Book review of report from inside a nursing home outbreak in Canada
In January 2021, a tragic story unfolded in Ontario. It took place in a long term care home called Roberta Place. The home had 137 beds and 130 residents. A covid outbreak was declared when an asymptomatic member of staff tested positive on 8th January 2021. Within six weeks, at least 129 residents and 106 staff members had fallen ill. 70 residents died.
The mortality rate was much higher in this particular nursing home compared to similar outbreaks in other nursing homes around Spring 2020. Generally, around 16% of those testing positive in such homes died and around 6% of the total number of residents.
Why was that?
As it happened, the residents had not been vaccinated before the outbreak. There was a national scandal when it was revealed that Moderna vaccines that were intended for this area had been diverted to Toronto to meet an arbitrary 21st January deadline. Numerous officials claimed that if the vaccines had arrived earlier, the outbreak could have been avoided.
One of the nurses who worked there at the time, Christie Beattie has published her journal of the period, Behind these walls – inside one of the deadliest covid outbreaks in long term care, and it is very revealing. She has anonymised her patients using their room numbers and has told the story of her experience during the outbreak. We have quoted from it verbatim, selecting extracts that we felt our readers would think were most important.
“I felt lucky, a few weeks before outbreak, in early December… I was told our home had been chosen as one of the first homes in Canada to receive one of the newly developed vaccines. There were 25-30 spots and it was first come, first served…. December 29th at 11:30am I received my first dose of Pfizer. What a relief.”
“The majority of employees ended up with Covid, some had received their first doses and a week later were positive. We were truly SO close to some form of safety.”
There is evidence of an increased risk of infection in the period shortly after injection. This is because the immune system is otherwise occupied dealing with the effects of the vaccine. This means that the increase in infections in this home at this time were perhaps not that surprising. Since some of the staff and residents manifestly had covid at this time, the home will have had virus particles lingering in the air. As is now pretty much accepted, the virus can travel large distances and remain floating in the air for hours.
Beattie described the first resident having symptoms on the Thursday before the outbreak was declared – i.e. 7th January.
“As the virus spread like literal wildfire through the home I decided to put my family first and stay home for the next week until I received my second dose of vaccine…January 20th I was scheduled to receive my second dose of Pfizer at 1150hr then I was heading into work.”
An article published on 21st January 2021 said 21 residents received the Pfizer vaccine but Dr Lee, the local public health doctor said 19 of these residents were shown after vaccination to have been already infected. The claim is based on the belief that the incubation period, between exposure and first symptoms is constant. In such circumstances the viral infection must have already been in the pre-symptomatic phase prior to vaccination. However, in the presence of immune suppression it is highly likely to be shortened and there is evidence of a 400% increase in hospitalisations for covid on the day people received their vaccines.
Either way, it is clear that the outbreak originated with staff members who were infected within a week of vaccination and that any residents who had been immune were then vaccinated, and immune suppressed, from 21st January.
She returned to work after these few had just received a vaccine and with the rest not vaccinated because they were infected already.
Why was the death rate so high?
In an interview, the author says,
“Some people who don’t believe in the virus were saying we were letting the residents die, that we were dehydrating them and they weren’t dying of the virus. It was insane.”
In her book she says:
“Given their condition most required assistance to eat a few bites and drink as much as they could. Honestly they were becoming so dehydrated the doctor started to order Hypodermoclysis (fluids into the subcutaneous tissue, similar to an IV but just not in the vein), it was more for comfort – we knew it wasn’t going to save most of them. At this point we had only lost one resident.”
Some staff were sick. One healthy middle aged personal support worker ended up on intensive care and nearly died but was saved with a double lung transplant.
Care was compromised by a combination of fewer staff, less skilled replacements and greater needs of the residents during that period.
“Many other staff members… had also tested positive and the tower continued to fall. It seemed like both residents and staff were “dropping like flies.” By the end of the weekend half my floor was symptomatic and isolated, my coworkers were talking about not coming back for their next shifts and honestly I can’t blame them, it’s a fend for yourself situation and everyone has the right to protect themselves and their families”
“Most people this ill get that nurse to patient ratio of 1:4 or 1:6, but not in long term care. I had agency nurses help my until 1800hr, then I was on my own until shift change at 2200hr. Some days no one even showed up at shift change, so I stayed. What else could I do?”
“Most of our management were out sick with the virus or staying home to not get it so we had managers from other care homes owned by the same company to cover for them. They didn’t know who was regular staff and who wasn’t, who was supposed to be where and when.”
“At some point in the height of the outbreak we were so short staffed that we were sent groups of PSWs hired by I believe the Red Cross, or maybe agencies?… I paused and thought to myself, great they don’t know the job… This is not the help we need…. Some didn’t speak much English and I unfortunately don’t have time to do any training right now. Most of these PSWs worked quite hard but some were for the lack of a better word, useless. I would catch them in the breakroom sleeping or watching Netflix, or sitting in residents rooms talking with each other with the lights off so they wouldn’t be seen. There were plenty of times where I wanted to ask them to leave because their presence had become annoying watching them walk the unit and do almost nothing while being paid more than me. I asked a pair of them to go into separate rooms and sit with the residents and try and hold their hand. Less than 10 minutes later they approached me and said the resident wouldn’t drink and they didn’t want their hand touch.”
There is no mention of any doctor stepping foot into the home throughout the outbreak. Two residents made it into hospital, but died there. The only reported contact with doctors was over the phone orders for palliative care.
Christie Beattie was the only trained nurse looking after 30 patients, many of whom were unwell and with no visitors allowed to help with keeping them hydrated.
If she returned to work the day after her second dose, which is implied but not stated, that would make Day One January 21st. From then on there is no doubt that she worked incredibly hard.
By then 122 out of 130 residents had tested positive and 25 had died.
“DAY ONE: In report I was told of a few who were in need of pain medication, so I headed in their direction first, Dilaudid (Hydromorphone – a narcotic pain killer), in hand. Things seemed okay. Only a few seemed fatally ill, the rest seemed okay, maybe they would get better I thought.”
“The orders were that we could give the medication every 2 hours as needed and when they got really close to death the dose increased and it went to every hour as needed. This means using critical thinking skills to determine if the next dose is needed at the two hour mark before they “show” it’s needed, or in turn determining when it’s needed.”
“I got back to my desk and called the doctor with an update on 1415, I didn’t have to ask for the orders he just gave them. I quickly processed them, faxed pharmacy and went to my med cart to get what I needed to help her. Dilaudid. So much Dilaudid. I don’t think I’ve ever given so many injections in my entire nursing career. I drew up the 0.5ml and set off at 1415. I brought a glass of water with me in hopes of maybe getting her to drink…I tried desperately to get the O2 monitor on her fingers again but she grits her teeth and fought me. I held her hands and quickly injected the pain medication into her thigh, impressed at her strength for being so ill.”
Other nurses did not take the same approach. On day three, she says:
“I got report from two agency nurses. They told me they hadn’t given any extra pain medication and neither did night shift because no one needed it. What? How? These people are dying. They are suffering. How did they not need pain medication? Low oxygen saturation mixed with extremely high fevers doesn’t equal zero discomfort. Time to hit the floor and get to work. I knew I needed to get pain medication into those imminently dying. I knew that was critical. I drew up two syringes of Dilaudid, 0.5ml each. I didn’t need to see them to know they needed it. I know the night nurse hadn’t given any pain medication and I know the day nurse hadn’t and I don’t want any of my residents to suffer, ever.”
She then describes how one resident, who she had cared for the day before, died in front of her before she could give the Dilaudid.
She describes two covid deaths as happening before any medication was given. First, a covid patient in the floor above who had had no medication
“in very obvious respiratory distress, rapid abdominal breathing, blue lips, eyes glazed over, tense posture – dying.”
She did what she could for her.
“We set off to her room and did our best to get her comfortable. We gave her the Dilaudid, suppository Tylenol [paracetamol], a cool cloth for her head and chest to try and bring her fever down and started oxygen to try and keep her comfortable. A few short hours later she passed away.”
For the second patient, Beattie is not clear on the time scale of her description. She described talking to the resident’s daughter
“I needed consent for the palliative orders I suspected the doctor would write. She gave me consent for whatever was needed to make her mom as comfortable as possible. 1415 was still conscious at this point but in very obvious pain. Her fists were clenched, her jaw clenched, lips dry, head cocked to the right… I tried hard to take her vitals and she was combative, swatting at me and ripping off the O2 monitor.” She arranged a phone call, “she twitched and tried to get words out but they came out as groans and grunts. Frig these calls are heartbreaking” Her other daughter came to visit, “I would come in with 1415’s hourly pain injection.” She then describes how her breaths became “few and far between” before she died.
Ms Beattie interpreted clenched fists as pain and gave more medication.
She went on to describe deaths in great detail. Here were two:
1420-1 A woman who had covid, with fever and oxygen saturations in the 70s: “her lips were purple, skin pale and blue, shaking, clenched fists, eyes open as if she had seen the scariest thing she had ever seen in her life…I approached with a syringe of Dilaudid in hand to try and give her the injection, knowing this was not going to be easy. On a good day I had to be strategic about giving her routine medications, so add in her extreme discomfort I knew this would be a fight. I had one of the good agency nurses come in with me and hold her hands to avoid being punched or having her grab the injection and harm herself more. I approached the bed, stating who I was hoping she would recognise my voice or my name, I let her know I was there to help take some pain away. She was livid any time anyone touched her. Biting, grunting, swinging her arms, but the look of fear filled her eyes. I leaned over and told her that I know she is in pain and that I want to help her but she was too delirious, it didn’t matter what I said. I successfully gave her the injection with minimal fight and hoped it would bring her some comfort as it was clear the end was coming. When these people are in pain, they act out, they hit, they bite, they claw at staff, whatever they can do so we know they are displeased. You can’t reason with them; you can’t convince them to calm down or not fight you… She fought to the very end, not wanting intervention but desperately needing it. Fear and anger in her eyes…. After several doses of Dilaudid I was able to get her comfortable enough to relax and keep her oxygen on. These deaths are not peaceful no matter how you look at it. They all struggle for air, they all gasp, they all turn blue, they all suffer to some extent. It’s not a pleasant death but we make it as comfortable as we can because that is what I vowed to do as a nurse, bring comfort. I left the shift knowing she would likely be gone by the time I got back there at 1400hr the next day. I was right.”
1420-B “The day before…she was doing okay. She was talking her usual confused nonsense and adamant she had a wedding to go to. Honestly, this was relieving. The closer they were to their “normal” the further from death. I had checked her O2 a few times and I swore it was wrong. Her oxygen saturation was mid to low 70s but [she] showed no signs of cyanosis or shortness of breath. She was drinking well, a HUGE positive with the way this virus manifests. She was herself otherwise, a glimmer of hope…. As the shift went on she slowly got more confused, not a good sign. She was another who didn’t want to keep her oxygen on. I put it on 4-5 times that shift and tried to reason with her but any time I came back she had taken it off…A short while after..she shimmied herself down to the end of the bed and was almost falling out. I called the PSWs [personal support workers] to help me get her settled back in the correct position and I gave her some pain medication and Ativan to help calm her. I knew death was imminent as she was starting to go very cyanotic [blue], her lips got more blue as the moments passed. Her fingertips pale and cold.”
She contacted the friend who had power of attorney to tell her death was imminent.
“She was in disbelief, “Man that was fast” she said, and boy was she right.”
She then arranged a phone call with her,
“I put the phone to 1420-B’s ear and she immediately recognized the voice. She tried so hard to talk, to communicate in some way, but only small grunts and noises came out. She kept moving her head into the phone and furrowing her eyebrow.”
She died within hours.
There were three patients who died despite having no or minimal symptoms on 23rd January, two days after the vaccinators had been. She does not state their vaccination status but given they were previously healthy it is likely they were vaccinated.
1401 “She was her usual feisty self a couple of days ago, fighting the PSWs (personal support worker) and resisting care and nourishment. I was shocked to come on shift day 2 and told she was on the cusp of death, mottled legs, non-responsive. I hadn’t even ever heard her cough! No fever, nothing.”
That same day 1407 died.
1407 “I knew he wasn’t doing well. Just slept, never ate or drank. I don’t remember the last time I saw him awake but I did peek in on him to check his vitals from time to time throughout my shifts and ensure he wasn’t in any distress. He was always warm and comfortable, just fast asleep. He honestly just went to sleep and never woke up, one of the lucky ones who didn’t suffer.”
That night 1403 died
1403 – “I was surprised she went so fast; she was one I thought would be okay. She had a bit of a cough, minimal fevers. The night nurse let me know she declined quickly and went just as fast.”
It seems no one came to assess the cause of death or ever question if there may have been another cause. On day two she said “
At the nursing station sat stacks of shrouds and body bags, next to pre-signed death certificates.”
She was responsible for 30 residents. Of these 17 died by the end of the outbreak and a further 4 shortly afterwards. She reported a total of 72 deaths in the whole home out of 130 residents.
In addition, the husband of one of her patients died in hospital,
“Oddly enough one of my friends from nursing school was one of his nurses during his battle in a neighbouring town’s hospital.”
She ends with a post script about what covid is like “after vaccines”.
“It is now 2023 and the geriatric or at risk population have 3, 4 or 5 doses of the mRNA vaccines. When they are infected they for the most part are asymptomatic or have very mild cold symptoms. I have seen one death from Covid since the outbreak. Just one. No one suffers anymore, their bodies are ready to attack the virus after being trained by the vaccine. No one is scared. No one fears they will die.”
There seems to be no recognition that the difference she is describing was thanks to the arrival of Omicron not the vaccines.
This is an important book which gives a detailed and honest account of nursing during a covid outbreak. There is no question that Christie Beattie had the best of intentions and worked hard throughout. However, there are questions about what effect the low staffing levels, the lack of doctors and the extensive use of Dilaudid had on the extremely high mortality rate.
It is also unclear how many staff and residents developed covid in the first 10 days after vaccination, as has already been reported. It also begs the question, how many elderly residents deprived of any visits from their family, simply gave up the will to live.
Her book is available from Amazon: Behind these walls – inside one of the deadliest covid outbreaks in long term care.