Ep. 16: What It's Like To Tell Someone They Have COVID
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Dr. David Carr is an ER doc who has been on the front lines caring for patients affected by COVID-19 in Toronto. Host Shaun Francis spoke to Dr. Carr about the mistakes we’ve made these last few months, what it’s like to tell someone they’re infected with COVID, and the dangerous resource crunch we’re facing as the health care system tackles the elective surgery backlog while still fighting the pandemic—with flu season around the corner.
Mentioned in this ep:
Follow Dr. David Carr on Twitter @davidcarr333.
Here’s David’s conversation with basketball star Steve Nash.
David’s appearance on the Toronto Star podcast, This Matters, told people it was safe to go to the ER.
EPISODE 16: WHAT IT’S LIKE TO TELL SOMEONE THEY HAVE COVID FULL WEB TRANSCRIPT
Christopher Shulgan: Through the course of the pandemic, one of the people who has helped to lead the discourse is Dr. David Carr, an ER doc at the University Health Network in Toronto, who also teaches at the U of T medical school. I'm Christopher Shulgan, the executive producer of Eat Move Think.
[00:00:26.15]
Christopher Shulgan: Dr. Carr's interesting because he helped lead the discussion on how to protect yourself from COVID during an online video he made with the basketball star Steve Nash. That went viral. And when people's health was suffering because they were avoiding emergency rooms because they didn't want to catch COVID, Dr. Carr led the effort to convince people to change their minds. He said ERs were safe. If you're having health issues, it's fine to come in. And finally, Dr. Carr works at Medcan as a senior medical consultant. Shaun's conversation with Dr. Carr is wide-ranging and fascinating because it represents the honest and unvarnished view of someone who is fighting COVID everyday on the ground.
[00:01:08.09]
Christopher Shulgan: But before we get to Shaun's conversation with David Carr, a word from our sponsor. Medcan child and youth assessments will be happening through the course of the summer. That's a series of screening measures designed to provide parents with insights based on your child's unique physical, social and emotional needs. You and your child will spend valuable time with a child psychologist, physician, exercise physiologist and a dietician. The child and youth assessment is designed to provide you with tailored strategies to help your child reach their potential. This assessment is also appropriate as a first step to evaluate specific health and wellness concerns. To book an appointment or learn more, contact our client service team at 416-350-5621 or email clientservice@medcan.com. That's clientservice@medcan.com. Now for Shaun's conversation with Dr. David Carr.
[00:02:12.10]
Shaun Francis: Hi, it's Shaun Francis. Welcome to Eat Move Think. We're super pleased to welcome Dr. David Carr of the University Health Network and Medcan to our show today. He's going to speak to us about what it's like to be a frontline physician on the war on COVID. Welcome David. Maybe we could just back up a bit and talk about, you know, where were you in January and February, and were you tracking this? Was it on your radar? Did you ever think we would be in this situation?
[00:02:40.14]
David Carr: Well, thanks so much for having me, Shaun. Yeah, it's been an interesting evolution. You know, I work at a couple hospitals. I work downtown at the University Health Network, and I work at Medcan, a downtown health facility, and I work up north in Richmond Hill, at Mackenzie Health. And those are pretty diverse hospitals, and especially up north in Richmond Hill, where you have an affluent community that travels, that is composed of Persians, Italians, Koreans, and Japanese and Chinese. So we started to see it up north actually, at Mackenzie Health before I saw it downtown. And, you know, I remember when they started to say, "You know, you should start screening people if they've been to the States," and it just seemed so crazy. I saw my first COVID case with someone from Vegas, and I was like, "Why am I screening someone from Vegas? There's nothing in Vegas." And before we knew it, we were just so behind of realizing—especially in the States—how much disease was prevalent prior to it being published. There was just no testing. And then we got into these early warning signals of saying you have to assume that everyone you see has COVID-19.
[00:03:47.26]
Shaun Francis: What would be the top three errors now in retrospect as you're looking back?
[00:03:52.26]
David Carr: There's been cuts to public health. You know, look, I've been through SARS. SARS kind of came and went and petered out, and SARS really was a—it started out as an Asian problem and then a health care problem, but it didn't affect economically or globally. There were some clusters in Toronto and in Hong Kong and a few other sites, but this had the whole society affected, and that was really different. Unfortunately, it's kind of like when you lose weight or you fix your back, and when the problem's solved you feel like it's over and you don't have to worry about the steps that you took to get better, and then you drift back to those same problems. What we had done was we had eased back on public health, made a lot of cuts, and then when this came, we didn't have the infrastructure. So the ability to do testing, the ability to do contact tracing, we were just so far behind that, you know, we were setting up assessment centres but we didn't have capacity.
[00:04:48.02]
David Carr: And then as a frontline worker, you're seeing that some, you know, outside of the downtown core hospitals, you have hospitals and individuals waiting three to five days to get their results from COVID-19 testing. And in some of these cases, Public Health hadn't even called these patients back for several days after their tests were done. So it was a very difficult containment strategy with our testing and tracing practices.
[00:05:12.19]
Shaun Francis: Let's stay on this topic of transmission, and point of feeling that you are safe with the PPE that you did have. You know, I recall maybe a few months ago, seeing a video that was being circulated online of a doctor at Columbia Presbyterian in New York describing how, you know, he went from being afraid to not, you know, once he discovered or once he became confident at least that transmission really occurred when you were in close proximity with someone who's infected. And as long as he had his PPE on, he felt very safe. Safe enough that he didn't feel unsafe walking the streets of New York, getting into his elevator. He washed his hands frequently. But he said once he crossed that threshold of understanding transmission, at least in his opinion, he felt a lot more secure. Has that been your experience? Maybe you can talk about it.
[00:06:02.14]
David Carr: Yeah, I would say that completely echoes. I mean, I've maintained from the beginning that I have felt more safe working in a hospital than I do going grocery shopping at any of the major grocery stores. In a hospital, it's a very relatively sterile environment. Patients are screened, people who are suspected of COVID are put in the appropriate rooms. Our waiting rooms were empty. One of the things is our volumes went down around the province, 40 to 60 percent in emergency departments, so we've never had more space to deal with this in terms of this was a quick, unanticipated fix of hallway medicine because we had no longer patients in hallways. And then you just kind of got comfortable in your skin. The people who are getting this, you would think if this was an aerosolized virus for the most part in high clinically-relevant levels, then all of our intensivists and anaesthetists and emergency doctors would be the poster children of COVID. But they don't seem to be the ones getting it. And we've been—thank God—really lucky that it has been mostly droplet. We've spent a lot of education in terms of PPE practices, and I think that is a super important strategy of getting people back to work, starting with basics, in terms of hand-washing and physical distancing. And then in healthcare settings, the appropriate use of PPE for that particular space.
[00:07:22.18]
Shaun Francis: So what do we do to get the people back to work? Is there a strategy where we can live with it, but take precautions?
[00:07:35.05]
David Carr: We have no choice, because I think there's certainly COVID fatigue amongst people, and I get it. I mean, fortunately, the world has tremendous empathy towards physicians, especially on the frontlines, but at the end of the day I feel safe at my job. I have a job, I have job security. There are lots of people who have lost their jobs and lost their livelihoods. I mean, you run a company, you know this better than I do. People need to get back to work. It's not a strategy of not working. It's what containment strategies, and what is the next step? I mean, I do think we should wait a little bit for our reproductive value being less than one before we open up, and have some enthusiasm. But I do think there's going to be times where we put the pedal on and turn the pedal off, and people have to be weary of that. But there is no choice but to conduct commerce. Every sector is going to have to adapt, because staying home doesn't work. It can't work forever.
[00:08:31.10]
Shaun Francis: No, certainly not. We interviewed on this show Dr. David Fisman, a U of T epidemiologist, MD, PhD, and he had a great analogy. He said in February, when we thought the infection fatality rate might be four or five percent, we all went into lockdown, right? So it was analogous to, you know, a cat being chased up a tree and then we realize, "Oh, God. We're up the tree. We're safe now from the dog, but we got to get back down because we got to eat." And so no one ever really thought about what's the back down strategy, because it all happened so quickly.
[00:09:11.21]
David Carr: Yeah. Look, I think we dodged a bullet. Look, David Fisman's one of the most brilliant epidemiologists I know. And David said today, I heard that the true infective fatality rate is probably in the neighbourhood of a half a percent. So much different than our case fatality rate, which is roughly about seven percent right now in Canada. So I do think that look, this is not the flu, but I do think that this is probably not as bad. We have grossly under-tested, and we need to now have smart people, innovators, think about how we can redesign work spaces. Because this isn't going away, but it may not be as bad as we thought.
[00:09:54.14]
Shaun Francis: So David, talk to us for a moment as a frontline physician in hospitals with COVID, you know, how does it present itself? How do you diagnose it? You know, we hear of people, they turn around themselves in the hospital and others end up in the ICU. Maybe you can just describe that to us from what you're seeing.
[00:10:13.00]
David Carr: Sure. Again, evolving story. You know, there's several people who come in. The first person who comes in is the worried COVID. And early on, there were lots of people who were very worried about this, as it was really an unknown, and no one knew what. But they looked well, and these people were often turned away because they had no criteria for testing. Then we had criteria for people with travel, so we started to test those. Then the next wave came in, where the disease prevalence picked up, and we started to see people who had symptoms of COVID. So they came in with a cough, they came in with a fever. And we said, "Look, you probably have COVID. We're going to test you. The test might come back in a couple days but again, I want you to live your life as if you have COVID. If you have the means, move into the basement, isolate for yourself and your family, and come back in 14 days or isolate for 14 days." And then we started to see those patients come back, because the natural history is you have an incubation period of about five or six days, and then people maybe show up in the hospital about three or four days later. But then if they're going to get sick, they come back at about two weeks' out. So then we started to see people who you would maybe have sent home, who looked fantastic, like maybe a mild fever, maybe a cough. This loss of smell or loss of taste seems to be the physical exam or the historical question with the highest likelihood ratio, meaning of the one question you could ask, that seemed to be the most specific for COVID-19.
[00:11:41.22]
David Carr: So you had a lot of people who said, "Doc, I lost my smell and I have a fever." And you just said, "Okay, you clearly have COVID." But then they started coming back, and they started coming back sick. And we really didn't know what to do with these people. And one of the really frustrating things is look, I've treated scary, infectious diseases, flesh-eating disease, meningitis, tuberculosis, but I've read that textbook and I knew what drugs to give them, and I knew how to make them better. And I knew what would predict their outcomes. With this we had no idea, and we still don't have a ton of ideas. What we do know is in the three months that we've been dealing with this in Toronto, and worldwide—at least in North America—there's really no wonderful drugs. There's no secret sauce. Nothing has been fantastic. You know, we've started to think about chloroquine or hydroxychloroquine and we have a president who's taken that—at least not ours. And that fell by the wayside. We have all these fancier drugs, a new drug called remdesivir, that maybe works with people with mild to moderate illness. But for the most part, 80 percent, 85 percent of people are going to get better. We even think that 30 to 40 percent of people will remain asymptomatic. And one of the hardest things to deal with this, Shaun, is that I'm an inner-city doc, and people come, they don't speak English, they have no visitors, no sons or daughters to translate. And they're sick. And you kind of are someone who is trying to tell a person that you're going to need to insert a breathing tube, and you're having a FaceTime call much like we are having today, but you may be having the last phone call with your loved one to say that I'm going to put him on a respirator. I just want to let you know when you can see each other. but we were forced to make these decisions and we had to make them alone.
[00:13:30.15]
Shaun Francis: Yeah, extremely tough. How different is it than what you've seen with people who have the flu and go downhill like this?
[00:13:39.26]
David Carr: Well, you know what? The flu—firstly, so a couple things. The flu tends to be harder on kids. Certainly the H1N1 flu was particularly hard on children, harder on pregnant women. And those are two groups that actually have done quite well with COVID-19. But the flu just is a more gradual, insidious opponent in that this just hits. So you get this, you feel crappy, but then when you tank, you tank. And we started to see this group of patients that have collectively been referred to as happy hypoxic, meaning they're happy, but their oxygen in their blood is terrible. And they have levels in their blood that we've never even seen people talking to us that aren't blue and cyanotic. But there's this whole cohort of people who actually don't look bad, but when you look at their numbers on paper, you're like, wow, like, you're the sickest person I've ever seen. How are you talking to me and not breathless?
[00:14:33.04]
Shaun Francis: I heard it likened to maybe having high-altitude sickness.
[00:14:37.25]
David Carr: Yeah, so that's interesting. I know you do a lot of trekking. That is that suffocating. And that's what we see is—if you're not asthmatic, if you're an asthmatic or you're high-altitude, you're just gasping for air. And, you know, there's nothing we can do to help your oxygenation. You know, when you're on the top of Kili, you just declimatize and you're well. If you have bad asthma, we give you some puffers and you don't circle the drain. And I've seen those patients. With these people, there's nothing that I can do to help them, and that has been the biggest frustration. What I was going to say is, I've been calling a lot of people with COVID. So one of the jobs I had to do is tell people their results. Early on, when I was calling people about telling them they're positive, I felt like I was a parent yelling at people, because I don't think people were taken seriously. So I remember one of the earliest people I called was a 23 year old, and I could tell he was checking out at the supermarket, and I could hear the items being scanned. And he had been seen a day before and had a fever and was told, you know, go home and isolate. And then I get him on the phone and I said, "Hello, where are you?" He's like, "I'm at the supermarket." And I said, "Can you stop what you're doing right now and leave? You have COVID-19." People were just not paying attention.
[00:15:53.28]
David Carr: I remember having another call where someone—and I could hear they were in their car, and I said, "Is this an okay time to talk? Where are you?" "I'm just in the car." "With who?" "With my girlfriend." "Is it okay if I tell you in front of her some medical stuff?" "Yes." "You have COVID-19." And then I hear the girlfriend screaming. And I get it. And it was deliberate, because the reality is there were people just not paying attention to this. And look, these are isolated events in terms of when you're doing contact tracing or telling people. And you don't want to do COVID shaming, but these are people who are harming people. And that was hard to deal with. There are other people who took it so seriously, and there are other people who had so little means and did everything in their means to take it seriously. And I think a few bad apples didn't ruin the whole process. I think we've done well. I think people have listened and people have beared down, and we have good numbers to support that. We didn't get the values and the incidents that we were dreading because of people being responsible.
[00:16:57.01]
David Carr: And one of the side effects was we don't have hallway medicine anymore because there's no one in the hospital. I know we cancelled—I read an article—23,000, 24,000 procedures across the country. People even waiting for cancer surgery. What's the knock-on effect of this? Of people not seeking regular healthcare, who have cancer or heart disease, diabetes? So it's one thing to protect them from COVID, it's another thing not to be treated, which seems to be inevitably what we're going to see here.
[00:17:32.12]
David Carr: So it's an excellent point, and I think it brings us to the unsung negative externalities of our strategy. You're in a primary prevention healthcare company. You do screening, you save people's lives in terms of providing screening, screening colonoscopies, mammographies, cystoscopies, endoscopies, all these diagnostic tests that haven't been done. And when we reopen up, whenever we feel we have enough PPE and enough bed space to open up hospitals, there's going to be a lot of people who've moved from stage 1 to stage 3 of something who aren't going to get the care that they need. And I think that's going to be a very terrible eye-opening unmeasured cost. I'm in the secondary prevention business. When I'm not working at Medcan, I'm in the hospital. And I'm seeing a 40 percent drop in our code stemi. So our ST-elevation MIs are big heart attacks. We're seeing hardened stroke, which are time-sensitive conditions. We're seeing late presenters who are not getting the treatment they need. And I'm seeing people who are just still afraid to come to hospitals. And we're seeing ruptured appendixes, and people who wouldn't have waited so many days. So from a primary point of view, from a secondary point of view, we have big problems.
[00:18:48.13]
David Carr: I think we're going to have to redesign healthcare. Look, if 26 percent of the week is Monday to Friday, 9 to 5, as a person who works 24/7, 365 hours, I think the rest of the medical community is going to have to realize that we're a seven-day-a-week gig, and that all these elective surgeries are going to be done Monday through Sunday. And we're going to have to work in the evening because we are going to have to get through a tremendous backlog. And in the system that we had, where wait times and backlog was really difficult to navigate through, I'm not looking forward to the next line of backup and the next line of delays. I work in the Ivory Tower at UHN where we're doing transplants and crucial heart surgeries and stuff. And there are patients that have waited so long. When I hear my cardiovascular surgeons begging to operate, and it's not for selfish financial means, it's for the morbidity of their patients. And I think that we have to really think about how we open up healthcare, and realize that virtual medicine will play a major role in the future of healthcare.
[00:19:55.23]
Shaun Francis: I couldn't agree more. And I think that's the second shoe to drop, so to speak, which is, you know, there's a lot of folks—well, there's millions we haven't seen across the country. Well, both you and I, right? If we're going to pass away, it's going to be, you know, heart disease, cancer, Alzheimer's, right? And you know, we all know patients like that. We know Medcan patients like that. I spoke to one yesterday whose mother had stage 1 colon cancer that she had colon resected literally the day before the hospital shut down. And her surgeon said, "Honestly, had I not got this in, I can't tell you whether you would have survived, because it certainly would have progressed by the time I would have been able to book you. And, you know, I can't imagine the stories that aren't so lucky or don't have the fortune of getting into the UHN.
[00:20:52.23]
David Carr: Completely.
[00:20:53.06]
Shaun Francis: So, I know I totally agree and it's shocking that it took the pandemic to allow physicians to bill for a virtual visit, right? You know, it took this, but we're still in such the early days and I don't know what we're doing, right? In terms of the planning for all of those backup procedures. I really don't, because that level of transparency doesn't—you know, look, we're all in the same boat, right? But if we had several month delays going into the pandemic based on our infrastructure and people managing it, you know, I can only imagine what it's going to be like coming out of it.
[00:21:30.16]
David Carr: The secondary impact may be bigger, if not as big as the primary. I hope we open up with open minds on a government level and on a healthcare level, because we can't continue to operate like the way we were before. I mean, we've gone through flu season where we know we'd be at a 120 percent capacity of the hospital, and we've done nothing. We're going to have flu season again this year. It's going to happen in about four months. What are we going to do when we also have COVID? How are we going to deal with that? Because we never dealt with it before.
[00:22:06.13]
Shaun Francis: Yeah, and the backlog of normal patients, right? Who are seeking care.
[00:22:10.00]
David Carr: Yeah, so we got to start thinking now.
[00:22:13.02]
Shaun Francis: Yeah. So David, I know you are the medical director for the Toronto Blue Jays, you're an avid sports fan. I know you've been conversing with Steve Nash, our Canadian basketball icon. Can you talk to me about that and where you see sports going now in this new era? I know people really, really want it to come back, right? I mean, we're really missing that in our lives. You know, when will it come back? What are we going to do about it?
[00:22:41.22]
David Carr: Yeah, I'm going to take it on a tangent, if you're okay with that. I think that sports and athletes have a big goal. I think that the message has to be bipartisan. People are sick of politicians giving their own political slant. And I think having key figures like a Steve Nash, like a Steph Curry in the States who talked to Anthony Fauci, were key, because that's who we're speaking to. We're speaking to the people who are getting this, which is not long-term care. Its young people now who are spreading this. So that needs to resonate with that. And one of the reasons I just reached out to Steve Nash was because I thought he represented good Canadian morals and values, and he was philanthropic. And, you know, within a day he responded. And three days later we're doing a taping with Uninterrupted Canada. And he was great. But I think when you think about the NBA, and if you think about in the last 40 years and you think about contributions to infectious disease. So the father of infectious diseases is an Austrian physician named Semmelweis, who really was the person who brought up with hand-washing. But let's fast forward to the 20th century. I mean Magic Johnson gets diagnosed with HIV, and single-handedly changes philanthropy towards the disease. And also, destigmatizes the disease that had a negative face. Fast-forward 40 years later. So HIV, the most important virus of the 20th century, now you move to the 21st century and you have Rudy Gobert acting like an idiot, touching every mic, saying COVID's nothing. And then he gets COVID, and then Adam Silver shuts down the NBA.
[00:24:19.26]
David Carr: And it wasn't until he shut down the NBA that the rest of the world opened up. So if you look at COVID-19, and if you look at HIV, the NBA raised so much awareness. I mean, my friends were like "I'm still going on March break," then the NBA cancelled the season. And I think people took it real. And that's why I think you see the value of sports. Look, I'm missing sports, like, the most. I think the creators of The Last Dance couldn't have hit it better with creating a documentary at a time where no one could watch live sports. But I don't see the future of live sports being 50,000 people at the Rogers Centre. I don't see it being 20,000 people at the Scotiabank Arena. I think we're going to have to redesign, until we've controlled this virus, the way people watch sports. And that's disheartening. I think they're going to be playing games in different, maybe controlled environments with low prevalence rates. I mean, you know, you have to open up a country based on prevalence. But the prevalence in Quebec and Ontario is much more problematic than in BC. BC has a tenth as much disease as we do. They've done a much better job, so let them move forward with industry. That's their reward. And I think sports will be like that, too. They'll play in areas that are well controlled.
[00:25:41.04]
David Carr: I think as a Toronto-based sports club, the problem will lie in terms of border crossing. And home games in Toronto might be more challenging because if there's, you know, difficulties getting in and out of the border. But I do think that the NFL will open, I'm just not sure that 100,000 people are going to watch a college football game at University of Michigan this year.
[00:26:02.17]
Shaun Francis: There's this idea that's been tossed around about having a controlled site where all the teams will play or groups of teams will play, and not be able to leave the site. Is that crazy, or is that the new world?
[00:26:16.27]
David Carr: It's the new world. I mean, I think you realize that the demand for an athlete and how much their salary is based on the revenues of the teams. And if you're in a sport that takes tremendous revenue based on gate attendance, it's going to be hard to pay athletes, and it's going to be hard to know what they’re worth in this new world. So I think these leagues are going to have to be creative. They've lost tremendous gate revenues this year. But to get back to play, it's going to be being creative. And I agree with you 100 percent what you said, it's going to be in unique locations with strict regiments and strict rules being followed, shorter seasons. It's not going to be as much fun as it used to be.
[00:27:01.07]
Shaun Francis: You know, sadly, I'm supposed to go see Navy-Notre Dame in Dublin, Ireland, the last weekend of August. And neither school has cancelled yet. And Ireland hasn't cancelled. It's an international stadium, though, I'm not counting on it.
[00:27:18.28]
David Carr: Yeah, I wouldn't hold your breath. You know, it's funny, one of my colleagues, Andrew Petrosoniak, he's an emergency doctor at St. Mike's, he talked a lot about behavioural change, and he talked about it in the context of this past weekend, for those of the listeners who are in Toronto, at the Trinity Bellwoods Park where we had a mass gathering of people, essentially. It looked like a rock spectacle. And I like to think of it like this: which is if I tell a fourteen year old, or I'm talking to a friend about how to teach safe sex, if I tell you to say, tell your kid don't have sex, well, that's not going to work. But if you tell your kid, you're probably going to have sex one day. But when you have sex, I want you to know that these are the things you have to be careful, and you should have a plan. Make sure you have a condom. Make sure you're on the pill. Make sure you know about the partner, make sure there's consent. Have a checklist. We need to have people have checklists. Have a checklist to reintegrate in society. And that's what Andrew's point was about a change. We just need to teach people. The problem was the government eased restrictions, then didn't tell people how to congregate. There was mixed messaging. You're going to go back to normal life to some degree, but you're going to have to do it with these steps. Make sure you wash, make sure you mask, make sure you keep your distance. Let's reopen up with a plan, not just carte blanche.
[00:28:39.18]
Shaun Francis: And of course when you keep people locked up for 10 weeks, 11 weeks, right? You're going to get people wanting to get the hell out, right? So it's—unless you have a very, you know, phased on locking with good advice. I totally agree. David, thank you very much. This has been super informative. Thank you for everything that you're doing on the frontline with our patients, what you do for Medcan and what you're going to continue to do as you service the backlog that we've talked about, as we get through this crisis, which frankly is going to be a marathon and not a sprint. We appreciate it.
[00:29:17.16]
David Carr: Oh, my pleasure. Thank you so much for having me.
[00:29:35.11]
Christopher Shulgan: That's it for us today. Follow Dr. David Carr on Twitter @DavidCarr333. That's Carr, C-A-R-R. So two Rs.
[00:29:46.14]
Christopher Shulgan: This episode was produced by Ghost Bureau's Russell Gragg and Chantal Guertin. Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow Shaun on Twitter and Instagram @ShaunCFrancis—that's Shaun with a U—and Medcan @Medcanlivewell. We'll be back very soon with a new episode examining the latest in health and wellness.
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