“Since 8pm last night, there have been 95 new cases of COVID-19 in New South Wales…” There is comfort in knowing the numbers are reducing, but there is no room for complacency. We almost dare not to hope with so much time devoted to preparing for the worst. And we are constantly reminded of “the worst” – escalating numbers of cases in Italy, France and the USA. Nursing homes abandoned in Spain. We are desperate for this not to be the situation in Australia and certainly not to the aged care population, whose care we have been entrusted. My Apple watch vibrates, a timely message: “Remember to breathe.” Dressed in plain scrubs (an outfit I haven’t worn since my days as an intern in the Emergency department) and a simple ponytail, I walk into the hospital with an additional bag containing a change of clothes for the day’s end. You know there’s something serious going on when you see a geriatrician turn up to a rehabilitation hospital in scrubs.
If someone had told me I would start my consultant career in the middle of a pandemic, I would have said to them “that would be unpreceden…”
I begin my ward round – the first patient, Anne, an 80-year-old retired nurse recovering from a hip fracture, notices my outfit change. “Are you going to do surgery on me?” she enquires with a grin. I let her know that I’m the last person she would want to operate on her, which earns a laugh. After hearing that her pain was under control and all other bodily functions were working as required, I slowly delve into a conversation about limitations of care.
Although this is bread and butter of geriatric medicine, I reflect on the number of times I will be having this conversation in the coming weeks and whether these interventions will be within my control. She doesn’t need to hear about the trauma of rib fractures, or the likely futility of ventilation. With the certainty that comes with life experience, she didn’t fear the possibility of succumbing to the virus as “you’ve got to die of something.” Although she missed her family, she appreciated that we were doing all we could to protect her in this difficult time.
As I wash my hands, for what seems like the fiftieth time today and admire her bravery, I wonder about how each individual older person is responding to this looming threat. I consider the possible outcomes of this conversation regarding “limitations of care” in the future. As geriatricians, we are fierce advocates for our older patients; however, I fear a reality where advocacy may be outweighed by limitations of healthcare resources.
I sit down to review the correspondence after wiping down my desk, trying to amass as much information as possible for this steep learning curve that the entire health system is trying to conquer. What are the testing criteria today? What are the guidelines for personal protective equipment? Are there any new studies for the treatment of COVID-19? Oh dear, Donald Trump has tweeted about hydroxychloroquine and azithromycin – what is the evidence in the published trials? Which residential aged care facilities need phone calls to follow-up on their preparedness? What is my password for videoconferencing? Buried in this sea of new information is an email about a sale on hot cross buns at the hospital kiosk – the Easter bunny has snuck up on us this year.
My phone rings, it’s our nurse practitioner and the team are being inundated with referrals. The impetus of the Geriatric Flying Squad to keep older patients out of hospital is greater now than ever. We know that hospital admissions for older patients can result in delirium, increased risk of falls and medication errors – but now, of course, there is the added risk of exposure to COVID-19. There is a 70-year-old Italian woman in an aged care facility who has a fever and sore throat, an 80-year-old man from the home rehab program who has fallen down his back steps trying to hang out the laundry and a paramedic has called to report their concern for the care of a 90-year-old female with dementia at home.
Before I hit the road, I have a phone conference with Peter and his daughter. Peter is an 85-year-old retired novelist who is recovering from pneumonia and delirium. Although his walking has improved, his cognition hasn’t recovered to what it used to be. His daughter, who is waiting for a hip replacement, can’t manage his care at home and the time has come to discuss residential care.
These conversations are normally had in person – with all members of the team and family members to support Peter. However, due to social distancing rules and concerns about risk, we do this over the phone, in his room. As a hand extending through the speaker, amplified through his hearing aids, his daughter says, “I haven’t forgotten you, please don’t feel abandoned, we will come and visit when this is all over.” As I leave to head out in the community, a nurse walks in, bringing Peter a much-needed cuppa, with one sugar, just as he likes it.
Parked on the side of the road outside of the house, we cautiously don our personal protective equipment. I smile at a passer-by, forgetting that they can’t see behind my mask. I see them hasten their steps at the sight of two people in bright yellow gowns and visors. I ring the doorbell with my elbow, and we’re greeted by Elaine’s daughter – who is also wearing a mask. She’s just been notified of her swab results but is more worried about her mother. We see Elaine, her frail 92-year-old frame sitting on the couch in her floral nightgown, her breathlessness visible from 1.5 metres away. This in contrast to the photograph on the table next to her – hair perfectly coiffed, bright lipstick illuminated by the “9-0” candles.
There are many possible reasons for her breathlessness – smoking in her past, fluid in the lungs, the flu, and the elephant in the room. We hear that the neighbours have been dropping groceries at the front door and that her general practitioner, who has known her for thirty years, has been calling to check on her progress every day. On the drive back, I wonder what would happen to Elaine if her daughter was too unwell to care for her.
After changing out of my scrubs, I debrief with the team, heartened by their offers of toilet paper to a team member running dangerously low on supply. As I leave, I read the latest joke on the team’s noticeboard – “What concert costs 45 cents? 50 cent featuring Nickelback.” In all the doom and gloom, we have to smile where we can. When I get home, I put my bag into a plastic box at the front door and call out to my husband to distract our toddler. After a fomite-eradicating shower, I surprise my daughter, who now has a toothy grin, and hug her a little tighter.
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