Words of an ICU physician on the edge

Feb. 2021
Wendy Schneider

For Bram Rochwerg, an intensive care physician at Juravinski Hospital, the week before Christmas 2020 in his ICU was the most challenging of his six-year career. You could say that Rochwerg, who comes across as affable and exceedingly modest, lives and breathes everything related to COVID-19. 

When he’s not in the ICU, he’s involved in research relating to treatment of the disease. He headed up a team of McMaster University researchers who played a direct role in the World Health Organization’s November announcement that recommended against the use of the antiviral drug touted by U.S. President Donald Trump. 

Back in March, Rochwerg read with alarm reports of doctors in Italy and New York City being forced to make life and death decisions in overflowing ICUs. But despite the pandemic ripping through the province’s long-term care facilities, Ontario hospitals never saw the surge of COVID-19 patients last spring that they had expected. 

“We cleared out the ICUs. We made tons of capacity and then because of these draconian public health measures, we sort of dodged the bullet,” Rochwerg told the HJN, adding that, at most, his ICU saw only 10 critically ill patients during the spring and summer months.

All that changed by the end of November. The number of COVID-19 patients began to shoot up, increasing the pressure of a unit already acting at full capacity due to the backlog of rescheduled cancer and elective surgeries delayed during the first lockdown. The HJN spoke with Rochwerg in mid-December, days before the province announced another lockdown that would take effect on Dec. 26. 

“The last week on service in the ICU was incredibly challenging,” said Rochwerg. “We’re all feeling it. The hospital staff are getting sick, nurses are getting sick and everyone’s a little bit more stressed this time. Everyone’s trying to rise to the challenges, but inside the walls of the hospital there’s this increasing recognition that the situation is untenable.”

There is, however, hope on the horizon. Aside from the promise of mass inoculation, Rochwerg said he’s been encouraged by the positive impact of corticosteroids in reducing lung inflammation in critically ill COVID-19 patients. 

“With all the research I’ve been involved with … and so many drugs and interventions that we’ve investigated, up until this point there’s only one that’s proven beneficial in sick COVID patients and that’s run of the mill cortical steroids,” he said. “Otherwise, it’s just the normal stuff that we do for all patients with respiratory failure: good nursing, good vent care, and really just giving the body time to heal on its own.”

 It can be tough going on patients, he acknowledged, but drug treatment options for COVID-19 remain limited, as they generally are for any virus. 

There’s been another change in the Juravinski ICU over the last nine months—the timing of when to intubate patients. Rochwerg said that in the spring, when there were still so many unknowns, the common practice was to intubate patients “a little earlier than we normally would,” as a precaution against risk to healthcare workers and a well-meaning, but mistaken desire for more control over an escalating situation. 

“When oxygen levels drop to where you have no choice, you put them on the ventilator. But we’re not being too proactive with it,” he said, in recognition “that we should just treat these patients like everybody else.”

One area of discussion about which Rochwerg is unequivocal, relates to the drug regimen given to Donald Trump and Rudy Giuliani, who seemed to emerge relatively unscathed from their respective bouts with COVID-19, despite being in a high-risk category for complications. 

One of the drugs President Trump took, Remdesivir, as well as Regeneron, received a lot of attention, but McMaster researchers made a recommendation against them. The group believes the medications are not effective against COVID-19 and may distract from the things that do work. “Yes, it’s a deadly disease, but the majority of people still survive, even in the high-risk sub groups. So Donald Trump was probably going to get better no matter what,” said Rochwerg, adding that he thought it was equally likely that President Trump was admitted to hospital for side effects from the experimental drugs as it was for the disease.  

Rochwerg is “massively hopeful” that the vaccines are going to be effective and is cautiously optimistic that this spring, we will start to see a decline in COVID-19 rates as a result. 

Until then, he believes it’s important that we, as a society, continue to make the necessary sacrifices to minimize deaths, while prioritizing education, cancer screening and chemotherapy, surgeries and stem cell transplants. 

“Everyone’s fatigued. Everyone’s sick of the restrictions, of not seeing their friends and family,” he said. “For young, healthy people, the risk of dying from COVID is low, but the impact on our society is huge. In my mind, somebody who’s 50, 60, even 70 and was previously healthy is not old, and to see these people who’ve had no real past medical history dying, it’s still super impactful and hard. There is a light, but we’ve just got to get through these next two to three months.”