“I Wouldn’t Say it Was Innovation, it Was Just Commitment.”
Doctors redesign the ICU as COVID cases mount
By Tim Querengesser | April 30, 2021
Before the pandemic, Dr. Darren Markland regularly made his thousands of social media followers move. He inspired them to walk or jump on a bike, or figuratively moved them to tears as he wrote of patients and their final moments in graceful prose. During the pandemic, though, Markland tried to move power. He became known, nationwide, for his blunt talk on the evening news, where he repeatedly challenged health officers and politicians over decisions to loosen restrictions or go to war with healthcare and support service workers over pay. It was public criticism of power that only an intensive-care doctor doing the hard work during the pandemic could fling about without being fired.
Markland saw it all as his only way to influence the real determinants of health during the pandemic, which he says are social disparities.
But, is it innovation? Those who speak of innovation often do so by placing the innovator as the hero, bravely thinking outside metaphoric boxes that shackle that person to the status quo. Countless stories were written of ICUs innovating to accommodate more patients, as if this innovation was a choice. But Markland, literally inside a box at Edmonton’s Royal Alexandra Hospital’s ICU, was just trying to move the needle on a complex, wicked problem.
“What can I do as an intensive-care physician?” Markland says. “Just work harder, work with less, see more patients. It’s not innovative at all — it’s desperate. This is triage and war. How do I prevent people getting COVID? That involves changing social disparity and wealth disparity. Because those are the people we see — the disadvantaged people from multi-generational houses who have to work during the restrictions. I can’t fix that. That’s too far up the line for me.”
The ICU where Markland has tended to patients doubled its bed count, from 25 to 50, and its floor space has ballooned from its roughly 10,000 square feet, pre-pandemic, as it took over post-operative recovery rooms left unfilled as elective surgeries were cancelled. Here, in a hospital ICU that in normal times would see patients from the Royal Alex’s enormous patient catchment area — from northern British Columbia to parts of the Northwest Territories — Markland and his colleagues pulled more than 100-hour workweeks for months to keep people alive. On many of those days, Markland never saw his family. He stayed at the hospital and slept on a couch.
His once familiar ICU changed into some-thing that now feels from another world. Markland says it reminds him of an ancient market in Morocco. “Beds are always moving, the cleaners are always cleaning, linen is being flung from one place to another, and amidst it all we’re all in PPE all of the time and it’s this dance where you go into a room, you put on your stuff, you come out, you take off your stuff, you put on new stuff. It’s constant movement, noise. There’s always alarms going off and the chatter and background noise is 90 decibels all the time. You feel like you’re in an airplane hitting turbulence.”
CHANGING ON THE FLY
It’s not exactly the place you choose to innovate from, but it is one that required fast change. The first challenge was space. As patients who clung to life arrived in the ICU, and more of them arrived at once as coronavirus cases spiked, the physical limitations of a hospital quickly mattered. The ICU naturally grew, as it took over lesser used parts of the hospital. But it also shifted, Markland says, in how it used its space, from individual rooms — which were important pre-COVID-19, to reduce patient delirium — to shared rooms.
“In some ways we’ve kind of gone backwards, just because of the nature of this disease. Before we were very individualistic about our care but we’ve kind of had to turn ICU, at least COVID ICU, into an assembly-line process. We’ve taken over spaces in the hospital that are barracks-style places, recovery rooms. We’ve got huge open areas with 20 patients in them. There’s no privacy.”
The second shift was people. As elective surgeries went offline thanks to the crisis, surgeons, anesthesiologists, nurses, physiotherapists and other specialists were pulled into the main fight. At the pandemic’s peak, the ICU ran with three teams, each with a doctor and other specialists, up from the usual two teams. Beside these core teams, there’s a roaming doctor who looks after consultations on the wards, to free up the core squad to see more patients. There’s also an expanded rapid response team that arrives for an emergency independent of the regular ICU doctors, teams that banded together to slowly flip people onto their stomachs to increase the amount of oxygen in their blood (it sounds pedestrian, but if you get the procedure wrong, people die, Markland says), nurse practitioners trained up almost like doctors, and the ever-present cleaners and other support staff keeping it all, somewhat, on the rails.
In short, there’s a lot of people. This is where Markland’s views on innovation become clearest, or perhaps most combative. The usual talk of innovation seems to always land on tech or disruptive dudes in Silicon Valley. That’s just not what we need to discuss about the ICU, he says.
“All these other things like doubling up ventilators and monkeys turning IV pumps, that’s not how this place works. What makes a hospital run is people. Our nurse practitioners came back from retirement and pregnancy leaves early, and they augmented our doctoring ability. Our anesthesiologists who weren’t involved in surgeries have a lot of the same skill sets as intensive care physicians. They came up and offered their services and would go in and assess patients, or resuscitate patients when we couldn’t be there. When people were exhausted or sick, other doctors would come in, other types of doctors would come in from other centres and help out until things settled down.
“I wouldn’t say it was innovation, it was just commitment.”
In a desperate attempt to form the last line of defence Alberta had against the coronavirus pandemic, Markland and other healthcare workers have had to figure out how to do more with less. Will they be able to do it again, in the future, if we face another pandemic?
Markland says many of the plans rolled out this time around existed from the first iteration of SARS. “We’re pretty much following that playbook. We can do this again, we have the ability to do it again, we’ve always known how to do this stuff.”
And yet there’s a palpable feeling, Markland says, of being taken advantage of by the current provincial government. There’s a feeling that to talk of innovation is dodging the real threat on the horizon, which is losing people. A brain drain that has already seen doctors, nurses, and other professionals flee Alberta for other provinces. Markland spoke on the news not only of ways to reduce coronavirus cases but also the toxicity between the UCP government and its healthcare professionals, which have been targeted for systematic cuts to shave the provincial budget.
“Once [healthcare workers] pay their moral debt they will leave,” Markland says. “My nurses, when this is done, they’re going to be done nursing. They’re sticking it out because, you know, it’s the right thing to do. But when it’s done they’re going to seek other jobs or other provinces to do them in. We will lose a huge proportion of our professional staff. And we won’t be able to repopulate them in our current socio-political climate.”
Innovation, Markland says, is commitment paired with a willingness to do things differently. He feels his side of the coin has done that. But there is, of course, another side.
This article appears in the May 2021 issue of Edify