Jordan: There’s a phrase that has become sort of a one sentence shorthand for the worst case scenario.
News Clip: The situation is so bad, one specialist told local media they are overwhelmed. But in other countries like Italy, it didn’t take long for the Coronavirus to quickly overwhelm the healthcare system. How many of our hospitals could become overwhelmed? We’re going to see hospitals in this country in particular places overwhelming. Bed capacity of hospitals in many parts of the US will be overwhelmed if the COVID-19 Coronavirus continues to spread across the country.
Jordan: But here, in Canada, what does an overwhelmed healthcare system mean? Like, in the hallways of hospitals and inside the ICU wards that are preparing to deal with a crush of COVID-19 patients, what does that look like? And what can we do right now to keep that deadly scenario from playing out? We wanted answers that went beyond numbers and warnings? We wanted a report from the front lines, so that’s where we went. Virtually we went, I mean. Before we take you inside an intensive care unit. Claire, are you there?
Claire: Hey, I’m here.
Jordan: Can you quickly update the listeners as of 6:00 PM Thursday in case they’ve turned off the news? I hope they have. What’s the situation look like in Canada right now?
Claire: So Prime Minister Justin Trudeau spoke again to try to reassure people that the government will continue to do everything it can to help Canadians through this crisis. And he also had this message.
News Clip: But even if you don’t work in a hospital, you can still keep people healthy. For example, we still need blood donors. So if you’re able consider going in and donating. Book an appointment online through blood.ca or by calling 1-888-236-6283.
Claire: Now, he did say that we still don’t know how long this crisis could last, and he did warn that the extraordinary measures like the international travel ban could be in place for months. Uh, we also heard again Thursday from Canada’s Chief Public Officer of Health, Dr Theresa Tam, and she says, the next two weeks will tell us a lot. She also said that there could be a second wave of cases.
News Clip: Our collective resolve to overcome COVID-19 must be solid and unbendable. We don’t just need to flatten the curve. We need to plank it. And we need everyone from government, to communities, families, and individuals to work together.
Claire: And lastly, the Canadian anti-fraud centre is urging people to be careful about coronavirus-related scams. And these are popping up in texts over the phone and even in person. A common one is a text message that offers free face masks from the Red Cross. And there are also phishing emails from people pretending to be from the World Health Organization, and those usually try to get you to click a link. Now, there will definitely be more of these in the coming days and weeks, so just be extra vigilant about that.
Jordan: Michael Garron hospital is just up the street from me. I’ve been there. My daughter’s been there. It’s well-run. It’s efficient. And it’s not prepared for what’s coming. Because it’s impossible to fully prepare for it. But that doesn’t mean that nothing can be done. Right now doctors are making plans. They have suggestions for actions that governments across Canada can take right this second that would help us avoid that worst case scenario. And listen, they have suggestions– okay, not even suggestions– they have orders for you, healthy or not, that will give them a fighting chance. So not to put too fine a point on it, but maybe shut up and listen to them. I’m Jordan Heath Rawlings. This is The Big Story. Dr. Michael Warner is the medical director of critical care at Michael Garron Hospital in Toronto. Hi, Dr. Warner.
Michael: Hi Jordan. How are you?
Jordan: I’m doing all right. I think right now the more pertinent question is how are you doing?
Michael: Well, these are unprecedented times for everybody. And in particular for us in the healthcare system, we’re doing our very best to plan and prepare for what is coming. And it’s anxiety provoking for us. It’s stressful. But we’re hanging in there. We’re all in this together.
Jordan: Are we doing enough, as a country right now, to prepare for what’s coming? What do you think when you see the announcements that come almost hourly now?
Michael: So I have differing views depending on what is said. I think that the physicians and nurses and other healthcare workers on the front lines are quite clear on what needs to be done to stem the tide of COVID-19. We’re in a position in Canada and in North America to see what has happened in China, see what happened in South Korea, see what is the catastrophe that is Italy, and the real debacle that is the United States. We know that significant measures, proactive measures, need to be taken by the federal government in Canada to stop the spread, the community spread, of COVID-19. And I myself are quite disappointed that the messages that the public are getting from different jurisdictions, from different cities, from different provinces, are highly variable. I think it’s very confusing for people to know what is meant by social distancing. While social distancing is the only tool really, we have now in this quote unquote golden hour before COVID-19 takes over. And what we’re hoping for from the front line is that the messaging from political leaders and policymakers is not fuzzy. It has to be clear. We have to understand exactly what social distancing means. And I can explain what it means from my perspective so that businesses and individuals abide by it.
Jordan: Yeah. Please do explain from your perspective, cause uh, I have heard a number of different strategies and I’m doing my best, but I’m not sure if I’m listening to the right instructions.
Michael: So the first thing I’d like to acknowledge that social distancing is extremely difficult. You know, we’re mammals. We want to be with each other. To be social is an adaptive response. So we have to kind of go outside ourselves to do this. It’s also difficult because there’s no positive feedback loop. If I socially distanced myself from other people, I’m not going to see the benefit of that. People are still going to die from COVID-19 despite my efforts and the people who I saved through my activities, I will never know. So I think we have to acknowledge that it’s difficult. We also have to acknowledge that there are people who are already socially isolated– the frail, the infirm, the homeless, the poor, the people who have no support– for whom this is extremely difficult as well. That being said, when I hear from the government that, at least Ontario, that it’s still okay to assemble and gatherings less than 50 I’m extremely disappointed. COVID-19 is a biologic problem, it’s not a social or economic problem primarily. It doesn’t know that you’re meeting with a group of 50, or in a group of 10. Just to give your listeners some hard numbers. So if we take our group of 50, which apparently is okay, and COVID-19 has an attack rate of between 30% and 70%. Let’s say one person’s COVID-19 comes to your party and sneezes over everybody. 15 to 35 of those people at that party could get COVID-19 if we use the 30 to 70% range. And based on the data in China, 5% will require critical care. That means care under me in the intensive care unit. So one to two of those people in that group of 50 could require critical care. Keeping in mind that the ICU admission rate is much higher in Italy. So I think, you know, if I was running a call centre that had 49 people, I would say to myself, you know, the government says that it’s okay that my 49 people come to work, so I’m not going to shut it down. But that’s the wrong messaging. All non-essential businesses and services need to be shut down from coast to coast. People cannot be with other people. That means no going to the playground. No going on play dates. No sleepovers. No dinners with your neighbours. The mall should be closed. Public transit in general should be closed except for essential workers and those who have no other means to seek medical attention or essential services. We’re going to look back on this and say that you know, the Draconian measures that are ultimately instituted should have been instituted days prior. And, you know, why am I saying this? Because I know what’s coming. I can see what’s coming and what’s coming is a situation we’ve never had in Canada, in the modern era, where the healthcare demands exceed our ability to provide health care. Not just for COVID-19, but for all the other patients who have non-COVID-related illnesses, like stroke, heart attack, drug overdose, who we treat today, but for whom we’ll have no space tomorrow. That’s why I’m screaming from the mountain tops, ringing the alarm bell as loud as I can, because when I start working in the ICU in a couple of days, I may not come out for four months. So I need the public to know, for me, what I think they should do, and I need politicians to listen to me and to my colleagues about what needs to be done, not tomorrow, but yesterday.
Jordan: I think one of the reasons we wanted a perspective from the front lines is there are sentences and paragraphs in every story about this that talk about the healthcare system about to be overwhelmed. What I’m hoping you can provide is a look at what that physically means in a space like you work in a with a team like yours. What are you guys doing right now? What’s your capacity? How are you working to increase that?
Michael: So the inflection point for me, Jordan, was what happened in Italy, and in Northern Italy in particular. Northern Italy is the economic heartbeat of Italy. It’s very wealthy. Milan is the main city. It’s no different from Toronto. And their healthcare system is public and really not materially different from ours. Yesterday, 475 people died in Italy. The death rate in Italy will surpass China. It may have, you know, as of now. And the need for ICU resources has exceeded supply, you know, already, and smart researchers in Toronto have already mapped when we’re going to run out of beds and ventilators and even ICU doctors if this pandemic attacks Canada and the way that it has in Italy. So what are we doing today to prepare? So, you know, there’s good news from, you know, the Minister of Health in Ontario that 300 new ventilators have been purchased and may be delivered. The question that I would ask her is, you know, to the Minister, there’s only 400 ICU doctors in Ontario. There’s 14.5 Million people in Ontario. If we assume an attack rate of 30% and at 5% of those people who require ICU, that’s 217,500 people who could require critical care. I take care of between 12 and 16 patients a day. Any more than that, and it’s overwhelming. How is it possible that I’m going to take care of over 500 patients per day, assuming, you know, we, we reach those numbers, which it’s hard to predict, let alone assume the fact that I don’t get sick or quarantined and that I work 24 hours a day, 7 days a week. So the numbers is what scares us. So we’re trying to create excess capacity in the hospital and we’re doing that in a number of ways. So non-essential surgery has been cancelled. For every, you know, cancelled surgery that occurs, there’s a chance that patient could deteriorate and require ICU for a week or two. So we don’t want that to happen. Obviously we feel badly about canceling surgeries, but we need to keep the beds open. Canceling surgeries has also allowed us to train the nurses who work in the post anesthetic recovery room who have skills similar to a critical care nurse to cross train them so that when their number is called, they can work and care for critically ill patients because we may have enough ventilators. Perhaps we’ll have enough doctors. But the nurses are the ones who take care of the patients. So we need to have enough nurses. I’m running a seminar shortly on how to provide critical care to patients for physicians who aren’t intensivists. And you know, what I was hoping is that the government would have foreseen this need and there’d be a unified education program among the hospitals that I didn’t have to put together myself for my hospital. There’d be some coordination across hospitals in terms of how we’re going to manage this. I think, you know, the government is considering that and they’re working towards that, but this is moving very fast. We’re already in the ICU planning stages for this. We’re already creating triage tools for who we’re going to let live and who we’re going to let die when this gets bananas. That’s where we are. You know, we were working on a triage tool, which we haven’t implemented yet, but you know, weeks ago, because that’s what they’re using in Italy. And that’s what we could be using, you know, I’m not sure when, but in the foreseeable future, in our ICUs.
Jordan: What is that triage tool? What does it look like?
Michael: The details are being reviewed by the ministry right now, but the essence of it is that if you have. A demand for critical care services and a finite supply, physicians need an ethical, legal, and scientific framework to decide who gets care and who does not, and that you know, that system or that those decision tools have to be applied universally. What I mean by that is you can’t have patients going to hospital A where they’d be admitted, but in hospital B, they’re not admitted because they’re using a different tool. I think that’s really important because we need to make sure people trust us. In addition, there’s some arguments, and I actually agree with this, that it’s very difficult to place these decisions on actually the physicians who are at the four at the front lines. Because if I have the patient in front of me, it’s hard for me to weigh, you know, whether they should get a breathing machine versus a patient at another hospital, who may need to breathe the machine just as badly. So these triage tools are scaled in that it really depends on how bad things get. There’s a level one, a level two, and a level three. Level three is the worst case scenario. And that’s the, you know, field, hospital, catastrophic medicine. Um, you know, survival of the fittest, kind of kind of a triage tool. I’m hoping that we don’t have to use this at all. But if we don’t have it, if we don’t have a framework, then you know, in addition to the stress we feel by caring for all these patients, we won’t be able to have a defensible, reliable, evidence-based way to decide who gets access to finite resources.
Jordan: How can we increase those finite resources in a short amount of time? Is there any way, I know we talked about the 300 ventilators. Is there any way to quickly make more ICU beds to quickly train more people? I know we’re recalling some nurses. What else can be done?
Michael: So I think we should, we should definitely acknowledge that people are putting their hand up. You know, retired physicians and nurses, physicians and nurses who have skills in ICU who have, you know, stepped back from those areas because it is very intense to work, so let’s acknowledge that. We also need to acknowledge that it’s not just the doctors and the healthcare professionals you need. You also need the people who are going to mop the floors, change the beds, move the patients around. They are just as important. If we don’t have those people, the whole system grinds to a halt. But how do you make more of me? You know, I went to school for a long time. As did a lot of people in the healthcare industry, and you can’t make me, you know, by snapping your fingers. But there are some ways that you can extend me and you know, I’ve had quite an interest in business and entrepreneurship and startups, et cetera, and I would love for there to be a rapidly implemented inpatient virtual care system. What I mean by that is if I could sit in front of a computer screen and see 50 patients at a time, if I had all their data, so all their lab work, all their vital signs, all the settings on the ventilator, I can make decisions about a hundred patients a day. What takes me time is going from patient to patient, putting on the personal protective equipment, having family meetings, documenting, putting in orders. Those things are important, but on a regular day, I only spend about 5% of my time actually making decisions. The rest of my time I spend moving from place to place and documenting for the purposes of OHIP. So if you want to extend me, give me a technology solution that allows me to manage multiple patients where all I have to do is make decisions. Cause I’m the guy who needs to make the decisions, cause I’m the person with the training to make decisions for critically ill patients. We can have other physicians who may not be working, like surgeons, anesthesiologists focus on the procedures, which they can do and the, you know, the small amount of physical examination that’s required. But that’s, I think, a way to extend me. It’s not because I’m, I don’t want to get, obviously I don’t want to get sick, but it’s not because my life is more important than anybody else’s. It’s because there’s only 400 of us. And if we get sick or quarantined or unable to work because of exhaustion, then there’s nobody to make the decisions. It’s like having someone who needs heart surgery and all you have as a medical student. I don’t think we want to get there.
Jordan: Do we know if anything like that is being considered at any level of government?
Michael: So I’m doing what I can with my small social media following and doing things like this to anticipate what needs to happen. But to be honest with you, Jordan, there haven’t been definitive recommendations about social distancing. So I’m not very encouraged by that, and I think that although there may be people thinking about this, we actually need to be, have plans today. We can’t just be contemplating it. We need to get ahead of this and we need to like, and we can see where this is going. I can see how this is going to play out in a number of different scenarios. It’s, there are no surprises. We have the evidence, we see what’s happening in other countries. I think the only way to minimize the impact on us is a full North American shutdown of everything for perhaps a month. It sounds really aggressive, but if you and I are talking in July about the same thing, we’ll think back to this conversation and wish that more Draconian measures were taken when we spoke in March.
Jordan: A little bit earlier you mentioned having to go visit patients and use personal protective equipment. You probably can’t speak to the level of equipment across Canada or even across Ontario, but what are you seeing in your hospital? Are you guys rationing that stuff? Are you confident that there’s a supply of it? Where are we with that?
Michael: So personal protective equipment is highly important. So there’s a few different ways to look at that. So first of all, is it recognized it as an important issue? I think it is. And I think, you know, government has heard that. But you know, supply chains are supply chains, and you need raw materials, you need factories, you need distribution, there’s logistics. So you can’t make a bunch of N95 masks tomorrow. So, you know, in terms of PPE conservation, so we’ve had to lock down our PPE because it started to disappear. And whether that’s visitors or people work in the hospital, I get it, but you know, if it’s not there for me, then I can’t put a breathing tube in cause I can’t protect myself. The public needs to stop wearing masks and buying masks because every mask I see on a person’s face is a mask that I won’t have available to me to provide treatment to someone who is sick. We will run out of PP if this hits us like Italy for sure. We will, we’ll have to reuse it or come up with, you know, some other means of making PPE in a cottage industry. So that is a huge concern, especially for the front line workers, because lots of healthcare workers have become sick and many have died from this. And although we’re here for you, we all have families as well. And we never want to be in a position where we have to help someone without protection or where we’re forced not to help someone because we don’t have protection.
Jordan: You lead a team of people that’s either already under stress or going to be under a lot of stress. What conversations are you having with them? What are your meetings like? How do you prepare?
Michael: The hospital, my hospital, Michael Garren Hospital, which I believe has been at the forefront of this because of our excellent infection prevention and control team has been planning for this since January. But no amount of time and preparation could make us ready for what is about to occur. And even our great team, I don’t think could have anticipated what is coming for us in March, if they think back to what was happening in January. I can say that the stress level for me and for my colleagues has never been higher. This is all I think about. This is all I spend my time on. This is my entire life at the moment. And I’m not even working right now. I start work on Monday. So everybody is on edge. I think that the government taking the proactive steps that we are requesting, or that I am requesting, it would go a long way to help reducing the level of stress and fear among people in the hospital. We are ready, as best we can, and we will be there. But the only way to escape COVID-19 right now is to move to another planet. So we are, you know, we are in this just as much as everybody else. We’re the ones who are going to be there to try and save people. And the other thing is we’re not really clear, or I’m not really clear, you know, if I’m in the hospital for two weeks, can I go home? You know, where do I stay in the hospital? Who’s going to feed me? Who’s going to feed the nurses? You know, how do I get to and from the hospital? Those logistical things, you know, are the next things that people are going to be talking about. But these are the things that are on my mind right now. I have three kids. You know, I just want to make sure that they are safe. That’s, you know, my biggest personal concern. And then what happens if I get quarantined? If I can’t work for two weeks? There’s only five of us who work in our ICU. You take 20% of that five, you take me out of rotation, that puts extreme stress on my four colleagues who are, who will already be burnt out. So to answer your question, this is, you know, ICU doctors, we can handle a lot. We deal with life and death every day and have to make thousands of decisions. But between the 500 emails, the media requests, thinking about my family, the adrenaline will run out soon.
Jordan: What can people like me or people like our listeners who have just heard this conversation and are probably a little more worried than they were before, do to help take some of that strain off you?
Michael: So, you know, don’t buy a mask. The only reason to wear a mask is if you’re sick yourself, but you should be social distancing and self isolating anyway, so I shouldn’t see anybody on television out and about wearing a mask. Believe me, there are only so many of them. If you wear one, I won’t have one. The most important thing you can do is listen to me about social distancing. I’m right. The safest group number is one. Okay? Social distancing can make a difference. Once community spread becomes exponential, once 1 person infects 2, and 2- 4, and 4-16, and 16-64 like compound interest, we are in major, major trouble. If you’re listening to this and you’re young and you’re healthy and you think, you know, no big deal, I’ll be fine. First of all, that may not be true because there are reports coming out of the United States and out of Italy that people in their thirties are dying of this. It is true that if you’re sick and have other illnesses, you’re more likely to die from this. But think about it in another way. If you get COVID-19 and your manifestation is, you know, fever in the sniffles and you don’t socially distance yourself and you interact with someone, who then interacts with someone, who then interacts with your dad, or your mom, or your grandmother, or your grandfather, the symptom manifestation in that person could be completely different than what it was in you. So you have to take responsibility as an individual for society. This is different. This is a community effort. This is not about any one individual. Everybody has to do their parts without exception.
Jordan: Dr. Warner, thank you so much for taking the time today and stay safe and good luck.
Michael: Thank you Jordan, and thank you to your listeners. I hope you heed to my advice.
Jordan: Dr. Michael Warner, medical director of critical care at Michael Garron Hospital. That was The Big Story, once again, live from the basement, just like you’re probably live from your home office, wherever you are. You know by now we’re doing our best to stay healthy and sane and we want to hear how you’re doing. What are you doing to pass the time? Are you learning how to knit? Are you tackling long forgotten household projects? Are you lying on the couch eating through your quarantine junk food and living a slothful life? No judgment. This might be the end times. Send us a 30 second clip. Use the audio recorder on your phone or record a video and send it to email@example.com and we’ll feature some of them in an upcoming episode. You can also send them to us on Twitter at @thebigstoryfpn. I will leave you with what I’ve been up to. And yes, my backyard is disgusting. I’m looking forward to hearing from you. Thanks for listening. I’m Jordan Heath Rawlings. Stay healthy. We’ll talk Monday. So we moved into a new house last fall, and as a new homeowner, one of the things that I stupidly did not do was make sure that the backyard was raked of leaves before the snow started falling. So now that I’m stuck at home, I have a backyard that now has no snow in it, but has a thick layer of leaves that look nice enough on the top, but are just rotted through to the damn earth underneath. They’re wet. They smell like crap. There’s probably mold in here. God only knows what else? I should have done this in like November, but like I said, I didn’t really know what I was doing, but I’ve got time now. I got a rake. I got those leaf bags from Home Hardware, and we all need ways to get exercise in the middle of this, and it looks like this disgusting job is going to be mine. So that’s a big story.
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