I am a SARS physician
Editorials / Commentaries
Rick Penciner, MD
Assistant Medical Director, Emergency Department, North York General Hospital, Toronto, Ont., and Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto
I am an emergency physician. I have been trained to treat myocardial infarctions, broken bones and shortness of breath, but until now, the extent of my occupational risk has been limited. I have strained my back reducing a dislocated hip, been exposed to the occasional TB or meningitis patient, and suffered a needlestick injury or two. We emergency physicians have the attitudes of adolescents: There are risks in our daily lives, but we feel invincible; we feel that no harm will come to us. Now all this has changed.
Recently, in Toronto, we fought the battle of SARS (severe acute respiratory syndrome). For eight weeks we wore gloves, gowns, caps and masks -- continuously. The hospital cancelled all elective surgeries and outpatient clinics. A new lexicon of words rolled off our tongues with such ease: "N95," "barrier precautions" and "negative pressure isolation." Our hospital was close to the epicentre of the Toronto SARS outbreak, and we treated many of the original patients. We faced many challenges and overcame them. As an emergency department, we were proud of the work we did and we were proud that none of our staff got sick. We thought we had won.
In the next 8 days over 30 staff and physicians were hospitalized with SARS.
When the SARS crisis of 2003 was declared over, we followed directives from the government and public health and adopted new "standard procedures," including barrier precautions for the triage nurse and isolation measures for all patients with fever or respiratory symptoms. The hospital continued screening staff and visitors, but most of the staff stopped wearing masks. No sooner had we let our guard down, than we realized there was a new outbreak. This time, our hospital was the epicentre.
It seems that many hospital staff had unprotected exposure to patients later diagnosed with SARS. Our emergency department and hospital were closed. The same day, our staff members began returning with fevers and symptoms of SARS. The entire hospital staff and physicians were placed on work quarantine: We could work in the hospital, but otherwise had to remain at home, quarantined, for the next ten days. We checked our temperatures twice daily; we slept and ate apart from our families. The hospital discharged and transferred all of its remaining patients, including one who had been in the ICU for more than a year. Although the staff was on quarantine and there were no patients, apart from those with SARS, I still could not find a parking spot.
The hospital became a war zone. A command centre was set up, task forces met; administrators and chiefs scurried to important meetings. There were overhead emergency announcements, midnight phone calls to staff and frequent email updates. This was uncharted territory, and the navigation was challenging. Over the next week, the ED and its staff made an incredible transformation. Even though we were closed, we recognized a moral obligation to treat the staff that were sick: Our ED became a diagnostic unit for hospital staff with SARS. In the next 8 days over 30 staff and physicians were hospitalized with SARS. Many more were assessed and discharged. Two more SARS units opened and were quickly filled.
It had been an emotional rollercoaster, treating our friends and colleagues, worrying about our own safety and the safety of our families, and concerned for the future of the hospital.
It has been an emotional rollercoaster, treating our friends and colleagues, worrying about our safety and the safety of our families, and concerned for the future of the hospital. Our hospital had been designated one of four hospitals in a "SARS Alliance" (a fact that we accepted with both fear and determination). A SARS Assessment Clinic, complete with negative pressure ventilation, digital radiography, computers, phones and more, was constructed in our ambulance bay. The clinic was to be run by our department.
During that first week I assessed many staff members with SARS and many more who feared they had SARS. I became very good at making the diagnosis. If the patient had an epidemiological link and a fever, chances were they had SARS. I re-learned many things about medicine. I did not shake my patients' hands. I stopped using facial expressions to communicate with my patients (my face was covered by my mask). I often skipped the physical examination: It contributed little to diagnosis and exposed me unnecessarily. I stood two metres away from my patients when I took a history, and I ordered chest x-rays and blood tests on everyone. Daily, I reviewed the sequence of gowning, gloving, masking and -- more importantly -- the sequence of removing them. I stopped saying, "Don't worry, it's just a virus."
Only those on the inside understood what was happening. My family, friends and colleagues at other hospitals could not appreciate the magnitude and significance of these events -- of the twilight zone we existed in. Throughout all of it, the ED physicians, nurses, team attendants, unit clerks, and housekeepers dignified themselves with hard work, dedication and mutual support. The spirit was strong and we even had a few laughs in between the tears.
I was not asked to do this; I was proud to do it. For the foreseeable future, I am a SARS physician.