As in any war, writes ANDRÉ PICARD , the front-line troops doing battle with SARS are making the greatest sacrifices. Nurses have slowed the progress of the mysterious killer, but many have been placed in quarantine and asked to work long hours while their families fear the worst Saturday, April 5, 2003 ANDRÉ PICARD
It was a routine patient transfer. Mount Sinai Hospital in downtown Toronto is renowned for fighting infectious diseases, so troublesome cases often wind up there. On this Sunday night, the ambulance brought a patient from Scarborough Hospital, Grace division, who was suffering from severe respiratory problems. Susan Sorrenti, a nurse in intensive care, greeted the ambulance and helped the patient settle in. The man coughed, and coughed. He burned with fever. She bathed him with soothing cold water and offered comforting words. "I've had a lot of patients with atypical pneumonia over the years," Ms. Sorrenti said. "This wasn't that different. I just did my job, caring for the patient as best I could." But this was different. The man had severe acute respiratory syndrome (SARS), and the Monday-morning papers would reveal he was the 13th patient in an increasingly worrisome outbreak. As she did her work, Ms. Sorrenti took respiratory precautions, wearing a mask, gloves and a gown. But there was a period of time, during the transfer, when the nurses were unprotected, breathing in a potentially deadly virus. By Wednesday morning, the hospital had called to say she was under quarantine, and to monitor herself for SARS symptoms: a fever over 38 degrees Celsius, a dry cough, and difficulty breathing. After taking her temperature, Ms. Sorrenti checked herself into hospital and has been there, in isolation, ever since. She developed the dry cough too, but so far remains free of pneumonia. Like dozens of other nurses and front-line workers, she probably has SARS. Her workplace, Mount Sinai's intensive-care unit, has become her prison. In all the media coverage, particularly in Toronto, the impact of SARS on nurses has largely been glossed over. Because they worked most closely with sick patients at the outset, nurses account for the majority of suspected cases; most are recovering, but some are gravely ill. Hundreds of others without obvious symptoms are home under quarantine. In fact, the SARS outbreak has taken a massive professional, economic and emotional toll on the already beleaguered nursing work force. It has also underscored the nursing shortage, the everyday dangers in the workplace and dubious labour practices that would leave the health-care system in danger during a more serious outbreak or bioterrorist attack. "SARS is scary, but we deal with stuff every day: Violence, abuse, heavy lifting, exposure to chemicals and bodily fluids, and other infectious diseases," said Susan Brickell, president of Local 111 of the Ontario Nurses Association at Scarborough Hospital. "It's tough work." Just "freed" from her own 10-day quarantine, Ms. Brickell said SARS is different in that a new psychological line has been crossed. "Usually, we can leave our worries at work, but SARS followed us home. What upset nurses more than anything else is that, this time, we put our children and loved ones at risk. We became lepers in our community because we did our jobs." As union president at the hardest-hit health-care institution, she has heard many horror stories: Nurses whose husbands were sent home from work, children of nurses shunned at school, nurses refused rides by taxi drivers, single parents unable to get a babysitter, pregnant and immuno-compromised nurses forced to go to work despite concerns or forced to use big chunks of sick leave, casual nurses who no longer have a means of income, nurses of Asian heritage subject to discrimination, routine life turned upside down by the fear and the unknown. Even though not sick herself, she was heart-broken when her nine-year-old daughter watched the TV news and asked: "Mommy, are you going to die?" "And, you know what? I couldn't even hug her," she said wistfully. Hospitals such as Scarborough Grace are closed to new patients, but they are still functioning for those they had, and they still need nurses. That creates an unusual situation for many nurses: They are quarantined, but still have to go to work. They also care for SARS patients, and conduct the assessment clinics for the thousands of people who fear they have been exposed to the mysterious new disease. Yet, at work, nurses must eat alone, restrict their movements and minimize contact with others at a time when they are feeling particularly vulnerable. They also must wear full precautions -- masks, goggles, gloves and gowns -- which makes every little task more time-consuming. At home, the stress is not reduced: They must wear the masks and avoid physical contact with family members to minimize the theoretical risk of passing on the infection. After days, the forced isolation becomes suffocating. And neighbours and family members now look upon them differently, as Typhoid Marys. "In 33 years of nursing, I thought I had seen everything, but I've never seen anything like this," said Ann Brokenshire, co-ordinator of the prenatal program at Scarborough Grace. She thinks the impact of the outbreak will be lasting, that patients and nurses alike will view hospitals differently. Many of her patients, for example, are turning to midwives and home births to avoid the hospital altogether. Ms. Brokenshire's unit is closed so she is quarantined at home, but she does not think the public appreciates what nurses are going through. "Nurses are working extra hard and they are making a lot of personal sacrifices because of SARS, and I don't think they're really getting the credit," Ms. Brokenshire said. Most admired are the select group of nurses who are caring for their colleagues, in isolation units that have been established at a number of hospitals around Metro Toronto. The largest is at West Park Healthcare Centre, a former sanitorium now known for its respiratory care, but there are SARS units at Mount Sinai and Sunnybrook and Women's College Health Sciences Centre. Despite the risks, and what little is known about the new disease, no nurse has refused to care for a SARS patient. In fact, many have volunteered to care for colleagues, conscious that there are shortages. "I would be lying if I didn't say I was afraid," said Andrea Reid, a nurse on the Sunnybrook SARS unit. "Of course I'm afraid; it's the unknown." But, at the same time, she feels more in control than her patients. "They were unwittingly exposed, but I feel I'm armed with what I need to fight it, with every precaution imaginable." Being a patient is stressful too, particularly when she is a nurse who knows a lot about infectious diseases and the dangers they pose. "The first couple of days in here, I did a lot of crying and feeling sorry for myself," Ms. Sorrenti said. Her overwhelming concern was for the safety of her two daughters, aged 6 and 8, but they seem fine. "Now, I'm focusing all my energy on getting better so I can go home and see the girls." Despite the ordeal, she wants to get back to work, but thinks the workplace will be forever changed. "Because of SARS, all nurses are going to want more protection," and they'll probably get it. "This should be a wake-up call to take infectious diseases more seriously." Donna Tucker, chief nursing officer at Scarborough Hospital, said the outbreak also underscores the importance of communicating health issues to the public. But, once the crisis has passed, she hopes the media will put more emphasis on the hurdles facing front-line health-care workers. Doris Grinspun, executive director of the Registered Nurses Association of Ontario, said the outbreak has shone a light on a profession often taken for granted. Ontario Health Minister Tony Clement has called nurses the "heroes" of this outbreak. "What the public has seen in the past couple of weeks is something I already knew," Ms. Grinspun said. "It takes a special person to be a nurse, period." But the outbreak has also magnified concern about existing problems in nursing, such as shortages and casualization, the practice of hiring nurses for just a couple of days a week. Widespread shortages mean that many nurses work overtime, and that means there is little slack in the system. When hundreds of nurses were quarantined, there was such a shortage of skilled workers that the potentially infectious nurses had to keep working, which put patients at risk. Treating nurses as casual labour, which leads many to juggle shifts at several institutions, also can be a dangerous practice. "When you have casuals, they drag bugs from one institution to another. It's a really unhealthy public-health practice," Ms. Grinspun said. The casual nurses (only 54 per cent of Ontario nurses have full-time jobs) also take a financial hit. The Ministry of Health issued a directive that any nurse who worked at Scarborough Grace, York Central or any other affected hospitals could not work at other facilities. Quarantine also hit casuals hard because they do not have sick leave or benefits, so they have been stripped of their income. Ms. Grinspun said policy changes must be made quickly. "SARS has been difficult for nurses, but the next time could be much worse. If we have a flu pandemic or a terrorist attack, we won't be able to afford to be without even one nurse, so we better get ready." But, for the time being, she said, the emphasis should be on appreciating nurses' efforts. The RNAO, for example, has taken out thank-you ads in today's papers and has sent letters praising staff to all affected institutions. Ms. Tucker, chief nursing officer at Scarborough Grace, agreed that things will change, but for now, she has only one thing to say to her staff, toiling at the centre of the outbreak. "The biggest message I have is: 'Thank you. Thank you. And thank you.' If it hadn't been for nurses, this could have been so much worse." André Picard is The Globe and Mail's public health reporter. Nurse first to spot the killer in Toronto It was the weekend, so Agnes Wang spent a little time scanning the Chinese-language papers. She's a nurse and one story caught her eye: a father and daughter who had died from a strange form of pneumonia that had popped up in Hong Kong. When she got to work on Monday morning, Ms. Wang, who is patient-care manager at Scarborough Hospital, Grace division, began to review charts. She was struck by the fact that one patient, 44-year-old Toronto resident Tse Chi Kwai, had a strange breed of pneumonia, and his mother, Sui-chu Kwan, had died a few days earlier, also suffering from a mysterious respiratory ailment. "I said: 'This is a strange coincidence.' And I asked one of the nurses to check the patient's travel history," Ms. Wang recalled. "It turns out his mother had visited Hong Kong." The night before, infection-control officers had been notified, as they are whenever there is an unusual pathogen. But Ms. Wang's observation allowed public-health investigators to connect the dots. And so began the detective work related to Canada's outbreak of severe acute respiratory syndrome (SARS). Ms. Wang said it is nice to know she played a part in helping stem the outbreak, but she gives much of the credit to colleague Sandy Finkelstein. As director of the intensive-care unit, he had placed Mr. Tse in isolation, on a hunch. Dr. Finkelstein, in turn, credits the nurse for her sharp eye. Either way, the double dose of serendipity probably limited the spread of SARS dramatically. To date, at least seven people who came into contact with Mr. Tse, directly or indirectly, have died. Dozens of others are ill and, because of the rippling web of contacts, hundreds more are under quarantine. However, had the gravely ill patient not been isolated, and the connection to Hong Kong not made so soon, many more nurses would have had direct contact with Mr. Tse. "What's happening is pretty bad," Ms. Wang said, "but it could have been much, much worse. "Sure, if we had known ahead of time what we were dealing with, we could have done more. . . . But it turns out we were actually very lucky."
Fear factor: So just how big a risk is SARS?
Saturday, April 5, 2003
ANDRÉ PICARD
Severe acute respiratory syndrome is an international bug of mystery. By hitching a ride with travellers, it has caused thousands of cases around the world -- so many, in fact, that it has been dubbed the most significant outbreak ever spread through air travel. Thus far, seven Canadians have died and more than 100 may be infected. But the tally doesn't really seem all that high, considering the elevated level of concern. As the top disease specialists here and abroad struggled to find the cause, many questions remain unanswered. For the average Canadian, the main one is: how serious a threat is SARS? A few things to remember when trying to come up with an answer. The cause The leading candidate is a previously unknown coronavirus, a sort of "super-cold" that has jumped to humans from cattle or poultry. But many samples from sufferers contain metapneumovirus, a common cause of respiratory ailments among children that may have mutated. Another theory is that the two relatively harmless bugs have somehow joined forces. Scientists also concede that it is possible these two bugs may not be related to the illness, and that they have no idea what is causing SARS. What is almost certain is that the disease sprung up last November in China's Guangdong province. How SARS travels Like the common cold, it seems to be spread by droplets. If someone infected coughs or sneezes, anyone within about a metre is vulnerable. The bug also can linger, so if an infected person touches a door knob or elevator button, anyone who does the same soon after is at risk. There is also some evidence that the bug may be airborne, but clearly some carriers are "super-infectors" and far more infectious than others. The death rate So far, about four per cent of people worldwide who contracted SARS have died. In Canada, it's 10 per cent. That is far higher than influenza, but still about half the death rate of West Nile virus. Influenza, however, is such a common infection that it is a much bigger killer over all. More than 5,000 people a year in Canada die of the flu, even though there is an effective vaccine. But we don't shut down hospitals and run around in masks during the flu season, which lasts about five months a year. The signs The illness usually begins with a high fever (higher than 100.4°F or 38°C), a dry cough and a general feeling of malaise. In other words, the symptoms are identical to a host of respiratory illnesses. Until there is a test, the only distinguishing factor is contact with someone known to have SARS. If not, you don't have it. The risk factor So far, all cases in Canada can be traced directly to contact with an original SARS carrier; public health officials insist there has been no community spread. If it does gain a foothold, it could become a part of the infectious-disease landscape, like influenza. Evasion strategy It's boring and low-tech but washing your hands guards against a host of diseases, including SARS, and it's never a good idea to hang around someone with a hacking cough or to put your fingers in your mouth. Should you wear a mask? No, it will just make you seem paranoid. You'd be far better off tying your hands behind your back. Travel advisory It's not a good idea to visit areas where SARS has spread within the community, such as China, Hong Kong and Singapore. But there are all kinds of things you can pick up on the road, and in terms of danger, SARS isn't that bad. It's not that common and fairly easy to avoid. Travelling to Toronto poses no danger, unless you plan to sneak into one of the hospitals' isolation wards. As for Chinatown, SARS is no more common there than anywhere else in the city. Public health officials have done no racial profiling of sufferers, but there is no evidence that people of Asian origin are disproportionately affected. In fact, more than two-thirds of the people infected with SARS are healthcare workers, so it's hospitals you should really avoid, not Chinese restaurants. Treating the disease The vast majority of cases clear up on their own, although Tylenol can be used to reduce fever. When respiratory symptoms become serious, and sufferers get pneumonia, they are given a combination of Ribivarin (a powerful antimicrobial) and steroids. But there is no real proof that treatment works. Because SARS is likely caused by a virus (not a bacteria), antibiotics don't help. The final buzzer An outbreak like this is officially over when two incubation periods have passed after the last new infection: In this case, 20 days. Practically speaking, that means you expect SARS to be around for at least another month. More likely, it's here to stay. André Picard is The Globe and Mail's public health reporter.