Life and Death in the ICU
In the spring, Larry Pancer, a beloved pediatrician from Markham Stouffville Hospital, was admitted with Covid-19. His colleagues were terrified of losing him, and they nearly did—twice
Larry Pancer was hired at Markham Stouffville Hospital more than three decades ago, right after his pediatric training at SickKids. The hospital was brand new, and Pancer remembers holding the first child born there. He and his wife Patricia lived nearby and raised two kids, Ethan, who grew up to become a business professor, and Zach, who became a pediatrician like his father and went to work at his dad’s hospital. Zach and Larry never overlapped—Larry had just retired when his son was hired—but Zach’s colleagues regularly tell him what a joy it was to work with his dad. Larry is a bit of a legend around the place: a warm-hearted extrovert, generous with his wisdom, famous for his dad jokes.
In January of this year, Patricia died of breast cancer. After 37 years of marriage, Larry was trying to figure out what his life would be like without her. Then, just a few months after that devastating loss, while he and his children were still grieving, the unthinkable happened.
Larry Pancer: The first sign was a cough. This was in March. I didn’t have a fever or lose my sense of smell, but I had shortness of breath and chest pain. At the time, not much was known about the coronavirus. What we did know was that the prognosis was much worse for people 65 and older with comorbidity, specifically diabetes. I was 65. I’m also diabetic. My son Zach would call to say, “You’re high risk. Please social distance.” I tried my best, but I was still buying my own groceries. And at that stage, nobody was wearing a mask. My friend had to leave Miami on short notice because the borders were closing, and I picked her up at the airport. I’m not confident that’s how I contracted the virus, but it’s possible.
↑ Zach Pancer, Larry Pancer’s son: I dropped by my dad’s house around March 18. He was walking around with a cough, but he’d had a bit of an ongoing cough for a while. Two days later, he texted me: “Call me when you get a chance.” So I called, and he said, “Don’t panic. I’m in the hospital.”
Larry: I had fainted going to the bathroom in the middle of the night. I woke up next to the sink and thought, Okay, this is a little unusual. I called 911 and told them what had happened, made the bed, got dressed, let my golden retrievers out. When the first responders arrived and found me sitting in the living room, dressed in jeans and a T-shirt, they asked, “Where’s the patient?” I said, “It’s me.” They turned back to the ambulance and said, “Come on out when you’re ready.” I went into the hospital at 4 a.m. It was Markham Stouffville, where I’ve been a pediatrician for more than three decades, so at least it was familiar. Initially, the ER doctors suspected a pulmonary embolism, but a CAT scan showed pneumonia consistent with Covid-19. They swabbed me and admitted me to the general medical floor.
Zach: When Dad called me, we talked like two doctors about it. He told me his symptoms, how they were managing things and what the next steps would be. At the same time, as his son, I was in total shock. The virus had seemed so far away—all numbers and statistics. It felt like it went from TV news to Dad overnight. I wanted to see him, but the hospital had implemented a no-visitor policy. I felt helpless, but I tried to get as much information as I could, for his sake and for my own ability to cope.
Larry: The only other time I can remember patients not having access to family and loved ones was during the SARS outbreak in 2003. Markham was the epicentre of it. Having gone through that, our team knew a lot about how to set up a unit and create protocols for Covid-19. They’re both coronaviruses, but they behave very differently. SARS had a high case fatality rate; Covid is less fatal but significantly more infectious.
↑ Jeya Nadarajah, infectious disease specialist: Markham has a large Chinese-Canadian population, so we were worried that we would get an import of cases from Hubei province, but we didn’t. Then, near the end of February, we learned that a traveller from Iran had tested positive at the Vancouver airport. That shocked us. It was so far outside the epicentre. We knew at that moment that we’d already lost control of the virus. The turning point for the GTA was March 1, when public health identified three local cases involving travellers, one from Egypt and two from Iran. One of the latter group had boarded the Union Pearson Express, then took the GO bus to Richmond Hill. This was a symptomatic carrier who had carried the virus on a 35-kilometre stretch of small, indoor spaces, with lots of cold metal surfaces at the tail end of winter. We knew it would take roughly two weeks before we’d see the results show up in hospital. And sure enough, our first case arrived on March 12. He was a young man with mild symptoms. We sent him home to self-isolate, and three days later, he came back worse and was admitted. The next patient was a woman, and then two days later, Dr. Pancer.
Zach: I had to get tested for Covid because I’d hung out with my dad a few days before he was hospitalized. What if I was an asymptomatic carrier? I work with vulnerable children in the emergency department and I didn’t want to take anything home to my pregnant wife, Mae. Thankfully, I tested negative.
↑ Maelynn Burridge, Larry Pancer’s daughter-in-law: I met Zach in medical school in Australia, where I’m from. I moved to Canada to be with him three years ago. I’m a family doctor in Uxbridge, where I have my own practice. My residency had just ended when Covid arrived. The health network and I agreed to pull me out of the hospital because I was 18 weeks pregnant. It tore me apart. I’d been dreaming of practising for so long. As doctors, we want to be out there to help people. That’s why we’re in our field. And here was the biggest health crisis in my lifetime, and just as everyone was marching forward, I was stepping back. It was a hard call, but given everything the family had already gone through, I just couldn’t imagine if something happened to the baby. Zach’s mom, Patricia, had just passed away. The family couldn’t take any more tragedy.
↑ Subarna Thirugnanam, intensive care physician: When we knew Covid was coming, we moved many patients to another facility and started thinking of how we could create a quick visual system to keep track of the Covid patients in the ICU. There’s a big whiteboard in the staff area, and Vicky suggested we use it. Dr. Pancer was the first name we added.
↑ Vicky Fera, infectious disease specialist: I took care of Larry’s wife about six months before she passed away, and started taking care of Larry the morning after he was admitted. He looked weak and couldn’t breathe very well, but overall didn’t look too bad. I started him on antibiotics and hydroxychloroquine—this was before we knew hydroxychloroquine doesn’t work. Every day I’d check on him and every day, he was getting worse.
Larry: I was able to stand up and go to the bathroom on my own until about day two or three, when my fever shot up to 104ºF and I became delirious. I tried to get out of bed when I shouldn’t have. My blood pressure was unstable and would plummet. On a couple of occasions, I passed out. They moved me to the ICU.
Vicky: Overnight, Larry went from requiring two litres of oxygen to four. That’s ominous. At six litres, you’re put on life support with a breathing machine. Without that, complete lung failure is almost a guarantee. But at that point in the pandemic, we hadn’t done an intubation, and we knew it would be challenging.
Subarna: Intubation is the highest-risk procedure that can happen during Covid. Because coronavirus is so incredibly contagious, we’re working with fewer people in the room and with more protective gear.
Vicky: With Covid, only about two per cent of patients get intubated. For those unlucky few, the prognosis is much worse. There’s so much potential transmission from the air and saliva when you’re putting a tube into someone’s lungs, so the procedure has to be very controlled. I went over to Subarna, the head of our ICU, where our intubations occur, and said, “He doesn’t look good. Are you ready?”
Subarna: Intubations are scary by nature. It’s extra scary when the patient is someone who’s so cherished by the community. In 2013, during my third year at the hospital, I helped organize our staff family Christmas party. I’d heard that Larry sometimes dressed up as Santa to hand out presents to kids. I asked if he’d do it again and he said he’d be happy to. He actually looks like Santa, so it was perfect. He was so funny and made all the kids laugh.
It was so hard to tell him he needed to be intubated. I explained to him what it would be like, even though he already knew. He looked at me and said, “So am I going to make it?” He was crying. I had no idea what to say. I told him, “I wish I could tell you things will be fine. We’re going to do everything possible, but the truth is this is our first time, so we don’t know.”
Vicky: I work in pediatrics, where the outcomes of patients are generally good. Pediatricians tend to think everyone is going to pull through. We’re typically an optimistic bunch.
Subarna: Dr. Pancer became very sad. Very scared. He was expecting two grandkids, one from each son, and he knew that once he went under, he might never come back out. Usually we have these conversations with families in the room, but because no one was allowed in, I asked to use his phone to call his sons. He said, “No, I need time to process this.”
The situation was dire. I was in there for about 30 minutes and could see him getting worse right in front of me. He was having difficulty speaking in full sentences, struggling to catch his breath. I said, “I want you to take the time you need to speak to your children, but I’ll be back in an hour.”
Larry: I was not very with it mentally. I said, “Fine. If that’s what you need to do, that’s what you need to do.”
↑ Anand Doobay, chief of medicine: Larry called me and asked me to give it to him straight. I said, “It sounds like you need to be intubated, but you’re going to be fine. You’ll be back at your chalet in Blue Mountain by July. You’re going to meet your grandkids. It’s going to be a long road, it will be tough, but we’ll take care of you.” We both knew it was possible he could die, but I truly believed he would live. I said so. He didn’t need to hear that he had a 28 per cent chance of dying, or whatever the number was. We didn’t know what the number was anyway, because Covid was so new to us.
Zach: Subarna phoned me and told me that Dad needed to be intubated in the next 20 minutes. She passed the phone to him. In my head, I was thinking about all his risk factors. He was trying to be optimistic, saying, “I’ll see you in 10 days. Don’t worry about it. Don’t get too upset.” I didn’t feel like a doctor anymore. I was talking to my dad, so I said, “Okay, well, I’ll see you in 10 days.” When we hung up, I thought, That was the last time I will speak to my dad.
Subarna: Word had spread among the staff that Larry was about to be intubated. I was getting so many messages from colleagues asking if it was true, if he was going to be okay. But he was my patient and I had to respect his privacy, so I couldn’t say. Then colleagues started coming to the ICU to see him. I tried to play security, but no physician wants to turn away other doctors, so I called our director and said, “You need to send someone to man the doors because we are too busy to do crowd control.”
Larry: I hardly remember this, but just before they put me under, the isolation room in the ICU was filled with people, lots of people—all wearing masks and being safe, of course. I guess the news had gotten out. They were doing everything they could to protect me and to stick with protocols.
Subarna: I asked Larry for his height and weight. He said, “Why do you want to know that? For a casket?” l looked at the respiratory therapist, speechless. I said, “It’s so we give you the right volume of oxygen.” He laughed. He could barely breathe yet he was making jokes.
Larry: I don’t really remember that. What I do remember is the thought that my poor kids would be orphaned, and that they wouldn’t be able to see me before I died. We’re a pretty touchy-feely family, so it was hard enough before I tested positive, during lockdown, not being able to hug each other.
Anand: Subarna had developed the intubation protocol in the months before, running simulations and getting everyone up to speed. She thought out every step—bringing the patient up to the unit, getting them ventilated, inserting the central line, managing personal protective equipment. They moved pumps into the hallways so the nurses could adjust the fluids and IV medications without having to put on all the PPE. Subarna carved herself out as the leader because she knew it needed to be done.
Subarna: Everyone was upset that our PPE was in short supply and we’d have to reuse masks, but I was like, “Guys, at least we have masks.” When I was young, my parents moved us around a lot because of Sri Lanka’s civil war. We spent a lot of time in third-world countries without much access to food and health care. I lived in Zambia during the early days of the HIV pandemic and we had to bring our own syringes for vaccinations because the doctors were reusing needles. I come from nothing, so I was just grateful for everything we did have.
Anand: The preparation for Larry’s intubation took about an hour. There’s a number of things that make Covid intubations more complicated than usual, but number one is the additional PPE. The face shield can fog up so easily and cloud your view, when you literally have seconds to do these things. To maintain our distance from the patients’ mouths, we used a video laryngoscope to help guide the tube through the airways, but if the camera fogs up or gets fluid on it, you’re in trouble.
Subarna: It took roughly 12 people to do Larry’s intubation. There was the anaesthetist, me, a nurse and a respiratory therapist in the room. Outside, another nurse and a respiratory therapist were gowned up and ready to enter in case of cardiac arrest. There was someone working the pump, another two or three releasing drugs and acting as runners in case we needed something. We couldn’t hear each other because the door had to be shut for safety, so we communicated via cellphones in our pockets, under all that PPE, set to speakerphone, and there was another phone for the staff outside.
We huddled beforehand to go over everyone’s roles and play out disaster scenarios—what happens if this happens or if this goes wrong—and work through our backup strategies. I went into Larry’s room, covered head to toe in PPE except for my neck, which was the only part I couldn’t easily cover. I held Larry’s hand and said, “I know this is scary, but we’re going to do everything we can to get you better. You’re very well loved.” Then Larry coughed a big glob of mucus right onto my neck. I thought, Oh, shit. This is not good. I wiped it off, and my staff later poured a bottle of alcohol all over my neck.
Anand: The intubation didn’t go smoothly at first. His oxygen sank to levels that can cause cardiac arrest. We knew that if he died at that stage, it would have been because of something we did. You can’t envision anything more stressful in the medical field. Eventually, we succeeded in getting the tube in.
Larry: Subarna was very caring and knowledgeable. I remember there were dozens of people involved in my care, from endocrinology, because of my diabetes, nephrology, because I had renal failure, infectious diseases for obvious reasons. There were nurses, nutrition specialists, housekeepers and support staff. I can’t name them all. I can’t remember much of the next two weeks, because I was heavily sedated. I had no perception of time while I was out. It could have been two days; it could have been two months.
Subarna: I’m glad he doesn’t remember any of it because I do, and it wasn’t pleasant. The sheer volume of people at our hospital who went through the same things Larry did, and then died with just us there to hold their hand—it’s horrible.
Our hospital got hit so hard early on. We added Larry to the whiteboard on a Tuesday. By Saturday, there were close to 50 names, and we were looking for a second board. We had 18 patients in the ICU by the fourth week of March, while Toronto General had two and Sinai had none. I called the Local Health Integration Network director to say, “You need to take some patients from us. Otherwise we’re going to reach a point where we can’t handle our numbers.” We transferred patients four times. At our peak, the hospital treated 78 Covid patients at once. Twenty-four people died here.
Jeya: Everyone everywhere was at risk, but in many ways Markham Stouffville was right in the middle of it all. The York Region has large diasporas from Iran, Egypt, Italy and all over South and East Asia, and Markham is considered the most diverse city in Canada. Two-thirds of the population are Chinese or South or East Asian. Given all these risk factors, we had to do everything we could to contain the virus before it got to the hospital. We put together a mobile SWAT team—that’s what we called ourselves. Any time someone reported symptoms, we’d band together and go to their house or apartment or long-term care home and swab and so on. We also performed preparedness health checks for staff at long-term care homes.
Anand: At our hospital, the operating rooms and clinics were complete ghost towns, all shut or gone virtual. Our medical floors, however, were the complete opposite, full of patients and medical personnel. We all had the same worries: Are our patients going to survive? Are we going to get it, too?
Subarna: The day Larry and three other Covid patients showed up in the ICU, I didn’t go home, and I didn’t call my kids to say good night. To be honest, I was so busy that I didn’t even think to call them for three straight days. I slept in the call room and texted my husband to drop off food and a change of clothes. When I finally went home, I opened the door and my 12-year-old daughter just collapsed on the floor crying. She thought I had died, even though my husband had tried to reassure her I was alive. All I could do was apologize to her.
We had to be very careful because my parents live with us in an in-law suite. No one went over to visit. I only saw them through the window as I pulled in to the driveway. I would shower at work, put on new clothes, then go straight to the basement to shower and change again. My hair was falling out from overwashing. I tried to live in the basement. Any time I was upstairs, I wore a mask and wiped down anything I touched. I tried to avoid talking to my family about work, but I was constantly on the phone with patients and families, so it was hard to keep things separate.
Zach: Subarna is a superhero. She called me multiple times a day to keep me in the loop. It was hard to not be by his side. We were just at the mercy of this virus. My brother and I started making plans for how to get his family here from Halifax if Dad were to die.
Subarna: Zach is such a gentleman. When we would talk by phone, I could hear the resignation and defeat in his voice, but he never once asked us to break protocol, even though he has privileges at our hospital and could have theoretically shown his badge and gone in at any time.
We were closely monitoring Larry’s condition, watching out for blood clots or kidney failure or bacterial infection. Larry’s kidney function deteriorated quite severely, and as fluid built up around his kidneys, his body ballooned dramatically. That actually had the effect of saving his kidneys. Eventually, he turned a corner, and relied on the machines less and less. Around week two, he woke up. He could recognize me through the glass when I walked past his room. He’d rattle the bedframe to get my attention, and gesture to take his breathing tube out. His kidneys weren’t back to normal and he was still full of fluids, but he required less oxygen, which was a great sign. We extubated him and he looked good. He was awake, looking around, and seemed aware of his surroundings. I asked him a few basic questions, like “Where are you?” and “What year is it?” He thought he was at home in the 1990s, but that didn’t alarm me, because he was heavily medicated.
As I left Larry’s room, I thought about calling Zach. Normally when we remove a breathing tube, we inform the family. But I thought it would be a nice surprise for Larry to FaceTime him directly. I was really upbeat. Every time a Covid patient left the ICU, our staff would line up in the hallway to applaud them on their way out. I thought that the next time I saw Larry, I’d be cheering him on.
But it was just a few minutes later when the nurse called me back in panic. Larry’s lungs had filled up with secretions. He couldn’t cough or clear them on his own. It took us 10 minutes to get back into our PPE. The whole time, I was looking at his oxygen saturation level on the monitor, watching it dip below 75 per cent, beeping louder the further it fell. It was in the low 50s by the time he was reintubated. When I called Zach, I was crying.
Zach: I could hear it in her voice that she was beating herself up. I tried to keep a positive attitude. I told her, “We’ll get it next time.”
Subarna: About three days later, Dr. Pancer looked ready to be extubated again. My colleagues were surprised to hear it because of how badly it had gone the first time. But everything had improved: his breathing, swelling and physical strength. It went a lot more smoothly this time, so I left to check on our other patients. I knew he was in good hands.
Larry: My nurse asked me a few questions to orient me to my person, place and time. I knew my name. But when they asked where I was, I said, “I’m at my cottage in Thornbury, in the basement, lying in bed with my arm around my wife.” It was so vivid. I could actually feel Patricia on my arm. We were just lying in bed, very peaceful, very quiet, in our little utopia. A place that I love, with the woman I love.
She said, “Look around you.” The hospital room appeared, and I could see staff walking around in face shields. I was happy to be off life support but heartbroken all over again to realize Patricia wasn’t there.
Vicky: Larry asked me what had happened. I said, “Well, you were our longest-intubated patient.” He said, “Vicky, that’s not something to be proud of!” It was back to the old Larry.
Zach: Dr. Doobay helped Dad FaceTime me. I had grown accustomed to preparing myself emotionally every time my phone rang. It might be the worst news ever or the best. Dr. Doobay was in full PPE—face mask, shield, goggles, the whole thing—holding a phone so Dad could talk to me. I was at work in the emergency department in my full PPE. We could barely hear each other, but I could see things were going the right way.
Larry: When they wheeled me through the ICU, there were so many people applauding with tears in their eyes. I had no idea how sick I’d been until I saw how emotional it made them to see me recover. Physicians care a lot more about our patients than people realize. They worked so hard on my behalf. It wasn’t because I was a colleague. It’s because the culture there is to try your absolute best to do what’s right.
I was in rehab for over a week, working on walking, swallowing, speaking. Subarna visited me the day I arrived, on her way home. She had to get back into full PPE just to say hello, but I could see she was smiling and a little teary-eyed. She wanted me to know that my improvement would be gradual. It takes about seven days of recovery for every day on life support. I was intubated for 17 days, so she said I should expect it to take four months.
Subarna: I sat with him and he reminded me that he was expecting two grandchildren that summer. I told him about the dark jokes he was making just before we ventilated him. He couldn’t remember a thing. He just laughed and laughed. I didn’t stay long. I’d been up all night and needed to go home to my family.
On the way to my car, I passed by a trail of painted pebbles that children in the community had made, leading from the doors to the parking lot. They had messages on them, like “You are brave” and “Don’t give up.” It reminded me why we were doing this, for all of us to stay strong, get better and be healthy.
I had a few days off at the end of April, and when I came back to work, I looked at the whiteboard and said, “Wow, there’s white on it again.” We’d passed the peak of over 600 active cases in York Region, of which about a third were in our hospital’s care. We’d gone from 30 new inpatients every day in mid-April to a handful less than a month later. As time went on, I moved back upstairs. My kids were so happy for me to read to them in bed again.
Vicky: Our numbers are so low now that it literally feels like we dreamed it all up. And yet we’re already admitting second-wave patients.
Zach: We celebrated Dad leaving the ICU, but the relief quickly turned to stress. We weren’t sure about him leaving rehab so soon. He was walking with a cane and could only climb a stair or two before losing his breath. But he felt strongly about being home with his dogs, doing things at his own pace and just having a sense of normalcy again. We needed to make a lot of modifications to his home.
Larry: There was a hospital bed in my dining room. Multiple services were sent to my house every day. It was well coordinated and so nice to be back in my own place.
The whole time I was in care, I was trying to get my hands on a Diet Coke. I wasn’t able to in rehab because I would aspirate and choke. Everything had to be thickened for me. But by the time I came home, I could swallow fluids. I was so excited to find cans waiting for me in the fridge—but I couldn’t lift the tab. I didn’t have the strength.
Zach: We didn’t know how he’d cope, not just because of the physical stuff—cooking, taking a shower, looking after his dogs—but because this was the first time in nearly 40 years without Mom. How would he cope with the loneliness? I wasn’t ready to have direct interaction with him because Mae was still pregnant and I was still working with children. I’d just drop things off outside his house—food, stuff for the dogs, Diet Cokes. Finally, after his two Covid test results came back negative, I paid him a proper visit.
Larry: Oh my god, what a huge release it was to finally hug my son. I’m on a puffer today, and I still get short of breath very easily. Just sitting on a couch and talking to someone on the phone for an hour will tire me out. I’m as productive as I can be. I walk my dogs, carry my own groceries. I’m working again in a clinic a couple of half-days per week. But my improvement has plateaued. I have a barky cough, and a CAT scan showed I have a narrowing of nerve pathways in the spine, called stenosis. Everybody’s recovery from Covid is unique. I’m just happy to be vertical and above ground.
The first half of 2020 sucked and couldn’t have been worse. The second half couldn’t have been better. My grandson Luke was born in July, and my granddaughter Violet three weeks later. Her middle name is Patricia.
Zach: We surprised him with our daughter’s middle name when he came to meet her. Dad held her in his arms for three hours. It was love at first sight.
Larry: You couldn’t take her away from me.
This story appears in the October 2020 issue of Toronto Life magazine. To subscribe, for just $29.95 a year, click here.