The phone call Irena Veronese was dreading came on a chilly spring evening.
Her 54-year-old husband, Mladen, was in intensive care at St. Michael’s Hospital, hooked up to a ventilator, getting sicker and sicker with COVID-19.
Gently, the nurse explained they were running out of treatment options: The ventilator was set to its maximum levels; drugs paralyzed his body to ensure any available oxygen would go to his brain and organs; his kidneys were shutting down.
“She was trying to prepare me,” Irena said. “When I hung up the phone, I knew that if he took another turn for the worse, he would die.”
But 10 minutes later, while she was sitting at her kitchen table trying to explain the wrenching conversation to their teenage son, a doctor called back.
The critical-care team wanted to transport Mladen to Toronto General Hospital for a last-resort intervention — an artificial heart-lung bypass machine reserved for the province’s sickest patients. There were many risks — even the ambulance ride could be fatal — and no guarantees, but Irena agreed to give Mladen a chance.
“It sounds like a lifeline, something that can help him. Later we realized it was the only thing that would get him back home.”
Mladen is one of 32 Ontario patients with COVID-19 who have so far received this sophisticated life support at Toronto General. The extracorporeal membrane oxygenation machine, or ECMO, siphons blood out of a patient’s body from a vein in the groin, removes the carbon dioxide and adds oxygen, before pushing it back into a vein near the patient’s heart.
Typically used for patients with severe lung infections or those waiting for a lung or heart transplant, the machine is not a miracle cure. But at Toronto General, part of the University Health Network and home to the largest ECMO program in Canada, doctors are successfully using it as a final option for some COVID-19 patients whose lungs are critically damaged by the virus.
“It helps buy time for all the other therapies to work and the lungs to heal,” said Dr. Eddy Fan, Medical Director of UHN’s Extracorporeal Life Support Program, which is run by members of the Sprott Department of Surgery and Critical Care Medicine.
Even as Ontario relaxes physical distancing rules, and COVID-19 case numbers decline, patients severely ill with the virus continue to be referred to Toronto General for ECMO. On Friday, hours after Premier Doug Ford announced Ontarians can have a social circle of 10 people, surgeons put two COVID-19 patients on the life-support machine; days earlier, the program accepted a 22-year-old for ECMO, its youngest patient with the virus.
“Patients come to us steps away from death and this (machine) can help get them back to their loved ones,” said Fan. “But getting off ECMO is just the first step; it’s a long journey home.”
Mladen, who spent a total of 52 days in hospital, has no memory of the eight days he spent on ECMO and nearly three weeks on a ventilator. Now recovering at his home in Upper Bloor West Village, he still struggles to understand the extraordinary efforts to save his life.
“I think about the fact that I got to live and ask myself this question: Am I unlucky to have been hit with the virus so hard? Or am I lucky to have made it when so many others didn’t?”
His wife, who spent weeks worrying at home, waiting by the phone for updates, quickly answers his question: “You’re lucky, lucky, lucky. You are lucky.”
In January, as the first reports of severely ill COVID-19 patients emerged from China, doctors at Toronto General began to plan for a surge of patients with the virus.
As the main ECMO referring centre for Ontario’s ICUs, doctors knew they could be accepting patients from across the province. At that time, no one yet knew how fast COVID-19 would sweep through cities or whether ECMO would be a viable option for the sickest patients with the virus.
Still, Toronto General ramped up capacity for its Extracorporeal Life Support Program, purchasing additional machines, including the computer hardware and disposable tubing systems.
“We prepared to support 25 patients at a single time,” said Dr. Marcelo Cypel, Surgical Director of UHN’s Ajmera Transplant Centre, noting the difficulty in finding enough equipment during a global rush for supplies.
“This is something we have never had to do before, even during H1N1 in 2009. Previously, the maximum number of patients we had on this device is 12 or 13 at the same time.”
Since becoming a provincial referral centre in 2006, the life-support program cares for between 100 and 120 patients a year. About 70 per cent are those being treated for lung failure due to infections, including influenza and bacterial pneumonia, or while awaiting new lungs for transplant, Cypel said. The remaining 30 per cent of patients who go on the machine need mechanical assistance before a heart transplant or to help their heart heal from infection, he said.
Through the winter, as the coronavirus moved across the globe, physicians in the life-support program talked to colleagues in China and Europe to learn how to best support COVID-19 patients on ECMO.
“The main thing we heard was that some patients with COVID-19 deteriorate very quickly and once they start to worsen, you need to be prepared to escalate the amount of life support they need very fast,” said Fan, director of critical-care research at UHN and Mount Sinai Hospital. “We definitely saw that in our hospital and took that advice to heart and had many patients referred to us early in their illness to give us a better chance of helping them.”
Conversations with international colleagues also helped Toronto General physicians determine which patients had a better chance of surviving on the life-support machine, which comes with its own potential dangers, including an increased risk of stroke and blood clots.
During the pandemic, a four-member team of physicians together decides which COVID-19 patients to accept for ECMO based on set criteria, including a person’s age and whether they have any other serious health conditions, such as chronic heart disease or a recent history of cancer, Cypel said. Those with such conditions and people over the age of 65 are not considered for ECMO, though each case is made on an individual basis, he said.
In early April, Toronto General saw its first COVID-19 patients requiring ECMO in its ICU. Cypel recalls how rapidly patients got severely sick, even patients in their 20s, 30s and 40s.
“That certainly changed our perception about this disease. Many of them are the same age as us, the physicians. We certainly reflected on that; that getting this sick with COVID could happen to any of us.”
Six days after Ontario declared a Provincial Emergency on March 17, Mladen stopped working as a warehouse manager and Irena temporarily closed her esthetics business. Their 18-year-old son, Moni, returned from University of Waterloo, and the family largely stayed home and stayed together.
“I only went to get a haircut and to the grocery store; I think that’s maybe where I picked up the virus,” Mladen said. “This was still at the beginning and I don’t think people were as aware as they are today. Because I was still touching my face and my eyes, I think that was my problem.”
Mladen first felt ill on March 26, spiking a high fever, followed by body aches, a persistent cough and difficulty breathing.
On April 1 — his 54th birthday — Mladen was so breathless he couldn’t finish a sentence while speaking with his family physician, who had phoned that morning to check on his condition.
“When he heard Mladen on the phone, he said: ‘I’m calling an ambulance, you are not well,’” Irena said. “We all had a strong suspicion he had COVID-19, but we were told to self-isolate at home and until that morning he didn’t seem sick enough to go to hospital.”
As she watched her husband slowly walk to the ambulance stretcher, listening to his brother wish him happy birthday on his cellphone, Irena did not think he was critically ill.
Later that afternoon, from St. Michael’s Hospital, Mladen called to say he would soon be intubated and put on a ventilator.
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“That was a hard phone call because he was there alone and he was scared and I was telling him to trust the doctors, that they would help him. That was the last time I heard his voice until three weeks later.”
Though Mladen did test positive for COVID-19 — and influenza A — neither his wife nor son had any symptoms of illness.
Dr. Karen Burns, a critical-care physician at St. Mike’s, remembers calling Toronto General on April 4 to recommend Mladen for ECMO. That day, he was one of two COVID-19 patients in the ICU who were deteriorating rapidly, despite doctors and nurses doing all they could.
At the time, Mladen was sedated face down on the bed, in the prone position, and hooked up to a ventilator that was pushing 100 per cent oxygen into his lungs. Doctors had also chemically paralyzed his body with drugs to ensure his muscles didn’t use any oxygen so the little his lungs could process would get to his brain, heart and other organs.
“We were trying to do as much as we could, but we realized, from his blood gases and other markers, that we were struggling to support him and then you question how will he do over the next four to eight hours,” Burns said. “I felt like we had this window before he would really deteriorate.”
She recalls running back and forth between Mladen and the other sick patient, reviewing their charts, while talking to a physician at Toronto General.
“It becomes a judgment call of whether you are comfortable to transport them. These patients are the sickest of the sick and having to move them — unprone them, collect their pumps and ventilators, go down an elevator, get them in an ambulance — that’s dangerous. They are struggling for every little bit of oxygen …
“I’m glad we prioritized Mr. V. as I think he was cannulated and put on ECMO almost on arrival,” said Burns, who estimates St. Mike’s referred about one COVID-19 patient a week to Toronto General during the first wave of the pandemic. “Having that highly specialized resource concentrated in one hospital and being able to collaborate with colleagues there, any time of day or night, allows us to provide … the best possible care.”
Irena recalls getting a phone call at 5 a.m. on April 5 from a doctor saying Mladen was successfully hooked up to ECMO.
“He ended up being on ECMO for eight days,” she said. “There was still a lot of ups and downs, but I could see there was a fighting chance for him to get better.”
Cypel and his colleagues are collecting data on COVID-19 patients who undergo ECMO at Toronto General, with plans to soon publish their findings and provide guidance on how the devices can be used during the pandemic. So far, about 65 per cent of COVID-19 patients who receive ECMO have survived, said Cypel, the program’s surgical director.
Amanda Spriel, a cardiovascular perfusionist at Toronto General, is an expert in ECMO devices, overseeing their use on patients during cardiac or transplant surgery and in the ICU. Normally, one perfusionist cares for ECMO patients in the ICU; during the pandemic, there are four to a shift.
Spriel monitors the life-support machines, troubleshoots the devices, watches for blood clots and ensures the oxygenators work properly, all critical to a patient’s survival. Though she never spoke with Mladen — he was sedated his entire time on ECMO — Spriel remembers caring for him during his stay.
“He had a very straightforward and smooth ECMO run,” she said. “I didn’t have to make many adjustments. At first he required 6L of blood through the circuit every minute to oxygenate enough blood to support his organ function. As his lungs recovered, we were able to turn down the settings, then turn it off completely when his lungs were able to take over oxygen functioning again.
Irena called the ICU three or four times a day to check on her husband. On the day he opened his eyes — three weeks after being intubated at St. Mike’s — she and Moni talked to him on an iPad, though he was still unable to speak.
On April 22, after he had been transferred to a medical ward, Irena again tried to speak with Mladen.
“I realized he had no idea what had happened; he kept asking me: ‘Why am I here? Why am I here?’”
Moni suggested they each write a letter to explain. He wrote his in English while Irena wrote hers in Serbo-Croatian, the language they speak at home. She hand-delivered them to the hospital that day.
“They were so helpful. I reread them and understood a little more each time. I couldn’t believe I had slept through everything.”
Still, it took a few more days for Mladen to appreciate how close he came to dying from COVID-19.
“I kept asking when I could go home. Then one of the doctors — he was so sweet; he sat on my bed — he said: ‘Remember where you were a few days ago? This is a miracle that you are here and that you and I are talking.’”
Mladen finished his hospital recovery at Bridgepoint Active Healthcare, a Toronto complex care and rehabilitation hospital.
While there, he built up his muscles so he could go home without a walker and manage the stairs. A neurologist helped him overcome some lingering problems with nerve endings in his left leg. He also worked with a speech-language pathologist to practise swallowing. Weeks on a ventilator had irritated his throat and swallowing food — liquids especially — was tricky.
On May 22 — 52 days after leaving in an ambulance with plummeting blood oxygen levels and a grim prognosis — Mladen was discharged from hospital. The family, in tears after their first hug in weeks, drove home together in disbelief.
On July 2, Irena and Mladen will celebrate their 25th wedding anniversary. They don’t yet know how they will celebrate but Mladen said being together again after so many weeks of worry is a start.
Every day, they sit for a long time at their kitchen table, talking and drinking small cups of espresso. And they often stand outside to wave at friends and family who visit from a distance.
“They want to see him in person,” said Irena. “They just can’t believe what he’s been through.”