In the first of a series profiling the concerns of health workers on the COVID-19 frontlines, Marie McInerney reports that they are gearing up for the expected surge of patients, and worrying about their patients, colleagues and communities, as well as the risks to themselves and their families.
A stressful time for everyone
Dr Jason King, Gurriny Yealamucka Health Service, Yarrabah, Queensland
Dealing with the pandemic has already brought the most stressful, frustrating and difficult moments of his career for Dr Jason King, the senior medical officer at the Gurriny Yealamucka Health Service in Yarrabah in far north Queensland.
On Monday, King, a Yued/Whadjuk Noongar man, and his colleagues were setting up a fever clinic to test for local community for COVID-19, with just a week’s worth of personal protection equipment (PPE) in stock.
At the same time, he was struggling with “difficulties and disconnection” between federal, state and local level decisions about exclusions for 14-day isolation arrangements, and who is and isn’t an essential worker.
They were also dealing with a “community in shock” after Yarrabah went into lock-down late last week, its only road in or out now closed except for emergency and health workers like him.
King had both urged and welcomed the lock-down as part of heightened efforts across Australia to try to keep the novel coronavirus out of Aboriginal communities.
But on Monday police turned away a crucial food truck because of issues about the driver’s registration, sparking concern and confusion in a community where few can afford to do a full grocery shop at the only store in town. Nor do most have computers or online access to order deliveries.
King looks with envy also at the hotel accommodation being given to returning Australian travellers for their mandatory 14 day quarantine.
Gurriny Yealamucka is looking desperately for any quarters, including army tents, in case they need to isolate people in a town with chronic overcrowding and poor housing.
An average 10 people live in each home, many without power or good water or sewerage connections, and the community only has about six suitable quarantine spaces right now as it begins to do more testing.
Our model of care isn’t simply that of a suburban GP.
We collect data and interact with people on issues of food security, environmental health, spiritual and cultural health.
We were raising concerns of food security weeks ago, warning if we close that road in, you need to figure out how to get food in here, whether that’s food trucks or air drops.”
Yarrabah is Queensland’s largest Aboriginal community, known for the strong community approach it took to successfully turn around three waves of suicide in the 1980s and 1990s.
But the trauma and disadvantage have taken a toll, King says.
Of its 3,500 population, more than more than 580 community members are “in the highest risk category for poor outcomes” if they develop COVID-19.
That raises issues too for 12 Aboriginal Health Workers who live in the community, along with other support workers, including Social and Emotional Wellbeing staff.
“In a community that is already disadvantaged, and has a long history of trauma, the workforce is not separate to that,” King says.
Staff are working in rotation to make sure they get some down time while they can, and telehealth is being encouraged for those at high risk.
On top of the health risks, King says social distancing rules also mean the community can’t and won’t be able to support each other in customary ways, like Sorry Business.
This means “shutting down a bunch of those community cultural resources and points of resilience and strength that would normally sustain it, so we need to be aware of that and work on ways to help community work through that”.
But today brought a positive breakthrough, with Queensland Health agreeing to an expansion of its dialysis unit to two shifts a day, so community members won’t have to travel to Cairns for dialysis and remain there during the lock-down.
“We’ve been advocating for a two-shift model for the community for the last five years for this very reason,” he said.
King shaved his beard off on the weekend so his PPE mask can fit more securely. He added some glitter and colour to make it more fun for his wife and daughters.
Being home with them is “very rejuvenating” and the one hour drive back each day to Cairns is a useful bridge between work and home, an “opportunity to take one hat off and put the other one on and decompress a bit”.
“All the decision making, it is stressful, I have to say,” King says.
He’s also doing what he can to stay in touch with family in Western Australia:
It’s a stressful time for everyone, particularly for Aboriginal people who can’t get back to Country, where a lot of strength is derived from.”
That leaves big gulfs, he says, and now more than ever, Yarrabah and other communities “need to lean into the bonds of community, despite the physical separation we’re all experiencing”.
Safety at home and work
Dr Lisa Kenway, anaesthetist, Central Coast, New South Wales
Anaesthetist Dr Lisa Kenway told her son this week that he wouldn’t be able to hug her for a while.
The look on his face “almost broke me”, she said on Twitter. “This is going to be a long year.”
Kenway and her husband, an orthopaedic surgeon, are making preparations at work and at home for an expected COVID-19 surge, trying to make the most of “the calm before the storm”, she told Croakey.
Gosford Hospital on the New South Wales Central Coast is, she says, “going full pelt to try to train us for every possible scenario”.
New protocols have been developed very quickly that “basically change the way we practise”, focused on exposing the minimum number of people during aerosol-generating procedures, like intubation, and having the most senior practitioners on deck so they can get them done as quickly as possible.
Rostering is also changing, with contingency plans for night and day shifts.
Like other medical groups, the Australian and New Zealand College of Anaesthetists (ANZCA) is trying to address “significant and justified concern” from its members regarding the appropriate use of PPE during the COVID-19 crisis.
The principal issues are “the minimum threshold for PPE use” or “for which patients do I need to wear PPE?”. Questions being asked include, should it be only those with symptoms or contact history, or should it be everyone?
These are big issues, Kenway says, particularly when levels of PPE availability are still unknown, and there are complex considerations for surgery, like urgent caesarean sections. “Donning the PPE takes time and we can’t rush that.”
Kenway says she can’t fault the amount of organisational support she’s had “within my hospital, from the health service and from our professional organisations as well, providing us with the right information, the right training opportunities”.
Now she and her husband are focusing too on safe practice at home around their two teenage boys, “to protect the children when things escalate,” she says, with a catch in her voice.
“Although my boys are teenagers, we are a ‘frequent hug household’.
I’m just starting to step back and say that can’t happen anymore.”
They are doing a number of “small things” to mitigate risk:
Putting our phones in ziplock bags.
Trying to wear the same clothes to and from work.
Leaving our shoes in the garage.
Getting changed as soon as we get home, showering.”
They’ve also done some self-care as a family: downloading a yoga app that one son particularly is enjoying, and trying to get out for a walk each day with the kids if they can.
But they’re aware that too is likely to change.
Says Kenway: “I guess once we’ve had more exposure [to patients with the novel coronavirus], we’ll have to be really careful about keeping distance with the children as well at home, just to try to protect everyone as much as we can.”
Kenway admits she’s feeling “quite anxious at the moment about everything”, so taking these steps at home as well as work now is helpful.
“In a way it gives you a bit of control, having a plan about how you going to manage the risk,” she says.
“I’m finding that helpful, thinking through all this now so we have a system in place ahead of time.
“I feel really sad about having to not have as much physical contact with the kids because it’s a stressful time for them as well, especially seeing us go off to work and putting ourselves at risk.”
Does it make her wish she could run away?
“Not really. I did medicine in the first place because I wanted to be useful and help people and if I can’t help people now, then what’s the point?”
However, Kenway acknowledges this is the first time she has had to think seriously about the risk to herself and her family from her work.
“In Australia we’ve been cushioned a bit from that…I guess it’s something new for all of us.”
Urgent need for better protection
Alison Tortell, Member of the Australian College of Nursing, registered nurse, accredited immuniser, general practice owner and manager, Bella Vista, Sydney.
Last weekend, a Sydney painter turned up at the general practice he has been going to for more than 30 years and presented its owner with about 60 P2 masks from his work stocks.
Alison Tortell, the Bella Vista practice owner and manager and a registered nurse, had tears in her eyes as she thanked him, telling him how much it meant.
Tortell says her emotions are heightened at the moment and that the current work of the practice, both clinical and administrative, is “overwhelming”.
The introduction of whole-of-population telehealth consultations is helping with managing the risk of coronavirus infection for staff and other patients.
However, the push to promote influenza vaccination is adding to the pressures already on GPs and nurses in this pandemic. Waves of people are presenting for injections who otherwise would not have done so.
Tortell says there’s not enough time in the day to even think about doing mental health self-care for herself and the staff of six GPs, six nurses and six administrative workers at the practice.
“It’s just so overwhelming,” she says, again.
For Tortell, as for health services across the country, the biggest pressure is trying to access PPE – for the medical staff at the clinic, for nurses doing home visits to vulnerable patients and, ultimately, for those she expects to be providing palliative care at home when the expected surge of COVID-19 patients is too much for ICU capacity.
“It’s scary, quite scary, because we can’t, we don’t know what’s coming, and we can’t get our hands on any PPE,” she told Croakey.
About a month ago she was allocated a box of 20 n95 masks from the local Primary Health Network.
She has praise for the PHN’s efforts, but they too are waiting to hear when the next shipments might arrive.
Meanwhile, people are selling all sorts of PPE online, asking exorbitant fees and with no assurances that it’s appropriate or not.
Earlier this week, Tortell’s staff’s relief was obvious when she told them she had sourced some gowns, shoe covers and masks.
But there’s nowhere near the protection she wants to provide, particularly for nurses as the flu vaccination rush begins.
“Nurses are hands on. We’re touching 80-100 patients a day just with flu shots,” she says.
Tortell has told staff they should feel free to take leave if they need to, particularly if they’re worried about risks to their family. One has done so. Another is grateful for extra work as a distraction after her ex-husband said she shouldn’t see their young daughter until the crisis and her risk of transmitting infection is over.
As well as concerns about PPE supplies for general practice, the Australian College of Nursing is sounding the alarm for thousands of nurses, including those providing in-home care, who are not getting access to PPE under the current distribution arrangements.
ACN says that nurses who do not work directly for a public hospital or general practice are being discriminated against when it comes to the roll-out of available stocks.
A recent poll of members found 81 percent said they did not have the PPE available to keep themselves and their patients safe.
Note from Croakey Health Media
We welcome suggestions from readers about our coverage in the weeks and months ahead.
For the photograph of Dr Jason King, we acknowledge and thank freelance journalist/photographer/editor Christine Howes – on Twitter @HowesChowes
And stay tuned for part two of this series, Caring for the Frontline.