'Just so hard': how Melbourne's medical staff took on the Covid wave
There is only one Covid-19 patient left in Melbourne’s St Vincent’s hospital, where intensive care physician Dr Barry Dixon works. He still finds it hard not to focus on the bad days he experienced during the peak of Victoria’s second wave when upwards of 60 patients were in the facility.
At one point, a person he knew well was admitted to the intensive care ward, their lungs struggling, and Dixon worried about their prognosis. They pulled through, but he says it was a traumatising time.
“I think our hospital did a really good job overall, and there were highs and lows and definitely bad days, and at the moment I still think a lot of the bad days,” he says.
“I wouldn’t say I feel euphoric or have had time to reflect on how well we did and the fact things are much better yet.”
Doctors, nurses and other health workers in Victoria experienced Covid-19 in a way their interstate colleagues didn’t – by mid-August they were managing upwards of 650 Covid-19 patients across the state’s hospitals, including more than 40 in intensive care. There were days when people died in the dozens. By 17 August, 25 patients died in just 24 hours.
But the gruelling second wave also gave health workers an opportunity to learn about the virus, to do their own research, and to apply research coming in from global studies.
Late last year, Dixon and his colleagues completed a world-first study of more than 250 patients across several hospitals examining whether the blood-thinning drug heparin, when administered as an inhaled gas, assisted patients with lung injury and pneumonia.
The study, undergoing peer review for publication in the journal the Lancet Respiratory Medicine, found those given heparin were less likely to get a condition called acute respiratory distress syndrome.
The development of pneumonia and respiratory distress in Covid-19 patients is a significant risk factor for death. Buoyed by the positive results in previous pneumonia patients, Dixon began trialling the inhaled gas form of heparin on severely unwell Covid-19 patients at St Vincent’s and at the Northern hospital in Epping, which was also treating a high number of Covid-19 patients during the peak of the second wave.
He says it was too early to say what he found, because more patients were needed to strengthen the data. Dixon is in conversations with hospitals worldwide about continuing the study in their hospitals now that Victorian cases have lowered.
“The thing about any problem – and Covid is a big problem – is you want to solve it,” Dixon says. “But you need to do research when something is big and new like Covid, you can’t just keep doing what you did previously. When Covid came along some of us did an internal groan on the ward and asked, ‘Are we really going to do another study?’ But there is no other way. You need to do research and understand it, and wait and get good results.”
But when it came to the extremely sick patients that he was treating in intensive care on ventilators, Dixon says it also paid sometimes to go back to basics and not get distracted by new theories about treating the virus.
“There is so much discussion in the medical literature of the different aspects of treating Covid, which in some cases … risks introducing a lot of variability in the way people are managed, and I just think we have to be very careful about that,” he said. “Even in a pandemic, there are many times where you should just do what you would normally would, stick with that, and do it well.”
‘A real emotional toll’
Another challenge faced by hospitals was the furloughing of hundreds of staff infected with or exposed to the virus. For this reason, Dr Georgina Cunningham, a gastroenterologist, offered her services to the hospital’s general medicine unit early on in the pandemic.
Cunningham returned to Australia in March after doing a gastroenterology fellowship in London, taking up a position in the specialty at St Vincent’s. Her plane back to Melbourne was full of cruise ship evacuees. She and her husband got tested for the virus after landing in Melbourne, and both were positive.
While it is still unclear how long immunity after recovering from the virus lasts and how strong that immunity is, Cunningham believed she should be at the frontline of the hospital’s response because she would be more immune than most.
“I had seen colleagues in the emergency departments in the UK and how quickly hospitals were overrun there, and I worried a similar thing might happen here,” she says.
“I thought it would be better for me to see these patients than someone never exposed, so I got permission to put my gastroenterology work aside for a time and work on preparing for Covid.”
Initially, before the second wave hit, much of her work was assisting with logistics, preparing for what might happen. And then Victoria began to experience a second wave.
“I think we were all waiting for it to happen but when it did it was nerveracking,” Cunningham says.
“We also didn’t get much warning when the nursing homes started to be evacuated and so the numbers of patients also exponentially grew within a couple of days. When numbers grow that fast it’s very hard to adapt, even with good planning.
“There was a lot of staff furloughing as well; we didn’t have staff to call upon. It was also just so hard,” she recalls.
“If you have 60 Covid patients that’s 60 families that need to be contacted every day at a minimum because they can’t see their loved ones, and that took a real emotional toll on the frontline staff who were sometimes also delivering awful news.”
What surprised her was that so many of the elderly patients who were asymptomatic turned out to have Covid.
“For a time, most screening was done in patients and residents who were symptomatic only. But many patients don’t get really sick until the second phase of the virus, which occurs after about a week of what can be mild to no symptoms.”
But thanks to research from parts of the world that had grappled with the virus earlier than Australia, Cunningham adds, there were treatments at the disposal of staff not available during the nation’s first wave of the virus.
In July, just as Victoria was entering its second wave, the preliminary results of the UK’s RECOVERY trial were published in the New England Journal of Medicine, providing evidence that treatment with the corticosteroid dexamethasone reduced deaths by up to one-third in hospitalised patients with severe respiratory complications.
“We had all these ventilators in storage that we thought we would need to use, but we found that it was the general ward really where the burden was,” Cunningham says.
“We used dexamethasone in people with severe illness, which kept intensive care admissions down. The other thing we used was the prone position, which involves getting patients to sleep on their tummies in intensive care. You usually do it in awake, non-intubated patients but it increased patient oxygen levels well so our physiotherapists adapted it and repositioned patients all the time, especially those with mobility issues.”
Very different to other states
Prof Kirsty Buising, an infectious diseases physician, led the Covid-19 response at the Royal Melbourne hospital (RMH), which was among the hospitals to receive patients from Victoria’s embattled north and north-west corridor, identified as virus hotspots early in the second wave. It also meant hospitals like RMH and the Northern were receiving the majority of Covid-19 patients.
“Victoria’s had a very different experience to other states, and I would even argue that the north-west region of Melbourne has had a very different experience to the rest just based on the intensity, the absolute number of patients who we were having to deal with,” Buising says.
What struck her was how much every staff member at the hospital mattered during that time, no matter their speciality. Everyone had to share their expertise and work as a team, she recalls.
“We were all banding together. There was an incredible sense of teamwork and really we just knew that no individual, no specialty group, was going to manage this alone and that’s been a really strong learning here.”
The hospital was treating 99 Covid-19 patients at its peak. Now that the situation has eased, Buising and her colleagues hold meetings with hospitals in other states, sharing the lessons they have learned in case another wave of the virus emerges elsewhere.
But the impact of working through the state’s second wave – dealing with sick and furloughed colleagues, exhausted staff and anxious families – would stay with her for a long time.
“We’re all just learning how to stand down,” Buising says.
But “there is this concern that we don’t want to drop the ball too quickly because it might take off again. We are just trying to keep some degree of readiness in case of the worst”.
I had seen colleagues in the emergency departments in the UK and how quickly hospitals were overrun there
Dr Georgina Cunningham