THE summer of 2020–2021 was relatively normal across Australia. Victoria entered further lockdowns in February and May 2021 as the first cases of the Delta variant of SARS-CoV-2 emerged. In August 2021, Victoria, which had seen the most deaths (1346) and days in lockdown (185) of all Australian states, entered its sixth lockdown in response to six cases of COVID-19 caused by the Delta variant. Unlike previous lockdowns, case numbers continued to rise, with more than 1000 cases per day routinely reported throughout October.
As a part of the pandemic response, the Alfred Hospital, a quaternary trauma centre and a designated extracorporeal membrane oxygenation (ECMO) site with 638 general ward beds and 45 intensive care unit (ICU) beds, was designated a COVID-19 streaming hospital by the Victorian Government. That status meant the hospital would accept any adult patient who needed high acuity treatment for COVID-19 from other hospitals in the state.
Preparation and risk mitigation
Throughout all lockdowns, surgical teams split both consultant and junior staff into various subteams to avoid cross-contamination and ensure the continuity of care if staff were furloughed. Although each unit’s arrangement was unique, typically one subteam would cover the wards and attend theatre, while the alternate subteam would focus on outpatients. Swapping roles after each week, this arrangement minimised face-to-face interactions between subteams while still providing routine patient care. Although this worked well, it limited the flexibility of redistributing workload among the junior staff, such as when the number of acute inpatients was high, and also reduced clinical learning opportunities.
In previous lockdowns, the hospital’s resources had not been overwhelmed. Yet it was apparent from the infectivity of the Delta variant that this was not to be the case in the sixth lockdown. Wards and other spaces were reclaimed for COVID-19 beds, while the emergency department (ED) and ICU increased their geographic footprint by claiming new clinical space as their own. To staff this extra capacity, hospital departments redeployed junior medical staff (JMS) to these COVID-19-focused and critical care positions, including ED, ICU and the COVID-19 wards. With restrictions on elective surgery and community lockdowns reducing trauma admissions (here and here), junior surgical doctors, such as myself, were among the first to be redeployed.
In Victoria’s second lockdown (July–October 2021), JMS were redeployed to COVID-19 teams in small numbers. The sixth lockdown, which began on 5 August 2021 and coincided with the Delta and Omicron outbreaks, required large-scale redeployments to meet the significant clinical demands.
Each week, 22 JMS were required to staff the COVID-19 wards, with a further ten JMS redeployed to ED and eight to ICU. This represented almost a quarter of all JMS at The Alfred. To minimise the adverse impact on the JMS’s surgical career progression, the hospital redeployed more JMS for shorter periods.
Redeployment was accompanied by a plethora of communication and resources to upskill the JMS for their new role. These emails, video tutorials and online meetings detailed treatment guidelines, eligibility criteria for specific COVID-19 therapies, refreshers on donning and doffing personal protective equipment (PPE), and protective airway techniques.
Five COVID-19 ward teams were established to care for patients across three wards. During the most daunting overnight shift, a lone junior doctor was rostered to provide care for patients with COVID-19 in all three wards, as well as providing phone advice to peripheral hospitals and admitting newly diagnosed patients.
A surgical trainee in a COVID-19 medical team
Before starting my first shift of a run of seven nights, I was apprehensive. While the communication, guidelines and refreshers were helpful, I had not worked in internal medicine or critical care for 2 years and was full of self-doubt about my ability to manage patients with COVID-19.
At that stage there were over 21 000 active cases in Victoria, with 695 in hospitals. Of these, 157 were in ICU and 101 required a ventilator. The Alfred had over 60 COVID-19 ward patients and dozens in ICU.
Each night began with a handover among the medical staff and a phone call to the nurse-in-charge to identify deteriorating patients. The shift then proceeded at breakneck speed – up to 14 admissions a night (each typically requiring 45 minutes to clerk), countless reviews of patients with escalating oxygen requirements, and prolonged medical emergency team calls for hypoxia and tachypnoea.
As a surgical resident, I rarely had to manage such rapidly deteriorating respiratory patients, but now I was in a position of troubleshooting patients with high oxygen requirements, attending code blues and declaring deaths. The learning curve was steep. To help me push through these intellectually and emotionally challenging moments each shift, I had to draw on my broad experience from prior rotations, especially the medical and critical care rotations during internship, which provided the foundation and skills that were invaluable to safely manage these patients.
Although we felt out of our depth as surgical JMS looking after very ill patients with COVID-19, we were well supported. Overnight, the medical and ICU outreach registrars regularly checked in and were available to review concerning patients. The consultant on call was always accessible. Like any ward, one of the biggest sources of support were the nurses, who were quick to identify deteriorating patients, escalate concerns and arrange prompt telehealth reviews. These technology-facilitated reviews via an electronic tablet on the ward allowed the medical staff to preliminarily assess the patients virtually and prescribe interventions or investigations that could be instigated by the nursing staff. This practice helped to minimise delays to treatment and limit trips in and out of different COVID-19 wards. This not only saved us time and energy donning and doffing PPE but also led to better patient care, allowed a more efficient workflow, and reduced the risk of infection transmission.
As the weeks passed, I felt more comfortable in this role, or perhaps uncertainty became the new normal. Seeing the magnitude of death and suffering during these shifts, I could not help but wonder if there was more that we, the JMS on the ground, could do for these patients?
Ending the night shift with the virtual morning handover was not only an excellent way to discuss cases from overnight, but it also helped ease our insecurity. By taking these learning points, and that little bit more self-confidence, we continued to strive to provide each patient with the best care.
One of the greatest challenges working with COVID-19 patients was informing family members of their loved one’s deterioration or, worse, death. The grieving process of the family and friends was made even more traumatic by the strict visiting policies that limited the number of visitors and the time they could spend with their loved one. When patients were alone in the isolation room, we helped families share their final moments by video chats. It was a privilege both to witness this private moment and just be a presence in the room.
Just as great a challenge was communicating with patients who were COVID-19 deniers despite being admitted with COVID-19. Medical staff discussed how best to approach these patients. I am not sure we found the answer.
Like the deteriorating patients, I found it best to treat them with dignity and compassion and hope to make a difference.
In both these situations, medical staff were in a privileged position to offer our patients more than medical knowledge. Empathy is an essential quality of being a physician, regardless of their specialty. The ability to understand the emotions our patients feel and establish a connection with that patient may be our greatest skill.
All health care workers who treat patients with COVID-19 consider the risk of contracting a SARS-CoV-2 infection. While there was a real risk of getting COVID-19, staff at The Alfred are in a fortunate position of being fully vaccinated, and there is high vaccine uptake in the community that we serve, with 92% of people aged 16 years and over double vaccinated by December 2021. Additionally, staff have access to adequate PPE and are able to treat patients with COVID-19 in re-designed negative pressure rooms. Many colleagues elsewhere in the world have not had this level of protection (here and here), nor the benefit of well developed evidence-based guidelines to support their clinical decision making.
Although redeployment led to diminished specialty experience and lost learning opportunities, my career plans have not been disrupted. Other JMS have not been as fortunate. Some have been unable to apply for the Royal Australasian College of Surgeons’ training programs for 2 years running, as they did not fulfill the prerequisite time in certain surgical rotations and struggled with references due to the lack of contact hours with consultant surgeons over these 2 disruptive years.
While acknowledging these concerns, and the stress this may place on JMS, we also see the learning opportunities – the opportunity to work closely with critical care colleagues and care for critically ill patients. Through this process, I feel that we became better physicians and communicators. I also feel that whatever sacrifices we had made to our surgical training promoted patient safety.
There is no doubt that people who undergo an intense experience together form a very special bond. In time, I may forget the exact indications for sotrovimab or an inspiratory hold, but I will not forget the comradery that was forged among the junior doctors I worked with, either as a “split” surgical team or caring for patient with COVID-19.
Dr Dominic Maher is with the Monash University Endocrine Surgery Unit at the Alfred Hospital in Melbourne.
Acknowledgements: Dr Maher would like to acknowledge the assistance of Professor Jonathan Serpell and Associate Professor James Lee in the writing of this article. He would also like to acknowledge Professor Wendy Brown, Director of Surgical Services, Alfred Health, for leadership, wisdom and guidance during the COVID-19 pandemic, and her insight and thoughtful advice during the preparation of this article.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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