COVID Roller Coaster

This article was published on the Australian Society of Otolaryngology Head & Neck Surgery Newsletter Summer 2020 Edition.

It was eerie. After finishing up an emergency case at 8pm, I said goodbye to the anaesthetist and the nursing staff. The usual relief of finishing a difficult case was absent. We looked at each other quietly not knowing what’s ahead of us. In my mind, I wasn’t sure if I was going to see some of them ever again. I drove home under the cover of the dark wet windy winter that is Melbourne. Carlton, Fitzroy, Richmond and suburbs that are usually alive with lights and cheer are completely empty. The curfew has begun and my beautiful Melbourne is a ghost town. Its soul has gone. Fear is now locked behind doors.

At its darkest days in July-August, Victoria had 700+ new positive COVID cases a day. The hospitals were starting to get full. At St.Vincent’s Melbourne our PACU is converted into a clean ICU while the formal ICU is the “hot” ICU caring for COVID patients. Anaesthetists get daily briefing on the list of COVID patient in the building and their resuscitation/intubation status. A COVID theatre team is set up daily for emergency intubations or emergency SCOVID (Suspected Covid) cases. On the other side of town at The Royal Children’s Hospital, the NICU is dealing with their own COVID positive inpatient and outbreak, requiring the swabbing of every baby, every parent and every staff member who was in NICU for more than 20 minutes. I had to reflect on how long I was there accumulatively in the last week and which mask I was wearing.

How did Victoria get here?

COVID has certainly revealed where the cracks in the system are. The Chief Health Officer who is responsible for public health is not responsible for hospital responses. Hospitals, PPE and Health Care Workers are under the portfolio of the Chief Medical Officer through Safer Care Victoria. The Aged Care Facilities are the responsibility of the Federal Government, not the State Government. The Hotel Quarantine? Well, we’re still not 100% sure whose responsibility that was. We know a few people have lost their jobs over that. Chronic underfunding of the Public Health Unit at VIC DHHS also meant that only a handful of people were actually employed to manage this pandemic. The system could not bear the load applied to it. In the first wave back in March, the Premier cancelled the Melbourne Grand Prix and we dodged a bullet. The second wave, or the first tsunami, came about through cracks that, on hindsight, were pretty obvious.

More than 95% of all infections could be traced genomically to a family in quarantine. COVID came through a family from overseas, then a hotel worker was exposed. In a casualied work that is hotel quarantine, with lack of proper training, it was easy to see how COVID could leak through hotel staff to community. These workers are often from lower socioeconomic backgrounds and live in large households where there are others in the household who work in health care. Some religious holidays were occurring at that time which translated to very quick household to household transmission. The pandemic highlighted the structural inequities, the lack of coordinated response and the underfunded system.

Two weeks is a very long year in a pandemic. Multiple families across different suburbs were infected. COVID entered aged care facilities and hospitals, and because there was a lack of appreciation of aerosol spread at that time, PPE guidelines and ventilation were less than ideal. Once in a facility, COVID spread was rapid due to the nature of our physical contact. Delayed response to aged care outbreak meant that we had high morbidity and mortality situation occurring in that context. Aged Care workers were getting infected and the Government had to move Aged Care Residents to Private Hospitals. It was both scary and amazing to see the hospital response in Victoria.

Private and Public as one.

The COVID tsunami also occurred with a corresponding email tsunami. Every public and private hospital sent out their own version of COVID modifications. In one hospital, nametag lanyards were bad, in another hospital cloth surgical cap was bad but lanyards were cool. It was easy to see that so many of our protocols were made up along the way. It was a significant period of change. In fact, opportunistic leaders used this opportunity to make good changes within their departments. Private hospitals cared for COVID, SCOVID, and NOVID aged care residents. As elective operations were reduced, many of the theatre nurses I work with were deployed to aged care facilities or to the wards. I must confess, I am deeply impressed by the stories of care they provided. Theatre nurses who are usually in clean environments had to alter their practice and had to manage sick patients and quite a number of deaths, which is not routine business in a typical private hospital. Health care workers just rolled up their sleeves and did the job that was required of them.

In the hospital, universal masking, splitting of teams, routine pre-op swabbing, telehealth, zoom meetings, 50% elective capacity plus emergencies, 3-tiered PPE based on procedural risks, zoning of hospital facilities and many other changes occurred. In the community, 5km bubble, 8pm to 5 am curfew, school closures, stay at home directives, leave home for essentials only, and 1 hour exercise outside home were the enforceable norm. As I write this, South Australia has just entered and finished their mini lockdown. They had a brief taste of queueing for toilet paper. Today, masks outdoors in Victoria are off. We have had 23 straight days of zero transmission. The real test is when the borders are re-opened.

The role of the ENT Surgeon in a pandemic

It has been 6 months since I saw my colleagues’ smile and since I shook hands with my patients. The roller coaster ride meant that things have changed, some for good. Scrubs and masks are becoming the universal norm. Telehealth is well utilised. Meetings are more brief and many voices are better heard as everyone has the same “muteability” on zoom. Information exchange is rapid (How many WhatsApp groups are you in now?). The typical clinician nowadays can pretty much attend any Grand Round and conferences in other hospitals, other countries and other specialties from the comfort of their own home. As an ENT Community, we have also done much advocacy around the protection of our staff. The International ENT Community has published on mortality figures amongst ENT surgeons, which almost certainly influenced the protocols in many places and provided support for our colleagues in Dentistry, Maxillofacial surgery, Respiratory and Oral Cleft Surgery. At the national level, ASOHNS have been in close discussion with Federal Health Officers. At the local level, VIC ASOHNS and ENT Heads of Units advocated for protection.

And at the individual level, despite the heterogenous group that we are, ENT Surgeons have provided the necessary steady leadership influence around our workplaces. Turning up day after day both in public and private, modifying surgical approaches, rearranging clinics, sharing 3D-printed face shields, adapting to new PPE changes, communicating respectfully and many other simple acts that keep us and our community trusted. The fear amongst health care workers were palpable. The porters, theatre technicians, nurses on the ward and even cleaning staff were fearful. Though masks have covered their faces, their eyes speak of fear of uncertainty. Every time I spoke about the changes and the possible future, every eye and every ear was turned towards me. I soon realised early in the pandemic that speaking hope and perspective to my health care colleagues were just as important as talking about PPE and surgical modifications. Hope is a critical PPE armoury in this pandemic.

One theatre nurse said, “You know, I realise that ENT is the worst hit specialty this pandemic. You’ve got a high risk profile. Yet every ENT surgeon I have worked with has remained calm and unflustered. Thank you for being steady. We nurses appreciate that.”

If there is one other big thing I learned this pandemic, one surgical trait I wished I had more and in abundance, it is the lesson of humility. Scientific humility is knowing that we do not know everything about this virus, appreciating that airborne spread is a continuum with droplet, and changing our protocols rapidly based on new evidence. Surgical humility is adapting our surgical approaches to changes, respecting the concerns of every team member and being open to inevitable disruptions in workflow. Corporate humility is knowing that we need to advocate for our team and our patients, and that we need to listen to others (Infection Control, Occupational Health & Safety, Aerosol Scientists, Epidemiologists, Ventilation Engineers, Wellbeing Officers, etc.). Many colleagues and many in our communities suffered heavily through the lockdown. This pandemic showed that although we were all in the same storm, we were in vastly different boats depending on the pre-pandemic resources one had. As ENT surgeons, we are in a very privileged position and we have a moral and a community obligation to use whatever resources we have to support our communities. 

As other countries manage their COVID waves, we do have a good story to tell from Australia. Perhaps we can be that voice of support that other countries need. Many Victorians will not take for granted the freedom we now have after a difficult lockdown. There is still much work to be done in fixing our structural inequities and protecting health care workers but I for one will from now on treasure every Soy Chai Skinny Latte I enjoy with my colleagues face to face.