For weeks, Ciara Blair has watched the endless stream of COVID-19 patients flowing into the intensive care unit with mounting fear.

With each patient admitted, the registered nurse worries whether ICU staff at North York General Hospital have the stamina to endure this second pandemic wave.

“We’re all so tired; you can see and feel the burnout.”

As bad as it was in the spring, when so much was unknown about the virus, this winter is even worse: Many COVID-19 patients in the ICU are young, in their 40s or 50s. They seem sicker — the infection tearing through their bodies faster — than those who filled hospital beds in April and May. And they are arriving to the ICU at relentless speed.

It all takes a toll.

“You don’t forget the terror in your patients’ eyes, the words they’ve spoken to you, the words they’ve spoken to their family before you put them on life support, the way they get sicker and sicker as their body tries to fight the virus,” said Blair, her voice catching.

“The repetitiveness of that gets to you. And it feels like there is no end in sight.”

Staff in intensive care units across Greater Toronto have been working flat out for months, keeping up the gruelling pace of caring for the sickest COVID-19 patients with few signs of a slowdown on the horizon.

New provincial modelling presented Thursday shows while COVID-19 case counts are dropping due to stay-at-home orders, ICUs will continue to face crushing pressures well into February. On Jan. 24, half of all Ontario hospitals had only one or two empty critical care beds, and 35 per cent had no free ICU beds; almost all swamped intensive care units are in the GTA.

Even with the lockdown creating a potential downward trajectory in critically ill COVID-19 patients — and if more infectious COVID variants can be kept at bay — Ontario recently passed yet another bleak pandemic milestone: More critically ill patients with the virus have died in ICUs in the second wave than in the first.

A fraction of the 6,000-plus COVID-19 deaths in Ontario have taken place in an ICU. Since the start of the pandemic, 1,034 severely ill patients with COVID-19 have died in ICUs, with 618 of those deaths coming after Sept. 1, according to the most recent weekly report from Critical Care Services Ontario.

Last spring, North York General was among the first hospitals in the province to be crowded with COVID-19 patients. For 100 days, the community hospital at Leslie Street and Sheppard Avenue East cared for dozens of critically ill COVID-19 patients in its 21-bed ICU.

On June 30, ICU staff got a reprieve; it was the beginning of a 45-day stretch without a COVID-19 patient in the unit.

At the time, Rina-Marie Austrie-Fletcher, a registered nurse and the unit’s special projects co-ordinator, told the Star she “hoped and prayed it’s not as bad in the second wave.”

Now, six months on, Austrie-Fletcher barely remembers that summertime lull.

“Everything since then is a blur,” she said. “In the fall we started with four or five COVID patients in the ICU. Then in November, we started to see more and more patients on the general medicine ward, and after that the numbers just skyrocketed.”

As of Jan. 30, North York General, which now has 23 critical care beds, has cared for a total of 686 COVID-19 patients, 99 of those in the ICU. The hospital currently has 82 in-patients with the virus, including 14 in the ICU, all of whom are ventilated.

In the spring, overcoming the fear of a new, unknown virus was among the biggest challenges the ICU staff had to face. And while the fear has never fully waned, Austrie-Fletcher says the team is now familiar with their layers of personal protective equipment, the treatment protocols and the many ways the virus attacks the body.

“This time around, we know what we are doing. Now we’re scared in a different way.”

During the first wave, many of the COVID-19 patients in the ICU were older, often arriving from long-term-care homes where the virus had run rampant, felling those most at risk.

In recent months, staff say they are seeing more patients in their 40s or 50s or 60s, some with small children at home, others with parents or siblings being cared for in different areas of the hospital.

They say seeing young people being rushed into the ICU, their oxygen levels plummeting, has become hard to bear.

“When someone says, ‘Please take care of me because I have a five-year-old at home,’ it’s that human factor that makes this so hard,” said Austrie-Fletcher, a mother of two who has worked in the ICU for eight years.

“People say we are heroes for what we do. We are also human.

“You go home and think about it. You go home and dream about it. I just want it to be over.”

Dr. Phil Shin, the hospital’s chief of medicine and medical director of critical care, said he knows staff, many fighting exhaustion, are finding it difficult to face new challenges.

He says his own resiliency was recently tested at the end of a particularly long and trying ICU shift when he learned, in back-to-back phone calls, that a physician colleague had contracted COVID-19, and Shin’s mother was diagnosed with a serious medical condition. He recalls not handling the upsetting news well.

“That was a day that it really dawned on me how little emotional reserve I have left,” he said.

“We talk about this openly as a team: How do we maintain our resilience in the face of this prolonged effort? How do we acknowledge the emotions and the exhaustion people are feeling in this shared experience? We’ve realized working together as a team is crucial.”

Critical care physician Dr. Anna Geagea agreed she finds it harder now to muster the same levels of energy that once helped carry her through the toughest weeks of the pandemic.

Days that were long are now even longer, the hours flying past with little time to rest, she said. COVID-19 patients in the ICU, many of whom are on a ventilator, can take twice as much attention as a typical critical care patient.

“There are the procedures and then all the donning and doffing of PPE and going in and out of the isolation rooms. It’s physically tiring; the weeks on my shift feel like a constant workout.”

Like others on her team, Geagea prefers the daily face-to-face interactions with patients’ families, many of whom would be at the bedside in pre-pandemic times. Now, with visitor restrictions, Geagea calls families to provide an update on a patient’s condition, trying her best to condense the previous 24 hours into a short, yet personal conversation.

“If I only give patients’ families five to 10 minutes of my time — five to 10 minutes; that’s not very much — it takes me three hours to provide updates on the whole unit, three hours on top of my regular day,” she said. “Families are understanding, but those conversations are very hard; those families just want to see their loved one.”

In the last 10 months, Katie Oliphant has had hundreds of such conversations. The registered social worker, who started in the ICU in December 2019, is often the staff member who helps families stay connected.

In her gentle way, Oliphant encourages families to email an audio recording of a patient’s favourite songs or a video with messages of love that can be played at the bedside. She assures families evenly the most critically ill will hear their words.

“We play them as often as we can. I just want families to feel that they’re present.”

Oliphant says she learns about patients from their families and passes on the details — who is married, who has children or grandchildren, where they work — to the care team during daily medical rounds. Since so many COVID-19 patients are in the ICU for weeks, often sedated, hooked up to a ventilator and unable to talk, Oliphant wants staff to see the person, not just the patient, lying on the bed.

On good days, Oliphant will do a video call with family in the first moments after a patient can breathe without a ventilator or while taking their first steps after weeks in bed.

On the hardest days, Oliphant has to help families say goodbye, something she’s done dozens of times during the pandemic.

“I tell them it’s just like me bringing you into the room but on an iPad. I tell them I’ll place the iPad by the bed, close to their loved one’s face, and that I’ll shut the door and give them some privacy,” she said. “And I tell them to talk, just as if they were sitting beside the bed, and that their loved one will hear what they have to say.

“Knowing those are their final words to a loved one, it’s heart-breaking … I know people have trusted those messages to me and it’s a responsibility I don’t take lightly.”

Dr. Elliott Owen has, in the second wave, too often been present for a COVID-19 patient’s final words in the moments before they are intubated and hooked up to a ventilator. Each time leaves him haunted.

As head of the hospital’s Critical Care Response Team, Owen gets called to check on COVID-19 patients treated on general medical units when their vital signs or blood oxygen levels dip, signalling a need for more intensive care.

On a recent shift, Owen raced three patients from the medical unit to the ICU, gasping for breath, vitals crashing. Each was young — in their late 40s or late 50s — and doing relatively well just hours before. Back to back to back they were intubated; two have since died.

“We see the sickest patients in hospital; I know this and I know that sometimes the outcomes won’t be good,” Owen said. “But you still get that heavy heart when you talk to younger patients and you want to do everything you can for them, and they still end up on a ventilator. Those are the moments from this I won’t forget.”

Blair, who’s been an ICU nurse since 2014, says she will remember each of the COVID-19 patients she’s cared for. The hours at their bedsides, the worry while watching their monitors, the tears she cried while holding an iPad for families to say their goodbyes, none of those memories will fade away.

She says only those who’ve worked alongside her can understand how the pandemic has worn them all done. And it’s those same colleagues and friends who help her get through the long, hard days.

“We all support each other,” Blair said. “We talk and realize that we're all going through the same thing. If something’s been upsetting, or particularly hard, we’ve been good at talking about it.

“And if something good happens, or if we have a happy thing to share, we do that, too.”

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