Unappreciated nurses, missing test kits, tent life, and ICU trauma: Covid-19 vs MoH

“[…] When you see tents set up [outside hospitals] is when your health system is overwhelmed, but we were using tents from day one! These billion dollar facilities we have and they are not designed to treat infectious diseases.

“[…] And the tents are another story. They are sweltering hot with limited airflow, and our nurses are there 24/7 with patients using out-houses… I personally know one patient who stayed [in a tent] for seven days. Seven days! 

“Every time a space opened up in Couva or Caura they took someone else, because she wasn’t as bad as the next person. Now the person waiting in the tent cannot shower for the duration of their stay there. She can’t bathe, can’t see her relatives—she just had to remain there and use that one port-a-potty and wipes. And that’s it…”

How is the Ministry of Health’s parallel health care system handling the current surge in Covid-19 infections? How are the nurses coping?

Wired868 talks to Trinidad and Tobago Registered Nurses Association (TTRNA) president Idi Stuart about the challenges facing the public health sector, as they battle with Covid-19:

Wired868: We understand health care workers are now in a scenario in which they must regularly prioritise which patients receive life-saving care. How grim is it?

Idi Stuart (sighs): Well firstly, the judgment call as to which patient gets an ICU room and who should be taken out of one is made by the doctors. This is not generally a collaborative decision. But it is taking a heavy, heavy toll. This is an ethical dilemma that is put to you in training, but this is the first time in the lives of the majority of our physicians that they are being asked to make this decision so often and so rapidly.

Wired868: In what scenario would such a decision usually be made here?

Stuart: In the past, it would usually be when a specialist neurosurgeon comes down and can only do a certain number of life-saving surgeries. You might have a waiting list of 15 but he can do eight surgeries. So who gets the surgery?

You have to factor in things like the age of the patient and their chances of surviving the procedure. Do you go with a 60-year-old grandmother over a 30-something-year-old mother with two young children? These are the questions you have to answer.

As a family member, you would understandably want to know that your relative is getting the best care. But in the real world, we know those doctors are going to make certain decisions based on the best use of resources.

Wired868: Is counselling being provided for health care workers? Is it adequate?

Stuart (sighs): The counselling is not robust. Dr Gerard Hutchinson is trying, but really it is woefully inadequate. To be fair to them, they have never been called upon before to do something like this and on this scale; and it’s not like there are a battery of psychiatrists at the Ministry of Health waiting on an occasion like this. This is new territory for everybody.

In fact, 95 percent of the health care workers in Couva are new. The majority have just one to two years experience since passing out training and now they are asked to handle a pandemic.

It isn’t easy to cope with the guilt of when a patient dies and you go home wondering if you did everything you could for that patient. And then there is no family to counsel a patient who is going to die, so just imagine the loneliness. All they have and the only person who they see that was with them for those 14 or 15 days was that nurse or doctor. That is the last person who holds their hand and tells them comforting words.

Right now, those patients and nurses are missing the senior medical staff who were moved out of Couva. That just caused unnecessary angst!

Wired868: Are you talking about the new ‘rotation policy’ at the NCRHA?

Stuart: Rotation?! There is no rotation! That is hogwash. What happened is the CEO [Davlin Thomas] (allegedly) had a disagreement with his doctors and he moved them. You don’t just move senior hospital administration and senior administrators, particularly in the middle of a crisis.

The CEO and ministers are the ones who take the fame and glory but the health care workers are the people who are working 12-hour shifts and who are really intimate to the patients and who feel it when they have to inform relatives of bad news. There needs to be more respect for that.

Wired868: How would you say the public health sector has coped with Covid-19?

Stuart: We will always have an opinion on how things can be done better but we generally won’t knock the government. We know they are in a difficult position. This Covid-19 disease is new to Trinidad and Tobago, so you have a situation where people are learning on the fly. So you gain that knowledge over time in how to deal with each scenario and each individual case.

If it is one area I think we are short on here is research, which is a key component. Even if something is happening in a different population, it may not work here because, for instance, we have a higher NCD rate. We top the world in diabetes, prostate cancer, and ovarian cancer, so our outcomes will be different.

One of the areas where you see those shortcomings in research is in our vaccination drive. First thing is we would really encourage the government to list every single side effect from every single vaccine. In England, within their NHS, there are pages of side effects so patients are fully aware. This is not to scare the population but to inform them.

Second, we are giving them vaccines and we are not following up to find out what side effects they are experiencing or what their experience is at all. We are saying there are no side effects to the vaccine but we are not building a database where someone can go back five years from now to see if there was a commonality of side effects or responses.

So what would we have learnt at the end of this? We will have to keep relying on the developed world for data, because from the medical aspect you can see how they execute at a different level. And as I explained, there are many reasons why something that got a particular reaction in one country might get a different one somewhere else.

Wired868: And how have nurses coped? Have you really been in self-isolation from your families for so long?

Stuart: Self-isolation is something that nurses expect to do when working with an infectious disease. Despite the mask and the gloves and so on, in the real world we know that is nearly impossible to do this job seven days a week, 24/7 without ever letting your guard down. It sounds simple but we know people are going to get closer to patients than they should or forget to wash their hands after they sneeze, especially if they are not very experienced. Hospital-acquired infections are a big part of the transfer of a virus and trying to prevent that is a major battle.

But experienced nurses know how to take care of themselves. They know not to enter their homes at the same place where everyone else is entering, to look for a spot to take off their clothes before they go inside, to bathe immediately, wash their clothes separately.

Once you work in certain areas, you learn to do things like that almost automatically. For tuberculosis nurses in Caura, this is normal for them. But it is true that nurses have taken extra measures to be extra careful. When HIV just came here it was a little before my time, but I heard stories of similar measures taken by nurses then. With the newness to this virus, you don’t want to put your loved ones at risk.

A number of nurses rented one bedroom apartments, especially if you live with your grandparents. So a lot of them have increased their costs in that way. If they don’t have their private vehicle, they may hire someone to take them to and fro so they don’t travel with the general public.

In Tobago, because it is such a small, close-knit family where everybody knows everybody, the taxi drivers started refusing to pick up nursing personnel. Fortunately the secretary organised places for nurses to stay during the early waves, as family and members of the public will ostracise them—not out of malice but out of fear.

We have asked that nurses actively treating Covid patients be put up within facilities near to their hospitals, so they can go from work to facilities and back again. And that has to happen with a proper rotation policy: one week in, and one week out. So at no time do you expose your relatives. But we are yet to get an answer to our request on that.

Wired868: Is there any issue with the availability of PPE at the various health facilities?

Stuart: The issue isn’t really about PPE. Those are for the staff who interact regularly with Covid patients. The real problem is there is no rapid antigen test kit at all the health facilities as was promised. So since the pandemic, there have been a number of patients who were not captured during the screening process at accident and emergency. And by the time they showed Covid symptoms, all of the nursing staff that interacted with them and the other patients on the ward they interacted with had got it too!

So you have had outbreaks on wards at hospitals outside of the parallel health care system, which understandably causes more strain on the situation where you have to quarantine all those nursing staff.

Since the first two outbreaks, we said we must have those rapid antigen test kits that the government said came into the country since last year. I understand only some [facilities] have started using them now. The only way you should be admitted to the general setting in a hospital is if you have had a negative rapid antigen test.

So the problem is not so much the PPE. The PPE is one dynamic, but you would not want to have that on constantly and it is more expensive anyway. Test them when they turn up to the hospital and transfer whoever is positive to Couva and Caura where everyone is donned up properly. If they are negative, place them in an isolated area for two days before they go into the general setting.

And that is another issue. Despite all the billions of dollars that passed through our health care system, all our hospitals are not designed with specialist isolation wards and none of them are designed to treat communicable diseases.

Wired868: What is different about a ‘specialist’ isolation ward?

Stuart: A specialist isolation unit will have one entry with a separate exit, sinks in certain areas so the nurse doesn’t have to leave to wash their hands somewhere else and come back, air should be extracted from that room to prevent spread of the disease with an extractor fan, there would be a filter to kill bacteria and microorganisms. It is a basic standard design. There should be two to three rooms for isolating patients; so anytime you have an infectious disease, you can place the person in these rooms.

Port of Spain General has no isolation room in the whole hospital! You have four rooms used as isolation rooms but they are not really isolation rooms. They had to put a pre-fab building to deal with Covid people, I mean come on.

So even with proper PPE, the room itself that we use for Covid patients doesn’t lend itself to stopping infections. Where is the staff who are treating patients going to take off their clothes? That is going to happen at the same place the next staff [relieving them] is putting on their clothes. You also want one entry and a separate exit, so the area the nurse and doctor enters is a clean scene and there is no chance of a nurse bringing in an infectious microorganism.

The mere fact that we have to set up tents outside all our facilities, old and new, demonstrates that our hospitals were not designed for communicable diseases, which is very strange to say the least when you consider how much money we spent on them… When you see tents set up is when your health system is overwhelmed, but we were using tents from day one! These billion dollar facilities we have and they are not designed to treat infectious diseases, or not being used for it. That is a worrying concern for us.

And the tents are another story. They are sweltering hot with limited airflow, and our nurses are there 24/7 with patients using out-houses. Just picture a fire officer with all his fire-fighting coats on him for 12 hours and imagine how uncomfortable that would be! Sometimes our nurses have to shower twice in one shift during their work breaks, due to the heat transcending down into the tent.

We also had some worrying weather a few weeks ago and we were bombarded with calls and messages from our members about the wind and rain wreaking havoc. Rain was blowing inside and you had nurses having to run through the rain to get additional supplies, or to transfer a patient.

Wired868: Can you explain what happens under those tents?

Stuart: Well the tents are there for screening and they are necessary because you don’t want to be in air condition with the Covid-19 virus. So when you go to a health facility with a medical condition, whether it is a heart attack or a broken toe, you don’t walk right into the building—you must be screened.

So there are three categories of persons waiting in the tent: persons who are being screened, persons suspected of being infected, and persons who are infected. Of course you want people with no symptoms to be moved out as quickly as possible to the main A&E room.

If you have even the remote possibility of a [Covid] symptom, you remain there [under the tent] until they test you and the test comes back. If positive, you go into a next area of the same tent to wait for your transfer. That can be anything from one day to seven days, or maybe you might recover right there!

I personally know one patient who stayed there for seven days. Seven days! Every time a space opened up in Couva or Caura they took someone else, because she wasn’t as bad as the next person. Do I send this 63-year-old person to Couva, or a 70-year-old who is deteriorating fast? That is part of the decision-making process.

Now the person waiting in the tent cannot shower for the duration of their stay there. She can’t bathe, can’t see her relatives—she just had to remain there and use that one port-a-potty and wipes. And that’s it.

By the way when this pandemic first started, the government was renting tents. Well I would have loved to have been one of those tent rental people! I think the government bought them afterwards; but [renting them] was a miscalculation. I don’t know of any pandemic that lasted a month, so I don’t know why they rented! We asked to see the bill for those tents and we haven’t gotten it, but we will keep pursuing it.

Wired868: How do we make things better for nurses during this pandemic?

Stuart: Well our nursing schools are closed and there are no students being trained, so we have had no nurses graduating since the pandemic started. At the same time, numerous staff continue to leave due to migration or retirement, as well as a few who are fed up of working under temporary contracts for years and are now going into different fields, because they have qualifications to go into other jobs. We are losing nurses with no one to replace them, which adds to burn out.

Nurses would want to get some type of recognition from the government for what they are going through. You are a sport journalist and you would see sport personalities receiving awards in a number of areas. Can you name one nurse who has received a national award? Ask the average person if they know the name of any nurse.

Police officers, doctors, and other public servants have gotten awards. If the government doesn’t see the need to recognise nurses now, then they will never see the value of nurses!

They say at press conference that they value nurses but that is easy to say. Right now, nurses are denied vacation, they are denied casual leave, they are asked to work extra hours, stay away from family, rent facilities. There are a number of things that nurses are going through. How is the government recognising nurses?

In other countries, we saw nurses are afforded hazard allowance and so on—something to say: we see what you are going through, you will never sing a hit song or throw a javelin at the Olympics, but you are saving lives and we recognise this; and here is something.

You will never hear of a police officer on a three-month contract, but 50 percent of nursing contracts are three-months, six-months, or one-year contracts that do not carry gratuity, pension or any benefits of a contract. It is only a contract by name.

That is why we are calling for the removal of the current CEO of NCRHA. Even before the pandemic, he has nurses working on short-term contracts even with spots for permanent positions available at his RHA. He (allegedly) finds a way to save money for those ads they’re always running, as if they are some sort of private organisation that always needs to advertise. Only the NLCB advertises more than the NCRHA! Where are they getting that money to advertise? Out of the pockets of the nursing personnel, that’s where! Give them proper contracts or permanency!

Also we want health insurance and life insurance for nursing personnel. Police and Fire have that, but if nurses drop down they have nothing to get. We are working on 2013 salaries and you are entitled to an annual increment of TT$200. But to save money, the RHAs have not been carrying up salaries according to years’ service. You often have a scenario where a nurse who has been in the service for 10 years is being paid the same as a junior nurse who just came in when, with the increments, she should be getting TT$2,000 more [than the junior nurse].

Hopefully with the finance minister saying they will pay out VAT payments, they will also make payments to RHAs. But then the finance minister has repeatedly said that he gives the Ministry of Health and the RHAs what they need and it is up to them to see about how that money is spent. So we hope the minister and CEOs make sure and pay nurses who are owed their backpay of increments.

Stuart (continues): Secondly, we say ease the [financial] burden of nurses. Put them in the hotels that are basically closed now and house them there, so they don’t have to risk going home to their families, and then shuttle them back and forth. They can also use places like UWI, SAPA, and so on that have rooms. Save them that additional bill that they have taken up in terms of rent and so on.

And then there is the issue of issuing lunches. Now they do it in Caura and Couva, but what about everywhere else? Nurses were working three eight-hour shifts before  and now they are working two 12-hour shifts. Where are we getting food? All the food establishments are closed!

Nurses are going home exhausted and drained, you expect them to cook at that hour?! Provide meals for nurses; and not only those in the Covid areas but the general settings too. Soon, if we continue the way we are going, we will no longer have a parallel system anyway—and that was shown with Augustus Long and the Arima and Point Fortin hospitals, which are now being used for Covid patients.

Slowly where we had a parallel health care system it is merging into one setting, but hopefully the numbers [of new cases] recede so we don’t reach to that.

Wired868: You mentioned the need for reinforcements. Can you say more on how the Ministry of Health can accomplish that?

Stuart: There are only two ways remaining. There were three, [one of] which was bringing back retired personnel. They tried that and some heeded the call, but some were hesitant—because remember it is the elderly who are most at risk with this virus.

Otherwise, there would be incoming nurses from nursing school. But unfortunately the government in its wisdom has stopped nurses training.

The only other avenue would be foreign nurses. But every single country is holding on to their nurses at this time and increasing their salaries. The only country we could turn to would be Cuba. We went to Cuba last year and I’m not sure why they haven’t revisited there for nurses. Even if they are short, Cuba would always lend assistance wherever they can. We owe a real debt of gratitude to Cuba for all the humanitarian assistance over the years.

Otherwise no other country would encourage their nurses to come here. It is only Trinidad and Tobago who appear to encourage their nurses to migrate. The THA actually set up a forum for recruiters to come and take away our nursing personnel, which is unique to say the least.

Wired868: You mentioned awards for nurses—what categories do you have in mind?

Stuart: I’d say there are two areas. One is an honorary doctorate. I have never heard of a single nurse who got a honorary doctorate. I have heard them giving those to singers and athletes; but never to a nurse.

The second is a national award for long and meritorious service, which the government is accustomed to giving to public servants. Beryl Brewster was one person who served Trinidad and Tobago as a nurse and nursing educator, and she got the Public Service Medal of Merit (Gold). We put forward two persons that year and the president accepted one.

The other was a mental health officer, Walt Murphy. This gentleman, when persons think about mental health, his name comes to mind immediately. He is like the Professor [Courtenay] Bartholomew of mental health… There was little more he could have done in his lifetime again that could have propelled him to get an award.

Thankfully they accepted Beryl Brewster and maybe that was because she was trained in England and worked there as well. Maybe that is what impressed them, because she also had that ‘foreign persona’; and you know how it seems like you have to be appreciated away before you can be appreciated here. But she did a lot for nursing and we were thankful that she was properly honoured while she is alive.

Wired868: Tell us more about Walt Murphy…

Stuart: Well, he is a nurse, a mental health officer; and he comes from a family or nurses. All his brothers are also nurses. He was born in Tobago. He has a way of communicating, whether it is with student nurses, staff, patients. He has a gift.

You remember the district health officers in brown outfits who would go into communities  and talk to families to make sure you bring up children in a clean, proper environment? Well, he would go into communities and talk to people on drug use and alcohol use and work with families to get them through different, difficult processes. He was dedicated that he would do those things even on his off time!

The average nurse wouldn’t go in to his areas. He went to the most depressed areas like in the hills of Laventille. Whenever there was a case another person didn’t want because the environment made them feel unsafe, he would go in those areas—and with no security!

A number of nursing students, myself included, followed him on his rounds into these communities and saw the rapport he had with the people there and how he could defuse volatile situations.

You would see many times when a police officer interacts with a mentally unwell person it would result in a fatality. But when the police contact Walt and he goes on the call, that would never happen. Even if that person was wielding a cutlass, he would always defuse the situation because they trusted him. It was remarkable to see.

Those stories never made it to the public domain and maybe the national awards committee just brushed off our application. But the people whose lives he saved over the years would speak volumes about what he has done for the country. He didn’t see it as a job, he saw it as a way of life—and that is what you really want from a nurse.

He is a walking encyclopaedia in terms of mental health. We saw the awards committee sending out requests for nominations again, so we will put his name up and hope they accept it this time.

It is far too difficult for nursing personnel to be awarded in our view. We always see doctors being awarded, so it is not that they do not respect the field of health. The issue seems to be that they don’t value nurses.

If Trinidad and Tobago doesn’t see the value of nurses now, when will it ever happen?

Editor’s Note: Click HERE to read response from NCRHA CEO Davlin Thomas on criticism of his ‘rotation’ of senior doctors at the Couva Hospital, and the counter to that from TTRNA president Idi Stuart which suggests lives have been risked for the benefit of statistics.

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