Front Burner - One doctor's view from the ER during the coronavirus pandemic

Episode Date: April 13, 2020

Dr. Brian Goldman is seeing more coronavirus cases at the emergency department of the Toronto hospital in which he works. Today on Front Burner, Dr. Goldman describes a shift in the pandemic, from the intense intubations, to the discomfort of the required personal protective equipment, to the compassion of younger colleagues concerned for his health.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hello, I'm Jamie Poisson. That's the sound of the nightly thank you that rings out in neighborhoods across the country. It's a sign of appreciation to medical workers, those on the front lines of the coronavirus pandemic. Doctors, physicians, assistants, nurses have a unique, up-close, and personal perspective on COVID-19. And they are, of course, at risk of contracting

the illness themselves. Today, I'm talking to my colleague, Dr. Ryan Goldman, the host of CBC's White Coat, Black Art, a new podcast, The Dose, and an emergency room doctor here in Toronto. I actually don't know how he finds the time to do it all. But we're going to talk today about what it's like to do his job right now. This is FrontBurner. Dr. Goldman, I feel like we're all asking this question in a much more sincere way these days, but how are you? How are you doing? I'm doing fine, Jamie, and thanks for asking. A lot of people are asking me how I'm doing these days. I guess they're worried. This is a completely new normal. And I guess the best thing I can say about the situation,

other than saying we're all in this together, is that I have experience. I'm old enough to remember and have participated in SARS. So I remember what it was like to gown up and glove up and wear N95 masks. These health workers are taking precautions as they treat two of the infected patients at a Toronto hospital. This health supply store owner would normally sell

about 20 face masks a month. He sold more than 100,000 in a week and a half. We've got another 50,000 masks being delivered tomorrow. So this is not completely unfamiliar to me, but certainly the scale of it is much greater than it was for SARS. And, you know, I'm doing okay. Put it that way. I'm really glad to hear that you've been doing okay. I've been thinking about you, actually. I know that you were working in the emergency department at a downtown Toronto hospital this weekend, Mount Sinai. And what was going through your mind when you walked through the doors of the hospital to start that shift?

What was going through my mind is basically, am I ready? The practice is changing on an almost daily basis as the number of patients with COVID-19 goes up. We started off with basically, you know, experiencing no COVID patients and then a lot of the usual kinds of non-COVID patients who come to the emergency department just almost stopping, coming to a stop. Fewer heart attacks, fewer people with strokes, people weren't getting into trouble and falling and tripping and breaking their arms. And then as the numbers started to go up, we were preparing ourselves for what would be an onslaught of patients in severe respiratory distress. And we've been drilling, doing simulations. But there is no, Jamie, there is no substitute for actually

digging in and doing it. And so this is an extension of what I've always felt. When it's been five or six days since my last shift, I'm always apprehensive when I walk through the doors. That apprehension, can I handle the first crisis that hits? And especially, we're receiving, you know, we're on email chains where we're hearing about every badass resuscitation and how everybody's doing, you know, and how they're energized by doing it. And you're just waiting for your chance to have your first one. And then when you do it, you feel a lot better. Can you tell me a little bit more about this email chain?

So, like, what's an example of an email that would come through about a badass resuscitation? Well, you know, what we're doing as we are learning about, you know, there's the theory of protected code blue. Basically, in a protected code blue situation, we make the decision that this patient's in severe respiratory distress. And so all the guidelines right now are saying early intubation, put them on a ventilator early. And that means assembling a team, actually two teams. There's the team that goes into the room where the patient will be placed. And we are the ones who wear the virtual hazmat suits with the face shields and the head covers and the neck bibs. And then what you

do is you give the patient, so the people inside the room, there's an intubator, there's a person who puts the patient on the breathing tube, they give the medications which have arrived in pre-filled syringes, and then they proceed to use an instrument called a glide scope to intubate the patient on a video monitor. And the idea is like every step is designed to reduce the amount of coughing and choking by the patient, which would spew more virus. That's the dangerous moment when virus particles get aerosolized. And I know I'm talking a lot of tech talk here, but it is an intricate procedure. There is a routine for donning your hazmat suit, your protective gear, and there is a routine for doffing when you're finished. And you don't want to miss a step or get it wrong. That's why you have a monitor. So until we had our first one, we were doing simulation training. Once we started,

once we got to the first one, and then the second one or the third one, people do reports. They send an email to the group of physicians and nurses and other allied health care providers and describing what happened. Did you have a protected code blue on the shift that you just worked? Yeah, I did. Now, I'm not going to violate patient confidentiality, but I will say we had one. And, you know, happy to say that the team performed admirably. You know, everybody did their jobs. People were collegial. They were responsive. And, you know, when you have a lot of eyes on the problem, you have a lot of really, really helpful suggestions. And that's what happened. You mentioned that you're wearing like hazmat suits and 95 masks, all this protective equipment, personal protective equipment.

What is it like to be wearing that for hours on end? Well, we're not wearing them for hours on end. But yeah, so we're only using the hazmat suit, you know, the special gown that has less penetration of liquids and the proper face shield with the neck bib and the head cover and the N95 mask. We're only wearing those when we're in a protected code blue situation. For all the rest of the situations, you know, patients where we're going in and out of rooms, we wear a gown, which we, so we don a gown, single set of gloves over the sleeves, a face shield, a surgical mask, not an N95 mask. So we go into the room and see the patient. When we leave the sleeves, a face shield, a surgical mask, not an N95 mask. So we go into the room and see the patient. When we leave the room, we doff in a very specific order with lots of

hand washing in between. And so we keep changing those, the gown and the face shield as we need them and the gloves, not the mask, because we receive a set number of masks per shift. And so we have to be careful about those. And we're only going to change that mask when it's become obviously soiled, if somebody's coughed on us, which we hope doesn't happen very often. Now, so you asked how it feels. Yeah, I mean, you see all these photographs of people with bruises or marks all over their faces. It looks uncomfortable.

Yeah, so I hope it's not too much bruising. What you're talking about are the elastic marks or the marks of the mask tightly fitting around your mouth and nose. You probably want a mark there because that's your kind of good housekeeping seal of approval that it's sealed properly. But you're right, it's uncomfortable. The heat is incredible. No question when you're wearing the full, you know, the full hazmat suit, the full protected code blue, it's hot. It's really hot in there. And, you know, you can't have air conditioning in that room for obvious reasons. You don't want to spew the virus. You don't want to aerosolize particles of the virus. You just have to kind of tough it out. Okay. You mentioned you have a set number of masks. You know, what is your sense of how well stocked the hospitals are right now with PPE? Well, I know that I can't speak for every hospital. I can say that, you know, I've never felt, you know, personally where I work, I've never felt any lack of personal protective equipment.

I think that any limitation on the number of surgical masks is based on what we know about the current risk based on the number of patients that we're seeing with COVID-19. And it's based on evidence of what's actually necessary. So I personally am not worried. I can't speak for other hospitals. And as you, as we've all heard, some hospitals are concerned that they may be days away from running out. And startling new numbers tonight from the Ontario Nurses Association. They tell us the government is maintaining an average five-day supply of personal protective equipment at hospitals across the province and replenishing at that level for now until supply chains improve. province and replenishing at that level for now until supply chains improve. And that there have been, you know, certainly some hospitals in Ontario, I don't know about the rest of Canada, have launched drives to make sure that they receive donated supplies of personal protective

equipment. Volunteers are sifting through donated face masks destined for Toronto area hospitals. They've received 30,000, but they're asking for 3 million. Dr. Michael Warner is the medical director of critical care at Michael Guerin Hospital. There are people who are ready to pick up their needle and thread. I've had hundreds of emails and calls, people ready to participate. You know, if we need to make cloth gowns and cloth masks, just let us know and we'll get it done. And more power to them and more power to the people who have made those donations. You know, certainly this was one of the reasons for flattening the curve for practicing physical

distancing, because we wanted to make sure that hospitals weren't overwhelmed with COVID-19 patients so as to not completely obliterate stocks of personal protective equipment and have more patients who required ventilators than actual ventilators. So, you know, so far, we've been fortunate. And, like, we've certainly seen more patients, but not in an uncontrolled way. And thank goodness to the people who plan for this and to the fact that we had more time than, say, Italy and Spain did to anticipate the crisis, the surge, and try to deal with it beforehand. So is it fair for me to say that, you know, these distressing stories that we're hearing

coming out of hospitals in New York, hospitals in Italy, of emergency rooms overrun, not enough beds for all the sick patients? New York City emergency room, Dr. Calvin's son. We would hear calls of patients going to cardiac arrest upstairs, then cardiac arrest in the emergency room where they've been waiting for up to 80 hours for a bed and they just die. And now it's going to the waiting room where a few days ago I had to rescue a patient that went to cardiac arrest in the waiting room because they were waiting outside too long and the emergency room was too full. The patient ultimately died. We're not, or at least the emergency department at Mount Sinai in Toronto is not anywhere near that right now.

I think it's fair to say that. And furthermore, we have, you know, we work with colleagues in the emergency department who work at other hospitals. And they have not described a kind of any kind of panic situation where they're running out of personal protective equipment. That could change in the next few weeks. We know that we're not at the peak yet. The peak may occur sometime towards the end of this month, the month of April. But so far, we haven't reached a point where we're concerned about being overwhelmed. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization.

Empowering Canada's entrepreneurs through angel investment and industry connections. I wonder, without violating patient confidentiality, I know you can't do that, but what else stood out to you from the shift that you just worked? The thing that struck me, you know, may surprise you. That struck me. It may surprise you. The thing about emergency medicine is that we're eclectic by design. It's often been said that the emergency physician's knowledge is a mile wide and an inch deep.

We have to know a little bit about everything. And although some of my colleagues seem to know a lot about everything, but I certainly don't. I know a little bit about everything. And it's that eclecticism that usually defines emergency medicine. Well, with COVID-19, it's really interesting how we're all focusing on many aspects of the same disease, and that's COVID-19. And so, you know, we're all asking questions, like we're all trying to figure out the pattern. What's the pattern of this disease? What are the typical symptoms? You know, we know that the initial symptoms were supposed to be fever and shortness of breath and a dry cough. Well, can you get a congested cough and still call it COVID? Maybe. What about this thing about not being able to smell, you know, anosmia, not being able to smell things? And what about altered mental status? You know,

somebody who's confused or delirious, body aches and pains, more typical flu. And so that's one thing that we're really interested in, in trying to zero in and so that we can make a call and say, that's a COVID patient for sure, and be right. Another aspect, what are the harbingers that they're about to crash and require a protected code blue? We need to know that information. And of course, you know, we want to know what are the cardiac, what are the heart problems? Like we're finding out that patients who develop COVID-19, their blood tends to clot more easily. So that means that they can have an acute coronary event, like a heart attack, or they can have, you know, perhaps they can have a stroke, or perhaps they can have a blood clot in their lungs. And so what are the most common complications of the condition?

And of course, we want to know what's the early treatment. And, you know, all this talk about hydroxychloroquine or chloroquine. President Trump repeated that doctors should use the drug, which is not yet proven to treat coronavirus. They should do it. What really do we have to lose? The president says the federal government has now stockpiled 29 million doses of the drug. What do I know? I'm not a doctor.

And Restemivir and all the other medications that are being tried, we're trying to race ahead and figure out the optimal treatment that can keep people from crashing and in the absence of really well-controlled scientific studies, which could give us, you know, the answers to these questions. Dr. Goldman, before we go today, you tweeted recently about an ER doctor, a colleague of yours, who offered you an extraordinary favor. And I wonder if you could tell us that story. Sure. You know, I arrived at work to do a night shift, and my colleague, Dr. Paul Koblitz, who is about half my age, he and I were stopping and talking and talking about what was going on.

He offered to stay as long as the entire night if necessary so that he could intubate whatever patients I had if we had any protected code blues. And, you know, I'm old enough and experienced enough to have gotten past kind of those old feelings, the old shame feelings that we have. And I think a lot of, you know, I've written about this and I speak about this all the time. I think that a lot of health care providers have this kind of unresolved toxic shame. And I think a lot of health care providers become health care providers because they want to assuage their feelings, their fear of being discovered as inadequate or inferior. And I can remember a time, Jamie, 20 years ago when I would have been embarrassed by him offering to do that. And I still had a tinge of it, to be honest.

Does he think I can't handle it? He was worried that I would be infected with COVID-19 and because I'm older, I would die of COVID-19. And so it was gallant of him. I was pleased. I was grateful, and I thought that was wonderful of him. We didn't have a protected code blue that night, and we were still in the phase when things were quiet, and he did eventually go home. And we were still in the phase when things were quiet and he did eventually go home. One of the things that I've noticed is that everybody has been so collegial.

You know, my younger colleagues have been giving me tips on airway management. And, you know, I continue to receive those kinds of offers. You know, I'd like to think that when I can no longer practice emergency medicine, I will know when it's time to depart. But this is, Jamie, this is a raging controversy in the emergency medicine community people who I guess maybe they lack personal protective equipment, young physicians, you know, residents who have gotten COVID-19 and in a small number of cases have died. A nursing manager passed away. He had been treating patients sick with COVID-19. His name is Caius Jordan Kelly. He was only in his 40s. And I wouldn't want to visit that on a young dad or a young mom. I think that we shouldn't have a double standard about this.

And the other thing is that as my colleagues become ill and have to self-isolate or self-quarantine, we need a good supply of personnel who can take their place, well-trained. And so I don't think we should go too far with the ageism, you know, down that road of ageism. We have to think of the big picture. It's really interesting to hear you talk about that, Dr. Goldman. What is it exactly that keeps you going back to the hospital? What keeps you going back to work? You know, it's making a difference, making a difference in somebody's life physically, you know, medically, emotionally, sometimes it's spiritually. And as long as I can keep doing that, then I'm going to keep doing it. The other thing is that I'm not a loner by nature.

You know, I like my moments of solitude, but the social contact is pretty important to me too. And the idea that as we're asking people to physically distance themselves, and a lot of people are going stir crazy in their homes, I get in my car and I drive to work. And that's pretty awesome. I wish it wasn't to deal with COVID-19, and I look forward to the nanosecond when it's over. to deal with COVID-19. And I look forward to the nanosecond when it's over. But I do appreciate the camaraderie, the support, the fact that we're all in this together. You really feel it when you're working in the emergency department. Okay. Dr. Brian Goldman, it's a real honor to call you a colleague. Thank you so much for all the work that you're doing. And please, I hope that you take good care of yourself. Well, thank you. And it's an honor to call you a colleague, too.

So before we let you go today, we thought we'd leave you with some music. Yesterday, to mark Easter, Italian opera singer Andrea Bocelli, accompanied by an organist, sang to empty pews at the famed Duomo Cathedral in Milan. That's all for today. Thanks so much for listening to FrontBurner and talk to you all very soon. For more CBC Podcasts, go to cbc.ca slash podcasts.