Postcards from the edge

Postcards From The Edge was a series of short reflective accounts written after the start of the COVID-19 lockdown period and originally published on ‘Leaning on Fenceposts’ (https://blogs.otago.ac.nz/rural). Each piece was written by someone who works in rural New Zealand.

Rory is a rural doctor who is working at Thames Hospital.

The birds are louder this week.

Ending the first week of the COVID–19 lockdown proper, although still feels like a prelude. We have done a lot of talking. So many emails. Not many patients.

At least two cases of COVID–19 confirmed pneumonia have been admitted to a rural hospital. A DHB [District Health Board] freaked out. Interesting. Sanity prevailed after several hours. The patient stayed for a few days. The patient deteriorated and was transferred. This went smoothly. Surprising.

People have stopped coming to hospital. Seemingly unnecessary investigations have stopped – this seems to have been accepted by patients.

Some DHBs have become more helpful and communicative. Some are visiting rural health services, some are building negative pressure rooms. Most are talking to us and some are listening.

Others…

The birds are louder this week.

The kids are at home. Our bubble is huge. It still hasn’t rained.

The city seems to have come to the beach for a ‘holiday’. Anxiety over how we will cope if they get sick. The DHB didn’t make a statement. Mayoral pleas didn’t make the mainstream media. Road blocks and dynamite?

The birds are louder this week.

Maybe it will rain tomorrow….

I hope we stayed home early enough.

Clare is a rural doctor from Rawene in the far North, where she has been based for almost three decades

The end is where we start from

In Hokianga cultural memory is long and buried deep in the grain of its people. One hundred and two years ago there were mass graves and no ceremony as the flu epidemic reached and brought mortal sickness to our communities. Today there are memorial stones to mark these places.

Today we expect that one hole will hold the one who has succumbed to this new virus. We know that there will not be time for traditional tangihanga. We know that only one or two home people will be there to say farewell on behalf of the whole whanau community. We know that tears will fall in a hundred homes and there will be a sense of something incomplete.

Already in our hospital we have had one such farewell - not a victim of the infection itself but a casualty of the shadow it has cast over all of us.

Cultural memory has brought up the past and so it is not difficult to pass by a friend and know that the physical distance between us is a mark of the respect and manaakitanga we have for each other.

The past is always with us in the faces of this generation and this generation looks back and calls back to its ancestors and walks forward in the knowledge that it is possible to learn from that time in 1918 when what we knew and the ways we could respond were so much less.

As always, we acknowledge that which is greater than we are.

Noho ora mai I roto I nga ringa o Te Atua.

Brendan is a rural doctor on the West Coast working in primary and secondary care

On Wednesday night I finished War and Peace. It’s a book I’ve always wanted to read and had finally got round to getting started at Christmas. I couldn’t help musing how the world of work, and indeed so much we take for granted, had changed in that three-month period. Part of the book’s beauty is watching the characters endure extreme experiences and emerge at the end as changed people. It has felt, needless to say, like many of us are on such a journey ourselves.

Across the country you will have caught up with the news that it was Greymouth Hospital where the first COVID death has occurred.

So what lessons can we add for those of you across the country holding the rural health system together?

1. Trust your intuition. COVID was suspected on admission in the Greymouth patient. The case was de-escalated on the basis she didn’t meet case definition and would ‘be an unlikely index case’ following advice from Christchurch.

2. Remember the old adage in rural health: you know more than anyone else about your patient ‘at that moment’ because you are the one providing the care, whether they are in your clinic room, hospital or ED.

3. Have your COVID environment ready to go now! We’d ‘planned’ and talked about it but were falsely reassured as we only had one positive case and often feel isolated on the coast. Well guess what happened - the second case!!

4. Practice PPE. Practice PPE. Not just intubations or arrests but the patient journey from front door to back.

5. Keep communication pathways clean to avoid duplication and mixed messages.

We will emerge from this crisis.

As a network of rural clinicians we must be heard and be the advocates for our patients and health services.

In Tolstoy’s epic there is a strong message about leadership. It’s not necessarily going to be about us leading our teams with a logical plan, but adapting to the flow of events and thinking on our feet. None of us can control much outside our immediate sphere at the moment. But as rural practitioners we can remain connected. All the while we’ll continue to serve our patients, look out for our peers and ensure those we hold dear are kept safe and feel secure in uncertain times.

Keep safe everyone.

Philippa is a registrar in both the general practice and rural hospital medicine training programmes. She is working in Te Kuiti.

Life (and the coronavirus) is something that gets in the way while I’ve been busy making plans. Imagine the fuss of work: I am a Rural Hospital and GP Registrar in Te Kuiti), doing a paper, ramping up preparations for my StAMPS exam [Structured Assessment using Multiple Patient Scenarios: exit exam for the rural hospital training programme], I’m mothering a toddler, cooking the dinner, worrying what the neighbours think about my un-pruned Roses and the state of the Lawn. Then one Sunday the world changed and Monday was a very different place.

The thing about the separation between Te Kuiti and northern Italy being only a zoom chat away, is that the story of shifts filled with perpetual resus and death certificates seems like it can happen here tomorrow. Collectively this makes us scared, anxious, stressed. We lost sleep.

On that Sunday we met and made plans. We let go of our preferences to see patients in person, to examine them, to have that extra sense from their presence about what might be going on for them. We planned for testing, for treating, for the worst and for keeping our team safe.

On Monday our plans adjusted to fit the space. The medical centre and the hospital collaborated, made easier by us being both GP and hospital doctor. We learned how to consult over the phone. The patients stayed away from us. We made flow charts for ‘what to do if…’

At midnight on Wednesday (during my overnight shift) New Zealand locked down.

The fear and the rumours spread, often with a vector of misunderstanding. The CBAC [Community Based Assessment Centre] arrived. More meetings. We communicated. We supported each other.

On Thursday, on the way home, I felt lucky to be allowed to drive, lucky to be employed, disappointed to defer StAMPS, still mothering (and now without daycare), don’t care about the Roses, can’t do anything about the Lawn.

Now we wait for Ashley at 1 o’clock. We make arrangements to get groceries. We go for walks. We stand two meters away. We wear the PPE when out - flow chart says we should. We stay safe. We’ll be glad if the COVID bus doesn’t stop in Te Kuiti.

Emma is a Rural Hospital Doctor and Clinical lead at Hawera Hospital.

The cracks have always been there. For those working in rural health they are more visible now. We push forward for the sake of our patients, our rural workforce, our communities, flying the rural flag as we go.

COVID-19 has cracked the system. Hacked it, even.

Promoting rural health and rural hospital medicine in DHBs is a challenge at the best of times. With COVID-19, war mentality has ensued and at every level: clinical, managerial, collegial. Rural inequity greets us at the end of the pipeline. Policies and procedures written for us without any rural context. Limited resourcing to pull together our own. Musings of traffic light areas in our small facility. No resourcing for surge capacity. Local GP services disappeared from view, patients along with them.

Although, amazingly, the strangest things have happened without even really asking for them. Negative pressure rooms with something called an anteroom installed in a few days. No-one really understanding why they were needed, which treatments they enable, how we communicate to the outside world while in these industrial spaces and who, if anyone, is coming to retrieve our COVID-19 contaminated people.

No-one really likes change in our rural hospital at the best of times. COVID-19 forced it and the team have tolerated it to a certain extent. There has been unrest on the floor. Uncertain PPE restrictions.

Confusion.

Fear.

We watch from a distance as our fellow rural hospitals around the country are affected by positive cases of COVID-19 and we see the impact on their workforce and their services.

Then, among the anxiety, comes a sense of gratitude. We risk our health and the health of our families by working on the frontline but we have our jobs. We are essential and we are vulnerable, our bubble larger than most. A 2m distance difficult to maintain. We should consider ourselves the fortunate ones while our rural community of small businesses may be compromised. Wellbeing and mental health tested.

There is nothing like a crisis to re-evaluate the status quo. Positive initiatives could assist in moving us forward, if we choose to continue them after COVID-19 comedown. Increased efficiencies. Complicated resuscitation scenarios simplified. Flexible minds fine-tuned.

The after-effects of COVID-19 lockdowns are unknown. We are here for the long game but undoubtedly the cracks will remain but are hopefully connected around rural NZ until we can rise again.

Wilson is a medical student in the Rural Medical Immersion Programme (RMIP).

It was a year I had been eager to undertake ever since I had learnt of it in my second year of medicine. Like many, the Rural Medical Immersion Programme (RMIP) encapsulated different aspects of life that thoroughly appealed to me: integration into New Zealand’s rural communities, hospitals that are dominated by friendly faces (not endless corridors) with the freedom and independence to learn on my own terms, in my own time. My first four weeks had been some of the best I had experienced in medicine so far.

However, merely two days after returning to Blenheim we were all faced with the reality of a national lockdown and unprecedented, uncertain times ahead. This was a necessary decision that has undoubtedly saved lives and prevented widespread community transmission. With this in mind, it became a little easier to forget about the red stags roaring in the seaward Kaikoura range I had encountered on a tramp the week before.

During this time it has been a privilege working with my fellow students as they have used their differing backgrounds, knowledge and experience to ensure that others are not left behind in their learning. The friendly and uplifting atmosphere has been invaluable.

I was nonchalantly perusing Facebook the other morning when I stumbled across the following quote:

When asked if my cup is half-full or half-empty, my only response is that I am thankful I have a cup. – Unknown

Not normally someone to find meaning in white text overlaid on a stock image, this sentence seemed to weigh on me, given the current events. In the face of adversity and irreversible social change, I still have much to be thankful for.

That I, and those in my bubble are still in good health, alongside other family, friends and social networks.

That this lockdown has given me the time to work on myself and develop skills I’ve neglected for a time. A mission to see how many laps I could run around the block turned into a marathon. My homemade bread recipe has been tweaked, improved and reengineered. Kneading dough is a somewhat cathartic activity, I have discovered.

Although seemingly successful, we have not had an optimal medical response in this pandemic, with concerns regarding resource allocation and management. However, I’m also thankful for the collaboration and initiatives in the rural health sector in recent weeks. In such trying times, to see such widespread cooperation, advocacy and adoption of new technological practice in the sector is encouraging and opens many new possibilities for the future of healthcare provision in rural New Zealand.

Being able to find positive lights in such a dauntingly uncertain era will certainly not lift the darkness, but might make it just a little bit easier to see the way out, and what the future can hold.

Robin is an Australian trained rural generalist doctor. She works in Taupo in both community and hospital settings. She likes to dance.

They say it ain’t over till the fat lady sings but my ‘Corona Rhapsody’ playlist has never had so much airtime and isolation has seen a surprising surplus of cake and quarantini’s.

Did we miss a bullet? Was our overnight transformation to virtual general practice for naught? Do our hospitals owe the catalogue of in-actioned surge plans to a decisive pre-emptive strike from Sista J? Perhaps, but the truth is something way better.

The choice Kiwi’s made every day for the past months, to trust the information that their government was broadcasting, that this virus was real, it was deadly and transmission was preventable through physical distancing measures, was a gift that they gave each other and ultimately themselves.

We healthcare workers put ourselves on the front line at 10 times the risk of contracting COVID-19 in our duty to care for our community. Although there have been infections, we are mostly safe because through trusting the physical distancing messages, our community cared for us. Kei runga noa atu Taupō, well done. I would wrangle a pandemic with you any day.

P.S. don’t forget to wear pants on zoom.

Margaret is a GP at Queen Street practice in Wairoa and is also the clinicial lead at Wairoa Hospital

Seven weeks down the track and we are on our way out of Level 3 into Level 2.

A sigh of relief as we are itching to go fishing, hunting, cruise around Bunnings and Farmlands, have a meal in a restaurant and visit the pub in Mahia.

Living under Covid restrictions has not been easy but as we look back over time we marvel at the positive changes both in Wairoa Hospital and Queen Street Practice (QSP), who are housed together in one large building with the Laboratory, ward, midwives, outpatients, public health, mental health, District Nurses, the kitchen, all sprawled around like spokes of a wheel, also under the same roof.

Covid has been a great leveler in the community as we all queue together respectfully, keeping our social distance and chatting away with Mongrel Mob, Black Power and others while waiting to be allowed into New World to buy our groceries. The strangest masks and gloves hide people’s faces and hands.

The Mahia Dairy puts out free bread and milk on a Thursday and announces it is time to ‘come and fetch’ on our social page. Young people run around doing Meals on Wheels as the elderly are too at risk to perform this function.

People have been kind to each other in a myriad different ways.

We have all increased our awareness of infection control which will stand us in good stead coping with mundane things like the flu and MRSA. Donning gloves, masks and funny looking gowns is now second nature and sadly we no longer hug and kiss our patients.

QSP and the hospital have worked closely together, lending or giving each other PPE, depending on who is running out, ordering PPE from a common site. The CBAC has been manned by a team of hospital, practice nurses, and community dental nurses. There has been a blurring of private and DHB boundaries and the Clinical Nurse Manager even has her own named coffee mug in the practice drawer as she meets frequently with QSP staff.

QSP and hospital nurses practice weekly emergency ‘sims’ together along with all the doctors.

A trainee intern, who was here before Covid in the practice, and had her overseas elective cancelled, is coming back for 2 months to do her stint in Wairoa Hospital. Maybe a budding rural GP?

So – for us, ‘Covid Time has rocked’.

Sara is a GP and a senior rural hospital registrar. She is currently completing a training rotation at Taranaki Base Hospital in New Plymouth.

Suddenly the apprenticeship is shifting gear; business as usual comes to a full stop. At the pointy end of training, fellowship is a blink away. My intention to do a bit more cardiology and respiratory medicine is now an irony. Our new negative pressure rooms feel far away from anywhere, and patients cannot have their usual plethora of tests. I’m more ok with this than my colleagues. Generalist rural training turns out to be excellent preparation for this community response

Introspection: COVID–19 is the disaster that follows you home. In most disasters there is a safe haven, there’s a safe place to retreat. The disaster is a usually a tragic tale to tell friends and family about, not one they are characters in.

Once upon a time is still now, adventure has exited the stage, leaving an uncertain future, as we build the plane we are flying. The invisible particle that has taken the breath from our nation is dubbed the ‘Ebola of the rich’ and will be the COVID–19 of everyone, even those who hide their faces in the sand like hypoxic orange flamingos. Like the disease itself, the ramifications of a pandemic pervade every organ of our carefully structured, safe system. COVID–19 is kicking down the sandcastle we have just built.

Developed nations are acting like newborns. Narratives prompt pragmatic action with inspiring commonsensical speed. Connections are light speed and real. This train left the station months, years ago and we woke up on it. If there is a station, would you get off?

Carol is a GP and Head of the Department of General Practice and Rural Health at the Dunedin School of Medicine, University of Otago. Until recently she worked on the West Coast.

So its hopefully nearly at the end of lockdown, maybe over half way through, possibly not yet half way. And how will the lesser level be compared to now? And what is the unknown distance that lies ahead of us until a new normal emerges, different to the past. This journey lacks sure milestones. We say a strength of generalism is dealing with uncertainty, so that stands us in good stead.

At times such as this, the long-established quid pro quo between clinicians and their communities comes into bright relief. The respect and reward is in exchange for the obligation to heal, knowing doing so may put us in harm’s way. I am reminded of Margaret Cruickshank, our first woman doctor, who succumbed when the great flu pandemic visited our long white cloud a century ago.

Our bubbles contain people dear to our hearts, some branded ‘high risk’. So we adorn ourselves with plastic, cotton and latex, to protect our loved ones from this unseen plague that we name corona. And we keep the Hippocratic faith, by curing sometimes, relieving often, and comforting always.

Kia kaha, kia maia, kia manawanui. Be strong, be brave, be steadfast.