The images are intimate and arresting: health-care workers carefully donning gowns, goggles, masks, and face shields; a critically ill patient being rushed down the hall to intensive care; a doctor using a baby monitor to communicate with colleagues through glass; a team of doctors and nurses lowering their heads in a moment of respect for a patient who has passed away.

These vivid images were photographed by Dr. Dawn Lim, EMBA ’14, a staff emergency physician at UHN in Toronto, Ont. Lim spent her days off and downtime documenting her UHN colleagues as they battled COVID-19 during the first months that the pandemic hit the city.

Lim says she decided to create the photo essay to tell the stories of the people on the front lines. It was also a way to help her cope with the stress and anxiety of being an emergency physician during COVID-19.

“I think our tendency is to just get through this, to put our heads down, work, and then go home and sit in front of the television,” says Lim, who works out of both Toronto General Hospital and Toronto Western Hospital. “But by taking those photographs, it helped me. It is like a time capsule of how we felt. What was it like to work as a team? What did it feel like to be separated but together? What were the things that it took to overcome that feeling of helplessness?”

Lim says her UHN colleagues welcomed the experience to be photographed for the photo essay. “I think very early on, people realized this is something that hopefully happens once in a lifetime. People understand that we need to remember this experience.”

Essential Service

Across the country, Canadian health-care workers are on the front lines of an unprecedented pandemic event. COVID-19 has torn through the world with devastating results. It’s a virus that has proven to be highly infectious and challenging to treat. It’s also knows no bounds — young, healthy people can become gravely ill, with elderly people or those with concurrent health conditions particularly vulnerable to complications.

As government-mandated lockdowns swept the nation in order to control the virus in early 2020, life changed for all Canadians. And for health-care workers, COVID-19 has been just as life-changing.

“As emergency physicians, we always understood that at some point in our career we would potentially be at the very front lines of a pandemic. History has taught us that,” says Dr. Warren Ma, MBA ’12, an emergency physician at the University of Alberta Hospital. Ma is also Zone Clinical Department Head for Emergency Medicine at Alberta Health Services (AHS), overseeing all 12 emergency departments in the Edmonton, Alta. area.

“We had a sense that something of this magnitude would create a fair amount of stress within our system and for our health-care providers,” he says.

As news of the spread of the novel coronavirus started emerging out of Asia, Ma says he and his team began planning. AHS set up an Emergency Coordination Centre in February so that by March, they had a pre-triage protocol already in place. Their plan had three main goals.

“The first was to protect our patients and provide them with care. The second was to protect our teams and make sure that we're safe,” he says. “The third was to support each other and the system. We kept it really straightforward, really simple, because anything beyond that would be a big struggle for our frontline physicians to manage with the amount of change that was being asked of them.”

COVID-19 has been a “big stress test” for emergency health-care workers, says Lim. When the virus first turned up in patients in Toronto, very little was known about how it presented and how it was transmitted, making physicians feel very vulnerable, she says.

Plus, the virus had hit some geographical areas with such intensity. “We wondered, were we going to be like Italy? Were we going to be like New York City? What was the personal protective equipment (PPE) supply going to be like?” Lim says, “So many factors were out of control — we were as afraid and unsure as anyone else.”

Protection & Connection

One of the ways everyone is best protected during COVID-19 is through the PPE health-care workers wear when caring for patients. Equipment includes gowns, gloves, masks, goggles, and face shields. These measures are extremely important to prevent the spread of infection, says Lim, but treating patients while wearing full PPE can be challenging.

“You’re basically wearing a plastic muzzle and it’s very hard to hear. The emergency department's baseline is very loud and you have to shout when you're asking someone for information,” she says. “The PPE separates you as well. People don't see your smile. People don't see the expressions of empathy. It’s a muting of the things that make us human.”

Lim remembers an interaction with an elderly man who had suspected COVID-19 symptoms. The man was a caregiver for his family with many people who relied on him.

“I told him, ‘I have to test you for COVID-19 and you have to isolate yourself from your family.’ And he just started crying,” Lim recalls. “It was so hard for me to see that. Normally I would bring a box of Kleenex and dry his eyes. But I couldn't do that.”

Another protocol that emerged has been the limiting of family members and visitors at hospitals to prevent the spread of the virus. Ma says that’s been a challenging aspect of emergency medicine during the pandemic.

“There have been a lot of interesting developments with virtual visitations through technology like tablets or phones, but many of those technologies are new to health care for that purpose. It’s been a challenge to roll out,” he says. “And having your family member at your side is not the same as having them on a Skype call.”

Taking the Worry Home

Lim says one source of stress has been concern about bringing the virus home to her family.

“I have young children and my husband is also a doctor,” she says. “I decided early on that I wanted to stay with my family because they are my strength. And we could see that this would be a long haul, going on for months. I really can't imagine being separated from my kids for that long.”

Lim says she has an “elaborate decontamination” process when she leaves the emergency department. “And when I come home, I go right into the shower. I don't even say hi to my kids or touch them until I have done that. And of course, I'm always watching to make sure that I don't have any symptoms.”

Ma says that trust in the personal protective process helps him feel safe when returning home at the end of a shift.

“We made a couple of small changes to our family routine,” he says. “One thing that we instituted fairly early on was the concept of not wearing regular clothes while at work. So I change as soon as I finish my shift. And when I get home, I repeat the hand hygiene and hop in the shower before I give my kids a hug.”

Managing Stress

Across the country, Canada’s health systems have been doing their part to help alleviate stress on health-care workers during COVID-19. Lim is Physician Lead for Corporate Wellness at UHN, and she says that her team got a lot of insight into stress and burnout from reports written about SARS, a pandemic that spread worldwide in 2003.

“From the literature during SARS, we know people really need to have what we call ‘psychological first aid,’” says Lim. “They need to have emotional support, not necessarily to see a psychiatrist or a therapist, but to be able to talk about their feelings.”

In March, Lim started a series of virtual “coffee chats” at UHN where anyone who worked in the emergency department — whether it be environmental services, security, x-ray technologists, nurses or doctors — could talk about their experiences during COVID-19. The hospital has also provided psychiatrists, therapists, social workers, and crisis workers to anyone who needs them.

“It is definitely a sustained stressful experience with ups and downs that is very challenging. But I think that these outlets are very, very helpful,” Lim says.

Lim notes that emergency room physicians don’t necessarily get the chance to see patients recover and don’t get the continuity that other physicians might get. But she was able to get a better sense of that through her photo essay.

“I met some of the patients and I heard their stories. For instance, there have been friendships forged between fellow COVID-19 patients, who became friends when they were in beds next door to each other. And we've had some incredible survival stories.”

Looking to the Future

There have been so many lessons and insights from the experience of living through COVID-19 as a physician and a health-care administrator, says Ma. “I could probably fill a thesis for a PhD.”

One of these lessons is the importance of a public health-care system, he says. “I think that when the dust settles, we will have seen some of the differences in challenges between varying system types. Having a public health-care system has been a key reason why Canada has been able to respond the way we have. It's not a perfect response, but we've been able to respond well.”

The pandemic has also brought up issues of capacity in acute care facilities. “If we're always operating at 110 per cent, which is almost every hospital in Canada, does that make sense if we need to respond to a disaster?” he says.

As well, there are opportunities for the private sector to help improve and innovate in the health-care system, adds Ma.

“People with the right skill set need to figure out how to support our public health institutions. For example, if we're going to look at reworking the entire supply chain for PPE, what is the optimal way to do that? There's an opportunity for the entrepreneur and the business community to provide some of that expertise to support health-care evolution to make it sustainable.”

Lim agrees that working through COVID-19 has revealed that work needs to be done to make sure our health-care system is truly sustainable.

“I’m thinking about all the patients who are homeless, our elderly patients who don't have Internet access to get their test results, or people who can't afford to self-isolate. The pandemic really influences people unequally and has shown us the gaps in our system,” she says. “I do hope we embrace these valuable lessons, and work on lasting improvements.”

Ma says that his COVID-19 experience has taught him a lot about his fellow Canadians. “As we move into this next phase, I’ve reflected on how incredibly responsive and understanding Canadians are in general. To do these large public health interventions and shut things down, that is a sacrifice that we've been asking of each and every Canadian,” Ma says. “One of the big things that I would want to say as a frontline physician is thank you.”

Lim agrees with Ma’s sentiments. “The constant messages of support, acts of kindness, and the donations have made a huge difference to morale.”

Canadians should know that health-care workers will continue to do their best whatever the future holds, Lim says. “We were here before this thing and we’re going to be here after the pandemic is over,” she says. “We're here because we love what we do.”