SARS: View from the front lines

As this article goes online, the number of cases of SARS (or Severe Acute Respiratory Syndrome) is declining, travel advisories have been lifted across most of China, and hospitals where the infected are being treated are using strict precautions to prevent the spread of the disease within their walls. But as the fear and panic subside, as reports of SARS-related deaths grow more rare, one aspect of the story is still taking shape. While the media is now noting that SARS-related fatalities never approached the worldwide figures for influenza or pneumonia, many of the less quantifiable impacts of SARS have not been widely discussed. The impact of SARS goes beyond the numbers of infected and deceased. Here, HMI World examines SARS’ impact on the global health community and uncovers a story of professional dedication overcoming fear, and the challenges faced by health care workers in Toronto as they battled this epidemic.

“It’s safe to visit Toronto!”

Dr. Thomas E. Stewart is not a member of the Toronto Chamber of Commerce, but maybe he should be. He is the director of critical care at Mount Sinai Hospital and University Health Network in Toronto, and his enthusiasm is, for lack of a better word, contagious. He has been on the front lines of the battle to control SARS, and when he takes the podium at the 4th World Congress on Pediatric Intensive Care, held in Boston in June, he is literally between flights. His phone has been ringing for three months straight. He leans forward on the podium and asks the audience of pediatricians and health care professionals a critical question:

“Are you willing to put your life on the line to do your job?”

Dr. Thomas E. Stewart

It’s a rhetorical question. No answer is required, but he provides one anyway. Yes, of course, he says, the people in the audience would be willing. He is able to tell us this because he’s seen it happen. He’s seen seven members of his staff contract SARS—one of whom never came into contact with a SARS patient—and Stewart himself has been quarantined for ten days. His first statement, that it’s safe to visit Toronto, serves in part to put away the paranoia and anxiety inspired by this epidemic. “This is a hospital disease,” he says. “The amazing story here is that health care workers still go to work.”

An unpredictable epidemic
There have been two phases of the SARS epidemic in Toronto. April saw the number of cases drop dramatically, and, as Stewart notes, health care workers in Toronto enjoyed a brief period of celebration. But the numbers soon went up again, and Toronto hospitals were forced to go beyond standard precautions and employ more rigorous barrier protections. The curve of the disease along an axis—with two large spikes in case numbers—corresponds with the emotions felt by Toronto’s health care community. The second wave of SARS cases aroused suspicion and discouraged many in the health care community. Today, Toronto’s health care workers are wearing the now familiar masks again, and taking additional, more aggressive precautions, such as full body coverage, with what they have identified as high-risk procedures, like endotracheal intubation. But unlike when the epidemic began, they’re not taking these precautions because they’re afraid; they’re doing it because these safeguards work. As Stewart points out, “We know that when the precautions are done properly, people can work safely.”

To date, according to Stewart, only about 18 percent of those in Toronto who became critically ill as a result of SARS have been health care workers. This percentage may actually be good news, since approximately half of Toronto’s total SARS cases were health care workers. Literally thousands of health care workers in Toronto have been quarantined at some time or another during the epidemic; many have kept working during a “working quarantine” which enables the health care system to keep functioning, yet takes an overwhelming emotional toll on the health care professionals, who are kept away from family and friends.

The SARS epidemic has led Toronto health care workers to adopt more rigid safety precautions.

A stressed system deals with a crisis
Stewart’s voice cracks when he tells the audience about the members of his own staff who were infected. He says they called each other each day to give and receive moral support. And while he speaks movingly about their dedication—in fact, their desire—to overcome this epidemic, not all health care workers have been eager to service the front lines.

Some nurses in Toronto have expressed fears about being assigned to SARS units. One nurse, speaking under conditions of anonymity to the Toronto Star, said, “I think we should have the right to refuse.” Another nurse, Martha Abrahamse, told CBC radio that nurses are in “survival mode,” and added, “We’re thinking of our own life, and we’re worried that we’re not going to be adequately protected, and that’s already been proven.” (Both quotations are from “Some nurses fear SARS duties,” Toronto Sun, 06/06/2003)

Elizabeth Brown, RN, MSN, MBA, HMI director of clinical services, says that the very nature of an epidemic creates nervousness and confusion—and concerns for one’s safety. “When there is a new epidemic or health risk, there is a lag in time before we fully understand the disease, the risks associated, and the best ways to protect our patients and ourselves. SARS came on the scene quickly, with a huge sense of urgency for information and understanding. But hospitals, professional organizations, and governmental agencies are doing their best to get the information out there, and provide the necessary training and equipment to help ensure that all clinicians can provide safe and equal care.”

In May, the International Council of Nurses publicly applauded the professionalism and commitment of nurses caring for SARS patients under difficult circumstances.

A doctor at Mount Sinai Hospital in Toronto demonstrates the safe method of performing an endotracheal intubation.

Heroes and pariahs
And so we start to see how the SARS epidemic is about more than a daily roundup of statistics—it’s potentially the catalyst for a number of negative impacts on the health care system. The shortage of health care workers to deal with the disease—which is compounded by quarantines and infections—creates an overworked staff. Exhausted health care professional are vulnerable to error. Factor in the time- and energy-consuming precautionary measures that must be taken by anyone dealing with a SARS patient, including having to wear and carefully remove additional layers of protective clothing, and the potential for error increases. Of course, these forced errors contribute to the spread of the coronavirus that causes SARS and begin the cycle again. As Stewart points out, “No health care system has the luxury of having extra beds to use in a crisis.” Since the epidemic began, Stewarts says, about 40 percent of the beds in intensive care units in the greater Toronto area have been shut down at some point.

In addition to the physical stresses that this epidemic presents to health care workers, the psychological toll has also been great. Stewart tells the audience that he was held at arm’s length—even by friends—when it became known that he was dealing with SARS. It is an understandable reaction, given that information about the disease and how it is spread has come out gradually. Many health care workers have had to deal with SARS at home, feared by spouses and abandoned by nannies, or in their communities, where they’re being discouraged from showing up at social gatherings and having difficulty with simple tasks, like convincing the people at the beauty salon that they’re not a walking contaminant. This ostracism has been transferred to children as well. “I think all children of health care workers were treated differently,” says Stewart. He points to the work of psychiatric support teams that have been “absolutely essential” in helping staff members, family members, and patients cope.

The story isn’t over yet, of course, and there is much to learn both about SARS and about the containment of epidemics like this one. But Stewart is confident not only that the epidemic has provided valuable lessons, but that the response of the medical community has been appropriate. He cites the rapid decline in the number of cases once the health care community was alerted to the threat, and sounds a note of optimism when talking about the worldwide collaborative effort that has made treating and preventing this disease possible.