Dr Jo-Anne Grey
MBBS FRACGP MPH DTMH CTH®
TMA member based in Melbourne
Since the bottom fell out of international travel with the global spread of the SARS-CoV2 and the subsequent declaration of the pandemic by the WHO, my life as a day-to-day travel medicine practitioner has changed dramatically. As part of the Victorian Department of Health and Human Services COVID-19 response workforce, I now spend my days in Melbourne’s quarantine hotels, conducting telehealth consultations with returned travellers in their hotel rooms and donning and doffing PPE to make “house calls” to rooms where necessary.
All international passengers arriving into Australian airports or disembarking at maritime ports must go into mandatory quarantine for 14 days from the day of their arrival at a state-designated facility in the city of their arrival. No domestic onward travel is allowed until the 14 days of mandatory quarantine has ended. Although this quarantine system has been in place, governed by the various State Emergency Health Acts since March 29, many returning travellers are still unprepared and or/unaware of what quarantine entails. This lack of awareness or misunderstanding contributes to a certain amount of angst and dissatisfaction amongst quarantine detainees.
Hotels chosen by the Department of Health and Human Services (DHHS) as quarantine facilities in Melbourne are four or five-star hotels located at Melbourne airport and in the CBD. At any one time, there are 10 - 12 hotels accommodating between 2000 - 2500 detainees. Each hotel is bristling with security staff, no public access is allowed, and on days when there are travellers arriving and departing, there is a sizable police presence.
There is a 24-hour roster of onsite nursing staff (general and mental health nurses in three eight-hour shifts) and 24-hour medical cover. Doctors either work 10-hour day shifts (0800-1800h) or 12 hours overnight (1800-0600h). Yes, this does leave a two-hour window which is technically not covered, but in practice, the night duty doctors provide cover if needed. Two PCAs (personal care assistants) are also rostered on each eight-hour shift. They are the link between nurses, detainees, and DHHS staff. For each eight-hour shift, there is also a DHHS contingent comprising a Team Leader and an Authorised Officer and a representative from the Department of Justice in each hotel. There are at least three security staff stationed on each floor 24 hours per day.
Quarantine detainees are interviewed by phone shortly after arrival by RNs, who complete a basic intake form, noting current medical conditions and medications, past medical history, and presenting medical concerns. This information, initially kept in a paper-based system, is now recorded in a central electronic database (somewhat hurriedly) purpose-built for the quarantine hotel environment. There have been a few teething problems, to say the least. The medical team has used the medical program, Best Practice from Day 1, so we are expected to record notes in both the nurse's COVID19 Survey Tool and Best Practice… somewhat time-consuming and frustrating.
During their time in quarantine, detainees receive a daily phone call from the nurses to check for symptoms of COVID19. Symptomatic people are swabbed on an “as needs” basis. All detainees are offered COVID19 screening on Day 3 and Day 11 of their stay – this is voluntary but the vast majority opt to have testing. Anyone expressing any mental health concerns is passed to the mental health nurse, who can call on the doctors, or the local mental health network triage service, should that be required.
As a doctor, the workload remains fairly constant, but tasks vary mostly with the quarantine cohort’s day of stay. Day 0 - 4 is usually a flurry of prescriptions for routine medications needing to be filled, people seeking quarantine exemptions (rarely approved by DHHS), and angry/anxious/aggressive individuals protesting about being in quarantine. During Days 5 - 9, people generally are resigned to their quarantine stay, but start to present with problems which may have been niggling for some time – reflux, infected toenails, rashes of all descriptions.
Then there are the interesting sports-type injuries, which mainly can be traced back to TikTok – a ruptured Achilles tendon (sprinting around the hotel room), dislocated elbow (lady thought it would be a good idea if her husband sat on her back while she did push-ups), a fractured radius and ulna (mother playing leapfrog with her children on their fresh air break) and a lady with a Lisfranc (foot) fracture who fell off the coffee table in the room doing a TikTok dance!
As our capacity to assess and monitor people is very limited in the hotel environment, we have a very low threshold for referring to the local hospital Emergency Departments. This necessitates not just the usual phone call to Ambulance Victoria and a courtesy call to the receiving ED, but also special permission from the DHHS Team Leader and AO so that the person can be released from quarantine, full HazMat precautions for paramedics and forewarning for the ED that a quarantine detainee is en route. Cases that have required hospital transfer include acute renal colic (kidney stones), choledocholithiasis (gallstones), pregnancy miscarriage, and an acute coronary event (Heart attack).
Every day brings new challenges and in the past week, there has been a second outbreak of COVID19 in security staff at a quarantine hotel. Contact tracing is underway and evidence points to a link between the first hotel outbreak (Rydges Hotel) and the current one at the Stamford Plaza. Unfortunately, all personnel, including clinical staff, who visited the hotel for more than 30 minutes during a two-week period have been tested and are now in quarantine. I visited the hotel for just over 40 minutes during the specified two-week period to administer rabies PEP ( Post-exposure vaccination) to a young fellow who’d been bitten by a dog in Sri Lanka just prior to his departure. The DHHS are unflinching in their application of the 30-minute rule, so I am now writing from the splendid isolation of my apartment. Thankfully, I am asymptomatic and have tested negative.
Seven doctors out of our pool of twenty have been affected by this outbreak, meaning our model of care delivery is being revamped. For the next fortnight, we will continue to work, delivering telehealth consultations from our place of quarantine, supported on the ground by our unaffected colleagues. No doubt, the COVID19 situation will continue to evolve and our ability to respond will depend on our flexibility and adaptability.