Sally Furniss
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Swine flu ground zero
By KATHERINE NEWTON - The Dominion Post Last updated 11:21 11/07/2009
ANDREW GORRIE/The Dominion Post
EVEN MORE INTENSIVE: Dr Peter Hicks works in Wellington Hospital's intensive care unit, where extra precautions have to be taken with flu patients.
ROBERT KITCHIN/The Dominion Post
AT THE FOREFRONT: Medical officer Margot McLean, along with colleague Annette Nesdale, was at Wellington Airport to identify unwell passengers who might have originally flow from North America.
MASK MODEL: Emergency department receptionist Karyn Makatea is the first face many patients with flu symptoms see when they arrive at Wellington Hospital.
ROBERT KITCHIN/The Dominion Post
THE COMMUNITY NURSE: Diane Stevens.
ANDREW GORRIE/The Dominion Post
THE EMERGENCY NURSE: Lee Allsop says though staff are stressed, they are coping.
ANDREW GORRIE/The Dominion Post
TESTING TIMES: Medical laboratory scientist Colleen Gribble processes a batch of flu swabs at Wellington Hospital's labs.
Related Links
<!-- -normal_story_landing- --> <!--start components/story/common_content--> They miss meals, and miss their families. They comfort, cajole and snatch sleep when they can.
They watch as regular duties pile up and wonder how they will ever catch up when this crisis is calmed.
As the number of swine flu cases in New Zealand races towards 2000 - with estimates that case numbers will not peak for a further two months - an already- stretched public health service is bracing to get even busier.
Ever since a group of Rangitoto College pupils returned from Mexico with influenza A H1N1, those charged with minimising swine flu's impact have worked around the clock to protect New Zealanders as best they can.
For 11 weeks they've missed lunches, driven to the airport at midnight to meet international flights and answered anxious phone calls.
Swine flu has swept past the containment stage, but the concerted effort from government and public health officials, hospitals, primary care workers and lab scientists prevented it from spreading in the community for more than seven weeks after the first cases were confirmed.
The Health Ministry's emergency response began less than two hours after it heard about the Rangitoto College group.
There was no time to wait to see how deadly and how contagious swine flu was, or how other countries were responding. "They key characteristics of any epidemic are uncertainty and urgency," say Sandy Dawson, acting chief adviser at the ministry's national health co-ordination centre. "[So] we got our systems up and going fast."
Public health authorities acted with similar speed. The day the Rangitoto pupils arrived home, Wellington's Regional Public Health sent medical officers of health Margot McLean and Annette Nesdale to Wellington Airport to intercept a flight from Australia and identify any unwell passengers who might have originally flown from North America.
That was the start of what threatened to become an overwhelming task, as Public Health's offices at Hutt Hospital became swine flu HQ for Wellington.
At one point, Dr McLean and other senior staff were meeting three times a day in their "war room" - with maps tracking the spread of cases, whiteboards, graphs, international flight timetables and half a dozen laptops.
"Then people would be ringing up cases and talking to contacts and people who were in isolation to make sure they were okay," Dr McLean says. "We'd be checking results from swabs, getting Tamiflu delivered out to people, getting messages together for primary care, and fielding lots and lots of phone calls [from] people wanting to clarify information."
Staff met every trans-Tasman flight arriving in Wellington between April 26 and last Sunday, giving advice or treatment to a handful of passengers each time.
It all added up to long hours for the service's 165 staff, with 95 per cent of them doing overtime as the workload peaked. "There were weeks when we were working 12-hour days," Dr McLean says.
The service had practised its epidemic response procedures - but not everything could be predicted. "The challenge with this response has been the volume and also the . . . uncertainties of dealing with a virus nobody knows much about."
In the last fortnight, that challenge was handed to hospitals and GPs.
With swine flu spreading rapidly through the community, routine testing and contact tracing of anyone who might have been exposed to it have became impossible, so Regional Public Health is taking a breather as district health boards take the lead during the "manage it" phase. "I'm feeling a bit calmer," Dr McLean says.
But there is little calm for those now at the pandemic's frontline.
With local virologists predicting swine flu's peak may be six to eight weeks away, the focus is on whether hospitals and primary care can absorb the extra work.
"Nurses and GPs out in primary care are really struggling," Sandy Dawson says.
"There may come a time when they can no longer cope [and] the thing that will be crucial is what sort of leeway we can get if we get swamped."
Some hospitals, including Wellington, have already resorted to postponing non-urgent and elective surgery. Officials expect that to become more common as the pandemic drags on.
General practices have also put some work on hold.
Follow-ups for chronic conditions and routine testing have been postponed at some practices, which is "sensible", if not ideal, Dr Dawson says.
Liz Fitzmaurice, Regional Public Health's primary care liaison officer, says the Health Ministry may need to make concessions, too.
"There's some paperwork that cannot happen. The priority is looking after sick people."
Despite a climbing number of swine flu cases, and now deaths, health officials are heartened that the virus has not proved as deadly as early reports were predicting.
"The overall systems have worked well because in some respects we'd been preparing for a much more serious pandemic," Dr Dawson says.
Separate groups within the health sector have worked very closely the entire time - unlike in some countries, where the response has not been less co-ordinated.
He points to Australia, where primary health is the responsibility of state rather than federal government, which has limited the scope of the national response.
"We do have a primary care sector that's much better tied in with district health boards and hospitals."
Consistent messages from officials and media meant most New Zealanders took swine flu seriously soon after it struck.
The ministry has not yet done any research into how the public has responded, but there is anecdotal evidence that people are taking public health messages to heart, Dr Dawson says.
That means taking time off work if you are sick, keeping children home if they are unwell, and being vigilant about basic hygiene.
"My overall impression is that people are doing well."
HOSPITAL UNDER PRESSURE
Battling to limit the death toll from swine flu is hard work for staff at Wellington Hospital's intensive care unit.
The unit has so far treated - and saved - two women swine flu patients in critical condition.
Peter Hicks, the unit's clinical director, says the severity of the cases demanded extra dedication from staff: "Both patients have been very sick and complicated to look after so that has an impact on what we do."
The women were hooked up to standard intensive care equipment - IV drips, ventilators, heart monitors and dialysis - but had to be monitored much more closely than other patients in the unit.
"There are times when their oxygen levels got very low and that makes for a high level of anxiety among staff." The patients were treated in isolation rooms, which prevented swine flu spreading in the unit – but could be unpleasant to work in.
"It can be quite claustrophobic," intensive care nurse Jayne Sheppard says. "You've got the mask, you've got the gloves, you've got the gown on. You do get a sore face by the end of the day."
Dr Hicks says two swine flu patients in the unit at a time is manageable, but a rise in serious cases would change that.
"It would take another two patients like this and we would be struggling with our resourcing."
That could mean desperate measures: "Our contingency would be to cancel a lot of cardiac surgery."
'IF IT GETS ANY WORSE I'M NOT QUITE SURE HOW WE'LL MANAGE'
A sign outside Ora Toa Cannons Creek Medical Centre warns those with flu symptoms not to enter.
"Wave to reception and someone will come to see you."
The ad hoc triage system is just one change that centre staff have made to help cope with the influx of patients they've had in the past month.
"We would have maybe 100 to 120 phone calls a day, compared to maybe 30 before all this happened," nurse practitioner Diane Stevens says.
"Often we might talk to someone two or three times a day and then call them back the next day to see how they're doing."
The medical centre has three GPs and Mrs Stevens is the sole nurse practitioner, which means she is able to prescribe some drugs.
Flu patients are seen by a doctor only if they are really unwell, so it falls to the nurses to pick up most of the extra work.
"It's hard. We're constantly busy. We're here early, go home late and sometimes don't have lunch."
The centre has been in pandemic mode for about a month and Mrs Stevens says there is no end in sight.
"We just go from one day to another, really."
She is especially worried that the number of patients is still increasing. "If it gets any worse I'm not quite sure how we'll manage."
Already, the centre has postponed a lot of routine work.
"We've stopped sending out recalls for cervical smears, diabetic annual reviews and cardiovascular risk assessments because we just can't cope with it.
"So then we're going to be in catch-up mode."
The Health Ministry's Health Line has taken some of the workload, but attempts to hire a temporary nurse have failed because of the high demand for extra staff throughout New Zealand.
"We'd like another nurse but that's not possible. We've advertised and there's no one."
SCIENTISTS AT THE PANDEMIC FRONTLINE
Away from the emergency department desk, in a hidden nook of Wellington Hospital, a team of molecular medical laboratory scientists has tested every flu swab the hospital receives - 1400 so far.
Laboratory services leader Russell Cooke says the lab usually tests one or two samples a week during winter.
Right now, they're churning through up to 80 samples every day. Each batch of 14 swabs takes about 90 minutes each to process.
The lab aims for a same-day service for any samples that come in before 11am – putting enormous pressure on staff, Dr Cooke says.
"Normally this is a nice, relaxed five-day-a-week service. We're now seven days a week . . . and often we won't be getting away until 6.30pm."
The squeeze on resources means staff are scrambling to keep up with other work. "We've still got to do the routine stuff and that's getting harder and harder," he says.
"We're trying to maintain a balance so that the important things still get done. You don't want somebody to get meningitis and that to go undiagnosed."
With fatigue setting in, the lab has a new weapon - an automatic extraction machine, which the hospital has leased from drug company Roche.
The machine takes just as long to process samples, but it can do 40 at once.
There's a certain professional thrill in being on the frontline in the midst of a pandemic, Dr Cooke says. "But I have to say, the buzz is wearing off now."
400 MORE PATIENTS PUSH NURSING STAFF TO THE LIMIT
Wellington Hospital's emergency department nurse manager, Lee Allsop, says her staff have been pushed to the limit for the past six weeks - and the thought that flu- case numbers have yet to peak worries her.
"We've had a big influx but we're coping at this stage. It wouldn't take much to tip us though."
Four hundred extra patients turned up at the emergency department last month - an increase of 10 per cent on last June, which was hectic anyway.
"A good proportion of that we attribute to flu-like symptoms."
Night shifts, when managers and other senior staff are not around, are especially stressful for the nurses on duty, Ms Allsop says. "There are more people coming in the late evening and there aren't as many people round to help at night."
Even during the day, stress levels are high. "Patients with minor problems are having to wait a very long time. We end up with more frustrated people waiting and staff don't have as much time to explain why."
Ms Allsop arrives at work at 7:30am and leaves about 7pm each day. "I miss my meal breaks and that. Normal things I just can't fit into the day anymore."
Because of "meticulous" hygiene, most staff have stayed healthy, but those who have been sick have been away from work longer than usual, she says.
"They're staying away until they're well enough to work."
A flu assessment centre at the hospital has mopped up some of the extra work, but Ms Allsop is not sure how long the department can sustain its present work rate. "I'd like to say ED can sustain any capacity . . . [but] we're getting to the upper limit."
BIRTH OF A GLOBAL PANDEMIC
* March 18: First swine flu cases suspected in Mexico.
* April 24: Mexico City confirms 20 deaths.
* April 25: New Zealand's Health Ministry activates its response centre when Rangitoto College pupils return from Mexico with flu symptoms. Suspect cases are quarantined and given Tamiflu.
* April 29: Three of the pupils test positive for swine flu.
* April 30: Swine flu is made a notifiable disease.
* May 2: The Government orders 125,000 courses of anti-viral drug Relenza.
* May 7: Passengers from all international flights given passenger-locator forms to enable them to be traced.
* June 2: A tenth New Zealand case is confirmed - the first in more than a fortnight.
* June 6: Health Ministry launches a public awareness campaign, telling people to maintain hygiene and stock up on essential items.
* June 8: Health authorities given powers to forcibly quarantine people with swine flu.
* June 9: First three Wellington cases reported.
* June 12: WHO declares a global swine flu pandemic.
* June 14: Health officials set up specialist swine flu centres as the number of New Zealand cases soars to 71.
* June 19: Wellington and Christchurch move from "contain" to "manage" status, restricting Tamiflu to severely ill patients.
* June 24: School absence rates rocket as parents heed advice and keep sick children home.
* July 1: Several hospitals, including Wellington, postpone non-urgent surgery because of a surge in flu-related admissions.
* July 2: Wellington Hospital admits it is struggling to cope as swine flu cases in the capital leap to 275.
* July 5: The Health Ministry's 0800 Healthline is inundated with calls after the country's first three swine flu deaths are reported.
* July 6: The Government orders 300,000 swine flu vaccine doses, which will be used to immunise frontline health workers.
http://www.stuff.co.nz/dominion-post/news/features/2584837/Swine-flu-ground-zero
By KATHERINE NEWTON - The Dominion Post Last updated 11:21 11/07/2009
EVEN MORE INTENSIVE: Dr Peter Hicks works in Wellington Hospital's intensive care unit, where extra precautions have to be taken with flu patients.
AT THE FOREFRONT: Medical officer Margot McLean, along with colleague Annette Nesdale, was at Wellington Airport to identify unwell passengers who might have originally flow from North America.
MASK MODEL: Emergency department receptionist Karyn Makatea is the first face many patients with flu symptoms see when they arrive at Wellington Hospital.
THE COMMUNITY NURSE: Diane Stevens.
THE EMERGENCY NURSE: Lee Allsop says though staff are stressed, they are coping.
TESTING TIMES: Medical laboratory scientist Colleen Gribble processes a batch of flu swabs at Wellington Hospital's labs.
Related Links
<!-- -normal_story_landing- --> <!--start components/story/common_content--> They miss meals, and miss their families. They comfort, cajole and snatch sleep when they can.
They watch as regular duties pile up and wonder how they will ever catch up when this crisis is calmed.
As the number of swine flu cases in New Zealand races towards 2000 - with estimates that case numbers will not peak for a further two months - an already- stretched public health service is bracing to get even busier.
Ever since a group of Rangitoto College pupils returned from Mexico with influenza A H1N1, those charged with minimising swine flu's impact have worked around the clock to protect New Zealanders as best they can.
For 11 weeks they've missed lunches, driven to the airport at midnight to meet international flights and answered anxious phone calls.
Swine flu has swept past the containment stage, but the concerted effort from government and public health officials, hospitals, primary care workers and lab scientists prevented it from spreading in the community for more than seven weeks after the first cases were confirmed.
The Health Ministry's emergency response began less than two hours after it heard about the Rangitoto College group.
There was no time to wait to see how deadly and how contagious swine flu was, or how other countries were responding. "They key characteristics of any epidemic are uncertainty and urgency," say Sandy Dawson, acting chief adviser at the ministry's national health co-ordination centre. "[So] we got our systems up and going fast."
Public health authorities acted with similar speed. The day the Rangitoto pupils arrived home, Wellington's Regional Public Health sent medical officers of health Margot McLean and Annette Nesdale to Wellington Airport to intercept a flight from Australia and identify any unwell passengers who might have originally flown from North America.
That was the start of what threatened to become an overwhelming task, as Public Health's offices at Hutt Hospital became swine flu HQ for Wellington.
At one point, Dr McLean and other senior staff were meeting three times a day in their "war room" - with maps tracking the spread of cases, whiteboards, graphs, international flight timetables and half a dozen laptops.
"Then people would be ringing up cases and talking to contacts and people who were in isolation to make sure they were okay," Dr McLean says. "We'd be checking results from swabs, getting Tamiflu delivered out to people, getting messages together for primary care, and fielding lots and lots of phone calls [from] people wanting to clarify information."
Staff met every trans-Tasman flight arriving in Wellington between April 26 and last Sunday, giving advice or treatment to a handful of passengers each time.
It all added up to long hours for the service's 165 staff, with 95 per cent of them doing overtime as the workload peaked. "There were weeks when we were working 12-hour days," Dr McLean says.
The service had practised its epidemic response procedures - but not everything could be predicted. "The challenge with this response has been the volume and also the . . . uncertainties of dealing with a virus nobody knows much about."
In the last fortnight, that challenge was handed to hospitals and GPs.
With swine flu spreading rapidly through the community, routine testing and contact tracing of anyone who might have been exposed to it have became impossible, so Regional Public Health is taking a breather as district health boards take the lead during the "manage it" phase. "I'm feeling a bit calmer," Dr McLean says.
But there is little calm for those now at the pandemic's frontline.
With local virologists predicting swine flu's peak may be six to eight weeks away, the focus is on whether hospitals and primary care can absorb the extra work.
"Nurses and GPs out in primary care are really struggling," Sandy Dawson says.
"There may come a time when they can no longer cope [and] the thing that will be crucial is what sort of leeway we can get if we get swamped."
Some hospitals, including Wellington, have already resorted to postponing non-urgent and elective surgery. Officials expect that to become more common as the pandemic drags on.
General practices have also put some work on hold.
Follow-ups for chronic conditions and routine testing have been postponed at some practices, which is "sensible", if not ideal, Dr Dawson says.
Liz Fitzmaurice, Regional Public Health's primary care liaison officer, says the Health Ministry may need to make concessions, too.
"There's some paperwork that cannot happen. The priority is looking after sick people."
Despite a climbing number of swine flu cases, and now deaths, health officials are heartened that the virus has not proved as deadly as early reports were predicting.
"The overall systems have worked well because in some respects we'd been preparing for a much more serious pandemic," Dr Dawson says.
Separate groups within the health sector have worked very closely the entire time - unlike in some countries, where the response has not been less co-ordinated.
He points to Australia, where primary health is the responsibility of state rather than federal government, which has limited the scope of the national response.
"We do have a primary care sector that's much better tied in with district health boards and hospitals."
Consistent messages from officials and media meant most New Zealanders took swine flu seriously soon after it struck.
The ministry has not yet done any research into how the public has responded, but there is anecdotal evidence that people are taking public health messages to heart, Dr Dawson says.
That means taking time off work if you are sick, keeping children home if they are unwell, and being vigilant about basic hygiene.
"My overall impression is that people are doing well."
HOSPITAL UNDER PRESSURE
Battling to limit the death toll from swine flu is hard work for staff at Wellington Hospital's intensive care unit.
The unit has so far treated - and saved - two women swine flu patients in critical condition.
Peter Hicks, the unit's clinical director, says the severity of the cases demanded extra dedication from staff: "Both patients have been very sick and complicated to look after so that has an impact on what we do."
The women were hooked up to standard intensive care equipment - IV drips, ventilators, heart monitors and dialysis - but had to be monitored much more closely than other patients in the unit.
"There are times when their oxygen levels got very low and that makes for a high level of anxiety among staff." The patients were treated in isolation rooms, which prevented swine flu spreading in the unit – but could be unpleasant to work in.
"It can be quite claustrophobic," intensive care nurse Jayne Sheppard says. "You've got the mask, you've got the gloves, you've got the gown on. You do get a sore face by the end of the day."
Dr Hicks says two swine flu patients in the unit at a time is manageable, but a rise in serious cases would change that.
"It would take another two patients like this and we would be struggling with our resourcing."
That could mean desperate measures: "Our contingency would be to cancel a lot of cardiac surgery."
'IF IT GETS ANY WORSE I'M NOT QUITE SURE HOW WE'LL MANAGE'
A sign outside Ora Toa Cannons Creek Medical Centre warns those with flu symptoms not to enter.
"Wave to reception and someone will come to see you."
The ad hoc triage system is just one change that centre staff have made to help cope with the influx of patients they've had in the past month.
"We would have maybe 100 to 120 phone calls a day, compared to maybe 30 before all this happened," nurse practitioner Diane Stevens says.
"Often we might talk to someone two or three times a day and then call them back the next day to see how they're doing."
The medical centre has three GPs and Mrs Stevens is the sole nurse practitioner, which means she is able to prescribe some drugs.
Flu patients are seen by a doctor only if they are really unwell, so it falls to the nurses to pick up most of the extra work.
"It's hard. We're constantly busy. We're here early, go home late and sometimes don't have lunch."
The centre has been in pandemic mode for about a month and Mrs Stevens says there is no end in sight.
"We just go from one day to another, really."
She is especially worried that the number of patients is still increasing. "If it gets any worse I'm not quite sure how we'll manage."
Already, the centre has postponed a lot of routine work.
"We've stopped sending out recalls for cervical smears, diabetic annual reviews and cardiovascular risk assessments because we just can't cope with it.
"So then we're going to be in catch-up mode."
The Health Ministry's Health Line has taken some of the workload, but attempts to hire a temporary nurse have failed because of the high demand for extra staff throughout New Zealand.
"We'd like another nurse but that's not possible. We've advertised and there's no one."
SCIENTISTS AT THE PANDEMIC FRONTLINE
Away from the emergency department desk, in a hidden nook of Wellington Hospital, a team of molecular medical laboratory scientists has tested every flu swab the hospital receives - 1400 so far.
Laboratory services leader Russell Cooke says the lab usually tests one or two samples a week during winter.
Right now, they're churning through up to 80 samples every day. Each batch of 14 swabs takes about 90 minutes each to process.
The lab aims for a same-day service for any samples that come in before 11am – putting enormous pressure on staff, Dr Cooke says.
"Normally this is a nice, relaxed five-day-a-week service. We're now seven days a week . . . and often we won't be getting away until 6.30pm."
The squeeze on resources means staff are scrambling to keep up with other work. "We've still got to do the routine stuff and that's getting harder and harder," he says.
"We're trying to maintain a balance so that the important things still get done. You don't want somebody to get meningitis and that to go undiagnosed."
With fatigue setting in, the lab has a new weapon - an automatic extraction machine, which the hospital has leased from drug company Roche.
The machine takes just as long to process samples, but it can do 40 at once.
There's a certain professional thrill in being on the frontline in the midst of a pandemic, Dr Cooke says. "But I have to say, the buzz is wearing off now."
400 MORE PATIENTS PUSH NURSING STAFF TO THE LIMIT
Wellington Hospital's emergency department nurse manager, Lee Allsop, says her staff have been pushed to the limit for the past six weeks - and the thought that flu- case numbers have yet to peak worries her.
"We've had a big influx but we're coping at this stage. It wouldn't take much to tip us though."
Four hundred extra patients turned up at the emergency department last month - an increase of 10 per cent on last June, which was hectic anyway.
"A good proportion of that we attribute to flu-like symptoms."
Night shifts, when managers and other senior staff are not around, are especially stressful for the nurses on duty, Ms Allsop says. "There are more people coming in the late evening and there aren't as many people round to help at night."
Even during the day, stress levels are high. "Patients with minor problems are having to wait a very long time. We end up with more frustrated people waiting and staff don't have as much time to explain why."
Ms Allsop arrives at work at 7:30am and leaves about 7pm each day. "I miss my meal breaks and that. Normal things I just can't fit into the day anymore."
Because of "meticulous" hygiene, most staff have stayed healthy, but those who have been sick have been away from work longer than usual, she says.
"They're staying away until they're well enough to work."
A flu assessment centre at the hospital has mopped up some of the extra work, but Ms Allsop is not sure how long the department can sustain its present work rate. "I'd like to say ED can sustain any capacity . . . [but] we're getting to the upper limit."
BIRTH OF A GLOBAL PANDEMIC
* March 18: First swine flu cases suspected in Mexico.
* April 24: Mexico City confirms 20 deaths.
* April 25: New Zealand's Health Ministry activates its response centre when Rangitoto College pupils return from Mexico with flu symptoms. Suspect cases are quarantined and given Tamiflu.
* April 29: Three of the pupils test positive for swine flu.
* April 30: Swine flu is made a notifiable disease.
* May 2: The Government orders 125,000 courses of anti-viral drug Relenza.
* May 7: Passengers from all international flights given passenger-locator forms to enable them to be traced.
* June 2: A tenth New Zealand case is confirmed - the first in more than a fortnight.
* June 6: Health Ministry launches a public awareness campaign, telling people to maintain hygiene and stock up on essential items.
* June 8: Health authorities given powers to forcibly quarantine people with swine flu.
* June 9: First three Wellington cases reported.
* June 12: WHO declares a global swine flu pandemic.
* June 14: Health officials set up specialist swine flu centres as the number of New Zealand cases soars to 71.
* June 19: Wellington and Christchurch move from "contain" to "manage" status, restricting Tamiflu to severely ill patients.
* June 24: School absence rates rocket as parents heed advice and keep sick children home.
* July 1: Several hospitals, including Wellington, postpone non-urgent surgery because of a surge in flu-related admissions.
* July 2: Wellington Hospital admits it is struggling to cope as swine flu cases in the capital leap to 275.
* July 5: The Health Ministry's 0800 Healthline is inundated with calls after the country's first three swine flu deaths are reported.
* July 6: The Government orders 300,000 swine flu vaccine doses, which will be used to immunise frontline health workers.
http://www.stuff.co.nz/dominion-post/news/features/2584837/Swine-flu-ground-zero