Sara Nolte, Canadian Emergency Medicine PA on the Frontlines of COVID-19

I love reading these pieces from my fellow PAs across Canada – I feel honoured and proud to be part of a profession filled with such caring, committed, and resourceful people!

Working in a busy downtown Toronto Emergency Department, our multi-disciplinary group (MDs, PAs, NPs, nursing, social work, etc.) has been working hard to prepare for the anticipated increase in sick COVID-19 patients. We’ve been exploring avenues to expand the PA role in the ED, incorporating some aspects of virtual care, and pioneering protected airway in situ simulation. If it wasn’t for the fact that a pandemic has been driving things, it would be a most exciting time.

These past few weeks where our clinical minds have been overwhelmed with COVID-19, I’ve come to see a few clinical themes evolving out of the craziness:

  • ‘Regular’ emergencies still happen. Not every chest pain, shortness of breath, cough, fever, weakness, or hypoxia is COVID-19. We need to remember to keep a differential and continue to look for other life-threatening causes of a patient’s symptoms (while following precautions and wearing PPE of course!). PE, MI, and toxicological issues are good ones to keep in mind. Similarly, patients with an underlaying COVID-19 infection, may have other issues that require management (e.g. stroke, PE, AKI).
  • ‘Regular’ emergency patients are sicker at presentation. People are delaying when they seek medical attention: they are either too scared to come to hospital, or don’t want to burden the system. As a result, our ‘regular’ ED volumes are down right now; however, those who do present to the ED, are coming much later than they normally would, and are often more sick than usual. We’ve seen more complications due to delayed presentations, such as perforated appendicitis, and MI-related wall ruptures.
  • Vulnerable populations are being recognized. We’re finally receiving more support for our homeless and low SES populations (which in itself is a public health crisis) in order to help keep them safe. Things like city-sponsored housing, cell phone donation programs, increased ED social and peer support worker presence. It still isn’t enough, but it’s more than we had – hopefully these resources will be expanded when this is over.

I also wanted to share some thoughts on a more personal and moral level. It breaks my heart to watch colleagues cope with not just the stress of work, but also with the sense of loss of the things that make us human: being unable to say goodbye when a loved one passes, not being able to touch your newborn baby, celebrations of love being postponed or cancelled.

And while we support each other from a distance through these episodes of grief, we’re also tasked with making some difficult moral decisions. Should dual-HCP families live apart – is our duty to family or healthcare more important? Which patient gets the last ventilator? When PPE runs out, will we still see patients – would I be a bad/selfish person if I did not?

There is no easy or right answer. We’re all hoping we won’t have to make these choices, and remain ‘cautiously optimistic’ about curve flattening, but that doesn’t make the anxiety or grief any less tolerable.

And since I don’t think we hear it enough, thank you.

Thank you to my colleagues for doing home visits, finding ways to still give routine care, providing follow-ups, and seeing the ‘regular’ medical problems.

Thank you to those of you doing groceries for family and elderly neighbours, helping with childcare, staying home when you’d rather be out.

But most of all, thank you for sharing your stories, your family video call screen shots, your stay-at-home photos.

These things make us feel more connected than ever (even to total strangers!), and remind us that even in our isolation, we are NOT alone.

About Sara Nolte, CCPA

Sara is a Canadian Certified Physician Assistant practicing in Emergency Medicine. She is a McMaster PA graduate.