Jordan: I don’t say this today because of the date on the calendar, but summer is over.
Clip: Our health officials are telling us that Ontario is now in the second wave of COVID-19.
The COVID-19 modelling collaborative is projecting Ontario could hit more than 1000 new cases a day by mid-October.
The Quebec government says the situation is critical. So three regions, including Montreal and Quebec City are heading to the highest level of alert. As of Thursday, for 28 days, private gatherings with people from different households won’t be allowed. Movie theatres, bars, casinos, libraries, and museums will close. Restaurants can only do takeout or delivery.
Jordan: After weeks of daily counts of news cases in Ontario hovering around a hundred or below the numbers have been rising steadily for more than a month now. The same, by the way, is true in Quebec and in BC and in Alberta. You can call it a second wave or a resurgence. You can call it whatever you want. The virus doesn’t care. All you need to know is that COVID-19 is spreading again and spreading quickly. There is hope that things will be better this time, but we don’t know well yet if that hope is based on evidence or on wishful thinking. And by the time we do know, it might be too late. Will we see more cases this time, but less serious illness and death? Are we only finding more new cases because of increased testing? Are hospitals and doctors on the front lines just better at battling COVID now than they were in the spring? The hope, obviously, is that the answers to those questions are yes. But we just don’t know yet. Meanwhile, there are other pressing questions with more complicated answers. Why are so many non-essential businesses still operating when case numbers now are equal to what they were when we were in full lockdown? Who right now is in charge of clear, concise public health messaging? And what do they say needs to happen next? And finally, what do scientists and doctors who are fighting this virus right now want us to do to save ourselves from disaster later on? These questions are complicated, but at least we can ask for answers.
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.
Dr. Warner: Hi Jordan. How are you?
Jordan: I’m doing well. I kind of naively hoped that, when we spoke the last time, as the first wave was winding down, that maybe we would not talk again. And while I’d missed talking to you, I was hopeful, but, that’s not the case, I guess.
Dr. Warner: And there was a period of quiescence, which I think a lot of us enjoyed, both as a mental break and just a chanc to do things other than COVID-related activities as a doctor, but things are back in full force for sure.
Jordan: I’ll start the same way I did the last time we spoke. How are you and your staff doing? How are you guys feeling? How’s morale?
Dr. Warner: So I think the difference this time is that we have familiarity with what patients with COVID look like, how to care for them. We’ve definitely changed the way that we care for them. And I think we’re in a better position to provide them with better, more tailored care to increase the chances that those who end up in the ICU will survive. So that’s reassuring. At this point in time, we have enough PPE, which was a major concern in the first wave, but familiarity also can contribute to fear and anxiety because a lot of us remember what it was like to have people dying on Zoom meetings and family members not being present in the ICU and having to be so super careful about everything that we did and everything we touched and I think that’s causing quite a bit of anxiety. And then I think most importantly, for healthcare providers, we don’t see a correlation between what we’re expecting to come through our doors and then the government policies that are, I guess, not in place to protect us and other people from the inevitability of the second wave.
Jordan: Well, I wanted to ask you. There’s an assessment centre at your hospital, at Michael Garron. And for those of us who are thus far lucky enough to not to have to have used one, can you describe what it’s like there and how full it is these days?
Dr. Warner: So it’s interesting. I mean, I’ve, I’ve been in that line up myself because I have three children aged 8 and under, and when my son brought a cold home from school, which he transmitted to me, he and I both had to get tested for me to be able to work and for him to return to school. And I also look out onto this lineup at our assessment centre from the ICU and it’s grown significantly over time. And there are many more children in the lineup. There are people with lawn chairs. There are people who are there for hours. I think our hospital is doing its best to process as many people as possible, but, what’s happening, Jordan, is the turnaround time for tests, which is beyond the control of the assessment centre, is really up to lab capacity, has increased to the point that test results for me took 38 hours, so I have to miss three days of work. And for our patients in the hospital, that fight for the same lab capacity can take up to four or five days. And for the average person, depending on the assessment centre they go to, it can take up to seven days. So where we’re failing here as a system is not being able to get our test results back to people and to public health in time so that they can actually do the things necessary, whether it be isolate or contact race, to reduce the risk of spreading COVID-19 further. So I think that assessment centres have long lineups and people are there to do what they should be doing, which is get tested if they’re symptomatic. But there are many problems within the lab testing system that need to be fixed.
Jordan: Well, what are your biggest worries about either the lab testing system or the case rise that we’re seeing in Ontario, also Quebec, and other parts of the country? What concerns you about that the most?
Dr. Warner: So, I mean, it’s challenging to kind of organized all my thoughts on this, but we’ll start with the worst possible outcome first. So, people dying in the ICU, and that may not be because of COVID-related illness. It could be the cause of non-COVID related illness that is diagnosed late because people have not been able to access the healthcare system over the past six or seven months as they could have before it. So people are going to be presenting with more advanced disease that is unfixable or incurable. Hospitalizations would be kind of lower down on that kind of hierarchy of concern, that we’re going to have too many patients in the hospital. And when I say too many patients, too many patients relative to the staff that we have. So although we didn’t run out of beds in the first wave, we also had a full compliment of staff because our staff were not waiting in line to get their COVID test result back or waiting in line with their children or isolating at home. So we could have a supply-demand mismatch whereby many staff are unable to work because they’re sidelined waiting for test results. In fact, in our ICU, there are four of us who work there who all have either two or three school aged children. So it could happen to doctors, could happen to nurses, could happen to custodial staff, physiotherapists. I mean, it really takes a village to care for our patients. So yeah, concern about not being able to provide care for the patients that need care with COVID and non-COVID illnesses, including influenza. I’m concerned about small- and medium-sized businesses, who I think had a chance to come through this, but because things are so far out of control now, I think the government is probably going to have to drop a hammer, as opposed to having a tailored approach to shutting down components of the economy. They’re eventually going to have to probably shut everything down to some degree as they did in wave one because things are so far out of control and people are going to go out of business and we either need to pay businesses to close now or make sure that businesses and their employees are protected through the second wave. I’m concerned about everybody’s mental health, including my own and my colleagues, because this is very challenging. And I’m concerned for the socialization of our children and their education. And I think it’s fundamental that we make school an essential part of the future, and that we do everything we can to keep kids in school. And if that means closing everything else in the economy, then so be it.
Jordan: That’s a lot of stuff.
Dr. Warner: Yeah, a lot of things. I wasn’t actually sure what I was going to say until you asked the question. So there it is.
Jordan: When you say “this has gotten so far out of control,” this might be kind of a dumb question, but for those of us who don’t dig into the numbers that much, what are you seeing that’s telling you that it’s out of control?
Dr. Warner: So there’s the effective reproductive number, R, with a t beside it, that’s the mathematical term. It basically means, let’s say the R value is 1.2. That means for every 100 people that are infected with COVID-19, they will go on to infect 120 people. And that’s kind of where we are in Ontario right now, which means just mathematically, then the case numbers, whether you identify them through testing or don’t identify them because they’re just out there, will invariably go up. And until that number is less than one, case numbers will not subside. So that’s the number. The number of positive tests per day,, I don’t think, I mean, obviously it’s important and the media will report it every day and people like me will even react to it every day. But it’s really the R value that’s most important and the seven day rolling average of case numbers. And the fact that because our testing process is so inefficient and people who are most likely to be infected by COVID, I’m talking about essential workers, racialized, marginalized people, cannot afford to stand in line for an entire day, let alone not work for seven days while they wait for a test result, that I think there are a lot of people who are going to self-select not to get tested. Not because they’re bad people, just because they can’t afford it. So we won’t know who has COVID and for the positive tests we end up getting back, Jordan, contact tracers will be getting that information four or five, six days later. It’s really stale, dated data. And they then their job to contact trace is much more labor intensive because the individuals who are deemed to be positive will not have known they’ve been positive, so they will not have adjusted their behaviour in the intervening time and could potentially spread COVID to other people. So it becomes this vicious circle where things just get out of control. If I frankly think they’re likely out of control already, whereby it’s only through policy initiatives that limit our ability to interact with strangers that are going to be efficacious.
Jordan: Well, I’ve seen you talk about testing a lot on social media and in other places. And the question that I see coming up all over the internet, I guess whether it’s right or not, is, are we really seeing more cases of COVID right now than we were in the spring, or are we just testing a lot more now and it was actually further out of control in the initial wave?
Dr. Warner: Yeah, I think that’s an interesting question. And people will point to the positivity rate in March, April, May, that was higher than it is now, although the trajectory of our positivity rate, which is basically the percentage of tests that ended up being positive is increasing significantly. We also have to keep in mind that the numbers were skewed in the first wave because so many people ended up being positive in long-term care homes. Basically, if one long-term care home was hit, just about everybody in that long-term care home would be positive if they were, in fact, tested. So it is true that we didn’t do as many tests in the first wave and then when you test more people, you are probably going to get more positives. But as I just outlined, I think there are lots of people who are positive, who we are not testing, particularly young people who could have minimal symptoms and not really know that their headache or a sore throat or feeling fatigued as an actual COVID-equivalent. So I think that the true answer is that we don’t know. But by the time we get hospitalizations, which are already increasing, and ICU admissions, which are starting to creep up, at levels where people are starting to get concerned, we’re far too late. The train has left the station at that point. So, I think that we need to acknowledge that this is real, whatever it is we’re experiencing now is real. And that the government needs to intervene to stop us from being in positions like at weddings with 50 people, going to casinos, that essentially put us in a position to fail. That put people together who don’t live under the same roof in indoor settings whereby COVID will spread. It just makes sense to stop those activities that are known to make the public health job more difficult.
Jordan: In a perfect world with governments, and I’m not singling out any level of government or any particular province, but with governments who were listening directly to the medical experts, what would we be doing now, or what would we have done in the past few weeks to organize and plan for this? Because I remember I talked to you and to epidemiologists and other experts earlier this year and they all said that a second wave will come. We have to be ready for it.
Dr. Warner: Well, there’s a lot of layers to that question and I’ll answer kind of sequentially. So to me, our entire pandemic response comes down to leadership and who is actually in charge. So I would argue, and I think the evidence would demonstrate that when people who have scientific backgrounds, people who are epidemiologists, virologists, people not like me, but other scientists and professionals who really understand this stuff, are the voice to the people and the government listens to what they say…in the context of the government having to concern itself with the economy, et cetera, those countries have been far more successful. I don’t think there’s really any degree of trust in our Chief Medical Officer of Health in Ontario among the general medical community that he is an effective communicator or leader. Premier Ford is not a scientist in any way. And Minister Elliot is also not an expert in anything related to healthcare. So I think that we need to make sure that Ontarians and the government are getting the same information and acting on it from experts. And those experts right now are trapped in the Twitter echo chamber or are speaking through other mediums to the government, via the media. So I would like to see science lead, as opposed to politicians lead and interpret the science behind closed doors. And I think if we were doing that then scientists would have told the government or the government would have taken the summer to shore things up, to prepare for the inevitable second wave, to make sure that public health was well-funded, to make sure that the digital systems necessary to transfer information among public health units were in place, to have a clear and transparent plan about if we get to X number of cases or an R value of this, then this policy decision will be made. Because right now, it seems like the government is reacting to the media’s reaction to case numbers each day. And if we do that, we’ll be primarily behind. I actually don’t know what the government is going to say on a given day because it hasn’t been laid out for us, what the goalposts are for economic rollback in the context of an outbreak that’s getting out of control. So, I think that we need more transparency and with transparency we will have some accountability, but we have neither right now. We’re also lacking leadership.
Jordan: I want to talk to you a bit about the stuff that’s directly in front of you. You kind of touched on it at the beginning of our chat about, we know more things, we have some PPE now, but what have you and your team been doing over the last few months to get ready? And what’s different in your world than it was when we talked in the spring?
Dr. Warner: So if we’re going to speak medically, so in the first two weeks of the pandemic, anyone. Who required a significant amount of oxygen with COVID-19, we would intubate, we put a breathing tube into their lungs and intubation carries with it some significant risks. You usually have to keep people asleep with some very heavy drugs that act like general anesthetic and patients aren’t mobile, which has its own risks. And the reason we did that is because we thought that if we didn’t control the airway, the health care workers would be put at risk because aerosols or droplets will be spreading everywhere. The treatment that is now the main stage, which is called high flow nasal cannula, which is basically supercharged nasal prongs that blow air into the nose and ultimately the lungs, was banned initially. And now it’s our go to, so I think that’s something that’s really interesting, that the medical community has really pivoted and taken evidence as it’s come up. And some of it has been dubious, for certain things, like hydroxycloroquin. We evaluated it and implemented it in real time, using COVID patients as a living laboratory, in an ethical way to make sure that we provide the best care as we learn more about this disease. And if you contrast that to policy decisions where we really haven’t learned anything from the first wave if I’m going to evaluate what we’re doing right now, it’s materially different than the approach. Dexamethazone, which is a steroid, which is used for other types of respiratory failure, which is cheap and relatively available is now commonly used. And we think that helps reduce mortality in patients with severe lung disease from COVID. We’re also starting to think about COVID, not just as an acute disease where the binary outcome of alive or dead is what manners, but also as a chronic disease where there’s morbidity. Morbidity is kind of the degree of illness one has from a disease and that there are patients who are going to have chronic problems, whether it’s mental health, brain, heart, lung, kidney problems from COVID. And that’s really important for your younger listeners to acknowledge and realize that even if they don’t die from COVID, which is of course important, they could be chronically unwell from it, which I think has important longterm healthcare outcomes that are yet to be seen.
Jordan: What about physically, like in terms of hands on, do you guys have more beds? Have you moved things around, do you have different protocols?
Dr. Warner: So critical care works as a system in Ontario, as I’m sure it does in other provinces. So every week the group of Toronto critical care docs talks. And every two weeks, there’s a provincial table for critical care that I sit on, where we see our resources of ICU beds, really, as a provincial resource. Patients can be moved from hospital to hospital. Certain hospitals have been identified as ones that should receive more beds and resources based on what they had to do in the first wave. There are different hospitals, like Toronto General Hospital that provides ECMO, and that’s extra corporal membrane oxygenation, or a heart-lung machine, which is used in severe cases of COVID when the heart-lungs no longer work properly. So that hospital in particular needs to have adequate resources. So we are very well prepared from an ICU-critical care perspective. We’ve adjusted the way our nursing model works. The way our physician model works. We are ready to go in every way. And our hope is that we’ve over-planned for what’s coming, but we are ready.
Jordan: I want to ask you something now that, I’m pretty sure that I know the answer to, but you addressed our younger listeners a minute ago, and I think this is an important question because I’ve seen it a lot. That this second wave is composed of tons and tons of cases, but very few, ICU instances and deaths. And what do you think when you see that opinion floating around?
Dr. Warner: Well, I think the story’s yet to be written. So that is the story today. I think that just to kind of parse out the first part of your question, I think the messaging needs to be tailored to a younger demographic. So there may be people in that demographic who are listening to me right now, but they’re probably not watching CBC or CTV News at 6 o’clock. TikTok, Instagram, et cetera, other forms of social media, using influencers, people they trust who don’t sound like their parents or grandparents. Those are the people we need to engage to help deliver a message in a way that doesn’t berate young people, because we were all young once and I can understand wanting to be with my friends all the time. We need to deliver a message in a way that resonates with them so that they can modify their behavior in a way that is in their best interest and also in the best interests of their parents and grandparents. So the second part of your question is, what is young people today will be older people tomorrow, especially if this social bubble concept of 10 people remains supported by public health officials. I think Dr. de Villa really tried to burst that bubble the day before yesterday in her press conference. And that it probably isn’t safe anymore to have a social bubble, which includes people outside your household, given the number of cases in the community. So I think that people would say this only affects young people and young people aren’t hurt as badly. That may be true today, but we can’t ignore the morbidity topic that I just discussed about chronic disease. And we also can’t ignore the fact that we’re expecting the peak in ICU admissions in mid-to-late October. And it’s only late September now.
Jordan: You mentioned this a bit earlier too, but I want to get into it a little bit more with the time I have you for. The communication around this and, you know, you just said that Dr. da Villa pierced the bubble concept, but the bubble concept is something that I and a lot of people I know had been relying on for months and treating that as if it was gospel. And when things seem to change so rapidly or even depending on which level of government you talk to, what should folks do if they’re just trying to figure out how to be safe, how to be responsible and they’re hearing different things?
Dr. Warner: That’s a great question because I’ve been confused myself. So in this social bubble concept of 10 people was something that people really bought into. And then I realized as soon as school started, that that concept had to get thrown out the window. Because my bubble now includes the bubbles of all my children’s classmates. So actually, I stopped.
Jordan: But nobody said that to us!
Dr. Warner: Well, I said it on my Twitter feed and so did a bunch of other people, and I also said that public health needs to acknowledge that in a press conference, but they haven’t and they didn’t own it. And they’ve allowed people to be in this state of perpetual confusion. And that builds distrust. I think they needed to call it out. Say you know what? This was the policy, but schools really aren’t as safe as they need to be. So we’re going to blow it up and just stay with your household. That would have been truthful. They’re kind of walking it back now, but it’s probably too little too late, which is why I think we’re entering a potentially dangerous time in Canadian history. I don’t mean to be provocative, but if we’re in a position where we don’t trust the people standing up at the microphone every day to keep us safe and to deliver a message that’s honest and succinct and transparent, then people become very nervous. And I think the message that I have for people is, you have to think for yourself and you have to act in a way that makes sense for your family. And the safest number of people to stay with is one. That is the safest number. And I’ve said that before. And if it can’t be one, then it should be the people under the roof with you. That is the safest number, especially with cases rising. And I think that’s the problem. The thing that government doesn’t understand, that people are looking for rules and guidelines for them to structure their life by. And the government has been hesitant to provide those rules because…for whatever reason, perhaps it’s political pressure, et cetera, they don’t want to seem draconian, but I think in many ways people are on their own. And that’s pretty scary, but I think people are familiar enough with COVID-19 to understand the general framework for how to keep themselves safe. And COVID only spreads if you interact with people that you don’t normally interact wi if you don’t interact with people in close quarters, then you’re not going to recover it or spread it. So that’s the fundamental truth. And if you can adjust your activities based on that theme and that truth, then you should be okay.
Jordan: Is there one final takeaway that you’d like to share with us, based on things you’ve seen either in your hospital or in medical policy over the last few months? If there’s something, a message that you’re not seeing fully conveyed that you think needs to get out there that you maybe haven’t mentioned yet, or want to double down on.
Dr. Warner: Oh, there’s lots I want to double down on, but, I’ve said this before, so right now, nobody really knows who’s at the provincial command table. Are there any doctors there? Are there any experts there? Who’s actually making decisions and why are they making those decisions? And there must be people at that table who do not feel that what’s going on is right. Who thinks that there’s inconsistency between the policies that are announced and what’s actually happening on the ground or the discussions behind closed doors. Now is the time to be the whistleblower to stand up, to be the hero, to not be worried about the fear of retribution or whether or not you’re going to get the promotion, but to say that this isn’t right. And I also would encourage the premier to stop listening to what I have to say on the news or what other, I don’t even call myself an expert, but what other experts say and bring us into your inner circle. We want to help. We want the government to succeed and continuing to ignore scientists and experts will only make it less likely you’re going to get reelected. So, if that’s the motivation, then bring people in because there are lots of people who want to help
Jordan: Dr. Warner. Thank you as always for your time today. I hope we talk down the road about how we successfully beat this wave back.
Dr. Warner: Thank you, Jordan. Take care.
Jordan: Dr. Michael Warner of Michael Garron Hospital. That was The Big Story. For more from us, head to thebigstorypodcast.ca you can find all Dr. Warner’s previous episodes by searching his name at the bottom of the page. You can also talk to us on Twitter @thebigstoryFPN. We will tag Dr. Warner so you can follow him directly. You can also find us in your favourite podcast player, Apple, Google, Stitcher, Spotify. Doesn’t matter. You can email us. We’re at email@example.com. Thanks for listening. Stay safe. I’m Jordan Heath-Rawlings. We’ll talk tomorrow.
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