Hospitals in Quebec are bracing for a surge of severely ill COVID-19 patients over the next month, in what many hope is the virus's last gasp.
"My sense is we're in for a bit of a run in the next few weeks," said Dr. Peter Goldberg, head of critical care at Montreal's McGill University Health Centre (MUHC). "We're preparing for probably a worse phase than either (wave) one or two in terms of ICU numbers."
For the past week, the number of new infections in Quebec has hovered between 1,500 and 1,600 per day.
So far, the Montreal area has managed to avoid an explosion of new cases, but Quebec City, Lévis and Gatineau are all struggling with high rates of community transmission due to more contagious variants of COVID-19.
In addition to an 8 p.m. curfew in those regions, schools are operating exclusively online and non-essential businesses remain closed.
Those targeted measures may help, but projections released Thursday by provincial experts suggest designated COVID-19 beds could be completely filled in those regions in the next three weeks.
In the Montreal area, hospitalizations are expected to continue to rise for the next two to three weeks.
"We're all very, very concerned about this," said Goldberg. "We can't look at Ontario and not be concerned."
After a relatively quiet few weeks, Laval's Cité-de-la-Santé hospital has also noticed a worrisome uptick.
Last week, the ICU had only two active COVID-19 patients. This week, it has six.
All but one are on ventilators and all six were confirmed to be positive for a variant of COVID-19, said Joanie Bolduc-Dionne, the ICU's head nurse.
"It's scary," said Bolduc-Dionne.
Although the hospital has stringent measures in place to prevent infection, staff now need to be extra careful to avoid contamination.
For the past month, ICU staff across Quebec have noticed the patients coming in are younger. The new variants are more transmissible and patients get very sick more often than in the first and second waves.
The shift in age is also due to the COVID-19 vaccination program. About one-quarter of Quebecers — most of them over the age of 55 — have received at least one vaccine dose.
In Laval, the average age of COVID-19 patients in the ICU is about 60, said Bolduc-Dionne.
In addition to the six patients in the ICU's red zone — reserved for patients who still have the virus — another four patients are no longer contagious, but remain in the ICU.
One of the patients is a previously healthy 56-year-old man, who has been on a ventilator for nearly three months.
Another woman, in her 70s, was extubated in late February. Initially, she appeared to be recovering but began to have trouble breathing again. She had to undergo a tracheotomy and still needs a ventilator.
"She's been here for 75 days," said Bolduc-Dionne.
Younger patients, more aggressive treatment
Dr. Alexis Turgeon, a critical care physician at the CHU de Québec–Université Laval, a large teaching hospital in Quebec City, says it currently has 15 COVID-19 patients. That represents about half the ICU's capacity.
The hospital is prepared to take on more, but if the number of COVID-19 patients continues to grow, less urgent surgeries will continue to be postponed or cancelled, because there won't be enough staff to care for patients post-op.
"We're on a thin line," said Turgeon, who hopes people will heed public health measures.
He too has noticed younger patients than in the first wave, which speaks to community spread.
With younger patients, medical staff can be more aggressive about treatment because they are usually in better health.
Younger patients are also less likely to say they don't want to be admitted to the ICU or to refuse to be put on a ventilator.
But this can lead to longer stays as younger patients fight for their lives.
One of the tools in the MUHC's arsenal is ECMO treatment, short for extracorporeal membrane oxygenation.
Highly specialized, it is offered only at a handful of Quebec hospital-sites.
It is typically used on patients whose lungs are so damaged that mechanical ventilation isn't enough to sustain blood oxygen levels.
With ECMO, a catheter is put in a large vein, usually in the neck, to collect blood. A pump is used to circulate the blood through a machine, which artificially oxygenates red blood cells and removes carbon dioxide.
In COVID-19 patients, carbon dioxide can build up because of the virus's tendency to cause blood clots in the lungs, said Goldberg.
The ECMO was used in previous waves, but Goldberg says its use has increased.
"There have been many young patients with severe, life-threatening illness who we thought would not survive without being placed on ECMO," said Goldberg.
But it doesn't come without risks. Patients who qualify for the treatment are usually under the age of 65 and have few pre-existing health conditions.
The survival rate for COVID-19 patients on the ECMO is about 50 per cent, said Goldberg.
"We have a young man who is 55 years old who was on ECMO for six weeks and who is going to be going home probably next week. That's very powerful," he said.
End in sight?
With a record setting number of COVID-19 cases in Ontario and ICUs there on the brink, it's impossible not to be concerned about what is happening here.
Although the situation is not as dire in Quebec, resources are getting tight.
For now, hospitals are in planning mode — trying to add extra capacity and recruit nurses to the ICU without comprising the care of non-COVID patients, said Goldberg.
"If we will have planned for nothing, we will be very happy," he said.