Side by side

The twin beds are just as I had left them. Side by side, pushed close, sleepover style. This lack of attention to regulation must have been overlooked by the home safety team. I smile at their two heads, one silver, one white as snow, on matching pillows. A large plaid fleece blanket covering both of their frail bodies.

I stop at Ingrid first, shaking my head at the oxygen tubing around her forehead. I try to reposition it—for the hundredth time this month, it seems. This time, she grabs my hand forcefully, holding tight. Stronger, always, than I expect.

“No!” she says firmly.

Then, never someone to belie her cheery disposition, she grins at me. “How are you?”

I lean close and smile at her, smoothing her hair back. My mask and shield allow only my eyes to connect with her.

“I’m happy to see you girls. How’s Lois?” It takes her a moment, reaching back into her tangled memories. She turns to the right, looking fondly at her roommate.

“She’s good.”

Ingrid brings her right hand up from under the blanket, showing me that it is clasped tightly with the hand of Lois. A sense of relief comes over me; things are as they should be. As good as they can be, given the circumstances. As I walk around their conjoined beds, I straighten their shared blanket, covering all 4 slippered feet that, despite the cranked-up heat, are always cold.

****

For 9 months, we managed to avoid a COVID-19 outbreak. We were situated in an area with low case numbers; yet, with staff traveling for work, an outbreak was always a risk. I felt almost righteous, to be honest. Other medical directors and colleagues were dealing with staff shortages, deaths, and the subsequent, always critical, media attention. So there was an ironic unfairness to the outbreak hitting us as it did—just as the vaccine rollout was starting, just when hope was on the way. We did not defy the odds, unfortunately.

Declared soon after Christmas, it hit the home like an air strike. There was an initial hopefulness that it would affect just a few staff, that our residents would be spared. Only several days later, however, the first few cases of fever emerged. Hopefulness turned to despair as, in what felt like rapid fashion, we saw positive result after positive result. While a few were able to avoid developing symptoms, most did develop them, and soon enough, we were surrounded on all sides. Things subsequently kicked into high gear—mass nasal swabbing, red-taped door frames, heightened screening, daily public health meetings, regular hygiene audits, and many new routines, the likes of which our previously safe little home had never seen.

I worked in the home full-time during the worst weeks of the battle, passing my other clinical duties off to my steadfast colleagues. I ran those outbreak floors like an acute hospital ward. At times, I was short with staff—exasperated by the lack of equipment and hours in a day, and, at the core of it, frustrated by the lack of medical options afforded to me to deal with this virus that was proving so deadly.

I developed a system and each day faced the battlefield. There is a sense of control in organization. I created a spreadsheet to document the presence or absence of critical clinical findings—fever, need for oxygen, lack of intake of fluids and food, need for fluid supplementation. I would enter the home with just my coat and spreadsheet. No need to bring in anything extraneous—less decontamination to worry about later. My pocket held the tiny pulse oximeter I had requested. The illness barometer. As I talked to each resident of the home, assessing them, taking in the brightness of their eyes, their level of dehydration, and effort of breathing, I would slip my tool inconspicuously onto an index finger, assessing their degree of illness, the need for intervention or possible hospital transfer.

Although it took time that I didn’t have available to waste, there was a calmness in the repetitive practice of applying the personal protective equipment. The “don” and the “doff.” Ensure mask and shield are on. Wash hands. Apply gown. Wash hands. Apply gloves. Reverse it on the way out. Wipe down the pocket monitor. Take a breath and attend the next room. One fallen soldier at a time.

I don’t know what drove me more, the sense of duty or of love. I felt the weight of the home on my back, felt the weight of the outcomes on my name. I counted the deaths, kept track of the ratio of lives lost compared with the number of positive cases, hoping to defy statistics. There was only so much medicine I could offer. Tanks of oxygen, metres of tubing, and subcutaneous steroids, the only medication in my arsenal. I became the physician from the history books, exhibiting the universal remedies—the time spent visiting and observing, the holding of hands and straightening of sheets, the positioning of a straw, encouraging drink, sitting at the bedside, spooning food that wasn’t wanted into mouths that needed it desperately. I celebrated every gain and winced with each setback. The dialing up of the oxygen, the transfer to hospital. I tried to feel nothing with each death.

I wasn’t always successful. Fanny had recently moved into the home, feeling it was time to give up the risks of living alone at her age. I agreed, having been her family doctor for more than a decade. We were both pleased that she could remain in my care. She was bright and lively, wheeling around her firetruck-red walker. I recall my heart sinking when she tested positive, trying to remain hopeful—she hadn’t yet developed any signs of illness. Almost overnight, however, she was weak as a kitten, short of breath, and required increasing amounts of oxygen. For 3 days in a row I fed her lunch, spooning mashed potatoes and gravy into her mouth and helping her sip chocolate milk to wash it down, as her hands shook too much to hold the cup. Although she fought hard and rallied for a day or so, one morning I came into work to find that she needed more oxygen than we could provide. In my mask, gown, gloves, and shield I sat on the edge of her bed and held her hand. I offered her a hospital transfer, which she firmly declined. I promised her I would keep her comfortable, made a difficult call to her son, and arranged for him to come and be with her. Instead of oxygen, this time I titrated up the morphine, relieving the distressing shortness of breath and keeping her calm.

The total emptiness I felt completing her death certificate. The frustration at writing COVID-19 as a cause of death for this elderly lady who was, ultimately, my friend. A long-standing patient who trusted me to be her doctor when I was fresh as a daisy in residency, and I had seen her through her aging years, chronic illness, hospital admissions, and this, albeit final, transition from independence. Would I cry, at some point, I wondered?

As the days ticked on, our short-staffed health care team were run off their feet and out of their element. I was asking them to “up” their skills at Mach speed, pushing them to be what I needed, what our home needed, to get through this fight. And I was asking them to do these things while they watched these residents whom they knew and cared for like family become gravely ill and suffer. I spoke to a cleaner outside one of the rooms. She admitted, “I cry in my car all the way to work and back.”

A personal support worker broke down in front of me, after learning that a favourite resident of hers had died. “They don’t deserve this.” All I could do was agree.

****

Today, as I make my usual weekly rounds, there are signs of hope. Our outbreak was lifted the day before yesterday. The whiteboard that had held an 8-foot version of my trusty spreadsheet has been wiped clean. It is now a welcome sign. But I can still close my eyes and picture red lines, slicing through the rows of those residents we lost, whose clinical statistics could now be flushed free from my mind. Onward.

Before I leave the home, I stop by the doorway of Ingrid and Lois’ room, one door down from Fanny’s now empty one. Watching them sleep, their chests rising and falling in unison, I am reminded of the oxygen tanks, the tubing, the fluid dripping into veins under skin, the fear of death. I had as good as labeled these best friends as joining our list of losses. Casualties of the outbreak. I feel the tears rising, finally, because here they are, still, alive and breathing. Heart to heart. Side by side.

• Copyright © 2021 the College of Family Physicians of Canada