Go to work – save lives
The opinions expressed are the views of the author only. The authors colleagues, supervisors and employers do not necessarily share any of these views.
For the third year in a row, elective surgery is being shut down in NSW. We have decided that the best way stop covid from disrupting health care is to go ahead and disrupt it ourselves. We have decided to shoot the hostage, to save them from the kidnapper. For a third year in a row a draconian measure has been passed down without a name on it, without a detailed evidence base or modelling on what the potential risks and supposed benefits of shutting down health care are. Are we overwhelmed, now? Or is this just in case we become overwhelmed in the future? I see no evidence that we have arrived at that point, not with my own eyes and not according to the data. All I see is the damage being done by shutting care down, which still has not recovered from the last two times we made this mistake. This seems like another illogical, short sighted and very dangerous move.
How do we define an overwhelmed healthcare system? Currently in NSW there are 2776 people in hospital with covid-19 and 203 of them are in ICU (1). They represent about a third of all people in hospital right now. The capacity of NSW hospitals is 12,500 beds, including 1000 in ICU (2). Currently we are not at that capacity. There is a caveat with these statistics too: just because someone is in hospital with covid-19, doesn't mean that covid-19 is the reason they're in hospital. Bear in mind that currently about a third of all people being tested turn out to be positive. Then, bear in mind everyone who sets foot in a hospital is screened for covid. Then, remember that about a third of the hospitalised population have covid-19. Is it possible that many of them are incidental findings? It is. While it's true that some of these patients are very sick and dying from covid, many are not. The vast majority of covid positive people I have looked after have had incidental infection and were in hospital for other reasons. Most had mild or no symptoms.
Have we hit capacity before? I don't know a single winter in the last 20 years of working in NSW hospitals where we didn't routinely red line our bed capacity. If only interns had a dollar for every time their pagers had alarmed with "HOSPITAL FULL -DISCHARGE ALL NON ACUTE PATIENTS". For comparison, in the 2017 flu season there were an estimated 29,000 people hospitalised and 2580 in ICU due to influenza in Australia (3,4). For the record, an estimated 3000 - 4000 died (5). That's more in one season than we've had in over two years of over-reported (6) covid, and elective surgery was never cancelled. It is estimated that if push came to shove and we really were overrun, we have the ability to almost triple our ICU bed capacity (7). But of course, that hasn't happened. We haven't had to go that far at any time in the last two years. There are no tent hospitals being rolled out and no people dying on the streets. If an overwhelmed system is defined as people dying of preventable illness because of a dysfunctional health care system– it isn't happening and it never has.
Do we define an overwhelmed system by blown out ambulance times, and when front line staff are under stress? These phenomena are real, but if we still have so many empty beds you have to ask the question: is this happening because there are too many sick covid patients, or have we created a problem because of our response to covid? Understaffing is occurring because of unprecedented screening and suffocating isolation rules. Never before has someone had to sit at home for a week despite being asymptomatic and having a negative test, just because they sat on the same aeroplane or in a cinema as someone with a disease. Never before have I seen hospital staff so crippled by PPE and protocols that we forget why the patient even came to hospital in the first place. Take an emergency caesarean section, for example. Under normal circumstances you can pick up the phone, call an urgent caesar and have a baby out fifteen minutes from when you hang up. Because of covidprotocols, it now takes four hours and ties up an entire team for that time. Covid didn't create this problem – we did.
Repeated shut downs amplify disease and create further dysfunction in the system. This is not the first time we have pulled the pin on health care. Many patients having their surgeries cancelled now have already had their surgeries cancelled once or even twice before. Cancelled surgeries, cancelled clinics and the general dilution of care makes for progression of disease. Instead of being properly cared for these patients can decompensate and end up in critical care services. We are literally shutting the doors on operating theatres and watching tumbleweed blow along the corridors, while the patients who should be at home recovering from an operation are turning up to the exact place that we need to take the pressure off – A&E.
7% of NSW health care workers have been sacked for being unvaccinated (8). They cover all disciplines and this will blow out further as the new mandate for boosters approaches. During a time of acute short staffing, it's worth reviewing what threat our unvaccinated colleague's pose. There is no doubt that the currently available vaccines reduce mortality and hospitalisation, particularly in the vulnerable. The most relevant question to this debate though is whether vaccination reduces transmission. There is no clear evidence or consensus that it does. Some data shows a reduction in transmission that wanes to no difference after three months. Several other studies show that there is no difference at all (9, 10, 11). So, if we are being honest with ourselves, an unvaccinated person poses no greater risk than a vaccinated person when it comes to spreading the virus. If hospitals are understaffed, why not put ideology aside, be pragmatic, and get our unvaccinated colleague's back in the game? Anyone who disagrees that this is about ideology, consider this: in two weeks' time the vaccination mandate will apply to primary care and private health care providers – and this includes telehealth. You won't even be allowed to talk to an unvaccinated GP or psychologist over zoom. There is no plan for where patients of these providers are supposed to go, so once again A&E and ambulances will likely feel the burden. All this comes at a time when mental health, depression, anxiety and suicide are off the charts (12,13). Covid didn't create this problem, we did.
Just because a surgery is not for cancer does not mean it can wait for years. Women with the excruciating, debilitating pain of endometriosis are waiting. Women are haemorrhaging, suffering prolapse and incontinence and are being made to wait. And for that matter, it's not uncommon for surgery for benign reasons to unveil cancer. Around 2.7% of hysterectomies (14) and 1.5% of ovarian surgery (15) for benign reasons have been found to uncover cancer unexpectedly. Combine this with the previous pauses on breast cancer screening, and there is no doubt that our actions have caused an upstaging of many cancers. I make no apologies for focussing on women's health because in truth, I believe it is being disproportionately damaged. Women are the rocks of our families and societies and the caretakers of the sacred gift of life itself. They suffer across their lifetimes for the ability to bring us to life. I didn't become a gynaecologist to let them down like this.
Pulling the lever on elective surgery is a serious move with serious consequences, but there is an alternative. What's wrong with waiting? If the system ever truly does become overwhelmed, why not just pull that lever then? Only a small percentage of elective surgical patients go to ICU. Those who do are likely to spend only a night or two there. We can turn the tap off and have an immediate effect, so why pull it so far away from the need for it? It's like the captain has ordered us to abandon a perfectly seaworthy ship, while the collision is still miles away. It's like we've decided to backburn to prepare for a bushfire that might never arrive – but instead of backburning the bush we've decided to backburn a town to the ground. We're burning houses to stop the bushfire from doing it. Maybe we're not overwhelmed and I'm right. Maybe I'm wrong. Show me some data that will change my mind and I'll oblige. One thing I do know is every time you shut down health care people suffer and die. In the last two years there have been so many odd policies, so many hysterical overreactions and we have aimed so much vitriol at one another in the name of fear that it's hard to know where to start undoing the damage. Maybe let's start with this one. It's an easy one. Let us get
back to looking after our patients.
Dr. Jason Mak