient. Remove the gloves, first touching only the outside of one glove, and then, with my bare hand, touching only the inside of the other. Remove the gown. Wash my hands. Remove the face shield. Wash my hands. Remove the mask. Wash my hands. Wash my hands. Wash my hands. Even in my own office at the hospital, I am apprehensive, upright, sitting at attention. I already wiped down every surface I could think of, but still. I type on the keyboard. I wash my hands. I touch the phone. I wash my hands. I talk only on speakerphone now so I don’t have to lift the phone to my ear. I thought I could be extra-vigilant at work, then come home, go to the basement, wash my hands, strip off my clothes, shower and then relax. Put my feet up. But I can’t. I have become toxic. Everything I touch turns to poison. I read an article this evening about cellphones being a vector of the virus and how to properly clean them, and I looked over at my own phone in horror. It didn’t matter that I kept it in a plastic bag all day, only taking it out before I left for the day. I felt that I had brought noxious blight into our home. I had a nauseating feeling in my stomach all night.
My parents called and asked me a thousand questions about how I was staying safe. As physicians, they both lived through SARS in the hospitals. I remember when Dad diagnosed a patient with SARS and needed to quarantine in our basement after being exposed. They’re worried for my safety. I let them ask, and I answered every question to try to put them at ease, but I could feel myself becoming more and more anxious as I absorbed their anxiety. Every muscle in my body is tight from the effort, and I can’t relax.
Thursday, March 26
I am so paranoid. When I went to put on a gown before seeing a patient, I washed my hands, opened the gown drawer and put the gown on, which I tied in the back. Then I realized I had touched the drawer and then touched my neck as I tied the gown, and I got that feeling in the pit of my stomach, like I had been compromised. I imagined in exquisite detail another person coughing on their hand, touching the drawer, then the microscopic virus ending up on me. I can’t help but let the thought metastasize—this is how I infect myself, then those I love, with horrific consequences. This afternoon, I saw a woman who works as custodial staff with the Environmental Services department pushing her cart of cleaning supplies around, and she stopped to wipe down each of the drawer handles of the cart that holds the gloves and gowns. I was so overwhelmed with gratitude I almost wept right in front of her. I said to her, “Thank you for your hard work. I’ve never felt so relieved to see something get cleaned,” and she smiled broadly. I have honestly never taken note of the cleaning staff as they work before, but the pandemic brings the hard work of the unsung on the front lines—grocery clerks, delivery people, cleaning services—into sharp relief. I’ve been incessantly thanking the nurses, too, some of whom have been conscripted to work with me on the ward, but many of whom are volunteers. Absolute heroes. And they see the patients many more times than I do, sometimes every two hours to check vital signs. If I don’t have a feeling of dread in the pit of my stomach, I have a lump in my throat from being about to cry.
I was thrilled today to see that my Ecuadorian patient is off oxygen and feeling better. I need all the positivity I can get. I went into his room expecting him to be happy to go home, alive and ready to become a father, but he looked just as fearful as the day we met. “I’m afraid I’ll give the virus to my wife,” he said. “Oh,” I said, realizing he was right to worry, since he’s less than 14 days after symptom onset and is still likely to be infectious. “Can you isolate yourself from her at home? Can she stay with friends or family?” I asked him. He shook his head. “I told my whole family in Ecuador about you, Dr. Ariel,” he said. “They are sending blessings to me and to you. But they are all in Ecuador. We have no one here.” The ward’s social worker is now looking for a solution. The couple can’t afford a hotel. They live in a one-bedroom apartment. Even if his wife slept in the living room and he in the bedroom, they only have one bathroom, and she could catch it from an infected surface there. I am happy to keep him in hospital until 14 days are up, but I know that for him, every moment isolated here is agonizing. He is so polite, so considerate, but he was so frustrated that he could barely contain his anguish. “I have to just wait here… I can’t believe I can’t go home to my wife because we only have one bathroom,” he said. I never thought that someone’s ability to reunite with their family would hinge on one trivial question, one I’ve added to my Covid physician standard of practice: “Does your place have more than one bathroom?”
Friday, March 27
Yesterday I admitted a dentist in his 40s. He had a fainting episode last night, and joked this morning, “The economy is collapsing and now I am too.” He is on Day 10 after symptom onset and is requiring more and more oxygen, becoming more short of breath. He’s panicky and frustrated. “I was feeling better earlier in the week, and now I’m getting worse. I thought I was getting over it!” he said. I explained to him that with Covid, the period of highest risk for respiratory failure is between days eight and 13. I told him if we make it to Tuesday, Day 14, we’ll be in the clear. I told him we were going to get through this together. He nodded and smiled weakly, his nasal prongs limiting the breadth of his smile. I’m worried about him.
My colleagues are so supportive, reaching out to me and seeing how I’m doing, thanking me for managing the Covid ward. Truth is, I didn’t volunteer for this position. I also didn’t decline it when offered the chance. At 32, I’m one of the youngest docs in the division and I’m healthy, so anyone who takes over from me is likely to have a higher risk of mortality should they contract the virus. When my colleagues hear about my younger patients, like the dentist, they wince and say, “I don’t want to know that. Don’t tell me that.” What they mean is, That could be me. I feel like I have to stay healthy and safe, not just for me, not just for Sarah and Etai, but for my colleagues, who were my teachers just a few years ago—an unexpected reversal of responsibility. I guess their thanks mean they realize that, too.
Steve, in his capacity as division director, has asked me to cover the weekend shifts of my colleague Mark, who is particularly distressed by the pandemic, and with good reason. During the height of the SARS outbreak, he worked a single shift on a ward of infected patients. Forty-eight hours later, he developed a fever and a sinking feeling that he might have gotten it. He had. Two days after that, he was admitted to hospital, where he stayed for three weeks. He had plenty of time to ruminate on what he could have done wrong. Like me, he went over every detail of his day on the SARS ward. Had his mask slipped? Had he taken off the gown incorrectly? Had he inadvertently touched his face? He didn’t want the nurses to have to keep visiting him, risking their health every time, so he took his own vitals. The doctors caring for him were his colleagues, looking after him as a patient but fearing for him as a dear friend. Mark kept getting fevers and had trouble breathing. He could tell that his colleagues couldn’t bring themselves to admit he was getting sicker. His breathing worsened, his chest X-ray got worse, and ICU was consulted. He thought he was going to die. In his mind, he renounced his worldly possessions. Health was all that mattered. He mourned his children’s loss of a father, his wife’s loss of a husband, and hoped they would get by after he was gone. He came very close to needing to be intubated. It was only when his fever broke that he realized he might survive. Gaunt, weak, but alive, he was discharged from the ward. The same ward that 17 years later has become the Covid ward. My ward.
Mark asked Steve not to put him on the Covid or medicine wards during the pandemic, and Steve understood completely. But with pain and a touch of torment, Mark told me, “I am also conflicted. If I don’t do it, someone else will.” The lessons he learned, of constant vigilance, of taking nothing for granted, of the supreme value of health and of appreciating waking up each day, I hope to take to heart—without having to become a patient on my own ward.
“Stay safe,” he said, like everyone says nowadays. I knew he meant it.
Saturday, March 28
Today was awful. Two days ago, after discussing a patient of mine with the infection prevention and control team, I discontinued isolation precautions and transferred her off the Covid ward to my colleague Ayelet’s general medicine ward. She had come in with pneumonia but quickly improved on antibiotics, and her swab for viruses came back negative. Today I learned that after arriving on Ayelet’s ward, she became sick again, was reswabbed, and tested positive for Covid. The original swab was a false negative—this patient likely had Covid all along, and the virus was hiding from our test. As a result, Ayelet and her entire team, along with nurses, physiotherapists, porters and anyone else who had contact with the patient, must now self-isolate for 14 days. They have to separate from their families, hole up in their basement or in a hotel, find a way to get food delivered, and sit with the fear that they might develop symptoms of the virus…and I feel partly responsible for having let my guard down. Like a Trojan horse, this damn virus sneaks in, hidden in non-specific symptoms and seemingly healthy patients. Now we’re forced to close the gates, shut everything out and suspect everyone, including ourselves.
Fourteen days is the longest Covid can incubate in a person before they develop symptoms, so it is the sentence for those unlucky enough to be exposed. Ayelet is devastated to be away from her husband and three children for 14 days, to have to be apart from them for the Passover Seders. I am devastated to have put her at risk. She has texted me, “Not your fault dude,” and, “I would never blame you,” several times. Still, it’s hard not to doubt my clinical judgment. During my training, I became used to the sometimes negative consequences of my clinical decisions. But I am not used to those decisions putting my colleagues and loved ones at risk. How can I ever be?
I am already so, so tired. I have cared for many more patients per day, been on service for more days at a time, worked 26-hour call shifts, and yet the mental effort of keeping track of my every touch and movement, the psychological pressure, the fear, is already taking its toll. Every evening after Sarah and I have put Etai to bed, I collapse onto a chair and wonder whether the severe fatigue and pressure in my head is Covid or just plain exhaustion. It’s like running a marathon underwater—how much longer can I go on like this?
Sunday, March 29
For a week I have been the Covid ward doc. Now I am a Covid ward doc. We had an influx of patients overnight, so they called in Ed to take over a second Covid team. As a veteran of the SARS outbreak, Ed will feel more prepared going into this than I did. This may be the surge we have been bracing for.
Steve keeps telling me that the safest place in the hospital is, ironically, the Covid ward. We don’t fear that our patients could have Covid—we know they have it. I didn’t fully understand or believe this until today. This weekend, while covering Mark’s patients, I rounded on a post-op patient to check on his blood sugar. “By the way,” I asked him, “any shortness of breath?” “Yes,” he answered. To my horror, he also answered yes to trouble with smell and taste. I freaked out. I hadn’t been wearing my full PPE when I saw him. I ordered him a viral swab, asked the nurses to put him in isolation, and apologized for ruining their day. I contemplated not going home and instead going straight into quarantine in a hotel or in our basement. But I know how hard social distancing has been on Sarah, trying to constantly entertain a toddler on her own, and I know she really appreciates when I’m there to share the load in the evenings. I called my infectious diseases colleague. He was out for a run, working off the stress of the exposures from yesterday. He calmed me down—I had only been in the room for a minute, after all, and we could wait for the patient’s swab result.
At home, decontaminating in the shower, I suddenly realized that I saw that same patient yesterday, too. I’d chatted with him for almost 10 minutes at close range. I freaked out again. I decided I wouldn’t go near my family for fear of infecting them. Poor Etai ran to hug me, and when I kept my distance, he was so upset and confused. I called my colleague back. “I thought I was doing so well,” I quavered. “I’ve been so careful on the Covid ward, and I leave to see one single patient…” His voice was measured and gentle. “Yesterday he was asymptomatic, and you made the right decision. It doesn’t change the calculus. This is why we have universal masking. Let’s wait for the patient’s swab to come back and go from there.” I thanked him. I’ll act like I’m not infected. But I can’t shake the dread that I could be. I hope the swab result comes back quickly.
Monday, March 30
The dentist was intubated this morning, Day 13 after symptom onset. I’m devastated. Each day his oxygen was up and down, but we were so close to Day 14, so close to being in the clear. We didn’t make it. I’m having visions of my colleagues ending up on my ward, sharing his fate. This virus is a bastard. And each day seems to bring new horrors.
Tuesday, March 31
I sent an opera singer home yesterday. A man in his 70s, thin and dizzyingly tall, he had come in last week with severe fatigue and a chest X-ray that looked like Covid. His first swab was negative, but his symptoms were too compelling to dismiss. Lo and behold, the second swab came back positive for Covid (I hate this test). The disease did a number on him, gave him such severe fatigue that he couldn’t walk a step or stomach any food. I worried he would get worse, so I brought up the potential need for intubation and whether he would want us to do that if he couldn’t breathe on his own, or if we should let him die peacefully. “I want to live,” he said, “but I also want to sing. Please, if I need the tube, please be careful. Don’t damage my vocal cords.” He is retiring this summer and was all set to have a series of send-off concerts and parties. “It was supposed to be my swan song… too bad,” he lamented. The one thing we all have in common—lost opportunities. “Maybe in the fall…” I tried to be optimistic, but it’s so easy to despair nowadays.
After a few days in hospital, the opera singer was doing well and off oxygen. I sent him home yesterday, and now I feel sick about it. He was on Day 10 of symptoms, walking better and ready to go home by any clinical metric I could assess, but now I’m having nightmares that, like my young dentist, he will hit the dangerous days 11, 12, 13 and become silently hypoxic. Isolated at home away from his wife, he could secretly die. I could have monitored him for longer in hospital, justified it somehow. Instead, he’s at home. Covid has completely shattered my confidence in my clinical decision-making.
Wednesday, April 1
Today the number of Covid patients went up again, so they called in Zac to become Covid doc number three. As the father of three young children, Zac decided he would isolate in his basement while on service because it felt like the right thing to do, but he’s torn up about it. He’s not sure if it’s actually necessary, and his wife and kids saw him off with tears this morning. The surge continues. The future is a black box, murky and foreboding.
Thursday, April 2
Steve gave me the day off today. It’s not unusual during normal times to work 14 days straight, so I told him I could keep going, but he insisted I take a break. It was nice to spend the whole day with Sarah and Etai. It was nice not to have to shave my face this morning. We ate lunch together, biked around our neighbourhood, and Sarah took a nap while Etai and I went for a stroller walk. We ran into a friend who was out for a run, and when she saw me, she sprang back as if struck by a force field. She thanked me for my service while inching away, then ran off. It is possible to be considered both a hero and a pariah simultaneously.
I felt weirdly detached today, like I was yanked from the centre of the maelstrom to a calm, faraway island. It was a relief to be out of the fray, but I felt guilty for not being there. Sarah’s been all alone caring for Etai and really deserves a day off, too. She says she wouldn’t have made it without having me home today, but I don’t believe her. She’s an absolute hero and she’s my everything.
Our neighbours have been really wonderful too, reaching out to help with groceries and errands. This evening we found a bottle of wine on our stoop—no note, no card, just anonymous kindness.
Friday, April 3
I’ve been calling the opera singer every day since he went home, and he’s getting better, thank god. Today is Day 14 after symptom onset, so he’s in the clear! It means the end of isolation from his wife as well. He thanked me profusely. “You’ve been so kind to me, you’re such a good boy, checking up on me, I just can’t believe it, your family should stay healthy and are so lucky and I’m so lucky to have met you—” and he became so overcome, it sounded like he was about to cry. He quickly excused himself and hung up. I was touched, but I feel like I did nothing for him but pay attention. Like William Osler at the bedside, I offered no treatments, just a bit of care. Gratifying… as long as the patients get better on their own.
More good news: the dentist was successfully extubated in the ICU yesterday and came back to my ward today. He looks like he has been through an ordeal, but he survived. He is still weak, still needing a bit of oxygen, but he’s no longer short of breath. He’s also no longer joking around. He has the fear in him now, the anxiety of someone who has come so close to death, looked over the side, for one moment about to plunge, and then pulled back from the cliff edge. I am so happy to have him back. My colleagues have been asking about him, so I can tell they’re happy too. There’s hope on the other side.
The number of patients has eased up a bit, so much so that we sent Zac home today. Back to two Covid docs. And I finally checked on the post-op patient’s swab, and it came back a few days ago as negative. Still more good news. So relieved. I’m starting to think I’m getting the hang of this.
Saturday, April 4
Sarah says that Etai is terribly lonely at home. When they go for walks, he beckons to each stranger they pass on the sidewalk, “Come play, come play.” One on one with Sarah all day, his language has exploded (he can count to 10! but skips five and seven), which is wonderful. Still, Sarah and I can’t help but be worried. What does it do to a kid developmentally to be so isolated? More and more, he pretends his stuffed animals are his friends. He insists on bringing them everywhere, in increasing numbers—at least they don’t radiate fear like we do. When I get home before his bedtime, he runs up and directs me, having learned my routine. “Daddy wash hands,” he instructs. “Daddy shower.” I skirt and dodge him, but he’s not afraid to get close. Once I’m clean and dressed, I kiss and hug him, because not doing so would be too painful. “Smile Daddy,” he says, and I dutifully obey.
Sunday, April 5
Visitors aren’t allowed in the hospital anymore. I feel awful for our isolated patients, even more so for the ones who are dying alone, never to see or be seen by their family again. The nurses, saints that they are, bring iPads into patients’ rooms to facilitate chats with their families. One woman dying of Covid was able to talk to her family for an hour today. She’s too weak to lift the tablet herself, so her nurse stayed by her side the whole time. There’s no way for me to meaningfully document that in her chart, but it’s by far the most significant thing we’ve been able to do for her.
Monday, April 6
To my horror, I’ve realized something unimaginable—I got used to being a Covid doctor. What was at first frantic handwashing, fraught clothes-laundering and showering the toxicity off like Lady Macbeth has become a calm ritual. I did what I had to do. I handed over to my successor, telling him about the patients on the ward and how the ward runs, and in his quavering voice I recognized all the stress I had shouldered two very long weeks ago. My subconscious, on the other hand, still feels the danger pressing in. Last night, I dreamt I had a sore throat. A simple dream. “Well, this is it,” I thought. “Guess I have to go into quarantine. Guess I got it after all, despite all my precautions.” Then I woke up and swallowed. I felt fine. I feel fine. At a time like this, feeling fine feels subversive, too.
I called the opera singer one last time today, Day 17 after symptom onset. He was feeling better, happy to be back with his wife. He got choked up again but this time didn’t hang up on me. “Come to my concert in the fall, doc,” he said in a hoarse voice.
I discharged the dentist today, Day 19 after symptom onset—in good health if not high spirits, grateful to be alive but somehow not unscathed. I am on Day 14 of my own Covid tour of duty. I feel okay—I get to take some time with my family, but I also feel like I’ve been through an ordeal. I was much luckier than health care colleagues in Lombardy and New York and other places that have so far been hit harder than Toronto. We are all praying that we are spared that fate, but you never know. Many of my colleagues will take my place and become Covid doctors before this is all over. Heck, I’ll be back on the ward in a week. I can feel the fear creeping back in. I hope I can show Etai what it’s like to be brave. Or maybe he’ll continue to be the one to show me.
All individuals depicted with identifying features have given permission to be featured.