Sixth wave or not a sixth wave: Depends on the testing

 As we are at the cusp of loosening restrictions on masking and other public health mandates, there has already been a jump in cases. Many indicators suggest that this could be the start of the 6th wave, however without adequate testing we have no way of capturing if the rise in cases is beyond expected. 

Despite the theoretical availability of rapid testing kits at pharmacies and other locations, many people have been unable to acquire them. Since you are prohibited from taking public transit when symptomatic, PCR testing is then only accessible via drive-through. This is impractical for people who cannot drive, cannot afford taxis, or do not have access to cars. When trying to order home testing kits online, the average delivery time is 5-7 business days, which is too long of a window to accurately capture positive cases. In addition, several websites are out of stock anyway. Lastly, while private PCR testing is potentially more accessible it is unaffordable for many people.

So where do we go from here? The only way to understand the evolution of cases is to collect the data. Without access to testing, we could easily underestimate the number of cases circulating in the community until it is too late. I would like to advocate for the distribution of rapid testing kits to all households, systematic testing in high risk environments to capture asymptomatic cases, easy reporting of positive at home testing results, and clear public health guidelines on when/how long to isolate. 

A rise in cases with the ease of restrictions does not automatically indicate an impending 6th wave. Yet, we will never know the difference unless we look for it. 

Life on the wards with Omicron

 As I rummage through the N95 mask cabinet I finally find the one in my size...it's the last one. I hope when I have to change it in a few hours I'll be able to find the same one on another floor. That familiar sharp almost chemically grassy odor penetrates my senses as the mask is applied firmly to my face. I adjust it to seal tightly around my nose, trying to avoid applying maximum pressure to the bruised areas underneath. 

I gown up with my mask, googles, and face shield to start rounding on my patients one by one. After seeing them I review their labs - another two are now COVID positive. That explains why Ms. C was so sleepy this morning and her toast sat untouched by her bedside. One patient who was admitted for an upper GI bleed is due to go for a special test today...provided they are COVID negative. When I called the gastroenterologist in charge to organize the test, I was told I was lucky that I only needed it now; they were unable to do it a few weeks ago because all the personnel were out with COVID and there were not enough staff available to complete the test. I hoped my patient's repeat COVID test would be negative so we can understand why they have been bleeding and can be discharged home safely. 

One of my other patients - admitted for a bacteremia (bacterial infection in the blood) - needed a repeat cardiac echo (an ultrasound that looks at the movement of the heart, how the valves are working, etc.) to make sure there was no damage done to the heart. We had tried the procedure from the outside (transthoracic echo) but the image quality was poor. This patient needed something called a transesophageal echo. This is a procedure where an ultrasound probe is inserted down the esophagus to visualize the heart from the inside. However, this patient was on a ward with an active COVID outbreak. After much discussion with the cardiologist we all decided that the safest thing for everyone would be to postpone it till COVID had calmed down. The procedure can be associated with a lot of coughing and would increase the risk of COVID spread to the staff. 

My evening shift in ICU started with a printout of the COVID protocol and signover for the many patients admitted to the ward - over half were there for COVID. A patient's worried daughter called asking for an update; I told her we would call her back. All the staff were in said patient's room, flipping them over for the night. Putting these ICU COVID patients on their stomach seems to help with oxygenation. I was instructed to follow up on bloodwork for this same patient that came back with concerning results. However I didn't get the chance to call my staff as a new transfer arrived with a deteriorating respiratory status from one of the wards. I read the chart "severe COVID pneumonia, patient unvaccinated". I scrambled to assess to be able to call for help early if intubation was required, having to remind myself  to step out soon to call back the blaring alarms of my pager - I was being called from other areas of the hospital. 

This wave feels different than the previous ones. People are less sick generally speaking due to vaccination and the properties of this new variant. However, because it is so contagious the sheer volume of people who are sick is that much more. While most will be mild cases, a small proportion - especially if unvaccinated - will end up in hospital/ICU.  The issue is that when you have a huge portion of the population sick with COVID, in absolute number of severe infections still translates to more hospitalizations than during previous waves. Even more challenging are the staffing shortages created by the healthcare workers who are infected and having to stay home to prevent further spread. This impacts EVERYONE's ability to get medical care of any kind. THIS is why public health measures are necessary to curb infection rates. Our system is overwhelmed, our workers are overwhelmed, we all are overwhelmed. So please I urge you to find that strength inside you to continue to follow public health guidelines. Mask up, stay home, stay safe, stay strong. 

A Thankless Thanksgiving

Thanksgiving feels different this year. The once vibrant autumn leaves seem dulled, the days more cloudy, the pumpkin spice lattes less festive. Oh yeah, that's what burnout feels like. Approaching the two year mark into this pandemic, I'm not the same person I was before. 

I used to tell everyone that I loved people, that I was a people person. I used to easily find the good in everyone and cherish the little moments of humanity shared with my patients. I used to feel a sense of devotion and calling to sacrifice myself to try to fill the cracks of our broken healthcare system. I haven't seen that person in a while.

At the start of this pandemic, we as healthcare workers rolled up our sleeves, hugged our families, and threw ourselves head-first into the frightening unknown of this virus. I personally sacrificed my health and ended up hospitalized with COVID-19 during the first wave while trying to care for complete strangers. The patients who once thanked me for my service now roll their eyes when I ask them to put on their masks so I can examine them. Every nose out of a mask in the metro is like a punch in the face. Every maskless person on the bus is a kick to the gut. Every anti-vax person is a painful reminder of how I could have easily lost my life to this virus.

The conspiracy theories run rampant and we continue to see vaccine hesitancy brought about by false claims and poorly disseminated health information. I feel like science rejecters and myself live on completely different planes of existence, with a framework of reality so different from mine I can't even begin to understand their perspectives. When I examine their newborns in the nursery, I feel a sense of longing and a twinge of jealousy; they are so pure and innocent, not yet hurt by the world. People care about them, want to help them, want to love them. Their cries pierce my soul because instead of the joy of new life I see flashbacks to young mothers on ventilators barely pulling through.

So while I recognize my privilege in life and in this field, I also continue to live and breathe the collective trauma that many have now left behind. While I am thankful for the development of these life-saving vaccines, it is a thankless thanksgiving to have to watch so many die simply because they refuse to take it. 

Vaccination Passports: A triple threat protection of our rights and freedoms

We have all felt that glimmer of hope that this pandemic would soon be behind us. Be it due to vaccine developments or cases declining, some sense of normalcy felt within reach. That was, until the Delta variants began to take hold and cases began to skyrocket, signaling the onset of the 4th wave. Whispers of a vaccine passport have been going around for some time and now that cases have begun to rise again this option is being utilized as an additional safety measure.

 

What exactly is a vaccine passport? As defined by the Quebec government website on Aug 13th 2021 it is: "A free official document showing that the holder is protected against COVID-19... It will not show your personal information or information about your medical or vaccination history." The criteria for where it will be used may vary based on the number of baseline cases and new cases in the community, however, it will not be required for access to essential services like education. While there may be mixed feelings surrounding this passport, I would like to share why this is an important measure in protecting our rights and freedoms. 

 

Firstly, regardless of your personal opinion on what constitutes a violation of your rights and freedoms, this virus doesn't care. As humans who coexist together in society, it is inevitable that we will be in close proximity to each other. Be it at the supermarket, on sidewalks, in schools, etc., we all share communal spaces. We are currently dealing with a virus that is predominantly transmitted from person-to-person through droplets emitted via coughing, sneezing, talking, etc. These droplets can go pretty far but most land within six feet of the source. This is why the established safe social distance is to keep a minimum of six feet apart. Masks are another added barrier to trap some of these droplets at the source and prevent them from travelling to others. Put the masks and social distancing together, and you've significantly reduced the risk of viral transmission. These minor inconveniences of wearing a mask and sitting further apart allow all of us to mitigate some of the risk of infection thus helping to maintain our freedom to come and go as we please. The vaccine is simply another mechanism to mitigate risk while we go about activities of daily living.

 

None of these interventions in isolation are perfect, which is why combining them makes them that much more effective. Irrespective of your vaccination status it is still possible to transmit COVID-19 asymptomatically or pre-symptomatically. We've already seen this in hospital outbreaks among fully and partially vaccinated people. You may not show signs of infection yet or at all but be capable of infecting other people. This is why the "but I feel fine" or "I haven't seen anyone except two friends" are not valid excuses. You have no way of knowing who your contacts have seen, and if they may be asymptomatically transmitting the virus to you. This is supported by the fact that 35% of Canadians infected with COVID-19 came from a source that was unknown. 

 

The vaccine is proven to be safe and efficacious at reducing the transmission and severity of COVID-19 infections. By reducing the viral load, there are less viral particles present in the droplets coming out of peoples' noses and mouths. Here we have what I like to call the triple threat against spreading COVID-19: decrease the viral particles in droplets through vaccination, trap the droplets in the mask, and keep six feet apart so the remaining particles can't make it to others. It's simple yet effective.

 

I know one of the biggest worries by those who are vaccine hesitant is the safety of these vaccines. Let me share some statistics to reassure you on this. As per Health Canada data from December 2020 to July 2021, serious adverse events after vaccine administration occurred in 0.006% of all 49,022,551 doses administered - this represents an extremely small proportion of the vaccinated population. Inasmuch, 84.8% of hospitalizations and 82.1% of deaths were among the unvaccinated, compared to 7.0% and 7.8% of those partially vaccinated, and 0.8% and 1.3% of those fully vaccinated. But what about the long-term safety of these vaccines? Based on the decades of data we have on previous vaccines, the risk of any long-term consequences following vaccine administration is extremely unlikely. Most adverse events occur within six weeks of receiving the vaccine, and there are multiple ongoing monitoring processes in place to catch and quickly act on any alarming side-effects that may arise. We saw this at work when concerns emerged about blood clots with the Astra-Zeneca vaccine. It was quickly pulled from the market to be further studied and re-evaluated. 

 

So, to recap, we've shown that these vaccines are safe and our triple threat approach helps to decrease transmission and ultimately hospitalization/death from COVID-19. So what's next? This is where the vaccine passport comes into play; this is a way to promote the rights and freedoms of those who have embraced this triple threat approach. Since they have significantly reduced their risk of transmission/severe disease, they are now allowed to engage in MORE activities that were previously deemed unsafe. This is not a means of infringing on the rights of anti-vaxers but promoting the rights and freedoms of those who are fully vaccinated to engage in activities as they choose. At present, you have the right to choose to refuse vaccinations. However, like all choices we make in life, you have to accept the consequences. 

 

These public health measures follow the same reasoning as to why smoking is no longer allowed indoors and in many public spaces - to protect those around us. You cannot tell who is immunocompromised just by looking at them. That woman standing next to you on the metro might be pregnant and immunocompromised. The young gentleman passing you in the grocery store might have cancer and be on chemotherapy. Until we don't share the same air (which I don't foresee happening anytime soon) your actions (where you go, who you see) have a DIRECT EFFECT on the people around you. People need to use public transit to get to work because many cannot afford any other alternative. Not everyone can have the luxury of having their groceries delivered. People with multiple medical conditions may have no choice but to have frequent hospital visits for care and have to wait their turn for hours in the waiting room. Our triple threat approach is a means of protecting everyone, but especially the most vulnerable people who need it, which could be any one of us. Things happen, life changes, people get sick. You never know when it might happen to you. This passport is a tool aimed at balancing the safety for us all, while trying to restore a degree of freedom and quality of life that we've all lost since the onset of this pandemic. We owe it to each other to support and protect one another.

 

So be smart, be safe, do your research. Get the vaccine. You never know whose life you will save in the process.

 

 

 

 

References

Canada, Public Health Agency of. “COVID-19 Daily Epidemiology Update.” Canada.ca, 28 May 2021, health-infobase.canada.ca/covid-19/epidemiological-summary-covid-19-cases.html?stat=num&measure=total&map=pt#a2.

Canada, Public Health Agency of. “COVID-19 Vaccine Safety: Weekly Report on Side Effects Following IMMUNIZATION.” Canada.ca, 10 June 2021, health-infobase.canada.ca/covid-19/vaccine-safety/#safetyIssues.

Canada, Public Health Agency of. “Government of Canada.” Canada.ca, / Gouvernement Du Canada, 29 June 2021, www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/main-modes-transmission.html.

“Covid-19 Vaccination Passport.” Gouvernement Du Québec, www.quebec.ca/en/health/health-issues/a-z/2019-coronavirus/progress-of-the-covid-19-vaccination/covid-19-vaccination-passport.

“Key Things to Know about Covid-19 Vaccines.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html.

“Safety of Covid-19 Vaccines.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/safety-of-vaccines.html.

 

Food for Thought: How the fashion world is contributing to eating disoders

 *Trigger warning - discussion of eating disorders and suicidal ideation. The views expressed here are merely my own based on anecdotal experience. Please contact your local crisis line or health authorities if you are struggling with suicidal thoughts or eating disorders*

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Over a year into the pandemic, I finally had enough courage to venture out and buy new clothes. I know most of us have to some degree experienced the "COVID 15lbs" and I was no exception. No amount of regular exercise could counteract the stress, the long hours, and occasional lack of access to healthy foods with the curfew in effect for several months. I could not deny that I had gained a few pounds and that most of my pants had gotten uncomfortably tight. It was time to treat myself to an upgrade. 

I went to my local thrift store and realized that my pants size had changed...again. As I perused the racks filled with last year’s "out of season pants", the same waist/hip size on brand-name pants was labelled as extra-large instead of large. As I tried on item after item, nothing fit until I started trying the pants on in the “plus size” section. For the first time in my life, despite only being 10 lbs over the upper limit of a healthy BMI for my height, I was now forced to shop in the “plus size” section. I was now labelled a plus-sized woman and could no longer shop in many of the “trendy” mainstream stores because they didn’t carry their items in my size. I was shocked, angry, and immediately self conscious. 

Thinking back to my pediatric-centered rotations over the past few years, I’ve spoken to dozens of adolescent girls and boys with eating disorders. They’ve cried in my presence, stating that they were too fat, that their thighs were too big, and that they “weren’t doing a good enough job losing weight”. Despite the fact that their ribs protruded, their blood pressures were unstable, and menstruations/pubertal development had halted, many of these teens struggled with suicidal ideation over their inability to meet their “standards” for thinness.

The rates of eating disorders among adolescents were already high, and have soared significantly throughout the pandemic. Sadly, the wait times to get help are staggeringly long unless hospitalization is required. While this is not the case for everyone, many teens were able to tell me about an inciting event for their eating disorders; anything from not being able to fit into an outfit to a comment made from a physical education teacher like “you are too big to do chin ups”.

As a physician I cannot deny that being overweight or obese is a risk factor for a slew of medical conditions. Regular physical activity, a healthy diet, and good habits are important for feeling good, and living a happy and healthy life. However, we need to stop misconstruing what a healthy body looks like and stop shaming people for not fitting this unattainable and unhealthy standard. This is especially true for women. Ten years ago, I remember asking an employee for a specific dress in my size, only to be told “sorry, we don’t carry that in your size”. By only offering these lovely clothes to people of a certain size, companies are subtly telling us that we are less valuable and not deserving of feeling beautiful.

Stop making size zero the standard for health and beauty because it is not. All women are beautiful. All women can do physical activity (to one’s own limits, being mindful of any injuries). All women, and people for that matter, deserve to feel comfortable and beautiful in the clothes they wear. This means offering the same clothes to women of ALL SIZES and shaming no one for the number on their clothing tag.

Eventually I found a few articles of clothing in the "plus size section" that were comfortable and fit me nicely. As soon as I got home, I cut off the tags and threw them in the garbage. My body suffered the effects of being a healthcare worker during a global pandemic like no other and I don't need my pants to make me feel bad about it. 

When Nature is Nurture

One year into this pandemic, I have settled into a "new normal" that consists of isolation, disinfection routines, and takeout. As the third wave begins to rear it's ugly head, as it often does, life decided to throw yet another curve ball my way. Earlier this week I received upsetting news about a loved one that destroyed all illusions of happiness and peace. My heart heavy and my tears run dry, I yet again have to ask myself "okay, now what". Whenever I feel directionless with nowhere to turn, I always go back to nature. Nature teaches you how to live in the now, appreciate the fleeting beauty before you, and learn to let it go.  

The once winter wonderland farm-scape that I have called home for the last few weeks is now a muddy swampland of groggy trees and thawing weeds. The mud slurps around my boots as I meander aimlessly across the rain soaked ground. Like people, animals too find healing in nature. The ducks that live here suffered from PTSD after being attacked by a predator. For months they were afraid to go beyond the confines of their shelter. Yet by spending time outdoors and using the confident chickens as role models, they have gradually ventured further and further outside their comfort zone, and  have finally made their way to the nearby stream. The once threatening beyond is now their tiny oasis where they can be seen happily swimming and riding the currents like river rafts at a theme park. 

As I squelch onwards, the horses approach me with curiosity and fascination - well a little less fascination once it became evident that I didn't come bearing any food. Instead of normally going back to eating their hay, the larger of the two horses approached me - one ear cocked back as though to say "What's up human, you look glum?" Like the imaginative woman that I am (combined with my inner childhood desire to be able to talk to animals like Eliza in the wild Thornberry's), I believed in that in this moment this animal wanted to be there for me. So I began unloading all of my feelings about everything over the last year on this animal, and in some strange way he listened. This horse remained inches from my face for over half an hour just listening to me talk. I thought at one point he had lost interest since he stepped away, however after using the bathroom corner he had designated in his space,  he came back to keep listening.  His ears learned forward and slightly outward, his head lowered to be at eye level with mine, his eyes half open but fixated on me, and his body posture relaxed. No judgment, no boredom, just pure presence. It wasn't until I smiled and thanked him (after he allowed to remove some straw that had been caught in his eye brows) that he walked away. It was almost as if to say "This human is okay now, my job is done."

Oddly, it was one of the most therapeutic interactions I've had all week.  To just deeply connect with another animal and to have each other's presence somehow meant everything. Presence and connection are everything. So as this pandemic continues to rage on and life continues to be hard, trust in nature that it will be there for you whenever you need it. It will be there to show you beauty and help you practice letting it go. Whether it be letting go of dreams, a life you once knew, or fear of the unknown, there will always be beauty and happiness ahead. I promise, just be patient. 

I'm Angry and You Should Be Too

I'm angry. It takes a lot to make me truly angry, but us reaching a similar number of cases as in April in the span of a few weeks enrages me. I'm angry at this virus, I'm angry at those who didn't take it seriously, and I'm angry on behalf of those who are going to lose loved ones because others didn't take it seriously. 

I want to be altruistic and be there to support patients during this difficult time, but I've found myself having altruism fatigue. All the "self-care things" I do for myself  like seeing my partner, going to an outdoor fitness class, being able to sit outdoors and have dinner with a friend are slowly being ripped away from me. What will I have left to keep me going? I'll have to figure out something else to cope. My entire residency is now laden with uncertainty. Will I finish this rotation or will I be redeployed to a covid ward? Do I still have immunity or am I just as much at risk as anybody else? Will I be able to write my exams or will they be cancelled over and over again? When will I get to see anyone that I love again?

Everyday for months I have watched people flagrantly violate the rules and regulations. To the woman in the Dollarama whose older child was not wearing a mask and actively coughing, how dare you. To the patient I saw who came in with COVID after having multiple "small gatherings" of over 20 people, how could you. To the healthcare workers I've seen in a variety of settings with their noses out of their masks for prolonged periods of time, what's wrong with you. To the family members of loved ones I have transferred to the ICU, I'm angry that you have to go through this. 

We are all collectively struggling to varying degrees with the same uncertainty, anger, exasperation, and fear of the unknown. As I've come to learn, anger isn't always a bad thing. Instead of letting it consume you, channel it. Let it fuel a fiery passion that drives you to take action and make change. Let your anger about this situation be a catalyst to speak your mind, educate those around you, and stand up for injustice. We owe it to each other.