‘Vaccines won't be enough’: A critical-care doctor on ICUs and the third wave

TVO.org speaks with Ontario science table member Laveena Munshi about variants of concerns, the pressures on ICUs — and the prospect of a fourth wave
By Nathaniel Basen - Published on Mar 31, 2021
Laveena Munshi (second from left) is a critical-care physician at Toronto’s Mount Sinai Hospital. (Courtesy of Laveena Munshi)

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According to Critical Care Services Ontario, there are 421 patients currently in Ontario ICUs with illness related to COVID-19 — the most to date. Wednesday morning, the province reported 2,333 new confirmed cases of the virus.

As the province manages the third wave, it relies on the Ontario COVID-19 Science Advisory Table to synthesize data and provide information to guide-decision making. On Monday, that table released a report that painted a bleak picture of the ongoing affects of variants of concern — which it says are more easily transmissible and more virulent.

TVO.org speaks with Laveena Munshi — a member of the science table and a critical-care physician at Toronto’s Mount Sinai Hospital — about why the third wave is unique, how her ICU is faring, and whether there’s a prospect of a fourth wave.

TVO.org: How are you doing?

Laveena Munshi: I just actually came off a week of ICU, and the year has been very difficult. At the very beginning, there was a lot of adrenaline. There was a lot of fear, and there was anxiety, but there was this kind of rallying together by not just the critical-care community but by our hospital and by the community with this common goal that we could get through all this. That provided a lot of energy and motivation and support for all of us that were working in the hospitals. But with every subsequent wave, we're getting more and more burned out, and we're getting more and more tired. So I'm fine, relatively speaking. I'm doing very well compared to a lot of tragedy and a lot of the loss in the world that other people have had to experience — but it's certainly taken a toll on all of us.

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TVO.org: You’re on the province’s science table. What has that experience been like?

Munshi: The Ontario COVID-19 Science Table is basically a group of experts and health-

smiling woman in blazer in front of bookcase
Laveena Munshi is a member of Ontario
COVID-19 Science Advisory Table.
​​​​​​​(Courtesy of Laveena Munshi)

system leaders across different domains of health care who have come together from the worlds of public health, epidemiology, infectious disease, emergency medicine, internal medicine, critical care, behavioural science, etc.

Really, the mandate is to try to review and synthesize any relevant scientific evidence for the COVID-19 health coordination table, for the government, and for the public. It's been a really amazing opportunity for me. It's been interesting because there is so much data that's coming in now, a year into the pandemic. It's been a pretty incredible experience, just to actually see how we take that data and try to synthesize it and interpret its findings. It's an excellent experience, and it's my hope that the science table has contributed in some part to informing policy and informing change and how we respond to the pandemic.

TVO.org: Outside of COVID-19, you’re an ICU doctor with a focus on acute respiratory failure and on immunocompromised patients and oncology patients who develop critical illness. Is that why you were asked to be a member of the table?

Munshi: In the research that I've done on acute respiratory failure, I've been part of the American Thoracic Society and the European Critical Care Society's mechanical-ventilation guideline, so I've done some research on respiratory failure. I think I’m meant to bring my lens surrounding management of patients with respiratory failure and also just the lens of a bedside critical-care physician.

TVO.org: What about COVID-19 has surprised you? Has it affected your understanding of those fields?

Munshi: COVID is basically acute-respiratory-failure management for intensivists — and it's fairly straightforward. On a day-to-day basis, we're continuing to just conduct our job of critical-care management. We're actually very fortunate that we haven't had to really learn a new disease.

I think the biggest challenge has been managing everything that happens associated with a pandemic surrounding the structures and processes of care. What I mean by that is, how do we actually prepare to handle the volume of patients that are coming in? That aspect of COVID-19 has actually probably been the greatest challenge for us. There was lots of learning about how to increase ICU capacity, and I think the most important thing that we've all learned from this is that you can increase the number of beds, you can increase the number of ventilators, you can increase the number of hospital rooms that are physically there — but the rate-limiting step at the end of the day is going to be the human resources: the number of nurses, the number of respiratory therapists, and the number of physicians with critical-care training. That's been a major hurdle that we encountered, particularly as we went into wave two.

As we enter wave three, the rate-limiting step in all of this has been the human resources.

Another major challenge at the beginning of the pandemic was having all this information coming in from around the world. On the one hand, it's amazing that we have social media so we can connect with people in Wuhan and Lombardy and New York to find out what's actually going on. But knowing what to do with that that information, knowing what to do with those anecdotes ... Should we change what we're doing based upon this one case of this drug working or this other case of that drug working? Or should we just stick with the basic principles of how we know how to manage acute respiratory failure?

Early on, we as a group chose to stick with the basic principles of acute-respiratory-failure management. Ultimately, I think that was the right thing to do.

TVO.org: In the past year, it’s become a popular pastime to look at data from around the world and become an armchair expert in infectious diseases or in health equity or vaccination or whatever. Your job at the table is to do that, but actually do it well.

A lot of Ontarians have been jealous looking at other provinces that have vaccinated higher proportions of the general population. Here, the government chose to prioritize health-care workers early on to a greater extent. You spoke about human resources being a limiting factor in hospitals, and I’m wondering if, in your work at the table and in your work at the hospital, you’re seeing the results of that choice?

Munshi: One of the biggest issues before vaccinations were present was that if one person had a symptom or one person was exposed, that had a profound impact on the people around them. Based upon what the department’s occupational-health guidelines were, that one person had an impact on many other health-care workers, and it really did have a major impact on workflow. During wave one and two, there was this constant stress about having enough nurses for the shift and having enough nurses for the next shift. Fortunately, in our ICU, to my knowledge, we had very few risks where entire shifts of people would need to be quarantined — but that that was certainly the reality in different areas. So the vaccination of health-care workers very much preserved that workforce and preserved the continuity of everyone being at the bedside so we can continue to care for patients that are coming in with COVID.

TVO.org: That's great to hear. But, on Monday, the science table released its most recent report, and a lot of it was pretty dire — focused mostly on the dangers presented by the variants of concern and the impact that they're having in hospitals right now. What are the main things that Ontarians should know about the current situation and that report?

Munshi: Earlier, when we were learning about the variants of concern — and the one I'm going to be referring to in particular is B.1.1.7, which currently makes up the majority of the variants of concern that we have in Ontario — we knew that the variant was more transmissible, but we hadn't seen any data yet on its virulence, or how severe it is. The report that came out most recently, which was led by epidemiologists David Fisman and Ashley Tuite, basically found that the variants were associated with a higher risk of admission to hospital, a higher risk of ICU admission, and a higher risk of death. So that was very sobering for all of us to see.

Interestingly, we're seeing a higher proportion of younger patients presenting to hospital and now being admitted to the ICU. Whether that has to do with the vaccine rollout in the elderly population or public-health-measure adherence, or whether there's actually something different about the variants across that age range — I'm not quite clear yet. But I think it's important to know that we are very concerned about the variants of concern now in Ontario, and we're very concerned about how it's going to impact this third wave.

The thing that makes wave three much more challenging is capacity. We were very fortunate in wave one: we were able to create a lot of ICU capacity across all the different regions of Ontario. After wave one, we recovered about 80 per cent of the COVID volumes. However, after wave two, we didn't see a significant recovery: the low of wave two was still higher than the peak of wave one, and even the ICU volumes didn't substantially go down. Now we're entering wave three. We're very nervous about the fact that we're really at the beginning of wave three with the variants of concern with less ICU and hospital capacity.

TVO.org: What does that look like in your own ICU?

Munshi: This past week, I was on the second ICU — so, the non-COVID ICU — and my role was also to consult on any patient that may be deteriorating in the ward. Within a very short period of time on Friday, there were four COVID patients that I saw and ended up admitting to the ICU. Our ICU COVID numbers have been progressively increasing over the past couple of weeks, and in particular over the past couple of days. So we're just seeing higher volumes; we're seeing younger populations coming into our ICU, and a large subset of them have the variants of concern.

TVO.org: As best as you can tell, are people catching the disease in the same ways but just more easily? Or are people catching it in ways that are different than in wave one or two?

Munshi: The mechanism of transmission of COVID has not changed, from our knowledge. The major sources of transmission continue to be when people are in close contact. We are still seeing essential workers who cannot work from home be a major source of COVID acquisition and transmission.

COVID fatigue is a very real phenomenon, and whether it's intentional COVID fatigue and non-adherence to public-health measures or unintentional COVID fatigue and non-adherence to public-health measures, I think those all continue to be the main sources of transmission.

TVO.org: How bad might this get?

Munshi: The science table is currently developing projections of how bad things will be. Given the fact that vaccines are not yet widespread, I think the next couple of weeks are going to be very bad. With the fact that the variants of concern are more transmissible, and the fact that, on top of that, it will occupy a greater proportion of hospitalizations and ICUs, we are obviously going to surpass the peak of wave two. But I can't give you numbers at this point about how bad it will be. We are in a race to vaccinate, but I don't think vaccines alone will be enough to blunt the negative impact of what the next couple of weeks have in store for us with the variants of concern.

TVO.org: Do you think the vaccines will be enough to prevent a fourth wave? Is there a sense that this might be the last bad wave?

Munshi: I really hope so. Strict public-health measures are going to be needed to try to minimize the consequences of wave three. Vaccines won't be enough. But I think after we get through wave three, and as we continue to vaccinate and move down the age categories, and with the opportunity to do more activities in an outdoor setting — it's my hope that the combination of those factors could help prevent us against being in a situation where we have a fourth wave.

TVO.org: Many scientific leaders have asked for a more robust policy response to this third wave, and Adalsteinn Brown, the co-chair of the science table, has seemed frustrated at times during his media availabilities. Has it been frustrating to see policymakers maybe not act on the table’s work in the way that members of the table might like?

Munshi: I think communication to the public and messaging have really been one of the greatest challenges of this pandemic, because at the end of the day, everyone is impacted in some way. Unfortunately, we all have a different lens that we're looking through. We all see something awful, but it's all different. As a consequence of this, we all have different priorities, and some of these priorities may be perceived as competing.

So I guess my first thought here is that we really do all need to realize that we are looking at the same end goal, but we need to look at that same end goal through the same lens. We all, at the end of the day, have the same common goal, which is to eradicate COVID so we can minimize the impact that it's having on the lives of everyone around us and also on the economy, which is also impacting the lives of everyone around us.

What we as a science table have been trying to do is take the evidence available and try to synthesize it and try to display it so both the government and the public can see the situation that we're in, the consequences of the pandemic, and the effectiveness of various measures.

Of course it's been frustrating. And it's frustrating for me because of what I see on a day-to-day basis. I am very sympathetic to the fact that other individuals who are not working in an ICU and not working in a hospital are also frustrated by the pandemic because of its impact on their livelihood. I wish there were an easy solution. And you're right, there's certainly been frustration where certain evidence has been presented that might have not been acted on in the way that I thought, or a group of individuals in health care might have thought it should be best acted upon. I do appreciate that there are multiple stakeholders involved, but, at the end of the day, in my personal opinion, the strategy that's associated with trying to minimize and eradicate COVID in the fastest way possible is the strategy for all of us to get to our collective goal — maintaining health and opening up the economy.

TVO.org: One thing you’ve spoken about in the past is visitor restrictions in hospitals. What is the current situation?

Munshi: During the first wave, there were very stringent visitor restrictions adopted across all health-care systems. This was largely done using the precautionary principle with the intention of protecting health-care workers and patients from acquiring COVID from the community, protecting families and essential caregivers from acquiring COVID from patients, and, at the very beginning, to try to preserve personal protective equipment.

However, I think after and during, we began to gradually see the potential harm associated with such severe restrictions. What we realized is that the risk that visitors — not just visitors, but essential care partners in particular — will bring COVID into the hospital is likely very low with appropriate infection- and prevention-control measures and thorough screening. There is potential harm to restricting visitors — essential care partners and families in particular — from coming to the bedside.

We've discovered over the past few decades that family members and essential-care partners are absolutely essential members in the delivery of patient-centred care — whether it be assisting with speeding mobility or hygiene reorientation in an ICU setting, family presence and caregiver presence has been helpful for delirium (and now, through COVID, we have evidence demonstrating that there's less delirium in patients that have family presence), and they're also extremely important for patient advocacy. So, fortunately, during waves two and three, many hospitals reflected upon the impact of very strict visitation policies, and many hospitals tried to identify the patient populations that were most at risk of these strict visitation policies. A lot of them have accommodated the visitation policies in response to a lot of these concerns that were raised.

TVO.org: Is there anything else that you think it’s important that Ontarians know?

Munshi: It's important for people to know that the end is very much in sight. My colleagues and I, we're all bracing ourselves for this third wave. But I am very cautiously hopeful that this is absolutely the last wave. As vaccines are rolling out, as people can spend more time outdoors, it's really my hope that, after this wave and with the summer coming, life will feel a lot better for all of us. So there is some sunshine on the horizon. And it's summer; we will get there. We just have to stay vigilant over these next couple of weeks to push through this unfortunate third wave that I know will be really challenging for a lot of us.

This article has been condensed and edited for length and clarity.​​​​​​​

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