Jordan: Today’s episode marks the third time since this crisis began that we’ll be speaking to a critical care doctor on the front lines. When Canada originally shut down, it was for good reason. It was because the doctors we rely on to help us fight this disease were worried they’d have to make horrible choices.
Michael: It’s very difficult to place these decisions on actually the physicians who are at the front lines, because if I have the patient in front of me, it’s hard for me to weigh whether they should get a breathing machine versus a patient at another hospital who may need a breathing machine just as badly.
Jordan: So far it hasn’t come to that. And I imagine for many of us, this new normal has become annoying, but maybe somewhat routine. And if we’ve been lucky enough not to be touched by this disease. It might even seem that life is kind of getting back on schedule. In Canada’s ICUs, though, it’s not. There a war is still being fought every single day. And like in any massive campaign, there are tragedies and triumphs and lessons to be learned and victims. And while we watch the numbers every day hoping that things are going in the right direction, so we can hopefully open up, the reason they are heading that way is because we are holding the line, so people like our guests can fight for every life they can save. So if you’re grateful that we seem to have avoided the worst case scenario, be grateful because you should be. That is a victory. But also every one of those daily numbers is a worst case scenario for someone. And our guest will tell you what they’ve learned in their fight to change that, as soon as Claire tells you what we’ve learned over the past 24 hours.
Claire: Manitoba is the latest province to release details of its plan to ease restrictions around COVID-19. Premier Brian Pallister says some restrictions will be lifted May 4th, including non-urgent healthcare and some retail businesses. And in the next few weeks, the province will see the reopening of some restaurants and more personal services. Things like concerts and festivals and other large gatherings were not included in this plan, and Pallister says they are not looking at reopening schools at the moment. Thousands of people in Northern Alberta, including Fort MacMurray, have been forced to evacuate their homes because of flooding, so the government has announced $11.7 million to help those who’ve had to evacuate during the pandemic. It’s giving out $1,250 to adults and $500 for children. Ontario is expanding emergency childcare to more people, including parents who work in retirement homes, grocery stores, and pharmacies. This is the second expansion of emergency childcare. It’ll mean another 37 centres open in addition to the nearly 100 others that are open. One of the emergency childcare centres in Toronto has closed for two weeks after three staff members tested positive for COVID-19.
Jordan: 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. He’s also one of the founders of thePPEdrive.com. Hi Dr. Warner.
Michael: Hi Jordan. Nice to speak to you again.
Jordan: Yeah. Thanks for coming back. We really appreciate these updates from the front lines. My first question, following right from that is just how is your critical care unit, your ICU doing right now?
Michael: So our critical care unit does have a significant number of patients with COVID-19. And at the same time that we have capacity, I’d say that we’re kind of getting in the groove of caring for patients with this problem. At first, it was a novel problem for us that we had to get used to. But now, the nurses, physicians, respiratory therapists have some familiarity with COVID-19 and in the patient presentations that come through our door. But it’s still a very different environment from what we’re used to. Still no family’s presence. The hospital is still relatively empty. And I’d say that the spirit, though it’s collaborative and teamwork related, it’s still quite sad and anxious. Because our world and the hospital is completely different.
Jordan: Are you guys learning sort of new tips and tricks and ways to make patients more comfortable or things you didn’t know before when you began this? I think we’ve heard a bunch of stories out of various hospitals like that.
Michael: So this is a new disease, and I think the great thing that’s happened is we’ve learned on the fly, so to speak, and through social media and the networks that exist among hospitals, we’ve learned from our colleagues in other places. So probably the first time we spoke, I was focused on ventilators. So perhaps our potential lack of ventilators and the fact that patients invariably would require intubation, that’s a breathing tube in their lungs to be kept alive when they have COVID-19. And what we’ve done now is pivoted significantly whereby instead of intubating these patients as our default, we’re providing an alternative therapy called high-flow nasal cannula, which is like supercharged nasal prongs to patients who can tolerate this treatment and survive with it. And what that does is it makes it so we don’t need to put a breathing tube in, which means we don’t need to sedate people with heavy drugs, which means it’s potentially more likely the patients will survive their critical illness. And that change has really happened the last one or two weeks. It’s interesting. When we first started caring for COVID patients, the treatment that I just described was banned in the ICU because it was thought to be too dangerous to health care providers. But we’ve since developed protocols to make it safe for healthcare providers, and hopefully this will lead to better patient outcomes longterm.
Jordan: Can you just explain that a little bit more? Why was it dangerous and how you’ve developed new protocols?
Michael: So the treatment– so just to describe the treatment in greater detail, it’s actually relatively simple. Most people are familiar with seeing patients or people who’ve been on TV with prongs in the nose to deliver oxygen. High flow nasal cannula are are more substantial prongs that deliver oxygen at a high concentration, but also at a high flow rate. So imagine 60 litres per minute blowing into your nose. It actually sounds uncomfortable, but patients find it actually quite comfortable. And because of the flow rate, there was concern that this would generate aerosols, which it does to some degree. And then because those aerosols would be in the room, the healthcare providers that are caring for those patients could be at risk. So we’ve just been able to develop a protocol to protect health care providers, making sure they wear an N95 mask and making sure we keep the door close to those rooms. And it’s proven to be effective. We’re burning through our N95 mass at a faster rate than we would if we didn’t offer this therapy. But that’s a good trade off actually. Cause it’s much better for patients.
Jordan: It’s funny cause that was my next question is just how are you doing with PPE? Are you guys rationing it? Is there still concerned that there’s not enough?
Michael: So today we have enough PPE. We’ve definitely rationed it. I wouldn’t say ration, I’d say we have conserved it in a evidence-based way. So when I come to work, I get two surgical masks for that period of time, whatever, however long my shift is, and I get a face shield that I’m supposed to clean myself in between patients, it’s kind of a 3D printed face shield. And that works for me. If I do need to use an N95 mask, I can get them, but they’re behind a locked door. And once I put that N95 mask on, I’m expected to wear it for the rest of my time in the ICU. So that type of conservation strategy is reasonable because it doesn’t put healthcare workers at risk, but it does point to the fact that there is not a limitless supply of this. And I expect to be in this type of situation for months, many months. So we definitely need to make sure that we have a reliable Canadian manufactured supply of PPE to take us through, not only what the hospital’s going to go through, but if we are to expand the economy and get businesses back to work, a lot of them will require PPE as well to provide a safe service to their customers. So we need to think about that as well.
Jordan: How has the drive going on that front?
Michael: So the, the drive, I think we got just about every piece of PPE we could from the community. And we pivoted the drive to allow for new things like hand sewn masks food for healthcare providers, innovative ideas to kind of distill hand sanitizer, 3D printing I mentioned. So it’s almost become an innovation hub. So the PPE drive, I’d say is complete, at least for the time being, because just about every new lead procured or produced piece of PPE is going to healthcare providers anyway. But now it’s an innovation hub for ideas to help manufacture novel PPE, or just come up with ideas to help our patients that are generated from the community.
Jordan: When you think about the next few weeks, and I guess, since you said it, the next few months that you’ll be in this, what worries you? You’re worried about people getting complacent? Are you worried about the virus surging back? What are you thinking about?
Michael: So I think people are, some people are expecting that this is going to end at a certain point in time, that life may return to normal. So I think people need to reframe their thoughts. 2019 is a year that you will think about in retrospect, but it’s not going to be what the future will hold for us. We need to get used to this new normal or new abnormal, and life might become less restricted over time, but it’s going to be a long time before we can imagine getting back to life we had before all this. It doesn’t mean life will be full of despair, but it means that we just need to accept the fact that there is no timeline for returning to what people perceive as normal. It also means that people need to continue to do the hard work of physical distancing. It has been effective, for sure, because our hospitals are not overrun. So people have done the right thing, and we need to continue to do the right thing. Even if there are other jurisdictions that may be less affected by COVID-19 where restrictions have been lifted, for example, a person in Ontario may look at what’s been proposed for Saskatchewan and wonder why certain businesses can’t open on May 4th like they can in Saskatchewan, but Saskatchewan has a handful of deaths and about 400 cases. In Ontario, we’ve eclipsed a thousand deaths and have over 15,000 cases and many longterm care homes are fighting outbreaks right now. So our situation is completely different. And I think that’ll be hard when we look across the country to acknowledge that different jurisdictions, and even different areas within provinces, might have different experiences with respect to opening things up over time.
Jordan: As a doctor. When you hear people talk about opening things up, what does that look like to you in a way that you think could keep patients safe and also keep you guys from getting overwhelmed?
Michael: It’s an interesting question. I think the decision to shut everything down was actually relatively easy because it became so apparent that that was the. The next step that to save everybody. If, when and how to ramp up, I think is a more complicated decision. My focus is on the health care system and there’ve been stories in the news lately about patients not getting access to care because resources are being set aside for COVID-19 I think that needs to be looked at. I think that’s an important thing to focus on because there are patients with cancer waiting operations and people who need bypass surgery and also people sitting at home awaiting joint replacements who might be taking oxycodone that they don’t want to take and that could lead to a healthcare problem down the road. So I think the next step is to see if we can turn the tap on a little bit with the health care system in a way that’s safe for patients coming into the hospital and safe for the healthcare providers providing that treatment. To me, that’s the next step. And if we can do successfully and safely and the healthcare system, which is a controlled environment, then perhaps that will serve as a platform for how to do it in the less controlled environment of retail, et cetera. So I think the first step is to make sure that we can open up the healthcare system to some degree incrementally and safely to eliminate the backlog of patients who are waiting for non-COVID related care, and also make it so that people feel more comfortable coming to the hospital for emergency care. Cause I think that’s part of why we haven’t been as busy, because people are afraid. If we can show the hospital is a safe place, I think that will help people feel more comfortable coming in.
Jordan: The last time we talked, or I guess when we first talked, you talked about doctors having to make horrible choices about who gets a ventilator or who gets treatment when there’s only a certain number of beds available. I guess we’ve mostly avoided that. When you think about what we’ve done to get to where we are, does it seem to you like we are out of the woods just in terms of– not in terms of COVID-19, but in terms of risk of overwhelming your system?
Michael: In this phase of the disease, I think it’s unlikely we’ll become overwhelmed in Ontario, which is really where I have a line of sight on. And in Canada in general, I’d say it’s unlikely because Ontario is almost as badly affected as Quebec, and neither system seems to be overwhelmed. So I think that triaged or rationing healthcare resources or, you know, having people die on ventilators just because we need the ventilator for someone else, I don’t think that’s going to happen in this phase. I don’t know what the future will hold. I think the fact that we’ve done the work to create these protocols is important because we don’t know what’s going to happen three months from now or three years from now, and it’s good to have a protocol to deal with that. But because people have actually listened and done the physical distancing is the reason why we don’t look like New York City or Italy or Spain, or the UK. So that has provided me with a modicum of comfort because that was my biggest concern as a physician, having to deny care to someone who I could, in another world, save. And I don’t think I’ll be in that position.
Jordan: One of the other things you mentioned to us that I thought a lot about is finding ways to make the critical care system more efficient, either by using your time more efficiently or divvying up the patients in different ways. Have you guys found any ways to do that, to increase capacity? Have you put any of that into play?
Michael: So it’s interesting, in a time of crisis, all the kind of artificial barriers to innovation come down very, very quickly. And I think we’ve seen that in the healthcare system where at least in the outpatient setting, physicians can provide virtual care, which I think for many situations, is effective and more convenient for patients, and probably for doctors in the long run. Within the ICU itself, we’ve installed cameras into many of our rooms, so I can see patients 24 hours a day and make decisions based on not even being in the room and wearing PPE, but just based on what the vital signs look like on the monitor. The way that we’re paid and in critical care has also evolved. The government is essentially paying us hourly instead of based on a piece work system where every patient has a fee attached to them. And that actually takes away a lot of the time I spend billing OHIP and thinking about billing and keeping track of everything so I can focus more on making decisions and taking care of patients. And the government is also allowing us to work in teams of physicians to care for critically ill patients, whereas in the past, only one critical care doctor could care for one patient each day. Now we have a team of doctors provide them care in an integrated way, 24 hours a day in the hospital, which I think is much better for patients. So that all happened in a matter of weeks. So we’ll see what lasts when this is over, but I think there are going to be some good things for the health care system that come out of this. And that is, I mean– there’s no upside to this in general, but that’s one positive thing that can come out of a pandemic. All the innovative ideas that have been generated and executed in a short period of time.
Jordan: That’s pretty amazing. Cause when you mentioned some of those things to me, when we first talked, and I thought about the bureaucracy, that is the both Ontario’s healthcare system and government, I thought there is no way that you’re going to make those changes that fast. And you’re saying that it happened.
Michael: Well, it had to happen. And I think that government in, at least in my hospital, the administration, for sure listens to frontline workers. And the public health physicians that are advising and the government can advise them about epidemiology and the general work related to this outbreak. But it’s the people on the ground who can tell government and hospital administrators what they need to provide care today to patients. And credit to the bureaucrats and to the hospital administrators, in general they’re listening. And a lot of money has been spent, and I think that’ll have to be counted for down the road. But I have not encountered a significant obstacle to really anything that I’ve asked for that’s been reasonable. And I’m grateful for that.
Jordan: Speaking of positive notes on this, have you guys discharged any cleared patients who were in the ICU and who were on ventilators and recovered? And if so, what’s that like?
Michael: So there are patients who have survived their COVID-19 illness who have gone from being intubated and ventilated in the ICU, to leaving the ICU, and that feels like a quote unquote win. You know, that’s a good thing. I’d say that the happiness we feel about those situations is overshadowed by the despair we feel as a team when we lose someone in their forties. So it’s– the highs are high, but the lows are unbearably low and it’s, I mean, we lose– people die in the ICU almost every day pre-COVID. it’s something that we’re used to. But what we’re not used to is having someone around my age, I’m 41, pass away in the ICU with their family not present, but watching over Zoom. You know, playing prayers, you know, those types of situations are so inhumane, and it’s really hard for us to kind of add humanity to that situation. But as a testament to our team, we have nurses, respiratory therapists, personal support workers who are in the room holding the patient’s hand as they die, so they’re not alone. So the lows are really low, but we’re doing what we can within the framework to provide humane care, to make sure that patients are not alone when they’re sick and definitely not alone when they die. But that’s, that’s very hard. It’s still very hard.
Jordan: Is there anything that ordinary citizens can do that would help with that? Like, I know we have various ways to show our love and respect, you know, rainbows in the window and a 7:30PM cheer. Does that make a difference? Are there other things that would? Sending food? Like, I don’t know.
Michael: I’m not sure whether you can, you know, it’s the grieving families I worry more about and what they’re going through cause they mostly don’t get to say goodbye in the way that you would normally say goodbye, or even say goodbye when someone enters the ICU in the first place, before we put a breathing tube in. The thing that helps me is when we, instead of focusing on the numbers, cause we focus on numbers so much with this illness, I want people to think about the fact that there are people behind these numbers. So, you know, today in the ICU there are 230 patients in Ontario, and yesterday it was 240. And people will interpret that as a good thing. And maybe it is a good thing, I don’t know. But there still are 230 people in the ICU whose families haven’t seen them since they’ve been admitted, and whose families mostly won’t see them if they die. And we can’t lose sight of that, that these are real people. And just some acknowledgement of that to counter balance what I hear about, you know, we’ve got to open up, it’s sunny outside, I want to walk, et cetera, et cetera. I get that. But the people on the inside who are dealing with this, who are dealing with COVID-19, who didn’t ask for it, but are dealing with it as patients, we need to make sure that we respect them by acting appropriately when we’re well and healthy in out in the community. And that means holding the line on physical distancing, following public health measures, being patient with politicians who I do think have our best interests at heart, and just taking things slowly, not expecting timelines and focusing on the betterment of the community as opposed to individual interests.
Jordan: Dr. Warner, thank you so much for taking the time, and good luck and I’m sorry. That sounds like a really hard job right now.
Michael: We’re doing okay. Thanks Jordan. Thanks for the opportunity to speak again.
Jordan: Dr. Michael Warner, Medical Director of Critical Care at Michael Garron hospital and founder of thePPEdrive.com. That was The Big Story, for more, including Dr Warner’s last two appearances, you can go to thebigstorypodcast.ca or your favourite podcast platform, Apple, Google, Stitcher, Spotify. It doesn’t matter. You can also reach us by email, whether you want to send us a voice memo or a video or just some text, at thebigstorypodcast@rci.rogers.com. Thanks for listening. I’m Jordan Heath Rawlings. We’ll talk tomorrow.
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