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The doctors shouldering a pandemic in an already stretched system

Introduction by Croakey: Rural and metropolitan GPs and a leading Emergency Department doctor open up to Croakey about their critical personal and professional pressures and concerns during the novel coronavirus pandemic in the story below, which is the latest in our Caring for the Frontline series. See our first story here and second here

In this story, they talk about the worrying impact of their work and the pandemic on vulnerable family members, the need for urgent access to personal protective equipment (PPE), strategic and financial concerns, the convergence of grief and trauma, and a growing worry that patients are avoiding necessary health care out of fear of being a burden to the system or being exposed to COVID-19.

They also offer hope and coping strategies as Australia battles to “flatten the curve” and avoid the COVID-19 surge that has devastated other parts of the world.

The story comes as more than 4,500 healthcare workers pleaded in an open letter to the Federal and State Governments for urgent PPE access, amid reports that a “terrifying” shortage is forcing nurses and doctors to improvise with household items, buy unreliable equipment online and skip breaks.

Health Minister Greg Hunt on Wednesday announced that 11 million masks had been secured for “immediate” allocation.

The distribution breakdown will be: 7 million to hospitals, 2.3 million to Primary Health Networks (with 1.5 million for GPs as part of an “ongoing distribution”), 160,000 for respiratory clinics, 75,000 for Aboriginal community controlled health organisations, 500,000 for pharmacies, and 1.7 million for aged care.

Hunt, accompanied by his principal primary care advisor Dr Michael Kidd and AMA President Dr Tony Bartone, also issued two warnings.

One was in response to just a few but “very troubling cases” where people either assaulted or threatened health care workers, “verbally or by coughing on them”. Hunt said deliberate transmission of the novel coronavirus is serious offence and could carry a penalty of life in prison. It was also a serious offence to cause someone to fear they had been exposed deliberately.

The other warning was to Australians with acute or chronic health conditions to not avoid health care.

Kidd said one of the lessons from past epidemics and pandemics is that often people don’t continue to get the regular health care they need, which can “lead to more morbidity and mortality from preventable chronic conditions than from the infectious agent itself”.

The Australasian College for Emergency Medicine (ACEM) issued a similar warning on Wednesday, as did the Royal Australian College of GPs, which reassured patients that they don’t need access to digital technology to access telehealth – an old fashioned phone is enough.

(This New York Time article makes similar appeals, but also wonders what else might be lying behind a surprising reduction in emergency procedures for heart attacks and other emergencies, including acute appendicitis and acute gall bladder disease.)

Also this week: the New South Wales Government has offered free accommodation for health professionals who are worried they are putting their families at risk. In Victoria, health workers can get free accommodation if they need to self isolate.


Marie McInerney writes:

Mya Cubitt, Emergency physician and Chair of the Victorian Faculty Board for the Australasian College for Emergency Medicine (ACEM)

The pandemic is stretching Victorian emergency physician Dr Mya Cubitt in many different directions: as a doctor, as the Chair of the Victorian Faculty Board for the Australasian College for Emergency Medicine (ACEM), and as a wife, friend, relative and mother to three children, one at primary school while her twins are pre-schoolers.

“I’m being pulled into quite high-level discussions about system planning,” she says.

“I’m often pulled towards my kids who are a bit scared and confused.”

“I feel pulled towards trying to support my husband [also an emergency physician]…as well as (being) someone who needs support.”

“And then I’m still trying to do what I know I can do really well; that is, to care for patients. I don’t want to lose sight of that within everything else that’s going on because that’s my job.”

The difficulty is that all of this is happening at a time when the usual ways of managing high levels of stress –  like catching up with her husband, friends and relatives to refresh or to “stop being a doctor” – are not possible.

Dr Mya Cubitt and her daughter Lily

“The people you normally take rejuvenation from, they’re also suffering (stress), so it’s in every aspect of your life,” she told Croakey.

“In a normal day I might manage very high-level medicine, but when I come home, everyone around me is able to re-set me and give me back a normal perspective and that’s not there anymore,” she says. 

“That’s hard, I’m finding that hard.”

One of her biggest worries at the moment, in this possible calm before the storm, is about non-coronavirus related patients who may be avoiding much-needed hospital care either because they don’t want to be an added burden for the system or they fear exposing themselves to COVID19 in a health setting.

“I’m seeing patients who need to be in hospital who I have to convince to stay,” she says. “I think there are people out there who need care. We can still deliver that and I don’t want them to be sitting at home, worrying.”

A paradigm shift in practice

Yet strangely, she says, she feels safe at a personal level in the hospital, in her PPE gear and with the training she has received to wear it, and she has great confidence in the ability of emergency doctors to manage the medical crises around the pandemic. 

“That’s what we’re experts at, that’s our role,” she says. 

But she concedes that the breadth of the coronavirus crisis can be “very cognitively taxing”, even for veterans who are having to adapt to the ACEM’s newly developed COVID-19 clinical guidelines which she helped work on. 

The guidelines represent a paradigm shift in thinking, covering “everything from the physical environment that an emergency physician is working in, right through to how we manage airways, the way we dress, how we interact at handover, what’s safe about moving patients,” she says. “It touches every single part of our profession.”

“(Emergency doctors) are used to being able to deliver excellent care without having to think about it very much anymore. They are trained for it and have come to trust their judgement.” 

“When that’s taken away from you and you have to rethink everything in a very careful way, that’s very challenging,” she says.

But she also takes comfort and confidence from the extraordinary work that is going on at multiple levels and at unprecedented scale to manage this pandemic.

She is seeing it in the community building and collaboration in the health system, between professions and regions, in bringing together emergency health specialists with emergency management specialists, and in having to face ethical issues about access to resources.

Those sorts of collaborations, she says, are what reassure her about the prospect of Australia’s Emergency Departments being overwhelmed as they have been in Italy, Spain, the US and UK and in hearing reports of physicians weeping because they had to choose who received care and who did not.

It may not be what people want to hear right now, she says, but our system was already “a bit broken”, so some of those stresses are already happening. 

Victoria has experienced its highest ever levels of “access block” (where patients are stuck in EDs because of lack of inpatient bed capacity) as well as critically high levels of occupational violence towards physicians. 

Cubitt sees “room for optimism” that pandemic planning and unprecedented levels of collaboration may help address these ongoing problems, as well as weathering the coronavirus storm.

“I hope that on the other side of this, there are lasting system changes and improvements,” she says.


“Hell of a year”

Dr Tim Leeuwenburg, rural generalist, rural emergency responder, credentialed specialist, Kangaroo Island, South Australia

Dr Tim Leeuwenburg wasn’t able to do an interview, as a result of being “COVID crazy” busy with patients and teleconferences, but he sent through the following dotpoints:

  • I’m just reframing the COVID-19 issues from being a threat to considering it as a challenge. One for which I am trained and capable.
  • Helped to author guidelines for airway management of COVID19 patients, to help others.
  • Control the things I can, let the others go.
  • Engaging with community, trying to deliver strong consistent messages (in absence of sensible Govt info!).
  • Acknowledging this has come on back of losing a house in the Kangaroo Island bushfires on New Year’s Eve and loss of my father to cancer in late January.
  • Hell of a year!

 And via Twitter:

He also recommended: https://codachange.org/2020/03/30/covid-anxiety-noise/


Risks at home

Dr Cath Keaney, Melbourne GP

When Melbourne GP Dr Cath Keaney started to feel a bit unwell one recent weekend, it was a shock to contemplate the ramifications if she became infected with the novel coronavirus: for the practice, for her patients, and for her family.

Her partner and son have chronic respiratory conditions, and it brought home “just how vulnerable my family are in all this”.

Keaney’s Preston practice moved quickly, before the pandemic was declared on March 11, to address infection control concerns, at first keeping symptomatic patients separate from others and then also providing telehealth consults where possible.

It was unsettling, she says, to not see patients in person. But it was also worrying that for the first couple of weeks, some patients would “basically lie” when asked on the phone if they had cold-like symptoms, and would turn up at the practice, putting the front desk and other patients at risk.

“I don’t know if it was people having a case of exceptionalism – ‘it’s about everyone except for them’ – or whether there was just not a general understanding in the community about how serious this pandemic was prior to it being declared,” Keaney says.

“GPs are ‘invisible’ in pandemic planning”

Her current concerns are not limited though to her practice and family, worrying that primary health care is “invisible” in coronavirus planning so far.

Asked about that, the Royal Australian College of General Practitioners told Croakey that representatives from general practice “have finally been involved in planning at all levels”, after it made such calls since the onset of the crisis.

In an emailed comment, RACGP President Dr Harry Nespolon added that the RACGP is not advocating for GPs to be utilised for surge capacity in hospitals, saying they are “needed in the community right now”.

Keaney agrees with the sentiment but believes GPs will need to take some of the load from Emergency Departments “once the COVID-19 tsunami hits”.

She wants to know: “What role do GPs have in addition to their baseline care in community medicine?”. And beyond that, of course, will they be adequately resourced for that?

Like so many health care workers, an urgent concern is around the lack of personal protection equipment (PPE) available right now, and especially if GP roles broaden.

Keaney’s practice, despite a big buy-up effort, currently has less than ten full PPE kits. She said today’s announcement by the Minister of a pipeline of new masks was “great news, it’s vital to have a continuing supply”. She just hoped distribution “will be fast and efficient and go where it is needed”.

It’s all left her feeling “a bit hamstrung in how I do my medicine”, having to do as much by telehealth as she can and then mitigating risks without adequate PPE in her face-to-face consults.

The routine now is that her patients sit two metres from her and she minimises the time they are face-to-face. Waiting room chairs are all two metres apart. The practice is bleached twice a day.

To protect her family, she takes off her scrubs at the end of the day, changes into a new set and different shoes, rides home, puts both sets into the washing machine and then showers.

Financial stresses too

On top of all that, the practice is taking a significant financial hit. This is a common story, according to the RACGP which told Croakey that up to 50 per cent of general practices may be down 30 per cent in income.

They agree that people might be putting off seeing their GP when they need to, in part out of concern that they will be placing stress on an over-stretched health care system, and part for self-protection.

But the early decision to mandate bulkbilling for COVID-19 telehealth consultations – since partially reversed – has meant there is “no room to mitigate against the long-term inadequacies of the Medicare rebate” for practices that look to quality care versus quantity, Keaney says, adding that the long years of the Medicare freeze are now “really biting”.

And that’s happening while the pandemic is demanding more clinical and administrative time and GPs and staff are facing the risk of infection, abuse from some patients, and ongoing PPE concerns.

“When we’re thinking about businesses that have lost 30 per cent of their income (the threshold for significant government assistance), it’s weird in a pandemic to think that GPs fall under that,“ she says.

“Health care needs have gone up, my stress has gone up, my work hours have gone up because it’s tricky to navigate the new (telehealth) technology, and I also have to field a lot more questions for families and friends, so there’s no stopping, there’s no downtime.”

In the past, her beloved two sessions a week of karate would have helped to relieve that pressure, but that’s now prohibited under social distancing. While she keeps it up in the living room via online classes, it’s not the same. “It was protected time, out of the house,” she says.

“I’ve had to rejig how I do stress relief,” she says, adding with a laugh: “I’ve not quite mastered it yet, but we’ll get there!”.


Croakey readers may also be interested in:

People Are Dying”: The Front Lines of the COVID-19 War Are in the World’s Media Capital

Australian Story: One day at a time

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