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Prof Grant Schofield talks to PreKure’s Registered Nurse, Sonya English, about her reality as an intensive care nurse, and what you can do today to help stop the exponential growth of COVID-19 cases in New Zealand.
“We have the advantage of experience globally. We are seeing today what’s happening in Australia, where cases are doubling over 24-hour period. And it is our opportunity as New Zealand citizens and healthcare professionals to proactively flatten that curve. It could save thousands of lives.”
Grant Schofield: Hi there, everyone. Professor Grant Schofield on a PreKure COVID-19 update. Here with Sonya English, who is part of the PreKure Faculty. Sonya, you’re an intensive care nurse and you have been for a while. What does that look like and why is that important in the current context?
Sonya English: I’m currently a critical care outreach nurse, or nurse specialist, and I have worked in the intensive care environment for nearly 30 years. I feel, just as a lot of my colleagues do at the moment, that looks like a really scary place to be. We know about COVID-19, we know what’s happening globally, and I know that we will bear the brunt of those extremely sick patients with multi-organ failure, who are needing life support. So yes, at the moment it’s a very tenuous time.
GS: So some people are going to get this illness, and estimates are between 20% and 70% percent of the population, we’re not sure. How rapidly we get depends on what we do. We could have a steep spike with a lot of people, or a slow burn with less people over a longer time. So, we talk about flattening the curve. Some people will get it and not even know they’ve got it, they’ll be asymptomatic. Some people will have mild symptoms. Some people will have more serious symptoms, and some people will have severe, life-threatening symptoms. Why is that, that people are so different?
SE: They’re different because of their health. In New Zealand – as many countries globally – we have many people in the community, rising numbers of people with chronic illness. Chronic illness, such as diabetes, dementia, heart disease, renal disease, cancers. Often it’s thought that it’s just affecting elderly people, but that that is not true. It’s increasingly, over my career, younger and younger people, getting down to as low as 20-year-olds with end-stage heart failure. So I think it’s important that we know that those people in the community are very vulnerable.
GS: So we talk about age as being the risk in the elderly, but, actually, it’s just probably that more older people have more chronic conditions.
SE: That’s right. That aging process. However, I’m seeing a lot of young people with comorbidity and that’s really frightening.
“We’ve got 176 ICU beds countrywide. And in Auckland we have somewhere around 80-90 adult beds.”
GS: The Head of ICU at Middlemore Hospital is describing the upcoming scenario, depending on how it plays out, as possibly catastrophe medicine.
SE: That’s right.
GS: What does he mean by that and why does he say that?
SE: He says that because of the figures that we’ve had from Italy. That exponential curve just going straight up. And what we know, if we look at the population of Auckland being two million people, if we get a 20% COVID-19 rate, we’re going to get approximately 750 people wanting ICU beds per week over a four month period.
GS: So hang on. That’s at the low end, right?
SE: That’s at the low end.
GS: …20% is the lowest expectation and 16 weeks is a long play-out.
SE: Isn’t it?
GS: 700 beds a week for ICU. How many do we have?
SE: We’ve got 176 beds countrywide. And in Auckland we have somewhere around 80-90 adult beds.
GS: And they have people in them already.
SE: They do. We’re heading into flu season. We have a lot of people with things like sepsis, which is overwhelming infection from the co-morbid state, from the chronic illnesses, already. And although we’re never at capacity, we try to not be capacity in ICUs, to have a bit of slack, or anything that happens in the community, there’s often not a lot of leeway.
GS: So that’s at the best case and it gets worse from there. If we had 70% of us get this with a 3% hospitalisation rate and we’re headed over, not a four-month period, but a two-month period, things could go rapidly south from there.
SE: That’s that catastrophe scenario that they’re seeing in Italy, where they’re having to make some very strong ethical decisions.
GS: And what do you mean by strong ethical decisions? What does that mean at the front line?
SE: Well, I guess part of the oath as healthcare professionals is doing the most amount of good for the most amount of people and I think that in catastrophe mode, we’re not going to be able to meet that. We’re going to have to care for, in the intensive care environment, those that are clinically well, previously, and that we can make some difference to, but for many we will not be able to ventilate them, put them on breathing machines. The chance of actually retrieving a quality of life or saving them from death is very low. We’re not going to be able to do that, so we’re just going to have to make those tough decisions. We’re going to have to triage and find the people that we can save and it’s not going to be that many.
GS: It means there are wards full of people, or they’re sent home, or what is that even going to mean?
SE: I think there will be, in some cases, wards full of people, isolated to certain parts of the hospital. However, you’ve got to think of ICU beds and beds in terms of staff that can man them. We’re going to have staff that are self-isolating because they’ve got COVID-19. I know that in some of the hospitals in New Zealand, already, we’re 25% down because of people self-isolating. So we need people to care for those patients and be able to triage those patients, as well as specialists that work in intensive care -specialists nurses and doctors – that can man the machines and the ventilators and actually have the skill.
“The beautiful thing is we have an opportunity now to do something about this, right now.”
GS: So, it doesn’t have to go this way. That’s what we’re saying, right? We’re not Australia and we’re not the US yet.
SE: That’s right.
GS: And so, what we would need to do as a community is take serious and severe measures which our government is directing us towards. What are those?
SE: I think that we have the advantage of experience globally. We are seeing today what’s happening in Australia, where cases are doubling over 24-hour period. And it is our opportunity as New Zealand citizens and healthcare professionals to proactively flatten that curve. We can do things such as, when we’re asked to self-isolate, to do that vigilantly, to understand what that means and put ourselves in self-isolation if we show any signs of colds, flus, being unwell altogether.
I think it’s about social distancing, making sure that you’re not attending any events with large amounts of people, not going to the movies – all those things that we do in daily life that are not necessities. We know about coughing and sneezing etiquette. We won’t be in the community if that’s happening. And also really effective hand washing techniques, looking at the World Health Organisation guidelines, wiping surfaces for 20 seconds or more, being really careful when we’re together with other groups of people for work that is necessary – currently, that we are trying to stay at least two meters away.
GS: There’s evidence from some of the Asian countries, a bit of civil obedience and actually doing this makes a massive difference. Flattening this curve will save hundreds, if not thousands.
SE: Thousands. I think Grant, it’s definitely thousands. I think that this attitude of ‘it’s not going to happen to me’, which often happens in health, it’s why we’re actually unable to reverse that chronicity of illness, but I think in this case we need to listen, we need to be vigilant and we need to do it today.
“We always talk at PreKure about prevention is cure. Never has this been more relevant.”
GS: For our PreKure whanau out there, take care, be civilly obedient and this is your chance to make a difference to your community. We’re not trying to alarm people. This is not a ‘shock and awe’ technique. This is just a basic reality check of what is and where we are now. And the beautiful thing is we have an opportunity now to do something about this, right now.
SE: And you know, Grant, we always talk at PreKure about prevention is cure. Never has this been more relevant.
GS: Sonya, one last thing that we didn’t talk about is schools and universities. What’s your opinion?
SE: They need to be closed today. We’ve talked all the way through this interview about prevention is cure, about that we have a chance to flatten this curve now. So I think for me it’s a no-brainer, close them for two weeks, and let’s knock this thing on the head early.
GS: The worst possible outcomes from being too strict on this are economic and a little bit of education, which we can fix up. The alternative to that is catastrophic. So I agree with that. I would call for that, for them to be closed.
Move vulnerable people to places where they’re going to be safer. Why would you wait until there is community transmission to send the kids home? Then they will be transmitting.
SE: We know they’re good portals for this disease. And trying to get children to be A1 with hand-washing and all of the social distancing, it’s near impossible.