St. Paul's has long been known as the go-to hospital in Vancouver for paramedics to hand over the steady stream of people who continue to overdose from illicit street drugs.
Then the COVID-19 pandemic happened.
Now the aging downtown hospital is on the receiving end of British Columbia's second declared public health emergency in four years.
Though overdose drug deaths dropped in 2019, the opioid crisis persists, with almost 1,000 British Columbians dying last year, 245 of whom took their last breaths in Vancouver.
The first four months of the year are off to a bleak start, with Mayor Kennedy Stewart announcing this week that 16 people in Vancouver died in the last two weeks of an overdose.
Another 42 lives were lost in the city prior to that surge.
It is with that context and sobering reality that Keith Walley and Moses Li find themselves in their roles on the frontlines of the coronavirus battle inside St. Paul's Hospital.
Walley is a doctor in the hospital's intensive care unit, Li is an emergency room nurse. They don't know each other, but are integral members of a hospital-wide medical team working to treat and save COVID-19 patients from death.
"The opioid epidemic has been particularly hard on all of us, but even more so on the nursing staff because they're at the bedside 12 hours a day," Walley said by telephone Thursday.
"Luckily—so far—COVID-19 has not resulted in a lot of deaths in our ICU."
But it is a potential surge in cases that worries Walley and Li, who points to the vulnerable population in the Downtown Eastside, where poor living conditions in low-income hotels and on crowded sidewalks could fuel an outbreak.
'There's very little resources available for people to self-isolate themselves and even perform regular hygiene," said Li this week while on his way to begin another shift.
"I don't know if you've ever been in a [single-room-occupancy] hotel in the Downtown Eastside, but it is not a very easy place to take care of yourself."
Li's concern has been shared by Provincial Health Officer Dr. Bonnie Henry at her daily media briefings. But she has also expressed equal concern about clusters of coronavirus cases flaring up across the province, no matter the community.
As she warned Thursday, "We are not over the hump yet, and we are going to have a bumpy ride for a while."
Prepared for a surge
Hospitals in B.C. and across the country have prepared for a surge in COVID-19 cases, with Walley and Li both working alongside their respective teams in running through simulations.
They have the equipment, the training and have taken extra precautions personally and in organizing the emergency room and intensive care unit to accommodate a possible influx in patients.
Walley, for example, has split his office into two halves to separate any potentially contaminated clothing and gear into a plastic bag.
He showers at the hospital before leaving for home and constantly washes his hands and applies hand sanitizer, as do his colleagues outfitted in scrubs, masks, gloves and protective eyewear.
Medical staff, he said, have to presume every patient in the hospital could be positive for COVID-19, particularly those who require an immediate response after their heart or breathing has stopped.
"That means there's an extra step now of putting on the [personal protective equipment] before we get into the room, and making sure that the right people with the right equipment are doing the right things in the room," he said, describing some of the gear worn by medical staff as "a spacesuit."
Health-care workers, as Dr. Henry has said in her daily briefings, are at high-risk to contract the virus.
Many have, including one of Walley's colleagues at the hospital, Dr. Joseph Finkler, an emergency room physician. He shared his story of recovery in the media recently, telling the National Post: "I sort of thought I was invincible from this thing."
Walley is naturally concerned that he too could contract the virus, but trusts his carefulness will keep him healthy. Just the same, he and his wife have discussed living on separate floors of their house if one of them shows symptoms or gets infected.
"I am almost hyper-aware of all of my movements, all of the things that I touch, where I'm standing, where other people are," he said.
"So it's a different realization for myself, and I've really changed my behaviour in a way where my underlying assumption is COVID-19 is everywhere."
'Steady stream coming in'
The number of coronavirus patients in St. Paul's has fluctuated, but Walley said the load is nothing compared to hospitals in Italy and New York City, where unfolding disasters of the human kind persist.
"At times, we've gone up to six patients who are COVID or COVID-suspected but it's been much lighter than what we planned for," he said, adding that he is in regular touch with colleagues in Italy, New York and Brussels to share information about the virus.
"There's a steady stream coming in—that's certainly happening—but it's not overwhelming the health-care system at this point, which is just really encouraging for everyone in our hospital."
The intensive care unit at St. Paul's has a total of 30 beds. Twenty were recently converted to "negative pressure" rooms, where windows were removed and large fans installed to ensure no air spills into hallways.
The hospital has the capacity to expand to 50 beds but Walley hopes an expansion won't be necessary, noting more patients have improved in the intensive care unit than died.
He didn't disclose the number of COVID-19 deaths for privacy reasons. But he shared some detail about an elderly man he described as "very bright and highly functional" who died of COVID-19.
He said the man's wishes were followed in death.
"It did mean he died of COVID-19 but everyone was kind of onboard largely because the patient himself made it very clear that here's how much help that I would like, and more than that was not in accord with his wishes," said Walley, acknowledging the challenge of having family say goodbye to a loved one in a sealed care unit.
"It's a process to try to help the family and patient out as best possible but it's under sub-optimal circumstances, that's for sure."
Through it all, Walley remains hopeful physical distancing measures and orders to shut down businesses, venues and parks are having an effect in slowing the spread of the virus.
He commended Health Minister Adrian Dix and Dr. Henry for their efforts in clearly stating the consequences of not adhering to measures that have gradually locked down much of the province.
And now, he said, is not the time to let up, with B.C. at 1,370 confirmed coronavirus cases, as of Thursday. More than 130 people are in hospitals, with 68 in intensive care units.
"The surge has not come for us, and the hope is it won't come because the B.C. approach here seems to really have taken that exponential curve and flattened it out," he said.
"So fingers and toes crossed we don't get the surge because of the good work that our public health officials have been doing. But we're still prepared for it."
ISIS fighters
Downstairs from the intensive care unit, in St. Paul's emergency room, is where Li is among the first health-care workers to see newly admitted COVID-19 patients.
Li spends half of his shifts planning and developing response strategies to accommodate those patients, much of it related to resuscitation.
Reorganizing the room to set up a screening area and using acute care beds for suspected COVID-19 patients has been part of what he described as "a rollercoaster of change."
All of it, he said, is being done to prevent the spread of the virus among staff and all patients, many of whom show up seriously ill for various reasons at the hospital.
"Many of the measures that we take to resuscitate people—helping people breath, putting in a breathing tube, or doing CPR—are very highly contaminating interventions," he said, echoing what Walley said about medical staff treating all patients as COVID-19 positive.
Normally in his role as clinical nurse leader, Li said, he would be involved in multiple projects related to patients with addictions and heart problems.
The pandemic changed all that.
"Right now this has taken the forefront, and it's kind of become my life," said Li, who was aware the coronavirus was highly contagious but surprised how rapidly it spread across the globe.
"As we got more statistics and information about it, it was then that my colleagues and I realized this was a problem."
Like Walley and wife, Li and his family cannot help but talk about the pandemic and how it's affected their personal and professional lives; Li's wife is a nurse in the intensive care unit at Vancouver General Hospital.
The couple has a 21-month old son and belongs to a tight-knit church group, where they continue to meet virtually to decompress from their jobs.
Unlike some of their colleagues, he and his wife share a unique experience in high stress situations, having worked with a humanitarian organization in a field hospital in northern Iraq during the liberation of the city of Mosul.
Some of their patients were suspected ISIS fighters.
Later that year, they travelled to Bangladesh and provided medical support to Rohingya refugees, who are known to be among the most persecuted minorities in the world.
'Heart-to-heart conversations'
Though working in those zones isn't comparable to a hospital setting in Vancouver, Li said the emotional effect of working during a pandemic—where the threat is invisible—has taken its toll on him and his colleagues.
The worry of contracting the virus and passing it on to their kids or relatives weighs heavily on them, he said, noting he's had "lots of transparent and heart-to-heart conversations with people who I've never seen cry."
Added Li: "While that's really hard for me to see, I feel very privileged to be in a place where I can support my colleagues in that way, and be able to share the things I'm going through, as well."
Still, he said, he is grateful that he and his wife have not lost their jobs like so many others in the city and across the country.
"We're trying to change our perspective to appreciate what we do have—we get to come home, we have a home, we have a family that loves each other a lot, and we have tons of support around us, especially right now from the community," he said, referring to the 7 p.m. celebrations across the city, where residents cheer from their balconies in appreciation of health-care workers.
Like Walley, Li is cautiously optimistic about the encouraging signs the Ministry of Health data has revealed recently, with the number of coronavirus cases not escalating at the rate of other provinces.
In fact, 858 people had recovered as of Thursday, though 50 had died, many of whom long-term care home residents, a population hit hard by the virus; 143 residents and 92 staff have the virus.
The vigilance of public health officials to track patients, implement measures to slow the spread of the virus and remain consistent in their messaging has been key to preventing a surge, Li believes.
"But I wouldn't say that we're out of the woods or anything yet," he said.
"I don't think anyone is having that attitude or opinion about this, but I think we have to also recognize the work of public health services."
'Realistic optimism'
Meanwhile, Walley has a wish from government and health officials in the days and weeks ahead: tell the public what the "end game" is with the drastic measures put in place that have affected people's personal and professional lives.
"If somewhere around now, the public health officials start to give us a sense of what the end game is, then we can all say, 'Ah-ha, OK now I know what I'm going to transition to,'" he said.
Whatever that end game looks like, Walley suspects it will require a significant increase in testing people for COVID-19 and anyone they have had contact with during the pandemic.
That would require testing thousands of British Columbians and isolating them and their contacts, if they test positive.
"That's a huge project, but I suspect that's what's going to be required in the end game," Walley said.
"If I'm right about that, then it's probably worthwhile telling the public fairly soon that's what's coming up in three months, or something like that. So that people have some vision, some plan of how they can get their lives back together."
For now, he remains optimistic, a feeling he didn't have four weeks ago.
"It's a realistic optimism. There is a ton left to do. This isn't an optimism where we go, 'Hey, we beat it.' No, no — not at all. But I am feeling optimistic."
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