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DR LI Wenliang, the whistle blower ophthalmologist who presciently warned about the outbreak of COVID-19 in Wuhan, died on 7 February 2020 after being infected with SARS-CoV-2. Dr Li, a healthy 33-year-old with a wife, young child and another on the way, worryingly did not fit the profile for adverse outcome of respiratory and multi-organ failure requiring critical care support. He had no high risk features of old age, chronic illness or advanced malignancy.
Of 52 critically ill adult patients with SARS-CoV-2 pneumonia admitted to the intensive care unit (ICU) of Wuhan Jin Yin-tan Hospital between late December 2019 and 26 January 2020, the mean age was 60 years; 40% had chronic illness, and 61% of patients were dead at 28 days. The duration from admission to ICU to death was a brief 7 days, with the fatalities being older (≥ 65 years), with seven of 10 requiring mechanical ventilation. Patients aged 65 years or over with comorbidities faced grim outcomes.
Of 83 731 clinical doctors registered in Australia in 2015, only one in four was aged 55 years or over, with the average age being 46 years.
Should the medical and nursing staff battling the surge in health care demands of a World Health Organization-declared pandemic be assured that each of us, on average 46 years old, will only experience minor illness should we contract COVID-19 from hourly and daily patient care and screening?
Should colleagues over 65 years with comorbidities be occupationally released as they suffer the impost of greater than two in three risk of dying if they contract COVID-19 and require admission to the ICU?
The March 2020 UK Health Secretary “battle plan” to roll-out emergency registration of retired health professionals to allow them to come back to work in the National Health Service (NHS) is like needlessly sacrificing lives to fight a dangerous war, when our older at-risk doctor colleagues are dealt such appallingly hazardous odds.
As a frontline emergency specialist of younger “vintage” (a healthy 50 years old), I am relieved that of 346 Guangzhou Chest Hospital COVID-19 cases, only 58 (16.76%) deteriorated to being severe, with a single death and no infection among medical staff. Deceptively, however, the average age of this good outcome patient cohort is a relatively youthful 38 years old, 8 years younger than the average Australian doctor in 2015.
Personal protective equipment (PPE) being worn by doctors and nurses manning the fever clinics that have sprouted into life seemingly overnight confer only physical isolation. PPE doesn’t insulate against worry about repeated COVID-19 exposures when a patient gags or coughs while I collect oral- and nasopharyngeal samples for testing. Hourly and daily encounters add up to a cumulatively high threshold, and I know I am not overreacting when even Westmead pathologists with no patient clinical contact are writing about assessing their sample disinfection procedures.
I know that despite my prospects of doing well in the unlikely event of cross-infection, it is only being human to be anxious during Australia’s chaotic surge to pandemic threat, paralleling the intense psychological stress Wuhan’s medical staff endured when that vast nation led the coronavirus infection census during January and February 2020. Up to a quarter of China’s infectious disease clinicians suffered high self-rated anxiety and post-traumatic stress during their peak surge, if the results of a survey at a single tertiary infectious disease hospital can be generalised.
As an Australian emergency physician deployed to screen for and treat potential COVID-19, I am convinced that the gravest single point cross-infection hazard I will have to face is exposure to aerosolised respiratory secretions of critically unwell infected patients when instituting non-invasive ventilation and, even worse, during intubation (here and here).
Frontline clinicians, most so in fever and GP clinics, emergency and critical care areas, remain at highest risk of COVID-19 exposure. However, we’d do well to remember traditional “no patient contact” specialties that also require caution against cross-infection. As COVID-19 diagnoses require chest x-rays and computed tomography chest scans, radiology staff need to remain at heightened vigilance with infection control protocols and practice.
Fear of contagion has in the past, during the SARS outbreaks and the H1N1 outbreak of 2009, led to staff social isolation and intentional absenteeism. Clinicians that turned up for work had to cover for colleagues missing in action. Even without the COVID-19 pandemic, hospitals and clinics would be gutted if doctors stayed at home with minor illness and injury. Battling on through illness and not letting the side down has traditionally been seen as a positive attribute, with taking time off seen as a weakness.
Doctors are wary about their absence forcing increased workload on their peers and view themselves as being difficult to replace at short notice. They are afraid of negative effects on career progress of using sick leave entitlements. In order for doctors who are sick or stressed to take time off work without feeling guilty about appropriately taken absenteeism, hospitals and clinics need to set up contingency plans that can be implemented at short notice to make up for unplanned shortfalls in clinical staff.
Clinicians should not be subjected to the acute stresses, physical and psychological toll exacted by having to compensate for our absent peers. In order to look after vast numbers of infected patients, the medical community and their worried family members facing cross-infection risk need support for psychological distress.
The additional staffing requisite to maintaining essential clinical services when we need time off to recuperate or have imposed absenteeism to adhere to quarantine regulations is critical. We need to look after the physical and psychological wellbeing of coalface clinicians to enhance the health system response to this pandemic.
Dr Joseph Ting is an emergency, prehospital and aeromedical physician as well as adjunct associate professor for clinical research methods and prehospital care at Queensland University of Technology’s School of Public Health and Social Work and Clinical Senior Lecturer in the Division of Anaesthesiology and Critical Care UQ.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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I’m a nurse talking with my infection control hat on. I cringe when I see nurses with no hair covering and very little in the way of face covering, swabbing throats and noses through car windows . Having a throat swab done makes people gag, cough and vomit. If that person coughs droplets on the nurses’ hair/faces, the nurse could fall victim to COVID – 19. Droplets from a cough can travel 6 metres and from a sneeze 8 metres.
I’ve been told to minimise face to face contacts and do as much consulting by phone. I’ve been told to not wear PPE or masks in the community. I’ve been told there are no showers for available for staff at the end of shift, and I can’t access wipes to clean my desk, phones and other equipment. As a 63 YO T2DM with paroxysmal AF I have my doubts at being able survive this pandemic, and most of my clients will be victims of the virus rather than their pre-existing illness
Does Australian health authorities have this Emergency Registration for former medical practitioners or GP’s willing to go back to work in the community health workforce, to help, support and contain this pandemic virus?
Some recent former medicos willing to take the risk and stop the spread of this contagion, but don’t know whom to contact or enquire about emergency registration- if there is such one by DHHS or AHPRA??
At first I agree with the author’s opinion and comments in the discussion. Particularly important and applicable is the practical recommendation expressed as “all drs/nurses should treat everyone as potentially infected – so must wear PPE AT ALL TIMES”
Concerning general policy: I work in onco-hemataology and bonę marrow transplant clinic and I believe that a strategy should be set up for patients with acute leukemia, malignant HG lymphoma and similarly aggressive cancers. Treatment of these cancers cannot be delayed. This raises the question of what strategy is better:
1) – separate hemato-oncological departments for Covid-19 positive acute malignancies , or
2) – admit these patients randomly to all hematology / oncology / transplantation departments and isolate them within those departments….
Totally agree with Prof C Sense
Abysmally slow response from our Government appointed Chief Medical Officers – an absolute disgrace.
May I suggest offering and using pharmacists as frontliners? They always keen with prescribing medicine and antibiotics to ease congestion in GP clinics. They always voice their willingness to get involve in patient care from behind the counter in their stores.
Why don’t we get them to prove themselves now?
No better time for Pharmacy Guild to come forward!!
Swab on, my fellow pharmacists health workers!!
Agree with Anon’s comment, all drs/nurses should treat everyone as potentially infected – so must wear PPE AT ALL TIMES.
Why are we not testing more people? The town of Vo in Italy has stopped the spread by testing everyone. Why isn’t there an Australian made test? Why aren’t factories being retooled to make PPE? Why aren’t booze distillers making hand wash? Why aren’t people being advised to wear a mask when out? Why why why?
Have been saying that we as a nation needed to take this more seriously from Jan when we had our first case. But have always been beaten back with “we don’t want to frighten the population”. So fast forward 2 months, we have a nationwide shutdown but most importantly a government that is so far behind the curve it’s negligent. Experts like Bill Bowtell, John Dwyer who led Australia’s AIDS/HIV efforts have been coming out to say we should be doing more but the government has done nothing. Medical and nursing staff should not be paying the price for the government’s mistakes. The government’s so called “top medical expert advisers” should just resign and allow people who can make the hard decisions do it. The anxiety is not just for health workers’ own health, it’s also they can bring it home to their families. Have hotels or similar been requisitioned so HCW can self quarantine there? NOTHING has been done. The government appears to have been caught by surprise by this disaster despite having had at least 2 months to prepare as well as an evolving situation in Italy that gives a very clear view of the future awaiting Australia. Took a wait and see approach to a prevention problem. Now taking incremental actions when what we need is decisive emergency action. Incompetent, negligent, late. Hoping actions are not TOO late.
We would wear full PPE & masks if we had any…………………………………..
What masks!
We were given a single box of 50 surgical masks, and made to feel like Oliver twist when we dared ask for more.
No doubt that reply was typed from the lounge room of the PHN person, who was working from home to avoid contact with her (non-clinically exposed) colleagues.
I’m 57 with Paroxysmal AF, my reception staff in their 60’s, one cares for her live-in 97 year old mother.
We are cannon fodder!
All front line health workers should be in full PPE, not just fever clinic staff. Note presymptomatic and mild presentations of COVID-19.
All GPs in clinics should wear masks at all times.