Two months ago, when COVID-19-related cancellations and closures were being announced on a seemingly hourly basis, The Suburban spoke with Dr. Marty Teltscher, an infectious diseases specialist and medical microbiologist at the Jewish General Hospital, for his opinion on the crisis. Now that areas of the province are starting to reopen, The Suburban spoke with him again about what possibly lays ahead and a behind-the-scenes look at some of the work being done.
This is an edited transcript of that interview:
The Suburban: What are your thoughts on scheduled re-openings and the current situation in Quebec?
Dr. Teltscher: I think what's going on in Montreal is much different from what's going on in Quebec. And we seem to be the hot spot in Canada and are slowly becoming one of the hot spots in the world. I don't think the numbers tell the full story.
What we are seeing now in Montreal as compared to the rest of the province is that there are much higher rates of illness and deaths, but this has to do mainly with the fact that we have a higher concentration of long-term care facilities and elderly in the region and they are being admitted to hospital. And what this disease unfortunately does to people is it will either cause them to succumb to illness or they will survive. But if they survive they are generally quite decompensated.
So, if they came from an autonomous or a semi-autonomous living facility they often will leave requiring higher levels of care, and this becomes a problem because it means that they may either need to go into another area of the hospital to wait for this type of placement, or they may have to go to another facility instead of going back to where they were living prior.
This is a slow process and every hospital is competing for the same resources. Hospitals like the Jewish General, which has been involved with this since day one, also has a very large number of these types of patients who are basically representing the overwhelming majority of the wards.
When we see that people have not recovered, it's not necessarily that they aren't beyond the initial COVID stage, it's that they are not deemed a cured case, because what we call a case that recovered in hospital is not the same as in the community. The requirements to be cured of COVID in hospital are more stringent because we want to avoid at all costs having cases start outbreaks in different wards.
So that's one aspect of it. The other aspect is the is the community outbreaks. Once we thought we had things sort of under control in the Côte Saint-Luc / NDG / Hampstead- area, then we have what's popping up in Montreal North, which has its own particular issues with respect to demographics, socio-economic status, population density which make it at higher risk than other areas of Montreal, or even Canada for that matter. And unfortunately it seems to have taken off there.
what we may see is this low grade vicious cycle where we have clusters that occur in long-term care facilities and then they occur in hospitals and then health care workers who brings it back into the community, which starts small outbreaks in the community which leads people back into hospitals. So there is this community-hospital interchange that can occur and it has to be broken up.
Now, with letting caregivers back into long-term care facilities, I think it's a necessary risk — but we have to also understand that by doing that we can bring what's in the long-term care facility back into the community if we're not careful. So my concern is that there is going to be this low level smoldering situation and that by reopening things — if we reopen it even slightly too fast — it will be a spark which can start another major wave and right now the hospitals probably could not manage that in the Montreal area.
You know, we are now aiming to start performing surgeries again, obviously at a reduced rate, but if we want to be able to offer full services and catch up on all the cardiac and oncologic and specialty care, then we're going to have to do this very carefully to avoid the system being overburdened by COVID cases.
The Suburban: We keep hearing that for communities to reopen in a safe way we should increase the amount of testing taking place, and ideally contact tracing. Where are we with that?
Dr. Teltscher: Part of the issue around testing is that the test is imperfect in many ways. We know that its sensitivity increases the longer you are sick, and that it doesn't necessarily pick up people who are asymptomatic, so there are issues with respect to how good the test is at detecting someone who is not manifesting symptoms. That has to do with the amounts of virus present in these types of cases.
So we know that in some cases we have a lot of virus in people’s upper airways and in other cases we have much less, but the people who have a lot tend to be more symptomatic and the people who have less are less symptomatic, but it's not always true. There are exceptions.
Then there is the aspect of having the right equipment and the right amount of equipment. We're always trying to find the proper swabs and there is a global shortage on this equipment. That is one aspect. The other aspect is having the proper reagents in order to do various forms of extraction of the virus that can be analyzed afterwards.
So all of this has been a problem in the past but now it seems like there is sort of like an equilibrium that has been reached and there is increasing capacity. Whereas it's been much more limited in the past few weeks I think we're going to slowly start seeing an expanded offering of these tests to the general public and I'm hoping that we also use it more liberally to screen people that are coming in for various medical procedures.
The initiation of blood testing might give us an extra tool to help detect it, especially people who are asymptomatic. Because if you're asymptomatic you may have a problem triggering a positive molecular test, but if you've developed any form antibodies then we should be able to detect it as early as eight days into your infection. In some kits it's as early as five days. But I would say that the combination of blood and molecular testing together will give us a better understanding of who has been infected, who is infected and what we should be able to do to break the cycle of infection.
The Suburban: What message would you like to give to our readers at this stage of the epidemic?
Dr. Teltscher: I would like to talk about the responsibility of all individuals in a “collective social hygiene contract.” Violation of this contract is in part why we got into this situation, and also why we remain in this situation. We must all avoid touching our face, eyes, nose and mouth. We must all practice immaculate respiratory etiquette. We all must wash hands, especially before eating, and immediately upon entering our domicile. Please take off your gloves!
We all must continue to keep a 2m distance between ourselves, as best we can. We all must follow social distancing recommendations, as tedious and tiresome as they can be. We all must wear masks in public places that require their wearing — people preparing food, people riding public transit, people coming to medical visits whether in hospital or office — whether we agree with the concept or not.
We must all be truthful about our health status and not leave home for food, work or recreation when we develop a cough or fever. Now is not the time to “tough it out” and go to work sick. Also, be truthful about your illness so that others, including healthcare professionals, can properly protect themselves.
The government should provide explainable, rational, science and data driven recommendations. And finally, the government should provide timely data updates with appropriate interpretations, without political spin.
The Suburban: Can you describe some of the work being done in some of the hospital’s various COVID-related departments over the past few months?
Dr. Marty Teltscher: Well, in some specialties some of the work dried up because we were not letting people in and we were reserving resources to deal with the pandemic. But we have been going full tilt and working more than usual, but in different ways since the very beginning.
Each member of our group has a different area of expertise, which is a good thing to have in a university hospital like this. Some of us are dealing with patient support, meaning we continue doing infectious diseases consultations and continue to advise on a daily basis at the online rounds for the COVID patients.
Every day at the Jewish General Hospital there are rounds in a few of the COVID wards that is attended by infectious disease, palliative care, and the treating teams. Our coordinating physician is a hematologist and our other coordinating physician is a respiratory specialist, so all these patients get looked at as a group every second day or so.
Then there are the preparations now to begin opening services. So we have had low-level outpatient services as compared to the past. Whereas in the past we would have a walk-in clinic that would see upwards of 30 patients a day, we had to close it for multiple reasons, including security — and also because we are all so busy that we can't dedicate time to that type of clinic. So people have been asked to call in and we give them pretty quick appointments. Between myself and one of my colleagues we would see these patients within a few days if necessary, or if we could delay the appointment we would push it off or we would use telemedicine.
The Suburban: Talk a bit about the increased use of telemedicine brought on by the COVID crisis.
Dr. Teltscher: So, whereas in Quebec it was very sparse, it is now probably going to be a mainstay of the system moving forward. We will see how much of it penetrates into different specialties and whether we use video more than telephone. I prefer video because I get to see the patient, but the telephone is fine as well. It becomes difficult once we have language barriers or if there is a translator working at the same time, you can't see the patient at all. And obviously there is no physical exam that’s possible with telemedicine, so sometimes we have to make the decision to do testing and then bring the patient in to be examined if necessary.
So the physical exam is the one aspect of telemedicine that's really missing. The second would be the human interaction. There is something to be said about physician’s term of “laying on of hands,” where it’s actually the curative touch. It's just patients acknowledging my touch and knowing that they are being cared for and helped, which is going to be missing in telemedicine for sure.
But I think it's an invaluable tool and it's really helped a lot of people during this time — especially the less mobile or the at-risk.
The Suburban: Tell us about some of the work being done in the hospital labs.
Dr. Teltscher: In Québec, most of the infectious disease specialists are also medical microbiologists who usually trained in internal medicine and infectious disease and medical microbiology. So we're working on all sorts of things in the lab, trying to implement new technologies and trying to optimize existing technologies.
We have a couple of people who have been dedicated to the molecular section. We also have the head of our microbiology cluster in Optilab, which is the grouping of various hospitals for microbiology services. He's been working on the PCR, which is what everyone calls “the test” for coronavirus. He has been working on that non-stop since the very beginning, always trying to adjust, make up for a lack of reagents, lack of swabs, failing equipment, bringing in new equipment that is better. There is always something to be done there.
The Suburban: What are you working on?
Dr. Teltscher: What I am helping to work on right now with a biochemist at the MUHC is implementation of what we call the blood test, which is serology. We are hoping that we can get something like that up and running by the end of May or mid-June, but of course none of these tests are Health Canada-approved yet, so we've been able to do sort of low grade verifications on it to make sure the kits work the way they are supposed to. So we have some things that are sort of ready to go but we have to get Health Canada approval.
On a provincial scale there is also a very large validation study of many of these different kits on many different apparatus that is planned for the next few weeks. So hopefully by the time these kits are Health Canada-approved, Québec will be totally ready to go and it will just be a matter of purchasing and having the reagents available to do the tests.
Then there are a few of us who are super busy doing infection control — a non-stop, 24/7 job since the beginning.
The Suburban: What do you mean by infection control?
Dr. Teltscher: Infection control is almost like what Public Health would do in the community. Infection control are specialists for what happens within a hospital with respect to transmitting infections. These are the people who are experts in personal protective equipment, transmission mechanics, and ventilation system-associated infections. So, anything that can happen between patients, health care workers, etc. in the hospital environment is really their expertise.
Another group is the research group. Some of us are dedicated to research, which is not my area of expertise, but they have many projects that are slowly ramping up. Of course, all of these have to be planned properly and they usually involve many different individuals and specialties — epidemiologists and statisticians and nurses. We have a few interesting projects that are about to come into action.
They are keeping busy as well, making sure that we try to better understand this disease, and especially with therapeutics, to see if there is something we can offer patients, because as of now we don’t have anything major to offer people.
The Suburban: Has the work evolved in any way over the past few months?
Dr. Teltscher: As a disease evolves with respect to how we understand it, different departments are finding that they have a bigger role to play. Initially, we looked at this as just another Infectious disease issue, but it became abundantly clear early on that this is actually going to be a pulmonary disease, or an internal medicine disease. And then it became an intensive care disease, and then when we found out that there was inflammatory clotting it became a disease of hematology and thrombosis.
It's sort of making its way around the disciplines of internal medicine. And we also know that there is liver damage and kidney damage that can occur, so all of these subspecialists have a role to play. If their help is needed they are called upon and they will visit the COVID patient and discuss the cases with the caring teams.
The Suburban: Any final words?
The last time we spoke I ended it off by talking about the nurses. But there's one group of people who don't really get the credit they deserve. Unfortunately, we don't really talk about them much but we should, and they are the lab technologists.
Lab technologists work shift work and often do extra work and they are the ones who are busy handling all of these specimens and they have to be very careful with all of these things and who are essentially running the tests that we're all talking about.
They perform the analysis and we double check everything as we are signing their results. But these are people who assumed the risk of handling raw specimens and then they also are the ones who will give us the data and information that we were looking for.
So I'm just really grateful that I get to work with a great team of technologists at the Jewish General, and I know that they are working very hard all over the province and we should really give our thanks to them.