Dear Patients,

We have some additional Covid-19/Vaccine information for you, but also some important office related updates further below.

1. Various Covid-19 vaccines are becoming much more available. This is one of the most important medical interventions ever. Taking the (very rare) contraindications into account, vaccine uptake should be somewhere between 99.9%-100% of the patients in our practices (ie – nearly every single one of you reading this).
2. The balance of risks and benefits for the vaccines is strongly in favour of vaccination. That being said, there are of course some risks (there’s risk in everything we do, including driving to work, swimming, etc). We will review issues regarding the risk of (very very rare) blood clots with some of the vaccines below.
3. If you have questions about the vaccines, please do not hesitate to book an appointment with us to discuss, we are happy to review it with you in detail.
4. If you are considering not being vaccinated, talk to us. We should really hear from you to:
   1.  Listen to your concerns
   2.  Answer any questions you have
   3. Discuss the overall pro’s and con’s
   4. There’s no ‘judgements’ here. Just facts, and our personal experiences for you to benefit from. This is about ensuring you have accurate information to make an informed decision. 
5. The most up to date information on getting a Covid-19 vaccine can be
   found here: https://www2.gov.bc.ca/gov/content/covid-19/vaccine/plan
6. The pandemic itself remains extremely serious. While much of the highest risk individuals in the population have received their first vaccine dose, we are seeing more, and younger, very sick patients. Maintaining protective measures is critical, likely until everyone gets BOTH doses of their vaccine (although the upcoming Johnson and Johnson one is a single dose shot).
7. The vaccines have now been shown to reduce not only severity of infection, but to actually prevent infection itself. They are not foolproof though, and there are some cases where vaccinated individuals have become sick. Thankfully they are usually far less sick than unvaccinated individuals, and deaths are extremely rare. Other counties that are further ahead than Canada in their vaccine rollout have seen cases absolutely plummet. Israel notably went from 4000 cases a day, to under 100 now. This despite relaxing protective measures in the course of that. Illnesses dropped in all age groups, suggesting decreased transmission to children when adults are vaccinated. The vast majority of their current cases and hospitalizations are unvaccinated individuals.
8. Our office (like most medical offices) continues to experience extreme challenges in managing the phone lines. We are called far more than prior to the pandemic, and our staff have a substantially increased workload compared to usual. This will likely settle down over the next few months, but please be patient with them…they are keen to help, but naturally appreciate kindness. Many of us are participating in vaccine clinics in our ‘spare’ time, so we are all quite busy.
9. Nearly all appointments are still primarily video/phone appointments, with the physician determining during that appointment if an in-office visit is necessary. We are hoping to open the system to in-office bookings again, but it will likely be at least another 2 months until then.
10.  Prescription refills – Please do NOT wait until the last minute to try to arrange refills. It’s stressful for you. It ends up being stressful for our staff and for us. It also makes it very difficult for us to keep urgent same-day appointments available for those who really need it – and there are a lot of those these days. Make sure you are tracking your medication supply, and arranging an appointment well ahead of time (if your prescription will run out in 3 months, book that appointment now, not 1 week before the 3 months is up). Think of it as if by doing this, you are helping someone else be able to get their urgent issue dealt with promptly. It makes a big difference.
11. If you have a real ‘prescription emergency’, please be aware that pharmacies are allowed to give you an emergency supply for as long as is needed until you can have an appointment with us (they typically give 2 weeks, but will readily give you a month upon request in most situations).
12. Please remember that some services are not covered by MSP, and we do bill privately for them. This is generally for services like work notes, forms, notes you need for your insurance company for physiotherapy/chiropractic or other treatments, and various other letters. In some cases, the visit to the physician itself is not covered and is billed privately. This generally occurs for driver’s exams, cosmetic related procedures/treatments, physical exams (‘checkups’) for those with no chronic medical condition/medical necessity for one, and any discussion regarding naturopath evaluations and treatments, or interpretations of ‘lab tests’ they ordered. Our fees are average based on guidelines from the “BC Doctors” association. Inquire with our staff any time for the most current fees prior to your visit / note request.
13. So what is the risk of a blood clot from the vaccines? First, to be clear, this risk is currently associated with the Astra Zeneca “Covishield” vaccine. It is a unique type of blood clot, called cerebral venous thrombosis (CVT), occurring in a specific part of the brain. There are important differences to ‘standard’ blood clots. The risk of a CVT blood clot is there, but it is very small. For context, the following are the risks of blood clots in various situations:
    1. Getting the Astra Zeneca vaccine: ~ 4 CVT blood clots per million people
    2. Taking the birth control pill: ~500-1200 ‘typical’ blood clots per million people
    3. Flying on a plane: ~1000 ‘typical’ blood clots per million people
    4. Smoking: ~ 1700 ‘typical’ blood clots per million people
    5. Getting Covid-19 itself: ~165000 (!) ‘typical’ blood clots per million people. For specifically CVT blood clots, it’s 40 per million (~ 10 times more than from the Astra Zeneca vaccine).

So remember, that while there is a risk of a blood clot from the vaccine, there is a far greater risk of all types of blood clots from Covid-19. Covid-19 is here, now. There is risk no matter which way you go. By taking the vaccine, you are reducing that risk dramatically from what it is right now. The blood clot risk applies to anyone taking the vaccine, and regardless of a history of prior blood clots. The average age has been ~46. Symptoms occur between days 4-20 after the vaccine is given. Symptoms include:

• headache
• seizure
• difficulty moving part of your body
• blurred vision
• shortness of breath
• chest pain
• abdominal pain (usually severe)
• swelling, pain, colour change in *any* limb

Early identification and treatment is key to a good outcome from this. If your symptoms are mild and you can reach us immediately, you can contact us to discuss. If your symptoms are severe, or if you cannot reach us immediately, someone should immediately take you to the emergency room (do not drive yourself), or call 911.

The pandemic has been trying on us all. We are so incredibly fortunate to live in a time where our scientific knowledge has advanced enough that we can change the course of a serious pandemic in 1 year. This isn’t over yet, and things may yet get worse before they get better, but we will hopefully all be taking our first clear steps back towards the world we were used to very soon now.

Keep well,
​
Your doctors at the North Shore Medical Group

​Hello everyone,

We’d like to update you all once more regarding Covid-19, and have some important information to
share regarding the state of the pandemic here in BC, vaccines, and perhaps most importantly, variants
of Covid-19 that have started to appear not just in other parts of the world, but here too. This will be a
mixed picture of some good news (regarding the vaccines), but some serious concerns regarding the
Covid-19 variants as well.

As before, we will begin with a summary of the key points that everyone should read, and more detailed
information below for those who are interested.

Key Points

1. The pandemic in BC is essentially in a state where it is ‘simmering’. The levels are not huge. Hospitals are not overwhelmed. But it is there. People are sick. Too many are still dying. And this could get worse quite fast. We could have dramatically larger numbers within as little as a few weeks. It’s critical to remember that if we wait until the numbers go up, it is too late. The only way to keep this virus at bay, is to stay ahead of it, and take action before there is a problem.
2. There are now a few variants of Covid-19. This occurs when portions of the virus mutate enough to change their function. At least one of the variants is *much* more contagious than the original Covid-19, and somewhat more dangerous.
3. There are now highly effective vaccines available, and virtually all adults should get it (like around 99.999% of you reading this). We will review the exceptionally rare cases where people shouldn’t get it below.
4. The vaccine rollout in Canada has been very slow so far, but thankfully that is about to change. The remainder of February will still be slow. It will however pick up in March. We are anticipating a massive roll-out beginning in April. This will initially be through mass immunization clinics (not family doctor offices). Additional information from the BC CDC available here: http://covid-19.bccdc.ca
5. Please avoid calling the office about this as our phone lines are already overwhelmed a lot of the time. We WILL update you. Probably monthly.
6. The timing of eligibility for vaccine will be based almost exclusively on age. That is, over 80 year olds in March. Over 70 year olds starting some time in April. Over 60 year olds likely in May. And so on. We (your doctors) have either already been vaccinated, or will be in March.
7. Health conditions such as diabetes, heart disease, hypertension, immunosuppressed state, history of cancer, active cancer etc will *not* affect the date you are offered the vaccine. These conditions do increase ones’ risk, but not as much as age does.

The Details

So what is happening with the pandemic?
It has unfortunately been rough in some parts of the world, while others have frankly tamed it very
effectively using straightforward (which does not mean ‘easy’) measures. Much of the USA, Europe, and
numerous other countries have experienced second waves (and even third ones) that were at least as
large as the first. Canada was no exception. BC had an obvious second wave, but with increased control
measures this has settled down *somewhat*. Many of these locations had relaxed various control
measures, and had to re-instate them in varying degrees. Some places went back into extreme
measures, with closing of all non-essential businesses, and schools. These measures are costly, but it is
100% crystal clear that they work. New Zealand, Australia, Hong Kong, Taiwan, and Vietnam are notable
for their highly aggressive measures. In some of these locations, just a few cases lead to a widespread
lockdown there. They have had incredibly good control with this, and while it is very hard initially on
their economies, they are able to relax their restrictions far beyond what we have done. In recent
months, Australia has had theaters open, they have had concerts and sporting events with audiences.
This has *nothing* to do with the fact that they are an island, and everything to do with the safety
measures, and the unity of action by their societies. Places like Vietnam have enjoyed excellent control
as well.

How do the new variants affect this?
In short, badly. Ireland went from having 500 cases per day, to *8000* cases per day in 2 weeks. That
is quite astonishing. They entered a hard ‘lockdown’ and brought it under control. The UK, where that
variant was first identified fared similarly. All schools in both those locations have been closed since
around January 1 st . That variant does not generally stay under control unless increased measures are
taken, *beyond* what was done for the original strain we were dealing with for the past year. That
being said, it *can* be controlled, just like the original. All the new strains can. In Ireland’s case, they got
it back down to about 1000 cases per day, where it has been simmering ever since. This isn’t all about
cases. Hospital admissions, critical cases, and deaths followed the increase in cases by about 1-3 weeks.
The key takeaway from this is that this is not over just yet. In fact, if we are not careful, and if we do not
respond rapidly enough, then we will certainly face a massive outbreak just like occurred in numerous
other countries. We are not ‘special’, and it can happen to us too. This means that you must continue to
wear masks in all indoor spaces AND try to keep your distance from others. If you have to get close to
someone, inside or out, WEAR A MASK AND MINIMIZE THE CONTACT TIME. 5 minutes is starting to be
long. 10 minutes is very long. This is why we are trying to keep our office visits with you short, and do as
much of the talking as possible by phone or video consult. Avoid going out if you don’t really have to.
Severely limit your travel. There is exactly one way these bugs got here in the first place. There is exactly
one way they move from one location to another – through us.

It is furthermore important to note that immunity to the original strain from prior infection may *not*
last, and may not be protective against the newer strains. Manaus is a city in Brazil that had a massive
first wave – so large that it was thought perhaps the population had truly developed herd immunity.
That was incorrect – at least as far as the new strains are concerned, and they are now in the midst of
going through that all over again with a new massive outbreak. How bad is it there? In this city of 2
million people, hospitals ran out of oxygen tanks. They couldn’t provide sick patients oxygen. Let that
sink in. These new strains are NOT to be taken lightly.

So why haven’t we done more here?
This is a choice made at the governmental level. Societies’ tolerance and stamina for these measures
play a role. If the new variants spread here, it is highly likely that our safety measures will have to
increase.

Are schools still safe?
We continue to have relatively few outbreaks in schools here, but it is important to recognize that other
locations have had large outbreaks. While there was suspicion for some time that children got and
transmitted Covid-19 less than adults, there is more and more evidence that this theory is incorrect. To
be clear, children definitely don’t get severe illness as often, and studies do suggest that children
become sick *slightly* less often than adults. There is growing evidence that they transmit the virus just
as much as (and possible more than) adults do. That being said, the measures taken in schools here so
far (which focus on clustering students together into large bubbles to prevent spread between them,
keeping windows open, and keeping some distance between students) have been at least partly
effective. High school students now have to wear masks most of the time. Grade-school children do not
yet have a mandate to wear one, but they would likely be highly beneficial to preventing the spread of
Covid-19.

For this reason, if you have children in grade school, we now *very strongly recommend* they wear a
mask indoors at school at all times (except to eat). Just because there is no mandate, does not mean you
can’t choose to do more than that. Some of us have our own kids in grade school, who have been
wearing masks at school for months. It’s very do-able, and is likely very temporary at this point. The
vaccines are coming (more on this just below), and masks may only be needed for months.

The new Covid-19 strains may have a serious impact on this. They are clearly much more contagious,
including among children. This is part of the reason we are recommending people go beyond the current
public health mandates and have school-age children wear masks starting right now. We don’t want to

wait for these strains to start spreading. We need to stop them. We need to hold on long enough for the
vaccines to be distributed. We need to buy time.

Okay, what about the vaccines??!
The good news is they work!
Really really really well.

The vaccine story is just about the best possible outcome anyone could have hoped for. The initial
studies done on tens of thousands of people showed that they were extremely safe, and reduce the
likelihood of getting serious illness from Covid-19 dramatically. Since then, the vaccines have been rolled
out heavily in a few countries, most notably Israel, where about 30% of the country has been
vaccinated. They used an age-based approach, and so around 90% of those over the age of 60 have been
vaccinated. The country is now witnessing a very dramatic drop in Covid-19 in those over the age of
60,*even while illnesses among the under-60 unvaccinated population were continuing to increase*.
The dominant strain there is the more highly contagious and dangerous one identified in the UK. So the
vaccine is doing just fine against it.

Better still, while it remains slightly early to confirm this officially, there are some good indications that
the vaccine not only prevents serious illness, but actually strongly reduces transmission of the virus. This
is key, and means the vaccine will likely play a critical role in helping to actually end the pandemic.

Of course this means people have to actually get the vaccine. At the moment we have a terrible supply
problem in Canada. Once that starts to change next month, essentially ALL OF YOU, we repeat
essentially ALL OF YOU, should be getting the vaccine.

Who shouldn’t get the vaccine? If you previously had the Covid-19 vaccine and had an allergic reaction
to it, then this needs to be discussed in detail with your doctor. If you previously had an allergic reaction
to a substance called polyethylene glycol (PEG), this should be discussed with your doctor. If you have
had an anaphylactic reaction to an unknown substance then you should discuss this with your doctor.
That’s it.

People with a history of allergies in general will be getting the vaccine, but may be observed on site for a
short time right after the shot. Tens of millions of doses of the vaccines have been given. By the time any
of you reading this get it, it will likely be over 100 million people worldwide. We already know right now
that the likelihood of an allergic reaction is about the same as the odds of you getting hit by lightning in

the next 18 months. Is getting hit by lightning this year something you were worried about? You should
be exactly that worried about an allergic reaction to the vaccine.

What about other allergies? This is generally not an issue. Allergies to one thing generally don’t predict
allergies to something else. If you are allergic to nuts, we don’t tell you to avoid milk. They have nothing
to do with each other. Out of abundance of caution, there will be protocols in place to collect your past
allergy information from you, and you may be asked to remain at the vaccine site for a short time. This is
because in the rare case of an allergic reaction, the vast majority occur within 11 minutes of the vaccine
being given. The vast majority of allergic reactions have been easily treated *on site*. A small number
have had to go to hospital, and 100% of people worldwide who had allergic reactions to the vaccine,
including anaphylactic reactions, recovered with standard treatments for that, within a few hours.
Furthermore, they still developed some degree of immunity to Covid-19 from the 1 dose.

Which vaccine should I get?
Whichever one is available to you first. DO NOT WAIT. Period.

Will kids get the vaccine?
Probably. Studies have been launched for kids, and results should be available by late summer. It is
always important to do these studies, but at the same time, it would be unusual for there to be any
issue. In all likelihood the results will be exactly like in adults, the vaccines will be approved for those age
groups, and kids will get vaccinated too, but later in the year. In the meantime, if adults are all
vaccinated, community transmission should subside and this will help protect our children. They should
still get the vaccine later on because they are still susceptible, and some children do still get seriously ill,
especially to the new strains that are starting to circulate. A worrisome scenario is if adults are all
vaccinated and safety measures are relaxed, but the bug is still around, then cases among children could
skyrocket, with large numbers of children getting very sick.

The future is looking brighter, but we know everyone is tired of all this. Hang in there, let us know how
we can help you through this, we are hopefully at a turning point.

Best wishes, and stay safe,

North Shore Medical Group

Hello again everyone,
 
We wanted to provide you another update regarding the Covid19 pandemic. A lot has changed since our last communication, and we felt it was important to answer some of your questions, and provide some guidance on all this.
 
As with previous emails on this subject, we start with a brief summary of critical points. For those interested in additional details, please read on below. This will be a bit of a mix of caution, but also hope.
 
Key Points:

1. We are clearly in a second wave of the pandemic.
2. The pandemic in BC is not being adequately controlled at this time. Our current trajectory is not sustainable (although there may have been a levelling off in the last few days).
3. The only way to change that trajectory is to change our behavior. 
4. Numerous countries have shown us that this pandemic can be controlled by changing our behavior. They did it. We can do it. Period.
5. The biggest risk factors for getting infected are: Being indoors, with no mask, for over about 10-15 minutes in the presence of others.
6. There are now at least 3 vaccines that appear to be safe and effective, and which will start becoming available here in January *for select groups*. 
7. This is really important: The vaccines will not change our public health measures for *many* months, and possibly a year or more to come. This is because it may well take that long for the vaccine to become widely distributed enough for herd immunity to occur (approximately 70% of the entire population).
8. Our office will be maintaining strict public health protocols for months to come. Please follow our instructions closely. Please be kind to our staff. This is stressful for everyone.

 
The details:
As most of you have no doubt seen, as society in BC opened back up, Covid-19 began spreading once more. It has started spreading quite a bit, with a doubling of new cases per day roughly every 3 weeks over the last 2 months. It is critical to recognize that that is *not* sustainable. That curve has not been flat, it has been rising, steeply. Continuing for even a couple of more months along this path would likely lead to an overwhelmed health care system, much like occurred in other places such as Italy and New York. Additional measures were therefore put in place by the Public Health Office, such as requiring masks for all public indoor locations (other than schools), and limitations on athletic activities and visits to your home. These measures are entirely appropriate. What is not clear, is if they are enough. There has been a slight levelling off in the last few days. The challenge is that while cases, hospitalizations, and deaths can be kept low if there aren’t many in the first place, it’s very hard to get them low again once they go up. So far, no other country has successfully done so, without measures substantially more aggressive than we currently have in place. The flip side of that, is that several other countries have repeatedly demonstrated that they are able to suppress surges in viral infections. They have shown us how. We ‘just’ need to do it.
 
It is critical in this environment, to understand where virus transmission becomes a risk. We have known for some time that virus is spread partly by ‘droplets’, invisible fluid we expel when we breathe and which tend to travel up to about 6 feet, and then settle toward the ground. It is now clear that there is ‘airborne’ transmission as well. This means that not all of the virus settles to the ground, but rather hovers in the air for a much longer time (the duration of which remains unclear, but is probably 2-3 hours), and may travel a significant distance that way (around 20 feet or more depending on air currents, fans etc). This is why keeping distance from others is so essential, and why it is hard to maintain enough distance indoors. Masks can add a layer of protection and decrease the likelihood that you breath in the virus while in the presence of others. It is not a full-proof shield though, and should be seen as a *back-up* method of protection. Keeping your distance is much more important. Lastly, minimize your time in close contact with others as much as you can. You are less likely to get infected if you are next to someone for only a few seconds. With about 5-15 minutes of exposure time though, the risk goes up…a lot...even with a mask on. You can see from this why most infections are being passed on in people’s homes, at many places of work, dine-in restaurants, and gyms/sports facilities. You can also see why transmission outdoors is much lower (but not zero) risk.
 
What about kids? This remains a frustratingly controversial topic. As previously noted, there is some limited evidence that kids *under 12* become infected less than older kids or adults. Since we last updated you, there is growing evidence that if they do get infected, they transmit it to others just as well as anyone though. So while they may get it less, and while they get sick less, they nonetheless spread it just as well as anyone. Kids can wear masks though, and it would seem clearly helpful for everyone over age 2 to wear a mask whenever they are in close contact with others, indoors or outdoors. We need to turn this around somehow.
 
When will we have the vaccine?!??
It certainly feels like it can’t come soon enough. There are currently a few vaccines about to be released to the public. It appears that they are highly effective. Their safety profiles are fantastic. They have been tested on tens of thousands of people, with zero serious adverse events. Canada will have access to these, and it is expected the first doses will be delivered here within a couple of weeks. *However*…it will take a *long* time to roll them out. These will arrive in batches, with early doses dedicated to various high-risk groups. The order of release will be something along these lines:

1. Hospital workers
2. Nursing homes (staff and residents)
3. Community health workers
4. High risk patients (over 65 with chronic health conditions)
5. Those over 65 regardless of health issues
6. Adults over 18 (16 for 1 of the vaccines)

 
It is impossible for us to know, but we expect groups 1-3 above will take until at least March-April 2021. So few (if any) of you reading this will likely be getting the vaccine until at least late Spring. Hopefully many people in the community can be vaccinated during the late Spring and Summer. Vaccines for kids (current vaccines are for adults only) will probably come available right around then, and hopefully many kids can be vaccinated before school starts next Fall.
 
Some key points about the vaccines:

• Once you are vaccinated, you will STILL have to maintain public health measures *just like now*. This will be the case at least until September probably. Maybe for all of 2021. This is because the virus may continue to spread a lot until at least ~70% of the population is vaccinated. Also, the vaccines are very good, but not perfect, and we need to crush this bug completely. 
• We don’t know yet how long immunity lasts. It’s at least 3 months. It’s probably much longer, but we can’t know until enough time using the vaccine passes. By the time you get yours in a few months, we will hopefully be able to say it lasts at least 6-9 months of protection. Most vaccines last a minimum of 2 years, many (like tetanus) for 10 years, and some (like for measles) last a lifetime. We’ll have to wait and see. If immunity is not long-lasting, this could become an annual event. This will make things much more difficult.
• These are not live vaccines. So, just like the flu shot, YOU CANNOT GET COVID FROM THE SHOT. PERIOD. You can have a side effect (we’ll discuss those when the time comes), but getting sick with Covid19 is NOT one of them.
• There are around 37 million Canadians. The vaccines are all set up as 2-dose series (around 1 month apart). This means we need to distribute and complete around 52 million doses to achieve herd-immunity. That’s around 142000 doses per day for 365 days to put it in perspective. This doesn’t happen overnight. Once the vaccine is available, we will be working very hard to get it out. We learned a lot from this years outdoor flu-vaccine campaign, and are prepared to roll out a highly efficient Covid one.

 
This isn’t over yet. But we are on the cusp of turning this fight around. We are moving from defense to offence. We need everyone to work together to get there though. So please do your part. Think of those around you. Take responsibility for your actions, even if you see others fail to. Whatever you do will help, and you will have made a valuable contribution to society by being kind, smart, and safe.

North Shore Medical Group Physicians

Hello everyone,
 
We would like to update you all further regarding Covid19!

It’s been a number of weeks since the last update, and while things were fairly stable for a time, it is beginning to change once more, and it’s important for all of us to review now what the current situation is, and what we need to do moving forward.
 
As usual, the key points are next, followed for those who are interested by a more in-depth discussion below. 

1. The pandemic is *not* over. It is now clear that unfortunately it likely won’t be over for some time to come. So it remains important to *persist* in your efforts to maintain physical distancing from those not in your household, wear a non-medical mask if you cannot avoid this, and wash your hands. This. Must. Not. Stop.
2. If you are sick, please tell us ASAP. We are often testing people with even slight symptoms. This is really important to stop the disease from spreading. It’s what we would have wanted to do in March but couldn’t at the time. Now we can, we should, and we will. If you are sick, we want to know. If you are not sure, but are worried you are bothering us, you are not. ‘Bother’ us. Please. 
3. A second wave here in BC is a very significant concern. In fact, it’s unfortunately highly likely. Numerous other countries employing similar measures to us have experienced second waves, often worse than the first, and we need to be prepared for this reality. Cases are already rising here again. More details below.
4. Due to the above, we will continue doing video/phone consults the majority of the time, with in-office visits reserved for when a physical exam is *needed*. All care starts with a video/phone consult first though. 
5. We ARE currently seeing patients in the office 1-2 days per week, but *ALL* in-office visits must be approved by the physician as necessary. More in-office time will be added in the future, but probably not until later this year. We remain available the rest of the time by video and phone (video preferred for most people).
6. Certain routine care such as pap tests have resumed, and we are clearing a backlog first. You will be called if you are due or overdue. If you are not sure, feel free to check with us, but perhaps wait 2-3 more weeks to see if you are called. 
7. Physical exams can resume but with modification. There will be a video consult first (20 min), followed on another day by an in-office visit for the physical exam itself (10 min). This is the same total time spent previously on physical exams/health reviews. The intent is to keep the in-office component focused on the physical exam itself, with any further discussion and review to occur by video again afterwards as needed. We want to seriously limit the in-office time. Most covid transmissions take 10-15 minutes of close contact. We want to keep as many face-to-face interactions below that time as possible.

 
The Details
 
The pandemic has been hard on everyone. We all want it to be over. We wish we could tell you it will be soon, but we also know you want a realistic assessment of what is likely to happen. This bug is really bad. The majority of people recover, just like we previously told you. It is definitely much less dangerous for kids than adults over age 60. But it spread far and wide and fast. 19 million people have had it worldwide as of today. 700 000 plus have died. There are likely millions who recovered but now have ongoing serious health consequences. In BC we have taken extraordinary steps to contain this, and have been far more successful than many other places. What did we do right? The lockdown was necessary at first for a variety of reasons, but hopefully can be avoided again, even if a second wave occurs. At the least, it can probably be more focused on specific regions, or types of activities/jobs. Other locations, including Australia, and Hong Kong, *have* had to resume aggressive lockdowns. Physical distancing is unquestionably effective. Hand-washing is effective. Masks are almost certainly effective.
 
Combining physical distancing with hand-washing and masks could in theory eliminate the virus. Wait, what?? The virus typically spreads from 1 infected person to about 3-5 others (although perhaps much more in indoor settings). The three measures above are likely to reduce viral spread from 1 infected person to less than 1 other person. So, if those measures were used in combination, by most people, for a number of months, this could then potentially dwindle cases down to zero. It is however challenging to physically distance at times, there is unfortunately a lot of (ludicrous) pushback against simple measures like masks, and there is understandable pandemic-fatigue that has set in, and so people become less careful. If you want to help yourself and everyone else, these are the three key steps.
 
Where are people getting it?
 
We know the virus is transmitted mainly indoors. The most common scenario by far, is where someone gets it while they are out in some congested area, or at work, and brings it home. Most people in the house then get it. Conferences are a huge problem. Anywhere people are singing is a huge problem. Bars are a very huge problem. Outbreaks from home parties are a major risk. On the other hand, outdoors tend to be fairly safe. There are no known/proven cases of people out exercising, or walking along the street and getting it from a passerby. Typically, when someone gets the infection, it’s because they were in the presence of a sick person for about 10-15 minutes or more. This all comes down to ‘viral load’. Your body will probably fight off the virus if you only get exposed to a little bit. When you breath in someone’s air repeatedly in close quarters for 15 minutes though, it gets to be too much. Going briefly into a store is probably fairly safe, but wearing a mask will reduce your risk, and reduce the likelihood you put others at risk.
 
As the pandemic is clearly not ending any time soon, we must continue to conduct most medical care by video (or phone if necessary), and avoid unnecessary in-office visits. We are gradually resuming some of the routine care such as pap tests, and routine checkups, but with some modifications. The most critical one is to minimize the time spent in office, to keep it below that 10-15 minute exposure time above. This is why we are insisting on video consults first, so we can assess if the in-office visit is really necessary, and to conduct most of the discussion that way, followed by a very brief in-office visit that is highly focused on getting the physical exam part done. There really shouldn’t be any further discussion in the office. If there are leftover questions to be answered, this should occur in another video (or phone) call later. 
 
In general, we are strongly in favor of video appointments over phone calls when possible, as we get a much clearer sense of how you are doing when we can see you. It makes a difference.
  
What are we (your doctors) doing to protect ourselves when we go out?

• We are exercising outdoors essentially as usual. We keep 6 feet away from others, even outside. If we anticipate touching anything then we have hand gel with us. 
• We are wearing a mask whenever we go indoors anywhere, even if it’s very brief (arguably this is not that necessary for a quick stop into a store, but again, it’s more about protecting everyone else than yourself). This is most important for busier places that you may have to spend more time in, like grocery stores and pharmacies.
• Hand gel goes with us everywhere.
• We do NOT wear gloves when we go out anywhere. It’s better to just be sure to clean your hands, and avoid touching your face. The hand gel comes into the store in our pockets, and we stop and clean them right after we exit, before we get back in a car for example. Gloves will not protect you if you end up touching your face with them. We try to think of our hands as ‘dirty’ when we are in a store.
• We do not wipe down groceries, rather we put them away and then clean our hands.
• If we order-in food from a restaurant, we ensure non-contact delivery.
• We have extremely limited contact with anyone from outside our households. You should certainly feel free to socialize, but you should very strongly favor outdoor settings **WITH** maintaining 6 foot distancing.

 
Does this virus transmit from surfaces?
 
It’s a bit frustrating that we don’t have a clear answer for this yet. Studies had come out a couple of months ago, showing that virus could be found on exposed surfaces up to 3 days later. BUT, that was after exposing those surfaces to massive doses of the virus, far beyond what even a very sick very contagious person would be shedding into their environment. What is clear, is that handwashing is the most important way to prevent yourself from being exposed to a virus that may be on a surface you touched.
 
I keep hearing that kids don’t transmit this, is that true?
 
This will be a dicey subject. The public health office here seems to be of the opinion, based on current evidence, that kids are not major drivers of the pandemic. Their interpretation of the data is that kids don’t get it as easily, and don’t transmit it much either. While there can be severe cases, and they can get very sick and even die, this is very rare, and not something to be too panicked about (as difficult as that may be). We are concerned however that more recent studies are showing that kids do in fact get and transmit the virus, perhaps as much as adults. Thankfully, the vast majority of them still do not get very ill. The problem is that this can still put teachers, and family members back home (or within their social ‘bubble’) at serious risk. Further research will be needed. School has already started up in many other parts of the world, including some parts of the USA where there is very poor control of the pandemic. It will likely become clear over the next 4-6 weeks just how much school-age kids transmit this. There is already fairly solid evidence that teens transmit it as much as adults do.
 
So how are schools going to open?
 
Despite the above, we are reasonably confident it *is* possible to open schools. How? First, we are doing far better than many other parts of the world. We do know that in areas where the case counts are low in first place (currently all of BC, despite the recent rise), and where some measures are taken in the schools to limit spread, the likelihood of a school outbreak is fairly low. This is why it’s so important for everyone to do our part to keep those counts down in the community. A number of steps have been planned to make adjustments here in BC to enable them to open safely.
  
We must also continue to learn from others. Some countries, notably South Korea, have been managing all this fairly well, with schools open, and case counts remaining stable and low. They are one of the few countries that has not had a second wave (so far). What steps have they been taking? Kids there *are* wearing masks in schools, they eat *very* spaced out, and the classrooms have been adjusted carefully to seriously limit how close they are to each other. Everyone gets a temperature check on arrival. Teachers are well-equipped. They were quite thorough.
 
Even if schools do open, things may be difficult at times. Kids (and teachers, and all the rest of us) will get sick from other viruses from time to time, and unlike in the past, no one can go to school (or work, or anywhere really) if they are even slightly unwell. Families with more than 1-2 kids will be challenged due to increased likelihood that someone in the house is sick (from something, not necessarily covid19) and stuck at home. Families will be wondering if someone at home is shedding virus but not showing signs of illness yet. There must be schooling and work back-up plans in place both for individuals and communities. This is a really challenging situation. *But*, it has been done elsewhere. So it can be done. We all have to have a lot of patience and understanding.
 
When can we test our immunity/antibody levels?
 
Just about every single place in the world can do this except for BC. There are a number of reasons for the hold-up that we won’t get into here. A number of you were ill, and couldn’t be tested with a nasal swab, and are wondering about getting this blood test now instead. It may be a moot point now anyways. It’s not clear how long antibodies to COVID19 remain elevated after infection, and some studies have suggested it may only be a few months. A significant number of people with confirmed COVID19, and who had high antibody levels, have been shown to have a large drop in their antibody levels after 6-8 weeks. Even if one has antibodies, that still doesn’t mean they are actually immune though. Also, it’s possible to have no antibodies, but have what are called memory T-cells (that no one has a test for other than research labs), and actually have immunity. So the test may not be quite as helpful as we thought it would be. I’ll let you all know when there is an update on this, but don’t expect any mass antibody testing here in the next couple of months.
 
How about a vaccine?
 
Vaccine research is progressing fast. I hesitate to use terms others have, like ‘warp speed’, as I think this is an inaccurate way to describe what is occurring. The research itself is happening at about the exact same speed as always, it’s mainly the ‘red tape’ that is being cut through much faster. Generally there is a long line up to have something ‘reviewed’ and ‘approved’ for the next stage, and vaccine research now gets immediately to the front of the line. No short cuts in the actual clinical research and evaluation itself are being taken. The studies are being done very methodically and carefully.
 
If we are very very lucky, a safe and effective vaccine will be available perhaps by early next year. More likely we are looking at middle to end of next year. Note that the manufacturers are planning to make about 1 billion doses by the end of next year. That is around 7-14 billion doses short of what the world needs (it may be a 2-dose series). So even if the first vaccine out of the gate is ‘perfect’, this pandemic is unfortunately *not* stopping yet. I suspect the first groups vaccinated will be medical staff, followed by (or at the same time as) people in care homes, then everyone over age 65 with health conditions, then everyone at any age with health conditions, then everyone over 65 and healthy, then everyone over 50, then if the pandemic has not wound down, everyone else. If certain groups (like kids) are found to be driving the pandemic, they might be vaccinated much earlier, even though they are not typically getting very sick from the virus. By the time the vaccine is available, we will know all this.
 
Will life go back to normal?
 
We are reasonably confident, one way or another, that it will. This does depend somewhat on how long we stay immune for if we get the virus though. If people who had it are immune for about 5 years, this will almost certainly dwindle down over roughly that time. If immunity is short lived though, we do face the possibility that the virus just circulates around and around indefinitely. That’s a gloomy prospect for sure. This is why a vaccine may be critical. We suspect immunity does in fact last some time, as we are still not seeing clear cut cases of recurrence in the same individuals. It will take until at least late this year to be more confident about that. 
 
There are a couple of treatments for in-hospital patients that provide some limited benefit, but every bit helps. There is also a growing list of other possible treatments, and some of them do show some promise. These treatments are generally directed at those who get sick enough to need a hospital admission, not those who are recovering at home. There will be results for those new treatments probably in another 2-3 months. An effective treatment (without a vaccine), may enable us to manage this without worrying quite as much about it’s spread, just like we take some measured steps to prevent things like strep throat infections, but we have an effective treatment for it when it does occur.
 
Some things won’t go completely back to the way they were, and that may be a good thing. The days of people going to work while sick are essentially done, for good, and we consider that a plus. Medical care has become much more available by video and other means, and that is likely to remain that way forever. We are learning new ways to connect with each other.
 
It’s not easy, but we will put the work in, and find ways to adapt, and make the best of our situation. This isn’t the only virus humanity has faced. We beat the others. We’ll beat this one too.
 
Keep well,
Your North Shore Medical Group Physicians

 Please Note: Our knowledge about best practices for COVID19 is changing all the time as new information becomes available. Please refer to our most recent update for the most up to date information.

Dear Patients,
Here is another Covid19 update for you. Some key information at the beginning, especially for those age 20-50. I’m putting a summary first, read on below that for all the details.
 
Summary:

1. Please continue very diligent social distancing. This means, you can interact / do activities with the people who live in your home, but that’s it. No one else. 
2. Many adults between the ages of 20-50 are having severe Covid19 and being admitted to the ICU. Many are even dying. Just because Covid19 is somewhat less dangerous in this age group, does NOT mean it’s ‘safe’. You are NOT “safe” from this. Social distancing applies to you too! When the media refers to ‘mild’ Covid19, that’s actually pretty severe already. It includes people at home who struggle to walk to the bathroom. Moderate is usually in hospital on oxygen, severe is in the ICU, critical is intubated in the ICU.
3. The government currently recommends 14 days isolation after you think you were exposed, and a further 10 days if you have any sort of infectious symptom. Please think of this as the bare minimum. Information on this is still evolving.
4. There were reports of a possible effective treatment with the drugs hydroxychloroquine and azithromycin. This got badly misunderstood on social media, and some politicians. It is NOT yet known if this is effective. There are serious risks, especially with hydroxychloroquine. It will NOT be used as a general treatment at this time. NO ONE should self-treat with any medications for this (other than Tylenol for those with no liver disease).
5. The MedVoice app has been made free for the next few months. This will help you communicate with me, and keep us efficient during the pandemic. Please try to use it for all your appointments, even video and phone appointments.

So first, a reminder that while children between the ages of 2-10 are only very rarely having severe Covid19, everyone else…again everyone else…can end up in the ICU. Far too many young adults between the ages of 20-50 are ignoring doctor’s instructions and going out and mingling. Not surprisingly, they are starting to represent a larger and larger portion of those in the ICU and dying. As I previously informed you, this is not “just a bad flu”…it's substantially more risky than the flu, which itself is already dangerous. In any case, even if you don’t get very sick, you may spread the disease to others who won’t be so lucky. It may be a family member. We have to do our job as a community. Stay home.
 
The current recommendation is for everyone to stay home as much as possible. Go out for things you *need*. If it can wait, then it should wait. Get your groceries, get your medications. That’s mostly it. You can go out (preferably close to home) with people who live in the same home with you (for a walk /exercise), but STAY AWAY from other people. Give them a wide berth. If you have to talk to them, you need to be a couple of car lengths away. Will it feel weird? Yes. Do it anyways.

About 97% of my patient encounters over the past 2 weeks were done by phone or video.
 
I do have some comments on the reports of a possible effective treatment with the drugs hydroxychloroquine and azithromycin. This is based on a study from France involving a SMALL number of patients. The study had some huge problems with it (like, a few of the patients in the control group got more sick and were excluded from the study for unclear reasons – the is highly unusual and unscientific). Despite that, it has generated a lot of excitement, because the
results (even taking those irregularities into account) were dramatic. Numerous additional research groups around the world have pounced on this, and started their own (hopefully better designed) studies to look at this further. Hopefully it won’t take too long to get results. Immense resources are being thrown at this, with large teams working around the clock to get the results asap. It’s pretty stunning actually how much is being done so quickly. This has never occurred before in history. 
 
Although this will be extremely good news if it pans out, it is NOT clear yet whether this works. Hydroxychloroquine can have SERIOUS side effects. Two people in Nigeria died, and now one in Arizona, attempting to self-medicate with
these sorts of compounds. Therefore, these medications will NOT be prescribed by us at this time, so please do not ask. We MUST wait for further data. Even if it does work, the question then becomes, ‘who exactly will benefit from it’? Do mild cases really need it? Does it only work if we give it early enough? Can we safely reserve it for those in hospital? We just don’t know yet. Unfortunately, others have not been so responsible in their communications, and there is already a massive shortage of the drug worldwide. This is now a new problem, as both drugs are used for other health conditions. Hydroxychloroquine in particular is used for people with rheumatologic conditions. Without it, their condition may flare, and they end up in hospital…exactly the LAST place we want them right now. The drug companies that make these medications have ramped up production, and hydroxychlroquine is cheap and large amounts can be made in a few weeks, so the shortage shouldn’t last too long. But this underscores why it’s important to report on these developments responsibly, and plan ahead. 
 
Please remember, even if this drug-combo doesn’t work, our situation remains solvable. Information continues to be gathered from other locations where this has been controlled. The original outbreak was in Wuhan, a city of 11 million, in the province of Hubei in China. Hubei has had zero new cases for 4 days in a row now. They have a date posted to end their ‘lockdown’ soon and resume life (in a couple more weeks). Cases in South Korea continue to dwindle. Hong
Kong, Taiwan, and Singapore have maintained a low case count from the beginning, even with kids still going to school, and businesses open. We do need get our surge clearly under control before relaxing anything. But it proves this can be done. We need to learn, and we need to act on it.
 
Lastly, I previously mentioned the MedVoice app to you. This is a program that helps collect information from you in advance of a visit (not just an in-person one, but in advance of video or even phone consults as well). It gathers key details from you, and makes that available to me. It should always be used in association with a visit, NOT on it’s own. You can create a patient account at www.medvoice.ca, and/or download the iPhone or Android app. It will ask you
for my “Doctor ID code”, which is (please call the office for this). I hope most of you will start using it for your video/phone visits with me for the next while as it will greatly improve my understanding of how you are doing, and improve our efficiency quite a bit. It will be free to use during the pandemic. Best time to use it is the day before, or at least 1 hour before we have our video/phone visit.
 
I will continue to update you... Keep well!

Please Note: Our knowledge about best practices for COVID19 is changing all the time as new information becomes available. Please refer to our most recent update for the most up to date information.

Dear Patients,
So I wanted to update you once again regarding Covid19. I’ll review some of the changes in office policies we’ve put in place over the last week, and some excellent actions taken by the government to make family medicine care more accessible. That part is important for everyone to read. Further down I’ll review some of the key improvements in our understanding of this pest, and how that may affect how this evolves (and when we get out of ‘jail’).
 
Office Policies and Access to Care
As much as I am often very frustrated with government policies, they really came through this time, and very quickly. Usually physicians are highly restricted in how we communicate with you (for example we get minimal to no compensation for phone calls). We are now (temporarily) allowed to manage your care over the phone as needed. Various other limits have been removed as well to simplify remote provision of care. The government has made an order that no employer may ask for ‘sick notes’. These were quick emergency measures, and they are looking at some additional changes if this is insufficient. There is a clear recognition that they need to maintain your access to care. 
 
I do encourage everyone to mainly use video consults, as I find I get a better sense of how you are doing when I can see you. However, if this is too difficult for you, or if we run into any technical problems, don’t stress about it, we will just use/switch to phone. The phone may show, ‘unknown caller’ at your appointment time, please be sure to answer that one. Most online booking spots have been switched to “video”, so they are widely available, but if you prefer a phone call, please just make a quick note of that in the message area, and please write the number you want to be reached at. Please also be sure to treat these appointments just like in-office ones, by being available on time. 
 
While I usually discourage video/phone calls for visits in relation to new or worsening symptoms, this will be partially relaxed for now. We can begin a consult that way, and I will determine if an in-office visit will be necessary.
 
The office will be available for select in-office visits, and we have taken a large number of steps to make it safe. First of all, if you came in now, you’d likely find it very empty. All the physicians at the office are doing primarily video consults, and our in-office times are staggered. We will also be spacing out any in-office visits by putting video consults in between, so there will usually be no more than 1-2 patients in the entire office at a time. Most support staff are working remotely. We have designated rooms for possible infections, and no one will be seen in those rooms if they are coming in for some other issue. So please don’t be scared about coming in. Some in-office appointment slots will start being opened up over the next couple of days as well. All the same, the majority of your care will likely be managed by video/phone.
 
Please bear in mind that eventually the government will remove these allowances, but for now I am very thankful to them for taking this valuable, supportive action quickly.
 
Please note that testing for COVID19 is very limited at the moment, mainly to patients in hospital, and potentially affected health care workers.
 
There is a self-assessment tool you can use from home, here:
https://covid19.thrive.health
 
Live updated wait times at emergency rooms and urgent care centers is here:
http://www.edwaittimes.ca/WaitTimes.aspx
 
The COVID19 Situation in BC
The aggressive actions that have been taken with most people staying home was unquestionably the right move. It’s hard on everyone, but it was absolutely necessary. While we will need to wait to see how this evolves, I am very hopeful that these measures will help get this under control soon. 
 
Keep in mind, that because it takes between 5-14 days for people to show symptoms, and (at least) a couple more days to be identified, cases will continue to rise over the next week, even if we have all been staying home all the time. It will look like its just getting worse and worse. What we see today in terms of positive cases, is actually how things were about a week ago. Some time next week, if this goes according to plan, the number of new cases per day
will flatten, and then very slowly start to drop. It may be hard to tell at first, as the number go up and down a bit. If we get a steady drop in new cases, the entire strategy may then start to change, although this depends on many factors. China has had zero new cases a few days in a row now, and restrictions there have started to relax. Taiwan, Hong Kong, and Singapore have demonstrated ways to keep society functioning, with people working and schools open, but this depends on first controlling this early surge.
 
There are a growing number of ideas coming up from all over the world about how to control all this using these measures, while enabling the vast majority of people (and eventually everyone) to resume a normal life. Our ability to relax social distancing may depend in part on getting more testing kits. We are very low at the moment, but there are supposedly 800K new ones on their way to Canada. 
 
In the meantime, the amount of information doctors are sharing behind the scenes is unprecedented, locally, nationally, and internationally. The doctors at our office are in near constant communication, many times per day to share ideas and adapt. I have seen the detailed plans for what happens in our hospitals if things do get much worse, and they are very well thought out. Doctors (and many others) everywhere are stepping up. I held a webinar for 150 community physicians the other day to teach them all how to do video consults. This was shared with hundreds of other physicians as well. We had a few days of crisis mode, but are finding our footing, and starting to think ahead. Please continue to be very diligent about keeping away from others, and excellent hand hygiene if
you have to go out. Hang in there! We’ll get past this. 
 
I expect there will be a lot of new information in the next 2-3 days and will update you again. Speak to you soon…

Please Note: Our knowledge about best practices for COVID19 is changing all the time as new information becomes available. Please refer to our most recent update for the most up to date information.

Dear patients, 
I wanted to provide you a further update on COVID19. The changes we are undergoing are happening fast. We will continue to update you and try to keep you informed, and to help you understand how best to work with us on your care.
 
Canada is beginning to adopt some aggressive measures to limit the spread of this virus. Other countries are being much more aggressive still. We are getting very frequent updates from our public health department (sometimes more than once a day). We are very actively monitoring numerous other sources of information on how to manage this. As a team, all the physicians at North Shore Medical Group are actively engaged and communicating with each other to optimize our collective approach.
 
There are three key recommendations you need to follow:

1. Take social distancing seriously. Other countries are suffering a lot, largely because this step came too late. The time, is right now. At our office, we will be making much more extensive use of video consultations to enable this, beginning immediately. More details on this below.
2.  It is absolutely critical that if you will be coming in, and have ANY infectious type symptoms (this includes ANY of the following: fever, cough, shortness of breath, runny nose, body aches, sore throat, or even diarrhea), then you MUST call the office on the phone before you come in. We will likely have you wait in your car, or in an open space outside the office until we have a room clear for you. We have had a few patients tell us after they are already in the room that “I’m here for a refill, but by the way, I’ve also had a cough”. This is absolutely unacceptable, and puts us, our staff, and other patients at risk. Always, always call.
3. Be aware that most people will not be getting swabbed/tested for this. Those with mild illnesses should self-isolate at home. We have specific testing criteria, and will not be doing tests ‘on-demand’. The criteria are, respiratory symptoms in those who are:

• Hospitalized, or likely to be hospitalized
• Health care workers
• Residents of long term care facilities
• Part of an investigation of a cluster or outbreak.

 
As we have told you previously, the majority of people have a mild illness and fully recover at home, this should not be taken to mean that this condition is benign. The other 20% of cases are severe. Many patients are in the ICU. While older patients with other health conditions are more at risk, France is reporting that right now, 50% of the patients in the ICU are under the age of 50. Countries are not putting themselves under ‘lockdown’ and destroying their economies for fun. People under the age of 20 continue to fare well, with only 2 serious cases reported world-wide, so
parents should not panic about the well-being of their children who are sick. Young people with the illness can spread it around however, and this can be critically dangerous for other people. So social distancing for everyone is very important.
 
With all that in mind, we are going to be making video consults widely available for the coming weeks. Video consults are very useful whenever a physical exam is not needed. The most likely time a physical exam is needed, is when you have a new, or worsening symptom. However, there is a lot the can be done by video, including reviewing most results, most follow up visits, many refills (which are really about reviewing the health condition the refill is for), and more. Staff will be strongly encouraging video consults instead of an in-office ones. We will be quite liberal with these for the next while, and at worst, if it is determined during a video consult that a physical exam is needed, we can bring you in at a separate time for this. All this will keep the office environment safer for when you do have to come in. The online booking system will gradually start showing many more video consult slots in place of in-office ones, over the next 24-48 hrs. Some in-office spots will remain available each day.
 
Lastly, for the short term (probably about 2-4 weeks, but it is hard to tell), we will be deferring all routine (annual) checkups, and paps. Children due for checkups will have a video consult as an initial visit, and it will be determined whether a subsequent in-office visit will be done. We will be ensuring their vaccines are kept up to date, as vaccination should NOT be delayed with this.
 
If you have not already created a Medeo account:
Please go to www.medeohealth.com, click ‘sign in’ at the top right, then click ‘patient’ on the next screen, then click ‘create account’. Once your account is created, you may then call the office to book an appointment, or use our
online booking site https://booking.medeohealth.com/north-shore-medical-group/. Make sure you pick “video consult” for appointment type. You will receive an email confirmation once the appointment request has been
accepted.
 
A few very important steps for a video consult:

1. Please sign in to Medeo 5 minutes before your appointment time. 
   1. Click the ‘start appointment’ button.
   2. Check the information shown, scroll down and click ‘Continue’.
   3.  You will now have an audio/video check, if all looks well, click ‘continue’.
   4. If you have done everything right, you will see a split screen, with yourself on 1 half, and black, or a message stating “Waiting for the provider” on the other. Please be patient. When the doctor is ready to see you, they will appear. Just like in the office, sometimes things run behind, and you may have to wait a bit.
2. If you are using a computer for the video consult you MUST use Google Chrome as your browser. DO NOT click on the link in the confirmation email and assume it opened in Google Chrome. Open Google Chrome from your desktop, go to www.medeohealth.com, and sign-in that way.
   
3. If you are using a mobile device (smartphone, iphone, ipad, etc), you MUST use the free Medeo app, which you can download from the Apple or Google store. You cannot use any browser on your phone.

We will continue to send you additional updates as we go along. I am hoping to provide some anticipatory guidance on what to expect with this situation, and when we will know if it is resolving. I will try to do that in the next couple of days.

Keep well, we will get through this! While it is a dramatic change in our way of life in the short term, and the effect on the economy is profound, Canada has an opportunity to fare far better than many other countries have. We can (and will) overcome this, and it doesn't have to take that long.

 ​Please Note: Our knowledge about best practices for COVID19 is changing all the time as new information becomes available. Please refer to our most recent update for the most up to date information.

Hi everyone,
I would like to provide you all with some further feedback and guidance regarding coronavirus. There will be an additional update later today or tomorrow. As you know, it has been declared as a pandemic. It has become quite serious. This isn’t the first pandemic the world has had, and thankfully, we have an immense amount of useful information already on how to deal with this one.

Before getting into that, let’s highlight one of THE most important aspects to dealing with a pandemic. That is, slowing it down. Pandemics can happen slow or fast, and this makes a *critical* difference in the consequences. Everything we
do now must focus on slowing it’s pace. 
 
Why?
When an infection spreads around we can get a surge of patients at doctor’s offices and the hospital.  Let’s focus on the hospital. If an ICU has 10 beds, and 20 people all have to go to an ICU today for 1 week that is a big problem. But if we can slow down how quickly people get sick and need the ICU, so there are 10 this week, and 10 next week, there are enough ICU beds for everyone. Same total number of people sick, just a different time frame. We need to enable that. This has become known as ‘flattening the curve’. It is proven to work, as far back as the Spanish Flu of 1918. We need to minimize the strain on doctor’s offices and the hospital so all the coronavirus patients AND all the other usual care can continue to be provided. We’ll tell you how you can help with this below.
 
What is a pandemic?
So now that this is a pandemic, what does that actually mean? A pandemic is when an infection is spreading all over the world in a sustained manner. As opposed to an epidemic where an infection is more localized (usually defined as
1 country). So basically there were a bunch of coronavirus epidemics (in China, South Korea, Italy and so on), but so many countries are now affected that it is reclassified as a pandemic. A pandemic may not cause a lot of trouble, it just depends on how dangerous the virus is. It remains the case that the vast majority of people recover from this coronavirus, but it is also dangerous enough that we need to take this seriously.
 
So what can you do to help?
You have no doubt heard that you should wash your hands. This cannot be emphasized enough. It is likely the single most effective action you can take. Critical times are before you eat, and if you were recently in a public place. Think about what you have been touching…Handrails? Doorknobs? The doors themselves? Countertops? Absolutely any surface on a bus or skytrain? Contact with any of these should prompt you to wash your hands. Nose itchy? Use a tissue. Eyes itchy? Use a tissue. But preferably only after you washed your hands.

Those of you with kids should be on the lookout for them to do the same. Insist they wash their hands when they get home. I know schools have been great about going over this them over the past couple of weeks.

Try not to touch your face. This is actually incredibly hard to do. Most people touch their face without even noticing it several times per hour. This is why it is so critical to keep your hands clean. It is the most likely way you can get infected.

You have probably heard of the term social distancing. What does that actually mean? It literally means keeping your distance. The virus most likely spreads up to about 6 feet around a person. As far as we know so far, it does not linger in the air, and so is mainly an issue when you are close to someone. It CAN however linger on surfaces, possibly for a long time. So avoiding touching affected surfaces, and avoiding crowds, or at the very least trying to stand apart from a crowd will help. Now is not the time for big gatherings and parties. No handshakes. No fistbumps. No elbow bumps.
  
So how do you greet people? It’s called “hello”, and it comes with a smile.
Do not. Do not. Do NOT go out in public if you are sick. If you absolutely must, then that IS the appropriate time to wear a mask. Wash your hands REPEATEDLY, and try not to touch anything. Life will eventually go back to how it was before, and other countries have proven this is possible, but for now staying home when you are sick may literally save a number of lives. If someone can bring something to you, ask them to do so. They can leave it the door for you. Perfectly safe.

Please take extra careful consideration of protecting the most vulnerable. If you have elderly parents, or perhaps family members with chronic health conditions such as diabetes, heart conditions, or asthma, then all the above becomes that much more important. The vast majority of serious and deadly cases remain in people aver the age of 60, and in particular with other health conditions. It is important to recognize however that this is potentially serious at any age, and even among young people the mortality is a few times higher than the flu. There is no known death worldwide in a child below the age of 10. 
 
Office Protocols, a review:
Anyone with any infection type illness MUST CALL the office. There will be specific instructions for you. We will be trying to minimize your time in the office. It may be that the entire story is collected from you remotely, and the only thing that happens at the office is that a swab is quickly done. Further discussion may follow by phone/video consult.
 
We have been taking many steps already to prepare for this, and we will continue to adapt as we go along. All of us however can make a difference, and it mostly takes changing our behaviour for a little while. Let’s encourage each other. Let’s look out for each other. As your physicians, we are there for you!

 Please Note: Our knowledge about best practices for COVID19 is changing all the time as new information becomes available. Please refer to our most recent update for the most up to date information.

Dear Patients,
Not surprisingly we have had a number of questions regarding coronavirus (the official name for this is now COVID-19). It’s natural to be concerned, and there has been a lot of confusion, so this will hopefully clear some of that up. The objective here is to provide practical information on how to properly protect
yourself, and what is helpful for this, and what is not. There is a lot of worldwide alarm, and while rational attention to this is appropriate, panic is not. The information I am providing is largely based on a just completed study of the spread and impacts of the condition among ~45000 cases from China.

How dangerous is it?
While all age groups can be affected, the vast majority of serious cases are people over the age of 50. Among young (under age 50) healthy people, the mortality rate is similar to the flu. For age 50-60 the risk is somewhat higher. After this the risk rises a fair bit. However, the vast majority of people still recover, even in the highest risk groups, even among those who end up admitted to hospital.
In all age groups, severe cases are also much more common for those with other health conditions, in particular heart disease, diabetes, and chronic respiratory conditions (in that order). 

What are the symptoms?
Mild cases show no symptoms at all. When symptoms are present, they most commonly are a fever, dry cough, and shortness of breath. Other symptoms such as runny nose and sore throat can occur but are very rare, and their presence suggests a different illness. 

Will there be a lot of this in Canada?
There have been about 2 dozen cases so far in Canada. The vast majority of cases remain in China. In the past 2 weeks there have been significant outbreaks in South Korea, Italy, Thailand, Iran, and Israel. Numerous additional cases have now shown up in the USA, and isolated cases in many other countries. While the spread of the virus may yet be stopped, I will not be surprised if we start seeing more cases here in the coming weeks. While other countries are starting to be affected, lost in all the confusion is that the number of new cases in China has actually started to drop. 

What should I do?
Standard infection precautions are important, and recommended at this time of year anyways regarding influenza. The virus is mainly contagious within about 6 feet of an affected individual, mostly while they are coughing. It can also linger on surfaces such as doorhandles, armrests, tables, and counters. It is not yet clear for how long it remains on surfaces.
What are the infection precautions to follow? Washing hands, especially before you eat. This sounds so simple, but is in fact highly effective. We are talking about a good scrub here, which should take about 15-20 seconds of
scrubbing, being sure to get between fingers etc. Also, try to avoid touching your own face. We all do this, a lot. Try to cut down on it. 
Do not wear a mask all the time. Masks should be worn if you are sick to prevent spreading it to others. 

What is the office doing to deal with this?
Several behind-the-scenes changes have been made to prepare for an outbreak here, and seeing affected patients in our office.
For your part, it is important that anyone who is sick, especially if you have fever, cough, or shortness of breath, inform us on the phone. We may decide to do an initial video consult in some cases. We need to know ahead of time so we can minimize your exposure time to others. If we will be seeing you in the office for a respiratory illness, please try to call us 1-2 minutes before your arrival as we may have specific instructions for you.
There is hand sanitizer at the front door and everyone, and I mean everyone, should be using this on arrival, and departure.
 We do have the ability to test for the virus, but please allow us to make the medical decision about whether the test should be done. 

Will there be any treatment for it?
Right now treatment is ‘supportive’. This mainly means providing oxygen to those who need it, which can help a lot. Some people need more advanced respiratory support. Vaccines take months to make, but numerous groups are aggressively pursuing this. There is also extensive evaluation being done with anti-viral medications to assess effectiveness. An anti-malaria drug may have some benefit, but is not recommended for use yet. It will probably be 1-2 months before any medication recommendation becomes available. 

This isn’t the first scary bug the world has had to deal with. There has been far worse in the past. Just like every other time, the best way for us to overcome this is by using our heads.

Please contact the office if you have any questions!