Case 38: Two of Twenty-One (COVID-19, II)

*If you’ve already read this, and you’re just looking for an update, scroll all the way down.

March 15, 2020. Unlike the taps inside our ER, this one in the ambulance bay dispenses warm water when I wash my hands. It burns for a few seconds; maybe this is how a snowman feels as it disintegrates on the first day of spring. Soon, my hands are warm but the sensation is fleeting. I dry my hands, put on another pair of gloves, then clean the stethoscope I’ve been using for the last several patients. I’ve been told that these are single use, that I should use a new stethoscope for every patient. But we’re going to see 90 patients at this COVID assessment clinic today, three times what we saw yesterday, and this number will likely grow exponentially. We barely have testing swabs – there’s no way we have enough disposable stethoscopes for everyone.

The cleansing ‘towelettes’ are alcohol based, and my hands become frigid and stiff as I clean the scope’s tubing. I lay the scope onto a clean surface, then change my gloves again. Like everything, glove supply is finite too.

I’m working with Angela, a veteran nurse who is smart, kind, and most importantly, funny. She’s one of the best. “For all I know,” she says, “I have COVID.” She laughs. “My nose is running and I’m chilled and shivering.”

“Me too,” I say. “It’s freezing, out here. I think the idea to set up an assessment center outside the hospital came before we figured out that this virus isn’t airborne.”

None of this was thought out well. The desk I’ve been given is above a sewer grate. Every few seconds I get a waft of waste. And this isn’t just ordinary waste. This is hospital waste. COVID isn’t the only reason I’m wearing a mask.

And although this place is cold and stinky, it’s amazing that this clinic actually exists. On Thursday, in the absence of guidance from Public Health or the government, our E.R.’s leadership threw around ideas. “You think a separate assessment clinic would be a good idea,” our Chief asked. “To keep possible COVID patients with mild symptoms away from vulnerable ones?” The next day, it was set-up, staffed, and running.

“It’s way colder than it was yesterday,” Mike, our security guard says.

“Ready for the next patient?” Angela says.

“Hold on,” Mike says. “Can’t bring in anyone until the ambulance offloads its patient.” Mike isn’t a doctor or nurse, but he’s one of this pandemic’s many unsung heroes. He’s here to help.

The massive entry and exit doors to the garage are closed.  Dividers are set up to make two lanes in our EMS bay – one for ambulances and one for the cars carrying patients into our makeshift drive-through COVID clinic.

Angela shows me the next patient’s chart. “Check out where this guy is from.” I look at the chart. He’s from a town two hours away. “Maybe they couldn’t test him there so he’s looking for testing here.”

A door opens slowly and the ambulance pulls out. Cold air blows in. As he’s been doing all day, Mike gets the make, model, and plate number of the next patient to be seen. He leaves the garage, heads to the parking lot, and knocks on a window. He chats with the driver, then waves him toward the ambulance bay. The entry door opens and my next patient pulls up in a pick-up.

I’m wearing a mask, a face shield, and tight blue gloves. My arms are crossed over my chest for warmth. I’m told I can use one of the cheap yellow gowns, but I’m using one of the thick blue impermeable ones because it’s so cold. And I’m wearing it over my winter jacket. I give the masked driver a thumbs up and motion him to roll down his window. Dave Sterling* is forty-four years old. He works in sales and travels across North America selling high-tech equipment. “I was in Chicago from Monday to Thursday,” he says. “On Friday morning, I got a call saying that I’d had close contact with someone who’s COVID-positive. It’s not like it was intimate contact, not even close contact like in an elevator, but just in the same working space.”

“How do you feel?”

“I was fine,” he says, “until Friday afternoon – two days ago. I started coughing and feeling generally crappy. I don’t know if I’ve had a fever because, well, I’m living in a hotel right now and I don’t have access to a thermometer.”

“You’re living in a hotel?”

“Well here’s my problem,” he says. “I have a nine-year old son who’s on a medication called Tacrolimus for an autoimmune disorder.” I tell him that I’m familiar with Tacrolimus, but that I usually see it prescribed to adults. It’s often used in transplant patients to suppress their immune systems so that they don’t reject their transplanted organs. “So, basically, I’m not going to go home if there’s any chance that I have the virus.”

I ask him a few more questions. David has no medical problems, he’s never had surgery, he doesn’t smoke, and he takes no prescription medications. There are still no firm guidelines on who to swab, I tell him, and I explain that if the guidelines had been followed as sent out by Public Health, then I probably wouldn’t have a swab left even if I wanted to test him. “I understand,” he says. The guidelines, I explain, tell me to swab anyone with a fever, a cough, and a positive travel history. The ‘travel history,’ part is meaningless. The latest document goes on to say that ‘travel history’ is defined by the WHO Situation Report, and, the current situation report lists Canada as a country with local transmission. So if you’re in Canada, you have a positive travel history.

And the constant barrage of emails only makes things more ambiguous. In fact, an hour earlier, I received an email from another hospital at which I hold privileges:

Effective immediately, all staff, physicians and locums who have traveled to any of the countries listed by the WHO as “local transmission” of COVID-19 will not be permitted to return to work and are required to self-isolate for 14 days from the date of your return back to Canada.

An addendum would eventually be sent. The hospital wouldn’t require self-isolation for those inside Canada (otherwise, one interpretation of the original email would suggest that no hospital employee could come to work.)

“So,” I tell him, “I’ve seen twenty patients already today and I’ve only swabbed one patient. We just don’t have enough swabs to -”

I barely finish my sentence when he says it again. “I totally understand.”

I’ve heard this over and over today. I understand. The patients I’ve seen range in age from four to seventy-nine. Some have coughs, some don’t. Some have fevers, some don’t. I’ve looked in ears and throats. I’ve listened to hearts and lungs. I’ve sent one patient into the ER to get his urine checked. I’ve swabbed and tested one patient: a health care worker who needs to get back to work. More than anything, I’ve counselled patients.  I’ve told them that if they have a cough and fever, they should assume they have it and stay home. I’ve told those with underlying illnesses that they’re okay for now, but if they become short of breath, they should come back. I’ve told patients that yes, they may have it, but whether I test them or not, immediate management won’t change. They should go home and isolate. Fortunately, today, the patients I’ve seen with fever and cough have very mild illness.

David has travelled to Chicago, but this is meaningless. If he’d just returned from Italy, that might be a different story. He also barely has a cough and he has no documented fever. Even today, when the triage nurse took his temperature before asking him to go back to his car, he was thirty-six degrees Celsius.

Before my shift, I spoke to Dr. Jimmy*, my colleague who worked the COVID clinic the day before. Like me, he had trouble making decisions. “I probably swabbed some people I shouldn’t have,” he said. “And maybe didn’t swab some I should have.” It’s not life and death. Fortunately, we’re not yet deciding who to ventilate and who to let die. And hopefully, clinics like ours in which we can err on the side of caution and counsel people to self-isolate (regardless of swab results) will help us avoid a situation where we’re overrun by critically ill patients.

I run through guidelines in my head as I have so many times today. I can’t sit down and study an algorithm. And I can’t call a colleague and debate whether or not to swab Mr. Sterling. Like the people who set up this clinic that will help #flattenthecurve, I just don’t have the time. There are a dozen cars waiting outside and more patients registering in the waiting room.

“I’m going to swab you,” I say. “I don’t want you to go home unless you know that you don’t have it.” The virus is no risk to him, but his son is a member of the at-risk population.

He doesn’t say anything, but his eyes are instantly watery. When he does speak, I realize he’s crying. “Thank you,” he says. “Thank you.”

The next day, I call him. “I’ll check the results every day,” I tell him. “The minute the results come back, I’ll let you know.”

Update, March 19, 2020: Swab Result: NEGATIVE for COVID.

Follow ER Tales on Facebook

Follow ER Tales on Instagram

Follow ER Tales on Twitter

or, Subscribe to the blog mailing list

*names changed