Regional and rural doctors left behind in Covid-19 fight
Dr Aniello Iannuzzi is frank in his assessment. “This pandemic has highlighted the number of deficiencies in our health system in this country,” he says.
A general practitioner from the regional New South Wales town of Coonabarabran, he’s one of just a few doctors working in the region.
“We don’t have intensive care beds in Coonabarabran, and we don’t have the facilities to care for ventilated patients beyond a few hours,” says Iannuzzi, who also serves as deputy mayor of the surrounding Warrumbungle Shire. “And then you have places like Baradine and Coolah, who are even smaller and have one doctor serving them.”
Coonabarabran is big enough to have a local hospital, where Iannuzzi sometimes practises, and six other general practitioners in town. While it does have a small emergency department, there is no onsite doctor; doctors are on call and attend when needed.
“We will be in this really awful situation where we have Covid-19 patients in our hospital that will be stretching the hospital’s resources and taking resources from other patients,” Iannuzzi says, “and we will have a situation where people have to die in our hospitals because we don’t have the resources to help them.”
If serious patient cases arise in Coonabarabran, they are driven or flown to a base hospital in a larger town, the nearest of which is about 150 kilometres away in Dubbo, an option Iannuzzi fears could be cut off by the time Covid-19 reaches his town.
“If we go forward a few weeks – and I don’t know how many – but if things keep going the way the curve suggests, we will get into a situation in which cases start to pop up in the Warrumbungles and all of a sudden we will have some really sick patients … Every other time we would ring up Dubbo or Tamworth or Orange, and say, ‘Our patient needs to go to intensive care.’”
Given the current infection rate, though, Iannuzzi says that “even if we get one or two patients, Dubbo or Tamworth could say, ‘Sorry, we are already full.’”
According to research published in the Journal of the American Medical Association, based on data from China’s 70,000 cases, roughly 5 per cent of those infected with Covid-19 will require an intensive care unit bed with a ventilator to survive.
But Tamworth GP Dr Casey Sullivan says this rate could be greater in regional towns, given the high morbidity rates in these areas.
Tamworth Hospital has just 12 ICU beds. The executive director of rural and regional services at Hunter New England Health, Susan Heyman, told The Northern Daily Leader the hospital was working to increase that number. The town is already on the back foot though, having confirmed its first case of Covid-19: a passenger from the Ruby Princess cruise ship that was allowed to dock in Sydney last week.
In Temora, a town of 4000 people between Cowra and Wagga Wagga, Dr Wayne Lehmann also has concerns about whether doctors will be prevented from transferring critical patients to the closest regional hub in Wagga.
“Wagga Wagga Base Hospital can hardly handle the work now,” he says. “They have enormously long waiting lists at Wagga Base for routine surgery. The hospital is constantly overflowing.”
Wagga Base hospital has 12 beds in its intensive care unit but is working to stretch this to 36 beds, should the pandemic reach a worst-case scenario in the city and its surrounding areas, The Daily Advertiser reported last week.
Wagga Wagga GP Dr Marietjie van der Merwe told The Saturday Paper that Wagga Base is planning on transforming existing wards into Covid-19 treatment areas.
While the town’s medical community is “reasonably well prepared”, van der Merwe said Wagga is “quite low in resources compared to other areas so, for example, if people get very ill, we don’t have a lot of ICU beds and equipment”.
“Temora Hospital hasn’t got a plan and, as far as we are aware, the patients with Covid-19 who are ill will be transferred to Wagga,” says Dr Lehmann. “We’ve only just got the two ambulances here, and that’s going to cause quite a lot of issues with sterilising ambulances and having enough protective gear.”
All four regional doctors interviewed stressed they were already running low on personal protective equipment (PPE), including masks, gloves and gowns.
Lehmann’s practice plans to triage patients over the phone and swab them while they sit in their cars. They will schedule patients to drive up about the same time, so they can test everyone using one set of protective equipment.
Even so, he says, “we will run out of protective equipment in no time. If we have a Covid clinic to do every day, I don’t think we are going to have enough to last us two weeks.”
Dr Iannuzzi says the Western NSW Primary Health Network (PHN), which the government has tasked with distributing PPE, “have utterly failed on their part to do that well”.
“They have given us, maybe, a dozen masks,” he says. “We didn’t receive gowns and we can’t get gowns off our medical suppliers as they are all out of stock, meaning that we cannot test people at our practice. We have to send them up to the hospital.”
Dr Sullivan says her clinic in Tamworth is also unable to test patients for Covid-19, having been provided with only 50 masks for six doctors. They are out of gowns and gloves, and are struggling to get more hand sanitiser because “all of the places we are supposed to buy from if we run low have already been bought out by members of the community”.
A spokesperson from the Western NSW PHN told The Saturday Paper it will deliver 40 P2 masks and 150 surgical masks to each practice in Coonabarabran by March 28. The spokesperson added: “The PHN has not been directed to, nor has access to, any other PPE items other than P2 and surgical masks.”
Lack of PPE can be a matter of life or death for front-line healthcare professionals, especially if they – or those with whom they live – are at a higher risk of severe illness from Covid-19.
“It’s a reasonably scary thing for us. I’m 72, I’m in the high mortality group,” says Lehmann.
In Dr van der Merwe’s Wagga practice, an elderly doctor recently announced he would have to retire due to the risk of passing Covid-19 to his wife, whose pre-existing health conditions put her more at risk if she contracts the virus.
Professor Angus Dawson, director of Sydney Health Ethics at the University of Sydney, has been working with the World Health Organization since February to research and write guides for healthcare professionals on the ethical dilemmas they could face during the Covid-19 pandemic.
He says creating a rational, systematic way of allocating limited resources is one of the biggest challenges.
“I’m thinking about what a healthcare professional does if they are in a situation where they themselves are not just putting themselves at risk, but an increased risk, what they would normally consider an unreasonable risk because they don’t have gloves or a mask,” he says. “Does that cancel out the obligation for them to respond to society, the needs of the patient?
“In what circumstances do you prioritise your own health over that of the patients?”
It’s a question Dr Chris Moy, the Australian Medical Association’s legal and ethics committee chair, is also trying to answer. “There are three competing concerns for doctors: the patient in front of them, other patients and themselves,” he says. “It’s not possible to force people to run into a fire.”
For those healthcare workers on the front lines in regional Australia, the reality is the choice may be made for them, with many fearing the healthcare system outside major cities won’t be able to cope should staff have to self-isolate while being tested for Covid-19.
“The government has not considered regional towns,” says Moy. “If you have a two-doctor practice and one or both doctors goes down, we don’t know what we are going to do.”
A spokesperson for the Western NSW Local Health District told The Saturday Paper the NSW government is putting an extra $700 million into NSW Health, part of which is going towards “doubling the state’s ICU capacity, as well as boosting other critical-care resources and equipment that can help us manage significantly unwell patients”.
But Dr Sullivan says this aid is not reaching already under-resourced and underfunded rural and regional healthcare systems. “On the news they are saying, ‘It’s okay, the government has got you. We are delivering PPE. We are providing extra services.’ But it is not coming to the bush.”
In Coonabarabran, Dr Iannuzzi says urgent action needs to be taken before the virus reaches rural and regional areas, including locking down communities and providing rural hospitals with higher-level equipment such as ventilators and ICU drugs.
“I think the government has failed to appreciate the magnitude of this,” he says. “The smaller the town, the more concerned I am. Basically, any town that does not have intensive care capabilities is going to be vulnerable. It’s a roll of the dice: if they get a spike, they are in trouble. I’m hoping we get lucky.”
This article was first published in the print edition of The Saturday Paper on Mar 28, 2020 as "Intensive scare".
A free press is one you pay for. In the short term, the economic fallout from coronavirus has taken about a third of our revenue. We will survive this crisis, but we need the support of readers. Now is the time to subscribe.