The Secret of Making Tiny Bubbles & Other Black Arts (first published April 14 2021)

I’ve known Blair Schwartz for a long time. We worked together as street medics before he started his journey as a physician. Blair says I was once his coach however I’m fairly he has always been my teacher.

This story is illustrative of Blair’s belief we need to treat the whole patient and always remember curing and caring is not mutually exclusive.

“In healthcare we all too often focus on disease. We focus on its pathophysiology, what our protocol tells us to do in response, or resuscitating to specific goals.?Attaining clinical stability, or a semblance thereof is a primordial goal. However, when time allows,?it is only by getting to truly know the person with the disease that you can ever hope to truly treat them.

As a junior ICU Fellow I had received a patient in transfer for shock of unknown etiology from a peripheral hospital. The young patient was known to our center’s transplant clinic and came by ambulance surrounded by her husband and children. Like a good intensivist I promptly began appropriate resuscitation and began my workup, ultimately culminating in a diagnosis of extensive Necrotizing Fasciitis (aka Flesh Eating Disease). I rallied the troops, called the surgeon and prepared to go to war with this newly discovered enemy. The extent of her disease meant she was likely to lose her entire leg up to the pelvis. I went to explain my diagnosis and plan to the family.

After presenting my case, her family started telling me about the woman who lay intubated in my ICU. She had spent several years on dialysis waiting for her kidney transplant, a process she told her children she found absolutely unbearable. As they began to tell me how she was before she was sick and how miserable she was during times she was dependent on others, I was able to get a perspective for this woman, her nature and her spirit. I was proposing a procedure that had a small chance of saving her life. It would be a life in a wheelchair with a protracted rehab course just to allow her to sit in that chair.

Together, we chose not to treat the disease, because we had taken the time to get to know the patient WITH the disease…” - Blair Schwartz

Blair and I have chatted on and off throughout the pandemic. I decided it was time to capture some of his thoughts while we’re still navigating our way through the event.

Q. For you, as a physician, what has changed since the beginning? Clinically and operationally? How did you prepare for the pandemic? Is the pandemic evolving in the manner you anticipated? ?

As a critical care physician, both nothing, and everything has changed. At a fundamental level, I’m still responsible for providing the best possible medical care to the sickest patients in my hospital requiring a variety of life support therapies to help keep them alive while we treat their underlying disease. That being said, the post-COVID era has changed EVERY aspect of day to day medicine for all healthcare workers. On the clinical front, nearly every single patient presentation we are faced with, we have to ask the question “Could this be COVID?”, we grapple with the decision to remove FULL isolation precautions once we feel we have an alternative diagnostic explanation and a negative test (or two), all the while knowing the tests aren’t perfect and that we may thus be directly responsible for contributing to a hospital based outbreak or infection amongst a colleague. Operationally, it has changed everything; From something as basic to now having a pair of COVID shoes at work and no longer our own clothing (a perk in my opinion), to completely changing the manners in which we move patients, proceed with diagnostic and therapeutic procedures and triage bed allocation for COVID and non-Covid patients.?

As a center, we were fortunate to have begun our planning early. In January 2020, when things were eerily grumbling along in Wuhan we began to prepare for what would happen. In a clearly thought directed choice, and mostly because my chief was on vacation at the time, I was tapped to attend a number of meetings to begin our planning. We met in a multidisciplinary manner having physicians, nurses, RTs from the relevant clinical domains (ED, ICU ward, radiology) but also early on looping in our housekeeping supervisors to plan for room decon, security to look at best ways to control crowds and move patients through the building and logistics to ensure our supply lines for PPE refill at the bedside were well coordinated. We drafted protocols to handle how we triaged potential cases, how we intubated them, moved them to the ICU, did invasive medical procedures on them and even how to handle their bodies in the event they died. We simulated each and every one of these procedures with actors, all before our province had seen its first case. On the clinical front, we communicated through the now ubiquitous zoom (but then, and still now I suppose, more akin to how Blofeld communicated with his evil confreres in the early bond films) with physicians in China and Italy to try to get a sense for what was coming, what they were doing, what worked and what didn’t. At the end of the month, when my chief returned and saw the binders of material we had generated, he said “aren’t you glad you prepared all of this, just in time for the pandemic to be over?”?

As for its evolution. If you had asked me in January, would I still be knee deep in COVID over a year later, I don’t think I’d have said yes at the time. However, as a student of history and looking back at the previous respiratory pandemics, I’m not surprised we’re still where we are.

Q. How have those changes played out for you as a human being, husband and dad? If you’re willing, would you care to comment on what it’s like being in a two-healthcare-providers-family and raising children?

I generally tend to frown upon the bellicose analogy that people have made with regards to this pandemic, but I will admit It does have some truth to it. Managing COVID is like long, drawn out, trench warfare.?There are the direct casualties of the disease, the indirect casualties (from being too scared to come to the ED or a delayed surgery), some healthcare workers are going to get sick and die, there will be a variable effect on different sectors of the economy and the populace will be divided on its effects/impacts and certain segments will protest in the streets.?

As a human, I chose critical care medicine knowing full well what I was getting myself into. I knew I would be regularly caring for people at the extremes of human physiology, using a variety of potions and contraptions to help edge them back to this side of styx. I knew that I’d often lose my battle and instead have to switch gears, hang up my armamentarium and instead focus on allowing them to cross over with dignity and support their family in trying times. I just never expected it in this volume and intensity. COVID has exploded in our ICUs and pushed us all to our limits of human endurance and emotional intelligence. We strive to maintain the same quality of clinical care and emotional intelligence as we did pre-pandemic, and doing so is draining. Our front lines are holding, bending, but I truly worry and wonder, at what ultimate price…?

We’re all exhausted. So when you live in a household with two frontline HCWs and have two kids under 7, things are going?to get interesting. Its all well and good to say, leave work at work, but we all know that isn’t a real thing. The interplay between COVID and my home first struck me early on, when my 6 year old walked me to the door before I went into work and said “ Have a great day at work daddy, don’t get COVID and die!”. I first thought it was the sort of innocent joking of childhood,?and he didn’t understand what he was saying; I was wrong. We worry daily about getting sick at work and bringing it home to our kids. We’ve worried about who would take care of them if we were bedbound or hospitalized ourselves; or worse yet, what we happen to them if we died of COVID. As those fears largely abated over time and with vaccination, we worry about the effects of our own extreme exhaustion is going to have on the boys down the road. We’re only human, and so our tempers may be a little shorter, our ability to run around and play with them in the yard or dining room is limited and we worry constantly that we are depriving them of what a childhood should be. They say children are resilient, I hope they are right.

Q. You got your start on the streets of C?te Saint-Luc as a medic. Was there anything in your experience with CSL EMS that helped prepare you for the work you are doing now??

They say there is no such thing as an ex-medic, they are of course correct.?My time as a medic permeates in all aspects of my medical career, most notably my chosen speciality of Critical Care. Two particular elements from my time on the streets that have served me well in my new COVID role, are the prehospital focus on scene safety and improvisation. From my earliest teaching sessions in pre-hospital care, every simulation started with a serious and concerted approach to making sure your scene was safe for you and your partner; if you didn’t say the magic phrase on your practical exam station, it was an automatic fail. The “you can’t help the patient, if you’re dead” mantra has really helped me and my team in this pandemic. In the past, HCW would rush into the room of any patient with an acute decompensation, in COVID we need to focus on being protected first, make the scene safe, don PPE, check your nurse and RT partner, have them check your gear and then go in and kick clinical ass.?

On the streets, we were taught to adapt, improvise and overcome the problem (and then call for a 2nd unit) a skillset that prehospital providers are renowned for. Work with what you have and work the problem. Pandemic medicine is now different. Often times we’d be lacking just the right piece of equipment or personnel to accomplish what we needed. My medic background always taught to take a look around, find a way to make it happen. Nobody is fixed to only one job, the physician can help turn a patient and wipe away a code brown, just as well as an orderly can be shown how to squeeze a bag ventilator every 3 seconds. Just get the job done, ask for forgiveness later.

Q. What’s the deal with you and coffee? Why is the ritual so important to you? Any fave local coffee grinders you’d care to plug? And while we’re at it, one of the essential lessons I learned during the pandemic came from you - the mastery of the art of creating tiny bubbles in the cappuccinos I prepare each morning for Di and myself. Was that part of your white coat training? Or does that fall into the black art category?

Ironic that you’re asking me this question, seeing as you bought me the first cup of coffee I ever drank. We were on a shift in the Luc, went to Delly Boys for the traditional breakie and you asked me how I took my coffee. I said I didn’t. You bought me a cup anyways and said if I was gonna do this gig, I had better start.?

Apart from the obvious caffeine hit and divine ambrosian nature of a good coffee, it is my morning ritual of making a latte for myself and Sabrina that is the constant. I did it before COVID, and despite the torrential pace of the pandemic, the short nights and constant worry… the ten minutes each morning I spend grinding, dosing and tamping my coffee to get the smooth extraction and perfect crema in my cup…. That is my me time. Nobody bugs me, nobody calls me and I can just focus on pulling the perfect shot of espresso before I start my day. It reminds me that as much as this pandemic sucks, some things in life are constant, and we’ll get back to it… eventually.

I’d definitely give a shout out to the guys at https://caffeingamba.com/ a local coffee shop who advised me on bean selection early on in my addiction and to https://zabcafe.com/ a group of local coffee nerds extreme who have been my go to roaster for a few years now and have really stepped up in the pandemic to ensure a constant supply of fresh roast gets to my door.

Tiny bubbles, or micro foam really is the perfect milk texture for a latte or flat white. We do learn about the use of parenteral caffeine as a respiratory stimulant in medical school, but milk texturing was far more of a dark art than anything my white coat clad professors passed on. Ensuring the proper angle of the pitcher, wand depth to get just the right texture, using the palm of the hand to gauge the temperature just right to allow enhanced solubility of the lactose to give the milk a hint of sweetness, but not to scald it. Ya, we don’t cover that in medical school… but we should !

Q. You’re into music. Would you care to discuss your love of Stan Rogers and your favourite tunes and versions of those songs? Do you listen to tunes to relax or are they playing in your head while you’re prepping for yet another intubation??

I’m fairly certain my love for Stan Rogers started one night at a pub, could be in Montreal, could be in Halifax, but definitely involved some pints of Kilkenny. It’s the inherent appeal of a celtic guitar tune, combined with his talent for blending history and wit into his lyrics that first appealed to me. I’d often sing Barrett’s Privateers to my first born when he was a baby and unable to sleep, he now knows most of the lyrics. For Barrett’s privateers only the original Stan Rogers recording will suffice…. But I have to admit, his son Nathan does a bone chilling (pun intended) rendition of Northwest passage, and while you might not think you needed a rock version of that classic anthem, you were wrong, and listening to Unleash the Archers perform that song definitely gets my sympathetic system ready as I drive in to intubate someone.