Paramedic Jeff Booton cleaning his ambulance in Lions Bay in the Canadian province of British Columbia. When he dealt with his first potential case of Covid-19 in March, Mr Booton felt both trepidation and a sense of duty. But in the ambulance with the patient, Mr Booton just did what he always tries to do: comfort the patient. — Photo THE CANADIAN PRESS

Amy Smart

Canada has had far fewer deaths and infections compared with its neighbour, the United States. Still, the trials and tribulations of those in the healthcare system are far from different. This report tracks a single case in Vancouver.

The call came in on an afternoon in March: A patient at a medical clinic in Vancouver had complained of chest pains.

Paramedic Jeff Booton watched the details flash across the screen as he and his partner made their way to the clinic in their ambulance.

It was his first potential case of Covid-19, and he felt both trepidation and a sense of duty.

"I see this job as working in the service of people. And getting to do so in the context of a pandemic is obviously wrought with fear and apprehension some days, but it's work that still resonates with me," he said.

When Mr Booton arrived at the clinic, he put on protective gloves, a fluid-repellent gown, an N95 mask and a face shield.

After a physical examination, they got back in the ambulance and Mr Booton did what he always tries to do: comfort the patient.

Paramedics see people during what can be pivotal personal moments, and Mr Booton felt the weight of the patient's worry.

Mr Booton was one of at least 125 health workers, ranging from dispatchers and nurses to hospital housekeepers, who cared for the patient. On that day, the patient was among 55 identified by dispatchers as possible Covid-19 cases in Vancouver, in British Columbia province.

This is the story of those who cared for a single case at St Paul's Hospital.

EMERGENCY DEPARTMENT

Dr Shannon O'Donnell knew she had only a few minutes to prepare after paramedics phoned the hospital to warn that a suspected Covid-19 case was on the way.

"I was a little anxious," she said. "We don't know what we're getting, how much distress a patient is going to be in or how sick they'll be. And you know, you're worried also about being exposed to infection."

The department had been eerily quiet after beds were vacated and the workflow was overhauled to make room for a possible surge in Covid-19 cases, Dr O'Donnell said.

The authorities have announced that the province has been able to control the spread of the virus, but the caseload was still growing when the patient arrived.

The paramedics took the patient directly into a negative-pressure room set up for high-risk cases. Glass walls allow for filtration changes to reduce the risk of the virus spreading by air.

Dr O'Donnell examined the patient through a heavy armour of personal protective equipment, like everyone he would interact with. He was one of the sicker patients she had seen.

"What was most striking to me was that he did require oxygen, but he also had a very high respiratory rate. He was breathing 30 breaths per minute, whereas you or I would breathe 15 or 16 breaths per minute," she said.

Covid-19 has transformed not only the hospital but Dr O'Donnell's home life, too. She and her husband, also an emergency doctor, have juggled the full-time care of their three children at home since schools closed.

Dr O'Donnell ordered blood work, chest X-rays and an electrocardiogram scan, and conducted a chest ultrasound with the help of registered nurse Rachel Mrdeza.

For Ms Mrdeza, some of the hardest cases have been the older patients who arrive incredibly short of breath, with a fever and chest tightness.

Emergency department workers do not typically learn if patients have Covid-19, because the test results come back after they move on from their care, but there can be strong evidence of the virus.

Under normal circumstances, the emergency doctor would work with several nurses, but only one is allowed in the isolation room at a time to protect against contagion.

By the time Ms QianQian Wu began her night shift, she was only the third nurse to see the patient.

Despite the promising case numbers in the province, Ms Wu said staff do not feel like they can relax. St Paul's Hospital is the main treatment centre for vulnerable residents in the area.

TESTING

While the patient waited in the emergency department, blood samples and swabs were sent to the hospital's laboratory.

Dr Marc Romney, medical director of medical microbiology and virology, said manual molecular testing for Covid-19 typically requires five to 10 lab staff.

A porter transports the specimen, a technologist reviews whether it was ordered and labelled properly, then two or three technologists conduct a multi-step process involving the extraction, purification, amplification and detection of the virus' genetic material.

A senior technologist and one or two physicians review the results before they are sent back to the attending physician and infection control team.

But the virology lab was transformed by the arrival of a machine in March that automates part of the process.

The Roche Cobas 6800 system was adapted from systems for HIV testing and lifted the lab's theoretical capacity to 2,000 tests a day, in combination with manual testing.

The work has been carried out at personal cost. One technologist was basically living in the lab and sleeping only five hours a night.

Dr Romney went weeks without a day off and did not see anyone in person beyond his immediate family and colleagues.

When 19 positive tests came back in a single day, another doctor "basically ran from her home" to the hospital to start communicating the results to doctors, public health officials and others who required the information, Dr Romney said.

"The front-line workers are amazing, and we are here to support them, but I think it's good for people to know there are also a lot of people behind the scenes working on this too," he said.

THE TRANSITION TEAM

More severe suspected Covid-19 cases are sent to the intensive care unit (ICU) for isolation. Back in the emergency department, Dr O'Donnell called Dr Mathieu Surprenant for an assessment while they awaited test results.

When he got the call from emergency, Dr Surprenant headed downstairs with resident Charles Yang.

This was not the hospital's first suspected Covid-19 case, and Dr Yang found himself wondering if it would follow the same trajectory as others.

The team examined the patient to develop his care plan. They looked at his oxygen levels and also at the patient himself. Did he look comfortable? Was he struggling?

A crash intubation would be risky for staff because of the time it takes to put on protective equipment, and a chaotic rush into an isolation room could spread the infection.

A care plan puts everything in place for a controlled intubation, if a patient appears likely to decline.

The team talked it over, and the patient was transferred to the ICU for monitoring overnight.

But it was not long before his oxygen levels began to cause concern for Dr Surprenant.

He believed the patient had reached the stage where intubation was his best chance of survival.

Making that call meant calling in a group dubbed the Covid airway team. Early in the pandemic, the experts in both airway management and donning and doffing specialised protective gear waited on call in a hotel across the street.

"Just dressing takes between five and 10 minutes," Dr Surprenant said. "They look like astronauts with all the layers."

THE COVID AIRWAY TEAM

Anaesthesiologist Shannon Lockhart was part of the planning group that conceived the Covid airway team.

The cancellation of elective surgery meant the traditional workload for Dr Lockhart and her colleagues would be lighter. Their idea was to form teams with respiratory therapists to perform intubations so that emergency and ICU doctors would not expose themselves to the high-risk procedure.

When Dr Lockhart was called to intubate the patient, she was ready.

"He fit the story of what you hear about Covid patients who look really well from the bedside, but their numbers don't look that great," she said.

Putting a breathing tube down a patient's throat under normal circumstances takes between five minutes and six minutes, she said.

That timeframe has ballooned to between 60 minutes and 90 minutes - dealing with the extra protective gear, preparing every possible material you could need in isolation, and the cleaning or disposal of everything in the room.

Dr Lockhart and a respiratory therapist gave the patient a sedative and paralytic, and inserted the breathing tube while another anaesthesiologist waited outside as backup.

Working with different colleagues in an unfamiliar setting while wearing cumbersome new equipment is stressful, Dr Lockhart said. But she has been heartened by watching hospital staff quickly respond and break down silos in which they typically operate.

After intubating the patient, the riskiest part of Dr Lockhart's new job is doffing her gear.

As the patient relies on strangers for care, Dr Lockhart too relies on someone she barely knows for her own protection.

She and the respiratory therapist watch one another carefully as they remove the equipment piece by piece, monitoring for any slip that would allow contamination.

THE ICU

When Dr Gavin Tansley met the patient, he was already sedated and breathing through a ventilator.

He had given the okay for intubation when Dr Surprenant woke him up with a phone call. He was already familiar with the patient's case.

Where possible, ICU staff keep an eye on patients they might inherit from other departments, said Dr Tansley, a general surgeon training in critical care. They ask themselves - if things get worse, what would we do?

"Very often, by the time I meet patients, they're already sedated or on a ventilator or so sick that they can't talk to you. So, your relationship becomes with the family, and you develop amazing relationships," he said.

It has been hard for staff to keep families from their loved ones, but they are finding ways to help them connect.

Dr Tansley sets aside time to phone them with updates. Nurses hold iPads up to patients so their families can at least see them on video.

RECOVERY

By the time the patient reached the ICU, about 25 health workers had already played a role in his case. Some interacted with him directly, while others played important but indirect roles in his care, ranging from hospital housekeepers to X-ray technologists.

About 90 intensive care staff saw him, and from there, he would be turned over to a general medicine team.

Mr Kevin Novakowski is a respiratory therapist, and in his 28 years of work, he has never felt an illness create such a constant psychological burden.

As Mr Novakowski monitored the patient, he began reducing the ventilator's power and gave him short trials without it.

"You're looking at their breathing and watching them and focusing on how their muscles look. Are they struggling for air, are they taking deep breaths, are they breathing fast, are they breathing shallow?" he said.

Weaning is a gradual process, like an ebbing tide. Off the ventilator, a patient's breath rattles.

The rattle may disappear and then return when they stand for the first time, or when they start walking.

It's a stressful process for patients. If they don't keep coughing to clear their airway, infections can return.

During those first trials, Mr Novakowski waits and listens.

"You listen to them breathing," he said.

"And then all of a sudden, it's just kind of really quiet and their breathing just sounds like our breathing - normal.

"And you think: OK. That's good."

• This story was contributed by The Canadian Press for World News Day 2020.