VANCOUVER — The call came in on an afternoon in March: a patient at a medical clinic in Vancouver complained of chest pains.
Paramedic Jeffrey Booton watched the details flash across the screen as he and his partner made their way to the clinic.
It was his first potential case of COVID-19 and he felt both trepidation and a sense of duty.
“I see this job as working in the service of people. And getting to do so in the context of a pandemic is obviously wrought with fear and apprehension some days, but it’s work that still resonates with me,” he said.
When Booton arrived, he put on protective gloves, a fluid-repellent gown, N-95 mask and face shield over his freshly buzzed dark hair — an at-home haircut that turned out shorter than planned.
After a physical exam, they got back in the ambulance and Booton did what he always tries to do: comfort the patient. Paramedics see people during what can be pivotal personal moments and Booton felt the weight of the patient’s worry. As they travelled together towards St. Paul’s Hospital, he told the patient what he could expect in the emergency department and what types of tests he might undergo.
“I can only imagine what he was feeling in that moment, but it must have felt like a true sense of vulnerability to what uncertainty lay ahead,” Booton said.
Booton was one of at least 125 health workers, ranging from dispatchers and nurses to hospital housekeepers, who cared for the patient.
On that day, the patient was among 55 identified by dispatchers as possible COVID-19 cases in Vancouver.
Since the pandemic began, more than 50,000 people in Canada have tested positive for the new coronavirus, and federal government figures say at least 2,900 people have been hospitalized.
This is the story of those who cared for a single case at St. Paul’s.
———
EMERGENCY DEPARTMENT
Dr. Shannon O’Donnell knew she had only a few minutes to prepare after paramedics phoned the hospital to warn that a suspected COVID-19 case was on the way.
“I was a little anxious,” she said. “We don’t know what we’re getting, how much distress a patient is going to be in or how sick they’ll be. And you know, you’re worried also about being exposed to infection.”
The department had been eerily quiet after beds were vacated and the workflow was overhauled to make room for a possible surge in COVID-19 cases, O’Donnell said. Provincial health officer Dr. Bonnie Henry recently announced the province has been able to control the spread of the virus, but the caseload was still growing when the patient arrived.
The paramedics brought the patient directly into a negative pressure room set up for high-risk cases. Glass walls allow for filtration changes to reduce the risk of the virus spreading by air.
Like everyone the patient would interact with, O’Donnell examined him through a heavy armour of personal protective equipment. He was one of the sicker patients she’d seen.
“What was most striking to me was that he did require oxygen, but he also had a very high respiratory rate. He was breathing 30 breaths per minute, whereas you or I would breathe 15 or 16 breaths per minute,” she said.
COVID-19 has transformed not only the hospital but O’Donnell’s home life, too. She and her husband, also an emergency doctor, juggle the full-time care of their three children at home since schools closed.
Together, they decided that if there were a major outbreak, one would work at the hospital and self-isolate from the family, while the other would care for the kids.
“My husband likened it to both of us running into a burning building at the same time.”
O’Donnell ordered blood work, chest X-rays and an electrocardiogram scan, and conducted a chest ultrasound with the help of registered nurse Rachel Mrdeza.
For Mrdeza, some of the hardest cases have been the older patients who arrive incredibly short of breath, with a fever and chest tightness. Emergency department workers don’t typically learn if patients have COVID-19 because the test results come back after they move on from their care, but there can be strong evidence of the virus.
“You know they’re in the window of vulnerability for having quite a dire outcome from COVID. That is really hard to see,” she said.
Under normal circumstances, the emergency doctor would work with several nurses but only one is allowed in the isolation room at a time to protect against contagion.
By the time QianQian Wu began her night shift, she was only the third nurse to see the patient.
Despite the promising case numbers in B.C., Wu said staff don’t feel like they can relax. St. Paul’s Hospital is the main treatment centre for vulnerable residents on the city’s Downtown Eastside, a neighbourhood that faces another public health emergency from the overdose crisis.
Wu began her shift by putting on the uncomfortable protective gear that she would wear all night. She tries to stay hydrated before work because she knows she can’t drink water with the mask on.
“It’s a little hard to breath sometimes,” she said. “And sometimes you get sleepy with it on for a long time, it’s very warm.”
Wu took the patient’s vitals and talked to him about his family and friends. She also noticed his laboured breathing.
———
TESTING
While the patient waited in the emergency department, blood samples and swabs were sent to the hospital’s laboratory.
Dr. Marc Romney, medical director of medical microbiology and virology, said manual molecular testing for COVID-19 typically requires five to 10 lab staff.
“It’s not like a pregnancy test you get from London Drugs, it’s much more complicated,” Romney said.
A porter transports the specimen, a technologist reviews whether it was ordered and labelled properly, then two or three technologists conduct a multistep process involving the extraction, purification, amplification and detection of the virus’s genetic material. A senior technologist and one or two physicians review the results before they are sent back to the attending physician and infection control team.
But the virology lab was transformed by the arrival of a machine in March that automates part of the process.
The Roche cobas 6800 system was adapted from HIV testing and lifted the lab’s theoretical capacity up to 2,000 tests per day, in combination with manual testing.
Romney excitedly talks about the changes and ideas they’ve come up with to deal with the pandemic.
“One of the machines that’s called an extractor, we had to be creative to bring it into the lab because we didn’t have a lot of capital dollars to do it, so we basically bought it off the internet second hand,” he said.
“We’re under tremendous pressure to deliver, it’s been a challenging time. But we’re pleased.”
It has also come at personal cost.
One technologist was basically living in the lab and sleeping only five hours a night.
Romney went weeks without a day off and didn’t see anyone in person beyond his immediate family and colleagues.
When 19 positive tests came back in a single day, another doctor “basically ran from her home” to the hospital to start communicating the results to doctors, public health officials and others who required the information, Romney said.
“The front-line workers are amazing, and we are here to support them but I think it’s good for people to know there are also a lot of people behind the scenes working on this too,” he said.
“It’s not just machines that are being plugged into walls, it’s very human what we do here.”
Romney said the lab staff are mindful that time is critical in fighting the virus.
“It’s a sacrifice but we understand the importance of what we’re doing and there’s kind of a window of opportunity to try and contain the virus. Part of that is testing.”
———
THE TRANSITION TEAM
More severe suspected COVID-19 cases are sent to the intensive care unit for isolation. Back in the emergency department, Dr. O’Donnell called Dr. Mathieu Surprenant for an assessment while they awaited test results.
The 29-year-old clinical associate put plans to move back to Montreal on hold when the pandemic struck. Moving in with other doctors seemed too risky, so Surprenant remained in his nearly empty apartment in B.C. on an extended lease.
“I’m sleeping on my inflatable mattress and I’m trying not see anybody,” he said, laughing.
“It’s been very lonely because when I’m not working, I’m not doing anything.”
When he got the call from emergency, Surprenant headed downstairs with resident Dr. Charles Yang.
This wasn’t the hospital’s first suspected COVID-19 case and Yang found himself wondering if it would follow the same trajectory as others.
“In my mind I was wondering, OK what are the precautions I need to take in order to protect myself and other patients while maintaining the level of care I would typically provide for a patient,” Yang said.
He thought of his fiancee at home and whether he would be putting her at risk.
The team examined the patient to develop his care plan. They looked at his oxygen levels and also at the patient himself. Did he look comfortable? Was he struggling?
“What we’re sort of afraid of is that they reach a certain point where they’re able to compensate with their own physiology and eventually just tucker out and decline at a rapid pace,” Yang said.
A crash intubation would be risky for staff because of the time it takes to put on protective equipment, and a chaotic rush into an isolation room could spread the infection. A care plan puts everything in place for a controlled intubation, if a patient appears likely to decline.
The team talked it over and the patient was transferred to the ICU for monitoring overnight.
But it wasn’t long before his oxygen levels began to concern Surprenant.
Best practices change rapidly as new information becomes available about the new coronavirus, the doctor said.
Initially, for example, the idea was to intubate as soon as possible because if a patient gets too ill, his chance of dying on a ventilator increases. But intubation is also more invasive than other procedures and risky for health workers because it pushes droplets of the virus into the air.
Since the pandemic began, recommendations have relaxed to allow for other treatments first but it’s a constantly moving target, Surprenant said.
He believed the patient had reached the stage where intubation was his best chance at survival.
Making that call meant calling in a group dubbed the COVID airway team. Early in the pandemic, the experts in both airway management and donning and doffing specialized protective gear waited on call in a hotel across the street.
“Just dressing takes between five and 10 minutes,” Surprenant said. “They look like astronauts with all the layers.”
———
THE COVID AIRWAY TEAM
Anesthesiologist Dr. Shannon Lockhart was part of the planning group that conceived of the COVID airway team.
The cancellation of elective surgeries meant the traditional workload for Lockhart and her colleagues would be lighter. Their idea was to form teams with respiratory therapists to perform intubations so that emergency and ICU doctors wouldn’t expose themselves to the high-risk procedure.
Anesthesiologists self-selected into one of three groups: The first wave was ready to start serving on the COVID airway team immediately. The second would step in if the first wave got sick. And the third would not participate because they or their loved ones were at risk of serious illness if exposed to the virus.
For Lockhart, the decision to be part of the first group, known as the “green team,” was easy. The hard part was creating a plan that would call on others to face the same risk.
“I’m 35 years old, I’m young and healthy. I have a family who is young and healthy, so the personal risk was pretty low for me,” she said.
“More challenging for me was identifying this was a useful model for our group, who are my colleagues and friends, and thereby potentially offering the services of people and putting them at higher risk.”
The uptake was good, however. She was among 16 who volunteered for the green team, making it viable.
When Lockhart was called to intubate the patient, she was ready.
“He fit the story of what you hear about COVID patients who look really well from the bedside, but their numbers don’t look that great,” she said.
Putting a breathing tube down a patient’s throat under normal circumstances takes between five and six minutes, she said.
That time frame has ballooned to between 60 and 90 minutes dealing with the extra protective gear, preparing every possible material you could need in isolation, and the cleaning or disposal of everything in the room.
Dressing feels like a race when someone is struggling to breathe. Once inside, the urgency to clear the airway is intensified by the heat the suit produces.
“The longer we’re in the room, the hotter we get and the foggier our eye protection becomes,” Lockhart said.
Lockhart and a respiratory therapist gave the patient a sedative and paralytic, and inserted the breathing tube while another anesthesiologist waited outside as backup.
Working with different colleagues in an unfamiliar setting wearing cumbersome new equipment is stressful, Lockhart said. But she’s been heartened to watch hospital staff quickly respond and break down silos in which they typically operate.
After intubating the patient, the riskiest part of Lockhart’s new job is doffing her gear.
As the patient relies on strangers for care, Lockhart too relies on someone she barely knows for her own protection. She and the respiratory therapist watch one another carefully as they remove the equipment piece by piece, monitoring for any slip that would allow contamination.
“It’s kind of an interesting position to be in when you’re trusting this person with this very important task but you may never have met them before.”
———
THE ICU
When Dr. Gavin Tansley met the patient, he was already sedated and breathing through a ventilator.
Tansley had given the OK for intubation when Surprenant woke him up with a phone call. He was already familiar with the patient’s case.
Where possible, ICU staff keep an eye on patients they might inherit from other departments, said Tansley, a general surgeon training in critical care. They ask themselves, if things get worse, what would we do?
In the ICU, the acute focus on ventilation shifts to the more holistic care of all the patient’s major organ systems.
“Critical illness is a bit of a funny thing where you really do recognize how intertwined all of these organ systems are,” Tansley said.
“With COVID in particular we see very familiar patterns where often times the kidneys won’t be working 100 per cent, sometimes the heart won’t be working 100 per cent. So, we need to support those organs with other medications or sometimes we need to add dialysis or additional interventions to optimize things as best we can while the body tries to deal with that virus.”
When Tansley decided to become a doctor, he wanted to help people heal. He didn’t realize then that in the ICU, he wouldn’t get to know his patients very well.
“Very often by the time I meet patients, they’re already sedated or on a ventilator or so sick that they can’t talk to you. So, your relationship becomes with the family, and you develop amazing relationships,” he said.
Reflecting on the case, Tansley said it reinforced some recent thoughts he’s had about critical illness that don’t get discussed. So much focus is on the patients, but their families are often experiencing trauma.
“Conversations we’ve had with this particular family reinforced that he was very, very cared for within this family and they were very much struggling with the fact that he was unwell.”
Being unable to visit their loved ones during the pandemic has added an extra layer of grief, he said.
It has been hard for staff to keep families from their loved ones, but they are finding ways to help them connect. Tansley sets aside time to phone them with updates. Nurses hold iPads up to patients so their families can at least see them on video.
Whatever they try, it’s not the same as being able to hold a loved one or even sit with them. The grief can add an extra layer of emotional stress for health workers as well.
“It’s just one of the many ways the coronavirus has changed the way we have to practise medicine.”
———
RECOVERY
By the time the patient reached the ICU, about 25 health workers had already played a role in his case. Some interacted with him directly, while others played important but indirect roles in his care, ranging from hospital housekeepers to X-ray technologists.
About 90 intensive care staff saw him, and from there, he would be turned over to a general medicine team.
Recovery is a long road involving a wide network of specialists from dieticians to speech pathologists and social workers. Behind the scenes, hospital administrators, education and outreach teams also do their part.
Kevin Novakowski is a respiratory therapist and in his 28 years of work, he’s never felt an illness create such a constant psychological burden.
“It’s changed me in a way,” he said. “It’s kind of always on my mind.”
In recovery, a patient begins physiotherapy to build his strength. Novakowski is there monitoring how it affects his breathing.
It can take weeks to months, and some never fully recover. Between 30 and 60 per cent of survivors of critical illness have ongoing medical or mental health issues, said Dr. Del Dorscheid, who oversees the ICU as an attending physician. That can mean residual lung disease for COVID-19 survivors, whom he said may receive intensive care for a week or more than a month.
But the first major step toward independence is weaning a patient off the ventilator.
As Novakowski monitored the patient, he began reducing the ventilator’s power and gave him short trials without it.
“You’re looking at their breathing and watching them and focusing on how their muscles look. Are they struggling for air, are they taking deep breaths, are they breathing fast, are they breathing shallow?” he said.
Weaning is a gradual process, like an ebbing tide. Off the ventilator, a patient’s breath rattles.
“They cough and they sputter,” he said.
The rattle may disappear then return when they stand for the first time, or when they start walking.
It’s a stressful process for patients. If they don’t keep coughing to clear their airway, infections can return.
During those first trials, Novakowski waits and listens.
“You listen to them breathing,” he said. “And then all of a sudden, it’s just kind of really quiet and their breathing just sounds like our breathing, normal.
“And you think, OK. That’s good.”
This report by The Canadian Press was first published April 30, 2020.
Skinstitut Holiday Gift Kits take the stress out of gifting
Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.
In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.
“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.
There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.
Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.
Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.
In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.
Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.
Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.
LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?
It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.
Here’s how you can prepare your digital life for your survivors:
Apple
The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.
For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.
You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.
Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.
Google
Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.
When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.
You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.
There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.
Facebook and Instagram
Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.
When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.
The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.
You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.
TikTok
The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.
Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.
X
It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.
Passwords
Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?
Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.
But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.
___
Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.
The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.
New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.
The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.
Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.
Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.
“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.
“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”
McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.
But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.
The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.
He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.
“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.
“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.
McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”
McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.
He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.
“Early identification of reading difficulty can truly change the trajectory of a child’s life.”
This report by The Canadian Press was first published Oct. 23, 2024.
