NZ Emergency Doctor Describes Crisis Caused By Lifting COVID Public Health Measures

https://www.scoop.co.nz/stories/HL2206/S00049/nz-emergency-doctor-describes-crisis-caused-by-lifting-covid-public-health-measures.htm

By Tom Peters

The World Socialist Web Site recently spoke with Gary Payinda, an emergency doctor in Whangarei in Northland, one of the poorest areas of New Zealand, about the out-of-control spread of COVID-19 and the crisis in public hospitals.

In recent months, hospitals have been overwhelmed by COVID-19, influenza, and other respiratory illnesses. There are numerous reports of long waiting times at emergency departments, sometimes with tragic consequences, including the recent death of a 51-year-old woman in South Auckland due to a brain bleed.

The Labour Party-led government decided in October 2021 to lift its elimination strategy, which had kept the country free from COVID-19 for most of the pandemic. In 2022, lockdowns were abandoned and schools and non-essential businesses were reopened, as the highly-infectious Omicron variant spread across New Zealand.

In November 2021, during the outbreak of the Delta variant, Payinda warned that New Zealand was risking a “preventable catastrophe” due to inadequate vaccination levels and a chronically under-resourced, rundown public health system.

Now, more than 10 people are dying of COVID-19 each day. In a country of just five million people, there have been over 1,400 COVID-related deaths, all but 59 of which have occurred in 2022. Nearly 1.3 million infections have been recorded, i.e. one quarter of the population. The real number is likely much higher. More than 300 COVID patients are in hospital.

The government is downplaying the situation, with Health Minister Andrew Little saying that the hospital system is “under pressure” but “coping.” Healthcare workers have responded angrily to such statements.

Payinda told the WSWS: “These are real human lives, and it’s not a very small number. It’s a fair number of deaths each day, and we are doing so little to try to prevent that, it’s really awful.”

He said that with the ending of public health measures, “what people didn’t count on is just the incredible infectiousness, or transmissibility, of Omicron. Even though any one individual case may not be as lethal, when you have so many more people getting infected, it becomes overwhelming, so you end up seeing more deaths, more hospitalisations, more minor cases, more severe cases.”

The spread of COVID, combined with “an already overwhelmed healthcare system that wasn’t really able to deal with demand even as it stood pre-COVID,” had created “a perfect storm.” Payinda observed that the same problems were now playing out in New Zealand as internationally: “If I read about or talk to colleagues in Australia, the situation’s very bad over there as well.”

Overcrowded hospital wards mean that patients could not always be admitted, and were left stuck in emergency departments (EDs) for “6, 12, 24 or more hours.” This “slows everything down in ED and creates dangerous situations that you’re reading about in the newspapers now: people calling ambulances and not having them arrive, showing up to ED and having to wait hours in the waiting room.”

Hospital staff are increasingly burnt out and “some nurses are retiring earlier than they would have, because they say: ‘I can’t keep going at this pace.’” Part of the problem is that they “don’t see a light at the end of the tunnel and don’t see any hope that it will improve in the near future.”

The out-of-control spread of the virus in schools is contributing to the shortage, as healthcare workers get infected by their children and are required to self-isolate. Despite the use of N95 masks and other precautions in hospitals, Payinda said, “basically anyone who interacts with kids has no way of protecting themselves from COVID.”

Tens of thousands of patients are unable to access treatment, as hospitals defer non-urgent operations to try and cope with the winter surge. Those deferred patients “don’t just disappear: someone who needed surgery last year is still around, and they’re probably sicker now than they were a year ago.”

He warned that the situation could get even worse with the new BA.4 and BA.5 subvariants of Omicron, detected in New Zealand in recent weeks: “The new variants often prove our vaccination efforts less efficacious; you can get reinfected more quickly.” In the United States, these variants caused an estimated 35 percent of new COVID infections last week, according to the Centers for Disease Control and Prevention.

A large number of people are not fully vaccinated. About 95 percent of people aged over 12 have received two doses of the Pfizer vaccine. According to the Ministry of Health, 2,676,744 people have received a third vaccine dose, which is essential to provide any protection against Omicron—although even triple-vaccination does not prevent every severe case. This represents just over half the population.

With the arrival of Omicron, Payinda said, “we lost our way somewhere and failed, miserably, to get people boosted. There are so many millions that need boosters but haven’t received them—let alone childhood vaccination.” Only 27 percent of children aged 5 to 11 have received two doses, and nearly half have not received even one shot.

Prime Minister Jacinda Ardern and her government have repeatedly described two doses as “fully vaccinated.” Payinda said: “That doesn’t apply whatsoever to Omicron. We should have said: to be fully vaccinated means you’re fully vaccinated and up to date… We would be having a very different conversation now had we got boosters out there with the same initiative that we did for the first two shots.”

Instead, the government had declared “mission accomplished” after almost all adults were double-vaccinated, and “then we opened up everything and we got rid of public health measures that are absolutely essential.”

Payinda is one of hundreds of medical professionals and scientists who have signed a petition urging the government to adopt a “Vaccines Plus” strategy. Their demands include a renewed vaccination push, as well as mandatory masks in schools, better ventilation of indoor spaces and other mitigation measures, such as monitoring carbon dioxide levels and using HEPA air filters.

HEPA filters are “wonderful for pulling COVID out of the air,” but cost about $600 to $800 per room, Payinda explained. “It’s very expensive and it’s not where we have chosen to deploy the funds, which is a bit scary if a variant arises that is much more deadly. It’s going to become a real issue and we’re going to wish we had done adequate ventilation and filtration in our schools, in our public places, in our hospitals.”

While governments, in New Zealand and internationally, justified the reopening of schools by claiming that children have a low risk of getting sick and passing on the virus, Payinda said: “We know that kids do get it, we know that kids end up with MIS-C [multisystem inflammatory syndrome in children], they end up with the long-term chronic symptoms of Long COVID, they end up getting hospitalised, young kids, at quite high rates.

“The thing that beggars belief is that we’re exposing people to these risks, especially kids, not really understanding the full impact of what these infections will do to their immune systems and their general health in the future. We don’t know how they’re going to be affected by this, how it will modulate their response to other infections.”

Removing mask mandates “in dense public places like schools, workplaces and whatnot, was really an incredibly poor decision,” he said. Without masks, people are risking “perpetual rounds of infection and reinfection.”

Regarding the growing complacency around mask use, Payinda noted that “there’s not much you can do that is as easy as putting on a mask. It weighs almost nothing, it costs almost nothing, it doesn’t hurt you, and it may prevent you from infecting someone else and someone else from infecting you. So the fact that we can’t do this most minimal of things, it’s almost like we’re going back in time to the days of Ignaz Semmelweis.”

In 1848, Dr Semmelweis, while working at a Viennese hospital, “said to the doctors: ‘You need to wash your hands, I think there’s something on your hands that’s causing women to die of puerperal fever, you need to maintain a level of hygiene.’ The people of his time made his life hell and said: ‘You’re crazy, this is unnecessary, stop bugging us.’ I think we’re at that stage now.”

There are now demands for New Zealand’s remaining public health measures to be ditched. The right-wing nationalist NZ First Party leader and former deputy prime minister Winston Peters recently called for the COVID vaccine mandates for healthcare workers to be removed, as they have been for other workers.

This was an example of public health being “weaponised” for political gain, Payinda said. “You have to ask yourself: where does this madness stop? Instead of saying we should be vaccinating healthcare workers against influenza so that we can protect vulnerable patients from getting influenza—patients on chemotherapy and compromised folks—we’re actually entertaining the idea of going backwards. What’s the next step? Stopping masking of healthcare workers?”

He also blamed the media for “broadcasting the sort of anti-public health opinions of business people and tourism experts, [while] ignoring the actual impact on health.” Payinda pointed to the growing complaints about the cancellation of flights around the world, which failed to make the connection with “people onboard airplanes not being masked, staff not being masked, and staff getting sick and unable to work. How can you not draw the connection between that and the disruptions to your family’s holiday or your business travel, or the greater expense?”

Payinda said there were not enough strong voices in the media debunking common myths about COVID—including false claims that the disease will become milder over time, and that if enough people are infected the population will achieve “herd immunity.”

“For a disease that doesn’t create any lasting immunity, there can’t be herd immunity,” he said. “Within a few months of infection, you could be infected again.” Recent studies have found that “in some cases, people who’ve been previously infected with a variant of COVID may actually be less well-protected against COVID than those who weren’t infected at all. In some groups of people, their immune systems are rendered weaker after the COVID infection than they would have been had they not had it. So they’re less able to fight off the next one. That’s a pretty sobering thought.”

Payinda is seeing “a lot of patients stuck with the prolonged after-effects of a COVID infection. More and more, when you enquire: ‘How did your COVID go three months ago?’ you’re hearing: ‘It went good, but I still have this residual cough or I’m not exercising the way I did before.’”

The number of people with Long COVID in New Zealand is not being tracked, but a recent US survey found that one in five people who get the virus develop long-term symptoms.

Payinda referred to studies showing that “once you’ve had COVID, you’re at increased risk of stroke, of pulmonary embolism, blood clots in your legs, widespread problems related to clotting and to chronic inflammation… and that risk seems to be elevated for as long as we’ve been studying it, so even out to 12 months people are still having more events than they would have otherwise, if they hadn’t had COVID.”

Payinda stressed that practical measures can be taken now to prevent more severe illnesses and deaths. “What I really fear is we’ve set ourselves up very badly for the future and we are going to lack all kinds of resilience—not just within the health system, but generally—for when we do get a worse variant. The odds are quite good that sooner or later we will, and hopefully we’ll react at the time.”

He hoped more people would “realise that this pandemic is affecting people profoundly, and there’s something we can do about it. It’s not like this is beyond us. We have the means to protect ourselves. We’re just choosing not to employ them.”

Original url: https://www.wsws.org/en/articles/2022/06/25/onqr-j25.htm
 

© Scoop Media

#CovidisAirborne #MaskVaxVentilation #COVID19 #Covid #PublicHealth #EmergencyMedicine #CorsiRosenthalBox #Masks #Facemasks #CO2Monitoring #Winston #Labour #National #NZGreens #Influenza #Flu #Vaccination #Boosters #NZHerald #Scoop #Stuff #RNZ

Lifeguarding and First-Aid: A Medical Debate

I’ll be participating in an online medical debate, for anyone interested in: #lifeguarding #FirstAid, #firstresponder #Lifeguard #CPR #C-spine #trauma #BLS

The International Life Saving Federation is having a medical talk (actually, a debate amongst several international doctors, researchers, and paramedics) on C-collar use and Hands-only CPR. Should be fun. It’s aimed at anyone involved in life saving, from lifeguards to aquatic agency medical directors. Registration is free.
There will be two other webinars in weeks to come on other Rescue Commission topics.

To register:
https://teams.microsoft.com/registration/1o6gZQtRk06GKHFqc5ww2w,8_61ShGRxkeJEjXpmKBxEQ,TTxeLtvid0mUUTbo1P4rcA,FY9IgWg54ECd3sA6cUMJig,XBShUBrQ5EOrY2WZ9iXr8A,CpQZPDNNG0aH8JqbWOTaGw?mode=read&tenantId=65a08ed6-510b-4e93-8628-716a739c30db&skipauthstrap=1

To learn more:
https://www.ilsf.org/2022/06/16/ils-rescue-commission-webinar-series/

(Feel free to share with email or link with anyone who might be interested in lifeguard first aid/resuscitation)

Gary Payinda MD MA DDU FACEM
Medical Cmte Chair, International Life Saving Federation
Emergency / Prehospital & Retrieval Medicine
National Medical Director, Surf Life Saving NZ
Councillor, NZ Resuscitation Council
drgarypayinda.com

Recommended Links:

Surf Life Saving New Zealand training resources

Westpac Rescue Helicopter news

New Zealand Resuscitation Council news

International Life Saving Federation Medical Committee Twitter

unroll @threadreaderapp

54 religious schools are hindering anti-cancer efforts: ‘Dark ages’ thinking, supported by our taxpayer money.

https://www.1news.co.nz/2022/05/26/exclusive-some-religious-schools-refusing-to-offer-hpv-vaccine/

some background info for you:
(public numbers available online)


nz hpv vax rates are around 54-67%


fully funded for 9-26 yo males and females


vaccine around since 2006, but only made available to boys in 2017


roughly 1/3 teen girls unvaccinated
roughly 1/2 teen boys unvaccinated


(the numbers are poorly tracked, hard to find, so much so that the numbers for boys are merely ‘modelled’, ie, educated guesses. sad)


80% of us get HPV in our lifetimes (this is not an affliction of ‘the promiscuous’)


medical studies have actually shown that HPV vaccination doesn’t decrease your age at first intercourse, nor your teen pregnancy rate (obvious, but there’s some dangerously backward people out there in world that equate HPV vaccination with an inducement premarital sex)


boys 53% (bs 78%+ in australia)
girls 61-67% (vs 81% in australia)
these numbers are the best i could find…data is hard to track down…a reflection of the low priority this is given by govt.
religious schools get $900-2300 per per student (!) per year…of taxpayer money. they are not independent; they are government financed.

per year in nz, approx:
Cervical cancer 190 cases, 60 deaths, 95% are vaccine preventable
Anal cancer 250 cases, 91% preventable with HPV vaccination
Head and neck (nose, tongue, mouth, throat) cancers, 50 deaths per year, 70% hpv preventable
Penile, vulvar, vaginal cancers: 90%+ preventable
and genital warts too (which are HPV)

you don’t prevent these cancer deaths if you don’t vaccinate your teens.


i’d love to see what areoat current numbers are for HPV vaccination. But i assume they are markedly lower than the ones I have posted above, which are all pre-covid.

drgarypayinda.com

Mask exemptions for runny noses? Really? Yes, really.

This is from the Ministry statement to the media yesterday:

The process for applying for the new exemption card is designed so that it would be hard for someone to get a card dishonestly. For a start, to receive a card, applicants would first need to make a legal declaration that they would meet a range of eligibility criteria. The cards will be anchored to the person’s National Health Index (NHI) number, and will have the person’s name printed on them. This allows for the person’s declaration to be checked in the event that someone complains about presentation of a fraudulently-obtained card.

This new process aim to:

make sure people from already vulnerable communities aren’t further marginalised by imposing a complicated application process on them; but also
give assurance to business owners that someone with an official exemption card has gained one legitimately and has valid reasons for being exempt.

There will also be a legal backing behind the exemption cards. Anyone who fraudulently misuses the application process would be in breach of a COVID-19 Order under the COVID-19 (Public Health Response) Act 2020. If convicted under s26 of that Act, people can be sentenced to up to 6 months imprisonment or a fine of up to $12,000 for an individual or $15,000 for a business.

The vast majority of New Zealanders have already shown they want to do the right thing to protect themselves and their communities, and to support the rights of their fellow Kiwis during the pandemic response. It’s only a small minority who’ve sought to seek to misuse the existing system and it would be extremely disappointing if they chose to do so again.

Use of a fraudulent mask exemption could be reported via https://covid19.govt.nz/news-and-data/report-a-breach/ or NZ Police.

My interview for FairGo episode on RATs

https://www.tvnz.co.nz/shows/fair-go/clips/fair-go-looks-at-the-new-gold-rapid-antigen-tests

(One hour of talking. Maybe one minute on the show. Ha.)

Bottom line: trust your RAT result if it is positive: You’ve got Covid. But understand a negative test result does NOT necessarily mean you are Covid-free.

RATS are good tests…not great tests. Great at identifying highly infectious cases.

Masks will continue to be the bedrock of Covid prevention. Get a KN95, and use it properly. Get your booster. Open doors and windows to ventilate.

Covid is a disease of indoor re-breathing of other people’s exhaled air. Preventable with masks and ventilation, same as every respiratory infection ever.

What’s my Omicron death risk? An online calculator

https://www1.racgp.org.au/newsgp/clinical/covid-19-chart-updated-with-omicron-risk-of-death

Remember, your Covid booster reduces your risk of hospitalisation by 90 percent.

If you wear a KN95, are boosted, and avoid crowded, poorly ventilated spaces, you are doing a great and effective job at minimising your risk during a respiratory (airborne) pandemic.

If we all did this: good mask use, boosters, and ventilation, we would have controlled this surge and blunted this pandemic long ago.

Get vaccinated. Get your kids vaccinated.Explain to them that getting Covid is vastly worse than getting the vaccine.You will likely feel tired for a couple of days and have a sore arm.But you’ll be much safer from Delta (which has killed 5 million worldwide), and Omicron, which is surging worldwide.

Even a child can understand that avoiding infection is preferable to becoming infected.

No one wants to unknowingly infect people who are vulnerable, or elderly, or have just had chemotherapy, or have autoimmune disease, or are one of the roughly 100 people in New Zealand who cannot be vaccinated due to medical reasons.

We protect all of these groups, as well as the health of our overall healthcare system (which is falling over in most places due to Omicron numbers), by wearing masks indoors around others and by getting vaccinated.

These infections are manageable, but only with widespread mask use and vaccination.

https://www.rnz.co.nz/news/national/459663/covid-19-paediatric-vaccine-roll-out-begins-for-children-aged-5-11

Boy or girl? People probably have no idea how many other variations babies are born with. A brief medical exploration of intersex.

Boy XY, girl XX. That’s how it works most of the time. But in every 1/50 to 1/5,000 babies born, there is a DSD, also known as a disorder of sexual development, commonly referred to as being intersex.

XY can be male, or rarely female.

XX can be female, or rarely male.

There are biological conditions that cause sex reversal, pseudohermaphroditism, hormone insenesitivity and hundreds of other conditions where chromosomes don’t decide one’s sex.

In the above diagram, one can see how embryos are born as essentially blank slates, with genes and hormones influencing which structures grow and which recede.

Most non-doctors would have no idea that the male and female sex organs start off the same.

In almost all of us, one primordial fetal structure becomes the penis or the clitoris.

In almost all of us, one primordial structure becomes the scrotum (fusing down the middle) or the labia, depending on a complex cascade of genes and hormones.

But in some, there can be a half-scrotum, half-labia. Or an unfused scrotum, or a penis that has a hole along the bottom, where it didn’t fully fuse. Or streak ovaries that didn’t fully develop. And every other variation in between.

Perhaps even more surprisingly, genes are not THE deciding factor. It’s way more complicated.

The penis can develop in a genetically female XX embryo. A clitoris can develop in a genetically male XY embryo.

That’s as far as I want to go for today into the amazing variations that are considered under the intersex umbrella.

Human sexuality and development is far more complicated than you or I might think. A matter best understood by a clincal geneticist or paediatric endocrinologist, or by an intersex person themselves.

Anyone who reduces it to something simple or just a black-and-white issue of male or female is being just that: simple.

Chats with Ruth: Covid Questions and Answers. “medical masks vs cloth face masks”

Spoiler alert: the most effective mask is the one you wear.

Mask tips: never use one with an exhaust valve (risk to others), avoid single-ply fabric. (quite poor filtration).

Wearing one under your nose is stupid.

They don’t have any real effect on oxygen levels or carbon dioxide levels…even in COPD patients. Surgeons, and now even ED doctors, wear them all day. That desperate asphyxiation feeling is mental. It’s just humidity and one’s baseline anxiety and fears.

There is little we can do that matters more in Covid prevention than masks, vax, and ventilation.

The ‘Burden of Proof’ is on this Economist Peter Crampton to prove his competence when speaking on issues of medicine safety.

Yet another neoliberal right-winger gnawing at the shins of a government agency that is tasked with helping the New Zealand people stay healthy, in part by limiting the corrupting power and influence of big pharma and corporate interests on medical questions of patient safety, affordability, and public health.

https://www.stuff.co.nz/business/opinion-analysis/127121998/burden-of-proof-is-on-medsafe-to-justify-its-existence

Economist Peter Crampton says Medsafe, the medical experts who keep us safe from ineffective treatments, harmful medications, and costly me-too drugs, should immediately approve any drug that is approved by two other ‘trusted’ countries’ pharmaceutical approval agencies.

No, how about we don’t do that. New Zealand’s Medsafe takes the zany approach that their medical experts should take some time to examine the evidence. Crampton gives them up to two days. FFS. They should take the time they need to analyse studies and do what is right for the NZ public. Having worked as a doctor in several international health systems, I have more trust for Medsafe doing the right thing than I have for Crampton’s economic wrecking crew looking after the public interest.

Why wouldn’t we want to put all our faith into a “better resourced” medication approval agency, like the USA’s? Because (like the USA’s) that agency might be so bought out by corporate big Pharma, or so manipulated by politicians and lobbyists, that it deserves more than a 48-hour analysis or a knee-jerk approval.

It’s boggles the mind that this economist, from the ‘free-market at any cost’, race-to-the-bottom ‘New Zealand Initiative’, doesn’t know better.

Perhaps he could find a more skilled economist, from a “better resourced” nation, to write his political pundit opinions for him.

According to his logic, they should be able to do a better, more capable job of it than he can, and much more faster. Maybe even within 48 hours.

‘At the boiling point, fed up and angry at the Auckland Covid lockdown’ vs ‘The Unvaccinated’: A civil discourse online.

I don’t expect to get signed emails from readers that frustrated and upset while being thoughtful and humane. I sought permission to reprint the whole exchange, and here it is:

Dr Gary,

Apologies for using this email but i wanted to send you a note as an Auckland resident who has been in lockdown this time for another 3-4 months  and double vaccinated with a science background who saw your recent worries re: Aucklanders bringing Covid north.

Possible you were misquoted but it appears to us in Auckland you are advocating we remain locked up and not able to work forever to make up for some peoples tardiness or ignorance regarding vaccination?

Could I politely point out some areas you surely are aware of:

We have done all that was asked of us in Auckland plus, to be frank, its government stupidity they put all the hotels in Auckland, and failed to properly protect many coming of our MIQ system.  In short we are a filter for all NZ and should not have been, its not our fault Covid is in Auckland only.  People all over NZ have surely not been living under rocks?  We knew what was happening and that it would and will come here, it cannot be stopped and despite our childish government it was never going to be stopped.

We are not responsible for poor vaccine purchase and rollout, or vaccine passes, etc.

I have been unable to work and been locked down for months in part because some of your residents don’t seem to take up a very, very simple challenge and get vaccinated.  I realise that some people may be in more difficult situations than others but really…. They have had loads of time to get vaccinated (I do appreciate the medical issues with some and I have sympathy there but that’s not the majority). 

Some of your residents have been leading normal lives while we go bankrupt here and have our freedom curtailed – there is (excuse my language) a bloody limit to human patience.  We are not charging north giving people Covid but people have had a chance to get vaccinated – enough time has passed.  People have been unable to get home to all sorts of tragedies in part because these people wont get jabbed.  Its also fair to say that many people are ‘vulnerable’ due to lifestyle decisions – I sympathise about the reasons but some people seem not to realise about their health decisions over many years.  I am aware that some simply don’t know about such things but at what point am I responsible for my own choices?

In short Dr I know you will be aware of our situation here in Auckland.  The anger here is at boiling point.  We don’t mind taking some stick and have put up with incredible hardship and removal of basic freedoms while many others carry on their lives by not getting on and getting vaccinated.  In short we feel enough time has passed, being help to ransom in perpetuity is not on and I would ask you to simply accept that other people also have a right to not go crazy or bankrupt because of a very few people’s choices.

I wish you all the best with the difficult situation ahead.

Respectfully

(Name withheld from publication at request.)


Hi [——],

It’s a great letter you wrote. I understand your situation. Can I have permission to reprint it in my website? I’ll put a longer answer online, but agree with a lot of what you say, and would have made vaccination mandatory long ago, when we first knew it was safe, saved lives, and would have allowed us out of level 3 much sooner.

I have no time for the willfully stupid folks using this moment for political wins using antivax as a weapon.

But I also know there are poor folks up here in Northland with awful educational experiences, Facebook or word-of-mouth misinfomation their only source, and fear they will hurt their baby by getting a vaccine that may in fact save their baby’s life. 

They don’t have easy access to any GPs around them, and when they drive to where one is, they have a debt with the GP that has to get paid. Unlike you or I, they would never go to a GP to have their health questions answered, the money isn’t there. Minimum wage doesn’t let a family live above poverty level, especially with Northland rents being what they are.
There are more vax clinics (with better hours) within walking distance in one Auckland suburb than in whole swathes of the mid-North. 40% of New Zealanders are functionally illiterate, and plenty of people don’t have enough petrol money for extra trips into town: it has to be convenient and timed right. We can offer alcohol sales in almost every village and town in Northland like clockwork, but can’t do the same for vaccination. There are towns that have lost their GP services completely. Health professionals, in general, don’t flock to work in impoverished towns like Kaeo. Moerewa, Kaikohe. Yet these are the places than need medical care the most. Residents have put up with a lifetime of just sucking it up and dealing with it, and for Covid it’s no different. Not making excuses for people to not get vaccinated, just acknowledging it’s a hell of a lot easier for me to get vaxxed than them.

I haven’t read what 500 words the Herald wrote yet, based on a 30 minute interview, but this problem needs aggressive prompt action… so they can get vaxxed and you can get on with your work and life. 
Mandatory vax, and huge rollout to Maori patients by Maori vaccinators in Maori community venues. If we can get liquor stores and meth delivery into every village in NZ, we can get a vaccinator down every street.

Cheers

Gary


Dr Gary,
Thank you for your reply.  I appreciate your decency with the reply and the respectful exchange of views.  I suspect if you and I were in Parliament we could have a decent argument but make substantial progress for many people that we both represent and put aside our minor differences.  If you delete my name from the letter and forgive the big finger typing errors yes feel free to publish.
On your response, I agree with almost all of your points.  In fact I suspect we have so much to agree on there is little to split hairs on apart from the issue of personal responsibility and perhaps my belief that parts of the Maori people are not standing up in that area.  I blame nobody for my poverty as a child or the abuse suffered, I drive myself forward to accept others experiences and yet I continue to educate myself and try to do the right thing.  I guess humans can respond differently to the same circumstances?
I look forward to continuing this debate as a sensible NZ citizen and holding incompetent Politicians to account – we both agree this should have been dealt with a year ago.  I probably don’t mirror all your views but I certainly accept that these communities require a different, smaller scale but intensely local flavour as part of a successful vaccination campaign.

Regards,

[——]

-END-


That’s it. Social media is a shitshow, and a circus making 29 billion dollars a year for Facebook (who pay zero dollars in NZ taxes) while destabilising democracy, damaging society and hurting public health. But every few years, it leads me to partake in a germane and reasonable conversation with someone.

——-

I think most people just want the thing fixed, and gotten on with, with individual and social responsibilities met. But most of all with results that don’t have us hobbled, and groups left vulnerable, all at the same time. As is currently the case.

Hopefully we’ll move towards maximal responsibility of the individual towards the society, and maximal responsibility from the government towards the individual. Governments are not here to make more profits for the wealthy, they are here to serve the needs of society. The needs of people. Things like safety, health, and education.

Mandated vaccination -and- massive outreach to communities, are what will get us to a place of increased safety. Partial vaccination works not much better than partially effective birth control. If we are serious about this thing, we will address it aggressively, and get on with living safely.

——

“If a community in New Zealand is large enough to have a liquor shop (not to mention door-to-door meth delivery), it’s large enough to have a nurse practitioner, a mental health counselor, and a dental therapist.”

-Dr Gary Payinda

All NZ Surf Life Savers will be Vaccinated. (Yes, the person ventilating you if you drown will have had their Covid shots.)

So proud of my organisation SLSNZ, Surf Life Saving.

Rescuers, first aiders, lifeguards: they and their patients and fellow lifeguards will now be safer from Covid.

90% less risk of hospitalisation, and death. 40-60% less spread to others.

The true meaning of life saving, and caring about others.

Well done SLSNZ. Very proud of this rescue organisation and its members.

https://www.surflifesaving.org.nz/media/995484/aw-slsnz-covid-vaccination-memo-final.pdf

Whangarei hospital: old, cramped, and not fit for purpose.

https://www.rnz.co.nz/news/national/454808/whangarei-hospital-leaky-roofs-dodgy-lifts-waiting-lists-and-covid-19-s-here

The article got most things right. Minor details they didn’t get quite right: windows falling out was years ago (10-ish?) and they were patched up. Ambulance ramping has been reported as an issue in Auckland and Hamilton, not Whangarei.

Issues they didn’t have the space to get to:

The lack of complaints by lovely, patient, and understanding Northlanders.

The repeated episodes of a ‘code red’ overwhelmed ED, the lack of sufficient beds for (admitted) inpatients, the surgical delays of many months, the overfull status of mental health and rehab, patients unable to get a nurse and ambulance to transfer them from Whangarei to Auckland for emergency care adding 4,6,12 or more hours to people’s emergency care, the tiny waiting room that creates infection risk, the cramped conditions the lab staff work under, and more.

Bottom line: a whole host of bad-for-patients stuff that would never be tolerated at a suburban Pakeha hospital.

Teachers, students, Covid, and vaccination.

There are a lot of teachers and students with great Covid + vaccination questions. I hope this helps a few of those questions.

For more info check out:

https://drgarypayinda.com for my other articles, interviews, and talks.

…towards the end of this video, I forgot to mention my main inspiration for making this (in addition to my day job as an emergency doctor) is that I’m on the Huanui College Board of Trustees, a parent to two high school students, and friends with a lot of teachers and educational staff, who provided me with some of the questions and discussions underpinning his clip. Thanks for your questions — always happy to try to give good, reasonable advice.

(To be clear: I speak only for myself as a doctor and parent, not on behalf of any organisation!)

Anything I can do to help the NZ teacher and student/parent community, just ask. Happy to do a group Zoom Question-and-Answer session if needed/wanted.

Spread this blog post if you think it is useful.

https://www.facebook.com/drgarypayinda

@GaryPayinda

@NZPPTA @EducationGovtNZ @MatatuAotearoa @NZScienceTeachr @NZSchoolTrustee edchatNZ @educationnz @nzteu

Medical Exemptions: a godsend for quacks

“Medical exemptions to mandatory Covid Vaccination:
If a staff member has particular physical or other needs that a suitably qualified health practitioner (in the course of examining the person) determines would make it inappropriate for the person to be vaccinated, that person will be exempt, and they can carry out work without being vaccinated. We expect the number of people who are exempted from the vaccination requirement to be very low as the Pfizer vaccination has proven to be safe for the very large majority of people.”

Medical exemptions –without official oversight– worldwide have proven an easily abused option. A bad mistake, prone to abuse by unscrupulous quacks.

The same as with any profession, a very small number of doctors operate outside the norm, which in medicine is called the ‘standard of care’.

Many communities are unlucky enough to a substandard doctor, often one beloved by the patients that seek them out. patients. Whether you call them quacks, charlatans, or just freedom warriors, they march to the beat of their own drummer.

The problem is when one of these doctors gets the ability to grant medical exemptions. Patients flock to them like moths to a lamp.

And their exemptions threaten the rest of the community. Mask exemptions, vaccine exemptions…each one erodes the safety net that protects us all.

There are virtually no medical reasons to avoid Covid vaccination.

We used to say anaphylaxis to the first dose of Covid vaccine was one of only two valid medical contraindications. The second was anaphylaxis to one of the vaccine ingredients (fats, sugar, mrna, salts).

But it turns out with medical oversight, almost every patient, even those with severe allergy, can be safely given the vaccine.

As with many things in medicine, doing the wrong thing is a lot easier, faster, and often more profitable than doing the right thing. If experience is any guide, we can expect that a few bad players will be responsible for the lion’s share exemptions.

Having a medical exemption oversight board is necessary. I hope our high-trust government is not too high-trust when it comes to medical exemptions. It opens up our vulnerable communities to too much risk.

If you hear of an abuse of medical exemptions, let the Medical Council of New Zealand and the Ministry of Health know. And click this link:

https://forms.police.govt.nz/forms/covid-19-breach

Face Masks, Stale Breath, and Freedom

(This one’s for CCB.)

You’re on Facebook. A friend posts their ‘research’ showing that face masks cause oxygen levels to drop and carbon dioxide levels to build up to dangerous levels, causing long-term risks of brain damage.

You know the person posting this stuff. You’ve known him since high school, and he was pretty dumb even back then. You doubt he has become scientifically literate in his spare time.

How do you respond to him? Do you post real scientific studies and show him facts proving that what he saying is bullshit? Facts have never worked against stupid people. They’re almost by definition impervious to knowledge.

Or do you tell him about the surgeons you’ve seen at your workplace? Really smart people that spent 14 more years in post-secondary education than he did, whose careers all tragically ended after only 2 to 3 years as a consultant surgeon.

It’s a well known fact that due to all the extra carbon dioxide they breathe — being forced to wear a facemask for hours and hours every day in surgery — that all surgeons end up with profound brain damage by the age of 36. Between the high CO2 and the low oxygen levels, they’re brains are devastated.

It’s just one of the dark secrets medical professionals keep from the public.

You decide that neither the truth nor jest will work. People will believe whatever they want to believe.

Last generation had thousands of fools who didn’t wear seat belts. Choruses of “They’re dangerous!” and “You can’t force me!” rang out for a decade until seatbelts became the law. And once that happened deaths were cut in half.

Masks are no different. Whether it’s this delta Covid, or the next variant, most people understand that masks (and vaccines) work great. For the rest, the non-believers…the mask-hesitant…the strong-minded individuals who are just waiting for a better, safer brand of mask to be imported…

they will just have to be forced to wear one by law, just like a seatbelt.

Eventually, they will realise they were just being oppositional for the sake of it, and accept it was a good idea: effective and not a big deal to wear a simple mask indoors around others while there was an infectious respiratory epidemic going around.

But those poor surgeons. So many brilliant young minds destroyed by re-breathing their own waste gases. Trapped in face masks they weren’t allowed to remove. No one’s going to be able to bring them back. The price of progress, I guess.

The End.

Don’t read this if you don’t want to know more about surgical masks, and how they don’t affect your oxygen or CO2 levels…even if you have severe COPD. Forward it to your friends.

https://doi.org/10.1513/AnnalsATS.202007-812RL

N95 mask fit testing

Had my mask fit testing today, after having messed up the prior one months ago due to a scraggly goatee. Cut that sucker off few weeks ago and tried again. It fits neatly inside the mask edges now.

——

Side note: if your doctor or nurse still has a beard and wears an N95 mask, they:

A) Really desperately love their beard and hate the way they look without it.

B) Don’t really understand how masks or asymptomatic Covid spread works.

C) Don’t really care too too much about the risk they pose to their patients’ health.

(N95s need to make an airtight, skin-tight seal with the face. They simply cannot do that if there’s facial hair.)

——

My fit test today, however, didn’t work as planned. My mask leaked. The tester made me bend the metal nose-clip a bit tighter across my nose.

“Lean over and then stand up, ten times, Turn your head, ten times, Read a story for a minute.” Voila, you’re done. Your mask fits.

Still not sure about the benefit of this versus the cost. (See yesterday’s post on the high-ish real-world efficacy rates for N95s that aren’t fit tested.)

If you’re smaller though (females and Asian supposedly have the toughest time) fit testing becomes much more important. Smaller folks often end up wearing the harder, less comfortable cup-like green N95. If you’re really tiny and fine-featured, you may have to wear a bulky plastic mask, like a painter’s respirator, to get an adequate fit.

Either way, perhaps more important than fit testing is doffing. Many (perhaps most) people have a tendency to contaminate themselves taking off dirty PPE. Sanitising hands between every step, keeping elastic bands from snapping, and not touching the dirty outside of the mask to your face are all tougher than they sound with a tight-fitting mask that’s moulded over the last 10 hours to become part of your face.

—–

Another thing: why no mirrors? Seems like hospitals want patients to avoid mirrors as much a possible. Maybe so patients don’t see how sick they actually look. But in the Covid era, having a makeup mirror outside each room makes a great deal of sense: you can see when your mask isn’t on straight, and when the edge is just a little bit folded over itself–rendering the seal broken and the mask much less protective. They tell us to check each other, but how likely is that to happen 20 times a day?

——-

There’s a point at which the inconvenience of something balances out against its effectiveness.

With N95s and Covid, we’re not there yet. At least I’m not there yet. Still happily willing to wear it, despite the humidity, the rubbery feeling, and always having to talk louder. On the plus side, no smells of rectal bleeding, farts, or smoker’s breath to contend with.

—–

I’m sure I’ll appreciate this whole mask thing a whole lot more when I finally get told: “You know that patient you saw yesterday? They came back positive for Covid.”

I’m expecting that any day now.

N95 fit testing is ‘Best’ but non-fit tested is pretty OK too.

Given the expense and scarcity of N95 fit testers (it’s quite a growth industry…could be a job opportunity here for underemployed aromatherapists), is it good enough to go with non-fit tested N95 #facemasks?

Yessir. Cloth masks are OK, bit those blue surgical masks are better. And N95 masks are even better. And fit-tested N95 masks are better still. And PAPRs are the best of all. Except for a Level IV biological hazard suit.

Bottom line is, perfection is unattainable, expensive, and often impractical. Good enough is good enough. Any dose reduction is a good dose reduction.

So, bring on the outdoor, 3-sided tents for patient care, bring on “fit-checked” N95s, bring on cloth face masks in indoor venues like churches and bars, and bring on open windows in schools rather than $700 hepa filters and CO2 detectors.

FFS, if we just had the wherewithal to require indoor masks and universal vaccinations beginning in April, we would be over this shitshow by now. Everyone vaxxed, everyone masked, Covid hospitalisations very low and ICU cases rare.

Then all we would have to worry about is the coming childhood measles outbreak. Because we can’t ever do the logical thing and protect all kids, we have 69% full vaccination rates among 18 month old NZ children. Those are the same levels as Bangladesh in 2018.

Shameful. Completely preventable.

Two positive covid cases in far north

If confirmed, it’s a tragedy for Northlanders.

We could’ve had strong mask and vaccination mandates and protected whanau, community, and country, and we could not even accomplish that.

We had the means to prevent this.

Two months ago I went to Cook Islands as part of a team that helped them vaccinate 96% of their eligible population in 8 weeks!

In NZ we have 500,000 unvaccinated adults and 800,000 unvaccinated kids. The kids can’t yet be vaccinated, but can still catch and spread it.

These adults, either through selfishness, ignorance, fear, paranoia, and gullibility, or deprivation and lack of access, still remain unvaccinated. People will die from this outbreak, and we could have prevented it.

The people “aren’t ready” for mandatory vaccination. They same way they “weren’t ready” for mandatory seat belts or the mandatory hepatitis B vaccinations that every NZ healthcare worker -already- must have.

We have let the most selfish, least community-minded, most ignorant minority amongst us rule the day, aided by the megaphone of Facebook, which makes more tax-free profit off anger and misinformation than it ever could off public health and a functional society.

Our tolerance for so-called “freedom” seekers, antivaxxers, and the like has cost our society dearly, with lockdowns that could have been avoided (wear your mask and get vaccinated) and hospitalisations and deaths to come that were foreseeable and avoidable had we the motivation to act.

These freedom seekers would have the country erode, so long as it doesn’t affect them.

And when it does they know they will always be welcome in the public healthcare system, cared for by the very social safety net they daily seek to weaken.

I’m sad for the people of Northland today.

Today on “Seems like BS, but actually works” — Make your own ‘Covid filter’.

Ever wonder why airplanes aren’t literally infested with Covid victims after every flight? It’s partly because they have effective and efficient particle filters running overtime on every flight.

(…and because, at least in most parts of the world, airlines have the wisdom to mandate the wearing of face masks onboard — hugely limiting spread.)

This filter is ideal for churches, bars, restaurants, and other high-risk crowded, ‘exhaled-breath-filled’ areas as an supplement. NOT a replacement for all the other things that work really, really well: vaccinations, facemasks, open ventilation (try to be outside, if you can’t, then keep windows and doors open, and/or avoid crowded indoor places when possible.)

Is it called a Rimsky-Korsakoff box? No, it’s proper name is a “Corsi-Rosenthal” filter box.

But I will just call it a “Covid filter”. You should make one yourself. It’s cheap ($100 for little box fan, easy and quick to assemble, and actually (surprisingly) works. The box the filter is cut and reused as the ‘holder’ that mounts the filter to the fan. Brilliant.

Many thanks to Dr Mike Howard (emergency medicine specialist and immunology PhD) for introducing our department to these Covid filters, and for ensuring our fingers stayed attached while playing with the box cutters making these. Seriously Mike, thanks for doing this for us.

https://drgarypayinda.com/

(I’ve included a link below to an article written by Dr Michael Howard at the start of Covid. It’s become a big part of his life staying abreast of Covid literature and helping others navigate the pandemic as safely as possible.

A commitment to learning and using that knowledge to help care for others. https://www.epijournal.com/ )

A RadioNZ interview I did with Nita Blake-Persen on the 600,000 still-unvaccinated adults of NZ and the ‘readiness’ of our already struggling healthcare system.

https://www.rnz.co.nz/national/programmes/checkpoint/audio/2018817033/whangarei-doctor-warns-of-low-vaccine-risk-as-hospitals-face-surge

If our healthcare system struggles to deliver timely care now, it’s a safe bet that going to get much worse as Covid burns through.

Will try to get the whole interview posted if possible, with Nita (https://www.rnz.co.nz/authors/nita-blake-persen) asking questions about the bigger picture of healthcare as seen through the lens of hands-on emergency department care.

Covid, Vax, PPE and ‘how to think about risk’ Discussion (+ video)

This is an hour long discussion I had with a small group of nurses, doctors, managers, first aid officers and lifeguards about recent Covid changes, some recent evidence, some distilled ‘lessons learned’, and how all of this can impact lifeguards. But it’s relevant to anyone trying to figure out how to deal with Covid risk in a responsible, rational manner.

A big word of thanks to the surf lifesavers who continue, time after time, to put themselves forward under challenging circumstances to help other people in trouble–whether than challenge is 3 metre swell or a pandemic. I am quite honoured to work with and for you.

-Gary

At Gareth’s request, here is an update on the rapidly evolving state of play regarding Covid for SLSNZ members, from a medical perspective. It is a partial summary of an hour-long Covid discussion on Covid, PPE, vaccination, and other pandemic issues. Enjoy.

Risk:

Must understand that the greatest risk of Covid is not from patients, but from family and friends, and colleagues.

You are vastly more likely to get infected via an overnight stay in the bunkroom, a social dinner or drinks at the clubhouse, or your fellow guard sitting with you indoors.

Bluntly put, the outdoors risk is minimal. The indoor social/group risk is substantial.

The way we minimise this risk is to:

1) Avoid proximity. Don’t ever be indoors, if you can be outdoors (remember sun safety and ensure your club has sun shades and fixed shade, especially for children. Melanoma kills 400 people a year, and lifeguards are a high-risk group.) 

There may be times you need to treat a patient in a first aid room. This will be a minority of cases. Most patients can be assessed and treated in an open-air environment.

But remember, your greatest risk is your fellow lifeguards. There have been superspreader events from lifeguards in other countries — to their peers. How to avoid this? Vaccination and masks.

2) Get vaccinated. Everyone should get vaccinated against Covid, it decreases your chance of death and hospitalisation by more than 90%. There is only roughly 1 person out of every million that cannot get vaccinated due to a medical issue, anaphylaxis. Everyone else can and should get vaccinated, to protect themselves and those around them. If you are caring for patients, then you have an obligation not to increase their risk of preventable harm. SLSNZ is awaiting word on final details of the government mandates for health and education workers, which will be shared with the membership as soon as possible.

3) Use face masks. Surgical masks (the blue, plastic/papery ones) are roughly twice as effective as cloth masks. Use them whenever possible. Studies have shown they can be reused up to 10 times and still remain effective. Face masks should be used whenever you are indoors around people not in your personal bubble, and when you are outside and cannot maintain 2m physical distancing from others. They really work, are cheap and simple, and can prevent Covid and/or reduce the amount you inhale. Perhaps more importantly, they decrease the chance of spread to others.

4) Understand risk (detailed in Risk section above). Your friends are a greater risk than your patients. Up to perhaps 40% of young people will have no symptoms. They will think they are healthy, they will feel fine, no cough, no shortness of breath. Yet they will be infectious to you and those around them. Wear a mask so you are not an unwitting spreader of Covid. If you infect a colleague or a patient of yours, the outcome can be bad. Get vaccinated too, because unvaccinated people are contagious for much longer than vaccinated people. If we used masks well, and vaccinated thoroughly, and maintained ventilation whenever we could, Delta would be a non-issue. As it stands, we still have a significant minority of the adult population (38% or 2.6 million) , as well all the under-12 child population (about 1 million), that are not fully vaccinated and are thus a potential tinderbox of Covid risk.

Recommendations are evolving, as expectations from government become clarified regarding patrolling during Level 3.

It is reasonable and appropriate and required to use a surgical mask, eye protection, and gloves for every patient interaction. Gowns are of uncertain effectiveness in this aerosol-spread disease, but still recommended. We are actively discussing N95 or KN95 mask use for longer/closer patient contacts. There are issues with supply and fit testing. Regardless, strive to maintain ventilation (ie, outdoor or open air care) and distance, whenever practicable. Always wear a mask, not just to keep yourself safe, but perhaps more likely, to keep the patient safer.

Hope this was helpful. Watch the video for a longer discussion. Skip the first 3 or 4 minutes while we wait for people to log on.

Cheers

Gary 

Dr Gary Payinda

National Medical Director Surf Life Saving NZ

Emergency Medicine Specialist

Catching up on CME: Random Emergency Medicine Notes (for EM doctors-in-training, or insomniacs)

https://docs.google.com/document/d/142Cj6_fbtA-3PNCL79jrMEJxFx1kzIhe_L1IAVgfxlo/edit?usp=sharing

#FOAMed

When a car’s airbag goes off, an electrical current hits the sodium azide inside, exploding it into nitrogen gas and hydrocarbons, and producing sodium hydroxide (lye), sodium bicarbonate, and metal oxides. When and if this dust gets into a patient’s eyes, it can cause caustic (alkali) burns. Liquefactive necrosis can take places over hours, unnoticed if the patient is unconscious, potentially destroying the cornea. So, always copiously irrigate eyes with water after an airbag deployment and pH test.

Ocular Burns and Chemical Injuries: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/798696-overview

Rhabdomyolysis CK>6,000 associated with 50% progression to AKI.

Urine output is key in rhabdomyolysis management. After first bolusing IVFs, check serum pH, (not urine pH) to ensure urinary alkalinisation at pH>6.5.

Rhabdo is commonly associated with hypocalcemia and hyperkalemia.

Beware endoscopy on Day 5 to Day 15 in alkali/caustic esophageal burns. Risk of perforation.

Norovirus: common cause of traveler’s diarrhea, watery. 

Shiga-like E. coli (ETEC): common, bloody cause of traveler’s diarrhea, bloody.

Third-trimester painless bleeding is placental previa until proven otherwise [on exams]. Get an ultrasound before you do a digital exam.

Ultrasound misses half of placental abruptions.

Facial trauma with bloody and clear discharge, consider CSF leak.

Older patient with painless haematuria:  ddx is infection, cancer, papillary necrosis.

Esophageal varices: terlipressin/octreotide first, then balloon/endoscopy/TIPS as needed.

Boerhaave syndrome: use water-soluble gastrograffin (not barium), less mediastinitis.

Idarucizimab (Praxbind) reverses dabigatran. Hemodialysis works too, removing 60% in 2 hours. rVIIa or PCC may help too.

Hyponatremia in myxedema coma is better treated by fluid restriction than IV saline. IV thyroxine is the mainstay of myxedema treatment.

Systolic>180 or diastolic>110 + essential hypertension = ED initiation of antihypertensive (such as HCTZ)

Clindamycin actually stops toxin production in toxic shock syndrome beyond solely its bacteriostatic effect.

Bladder temperature probe (thermistor) preferred to rectal. Rectal feces can remain cool and yield inaccurate rectal temps in hypothermic patients.

Warm IV fluids are an OK way of helping prevent heat loss, but are largely ineffective at rewarming a hypothermic patient.

Heat stroke: undress, wet, and use evaporative cooling in preference to axillary ice packs.

Lidocaine is ineffective treatment for hypothermic dysrhythmias.

Phenothiazide overdoses cause sodium- and potassium-channel blockage. Sodium bicarbonate is the treatment for Na-channel blockade, may also warrant anticholinergic treatment (promethazine/diphenhydramine), benzodiazepines, and fluids.

Pacemaker problems simplified: holding a battery over the pacer unit puts it into asynchronous mode, usually a rate around 70.

Oversensing is most common problem, with the pacer causing bradycardia. Fixed (temporarily) with a magnet.

Undersensing: patient is tachycardic or has extrasystoles.

Battery failure: slow pulse, no change when you put the magnet on.

Broken wires: no change when you put the magnet on.

NMS: neuroleptic malignant syndrome. Fever, rigidity, confusion in a patient on psych meds.

Thyrotoxicosis: metoprolol is OK. Dexamethasone for thyroid storm.

Pneumocystis pneumonia: 15% have a normal chest x-ray. Trimethoprim/sulfamethoxazole is the treatment of choice.

Syphilis: initial small round painless ulcer, gone in about a month. Secondary (2-10 wks later): rash, copper-colored macules on palms and soles, condylomata lata (flat genital warts); aortitis/tabes dorsalis/etc : 10-40 years later.

Prostate cancer patient with neurological findings: suspect thoracolumbar spine metastases.

Transvaginal ultrasound is poor at identifying retroplacental clot in placental abruption.

Rectal foreign body: if bleeding, suspect possible perforation. May want to avoid anoscopy. 

X-ray prior to digital rectal exam to prevent laceration/injury to examiner.

Gabapentin, metoclopramide, and chlorpromazine are all effective treatments for intractable hiccups.

Appendicitis: RLQ pain is the most important symptom to consider, with a + likelihood ratio of 8. Followed by the findings of rigidity, and periumbilical-to-RLQ pain migration. Non-specific symptoms/signs: anorexia, fever, vomiting…except in those under 18yrs old, in which case fever carries the highest + likelihood ratio. 

A NIF (negative inspiratory force) of <30 predicts respiratory failure in Guillain-Barre syndrome.

The line between simple and febrile seizures :

>3 seizures

under six months or over six years of age

seizures longer than 30 minutes

seizures that have focal signs

seizures that are not tonic clonic

Seizure meds:

1st: 2mg lorazepam

2nd: phenytoin or fosphenytoin 

3rd: propofol/ketamine/phenobarbital 

Isolated vertical nystagmus: almost always has a central / toxic cause.

Stroke thrombolysis with rTPA: alteplase. Obtain PT/INR only if suspecting a coagulopathy.

Trauma, hypotension/shock and intraabdominal free fluid: no delay for CT, straight to OR. It’s the strongest justification to perform a FAST.

Haloperidol toxicity: seizure, fever, long QT, ventricular tachycardia

Intracranial hemorrhage: nicardipine/clevidipine preferred to control hypertension. Hydralazine causes increased ICP. Labetalol doubled infection in one 2017 study. https://pubmed.ncbi.nlm.nih.gov/28904237/

Outside 4.5 hour stroke thrombolysis window? Direct that ambulance to a comprehensive stroke center, i.e., one offering mechanical thrombectomy. They may treat out to 24 hours.

Rivaroxaban (10a inhibitor) reversed by andexanet alfa (andexxa/10a). Also give prothrombinex (efficacy uncertain).

DAWN and mechanical thrombectomy take home point: on CTA/perfusion you want a small infarcted area, a large watershed area with reduced but not absent flow, and an amenable large vessel occlusion. 

-END-

A Covid wildfire is coming and we are frozen with fear.

The education secretary Iona Hoisted says principals can have year 11-13 students attend school in level 3 if they think it’s necessary, with bubbles and distancing. GOOD.

But they don’t have to use facemasks. BAD.

Someone pass this on to Iona: this is just ignorant, foolish, and dangerous.

I understand some NZ leaders are too scared to make vaccination mandatory, so we are going to watch Covid burn up the ignorant, the isolated, the vulnerable and the poor instead. Leaders must cater to the stupid in society, cause they need their votes to get reelected. I get it.

But to not make masks mandatory is just gutless. It is such a pitifully simple thing to wear a mask, and so effective at shutting down Covid.

We have been taken over by the stupid people. We’ll have a hell of a 3-4 months as it burns through. The hospital system will plug up and essentially shut down. People with non-Covid illnesses will suffer delays and some will die. This should make everyone angry.

Compulsory vaccinations and masks would have saved so many lives that will now be lost. And all the coming deaths would be almost completely preventable.

Covid Burning Through – Two emergency doctors talk about their experiences abroad and their preparation in New Zealand

Two emergency doctors talk about their real-life experiences taking care of sick children and adults in the U.S. — before moving to New Zealand just as we face our first significant community outbreaks.

If you’re interested in what ‘passing through Covid and coming out the other side’ looks like, this episode is for you. What can we expect when Covid eventually sweeps through the unvaccinated portion of our population? MIS-C, ‘happy hypoxia’, vaccination, antivaxxers, facemasks, overwhelmed ICUs, intubation, public attitudes, where the true Covid risk really lies, and how to keep it all in perspective.

In Stephanie and Bob’s words: “We’ve got this!

https://drgarypayinda.com/

https://www.facebook.com/drgarypayinda/

@garypayinda

Masks. They work. (Right?)

https://docs.google.com/document/d/1BXIDuK-FSU4tFIPZcZ9iRp8CKGzJT1_3C-6v4rIyzwU/edit?usp=sharing

Face masks prevent Covid infections. At least we think they do. The actual evidence has been sketchy, based on old studies from other infectious diseases, lab tests done with petri dishes rather than live patients, and studies that were generally not rigorous or large. 

It seems logical that masks would work. Covering one’s mouth and nose to prevent a virus getting in makes sense. And it’s the law that we use them in certain settings. But are face masks actually proven to prevent Covid infections? And if they are, exactly how effective are they? 

Until now we haven’t had a big, real-world, randomised, controlled trial to answer that question. But now we do. 

Last week a preprint study was released which looked at 340,000 patients randomised into two groups: one got free masks, education on how to use them, and encouragement from respected community leaders. The other group didn’t get any of these things. 

The first group tripled its use of masks. Their rates of Covid infection dropped. The results were big: for every 2.5% increase in face mask use, the overall rate of symptomatic Covid infection went down by 1%. For over 60s the effectiveness was roughly triple this. 

Face masks might be the magic bullet we have been looking for. Face masks are more effective at preventing illness than the other things we know work: physical distancing, social bubbles, hand washing, and staying home when sick. Face masks are also, of course, more effective than all the things that we know do not work: ivermectin, vitamins, and bleach injections. Face masks are the foundation of any Covid strategy. Face masks are a robust intervention: even if vaccination fails and a resistant variant spreads, there is no reason to think that masks will not continue to be very effective.

The authors from Yale, Stanford, Berkeley, and Deakin universities along with their colleagues in Dhaka, Bangladesh, credited the success of their face mask interventions to three things: the masks were free, were provided alongside education on hygiene practices like physical distancing, and were strongly supported by respected members of the community: clergy, elders and other village leaders. That last one, to my mind, is the key: to the average person seeing someone they know, respect and trust wearing a mask makes an enormous impact. 

This huge international study also showed that surgical masks, those blue masks you can buy in most any supermarket, were roughly twice as effective as cloth masks in preventing Covid infection. This fits with prior studies’ results. And while physical distancing increased marginally after the hygiene education, it was mask use that was responsible for the lion’s share of the drop in cases. 

The study also supported the well-known risk posed by crowding in houses of worship: unlike in the markets, where distancing increased, in houses of worship physical distancing was ignored despite the educational intervention. A tradition of shoulder-to-shoulder prayer couldn’t be changed, but the protective effect of mask wearing seemed to counteract this. And role-modelling made the difference.

A religious leader wearing a mask might be one of the most effective anti-Covid interventions that exists. One wonders if the converse, a religious leader refusing to wear a mask, might therefore be one of the more virulent factors in supporting Covid spread.

The study analysed many different variations of these interventions. Things that were found not to work included providing some communities’ leaders with incentive payments for compliance, texting people with frequent hygiene reminders, and putting up signs and advertisements supporting mask wearing. Seeing someone you ‘know and trust’ wearing a madk seemed to matter greatly. 

This study suggests showing our trusted and respected local leaders wearing face masks at work, school, in sport, and in our houses of worship is something we should highly prioritise in our anti-Covid campaigns, along with providing masks to New Zealanders free of charge. Simply put, face masks appear to be our most effective anti-Covid intervention. And seeing them on the faces of our local leaders makes a difference.

Reference: https://www.poverty-action.org/publication/impact-community-masking-covid-19-cluster-randomized-trial-bangladesh

“Near-drowning”: no; “Secondary drowning”: no; “Non-fatal drowning”: yes.

https://docs.google.com/document/d/1i_1G6M09wloKBUpzrlLlPdj2kJOkISLn86Clo523yfs/edit?usp=sharing

The Lifeguard’s Drowning Dirty Dozen: 

Fake News and Common Medical Myths Around Drowning

Dr. Gary Payinda

“Near-drowning”

There is no such thing. 

In 2005, the World Health Organization got rid of the old jargon and adopted two straightforward terms to describe drowning: ‘non-fatal drowning’ if the patient survived, and ‘fatal drowning’ if the patient died. If you hear a health professional or instructor using the term ‘near-drowning’ you know they are roughly 16 years out of date. Anyone who specialises in drowning uses the terms ‘non-fatal drowning’ or ‘fatal drowning’. Just like electrocution, where a person can be electrocuted and survive, a person can experience a ‘non-fatal drowning’ and survive. A person does not have to be dead to have drowned. They’ve just had a ‘non-fatal drowning’. This highlights the reality that drowning is a process. A process that can be interrupted, and lives saved. Let’s all use the correct terms.

Drowning

Technically, it is defined as “the process of experiencing respiratory impairment from submersion or immersion in liquid.” A more simple definition could be: experiencing persistent breathing problems due to water entering the airway.

A cough that goes away after an underwater dunking is not ‘drowning’. But a persistent cough after going underwater is a ‘drowning’, and more specifically: a ‘non-fatal drowning’.

“Delayed drowning” or “Secondary drowning”

There is no such thing. These are not medically accepted diagnoses.

There are no patients that drown, recover completely, then suddenly deteriorate or die hours to days later. If you had mild symptoms which completely resolved, you are safe.

However, if you drowned and had ongoing symptoms — even very mild ones like a cough, or faster than normal breathing rate, or mild breathlessness — you need to see a medical professional. They will listen to your lungs and measure your blood oxygen levels. It is quite possible to have seriously low oxygen levels despite feeling only mild symptoms after a drowning. 

Likewise anyone who had a moderate or severe drowning event, with symptoms like a loss of consciousness or serious trouble breathing, should have 111 (emergency services) immediately called on their behalf.

There occasionally are cases reported in the media of kids suddenly developing severe breathing problems and dying weeks after a drowning. These events are often sensationally attributed to drowning, but on a later autopsy proven to be due to a completely unrelated (and usually unsuspected) heart condition or heart infection. 

‘Dry drowning’ and other myths, David Szpilman, MD, Justin Sempsrott, MD, Jonathon Webber, RN, Seth C. Hawkins, MD, Roberto Barcala-Furelos, PhD, Andrew Schmidt, DO, MPH and Ana Catarina Queiroga, PhD, Cleveland Clinic Journal of Medicine July 2018, 85 (7) 529-535; DOI: https://doi.org/10.3949/ccjm.85a.17070

“Dry drowning”

There is no such thing. 

Outdated, poor quality medical studies suggested 15% of fatal drowning autopsies showed dry lungs. Doctors came up with various creative explanations for why this might occur, none proven. Newer post-mortem CT-based studies suggest the actual number is less than 2%. Either way, wet or dry lungs on autopsy are clinically irrelevant. Autopsy findings are increasingly being shown to be unreliable in drowning.

Schneppe, S., Dokter, M. & Bockholdt, B. Macromorphological findings in cases of death in water: a critical view on “drowning signs”. Int J Legal Med 135, 281–291 (2021). https://doi.org/10.1007/s00414-020-02469-9. “Nevertheless, it can be stated that none of the drowning signs we examined guarantees high diagnostic certainty.”

“Saltwater vs freshwater drowning”

Clinically irrelevant. 

The only factor that is important in drowning is the submersion time. The longer a patient is underwater, the more likely they are to die. The less time they are underwater, the greater the chance of survival.

Cold-water drowning

Clinically irrelevant in almost every NZ case of drowning. 

It is true that if a patient falls through ice into ice-cold water, and they are a child or very small person, there is an exceedingly small chance they can survive a long immersion (as long as an hour) without brain damage or death. In the vast majority of cases in New Zealand, however, the patient will drown in non-freezing water temperatures, and therefore the body will not cool down rapidly enough to make a difference. It is worth remembering that even in the most ideal circumstances, ie, a young child falling through ice, almost 100% of these patients, once in cardiac arrest, will remain dead despite all resuscitation attempts.

Do not count on water temperature. The thing that matters is the speed you can get a person breathing again. If you can resuscitate a patient within a few minutes of submersion, their chance of survival will be vastly improved.

Shock

‘Shock’ is a medical term, it immediately tells a paramedic or doctor that the patient you are treating might imminently die. If you are a lifeguard, you should use the term shock only for a medical condition of low blood flow to the brain and other essential organs. A person may be in shock if they have had an injury or illness and are:

  • confused, slow to respond, or unconscious
  • have a weak pulse and cold and clammy skin
  • have a heart rate that is very slow or very fast
  • have other evidence of severe blood loss, internal bleeding or a brain injury
  • have an irregular heartbeat or heart condition

Shock, medically speaking, is not emotional upset, fear, an inability to answer questions due to surprise or being overwhelmed, denial, disbelief, or anxiety. A first responder must never confuse emotional upset with a medical condition that will, if untreated, likely result in the patient’s prompt death. Use ‘shock’ to refer to the immediately life-threatening condition, and ‘anxiety’ to refer to the psychological symptoms which are also very important to address through sensitive mental health assistance, but need to be treated differently than ‘shock’. 

Hands-only CPR / Compression-only CPR

Largely irrelevant to drowning resuscitation. 

Hands-only CPR is optimal for just one thing: a primary cardiac arrest, the sudden collapse of a patient, often a mature adult experiencing a heart attack or dangerously irregular heartbeat (a life-threatening arrhythmia), where chest compressions circulate oxygenated blood to keep the brain alive for a few extra minutes until an AED can be used to deliver a shock to the heart. 


In drowning cardiac arrests, and in virtually all other causes of cardiac arrest, the heart stops not because it suddenly went into ventricular fibrillation, but because the critical organs were deprived of oxygen for so long they began dying. In the brain, this manifests as confusion, combativeness, and eventually unresponsiveness. The brain can undergo profound and irreversible damage due to hypoxia (oxygen starvation) in less than 8 minutes. With the much more durable heart hypoxia usually manifests as a fast heartbeat, then eventually a slowed one as the heart gradually succumbs, eventually developing irregular beats, and then stopping. This final stoppage is termed asystole, a non-shockable rhythm that almost every time irreversibly results in death. 

Restoring oxygen at some point during this process (the earlier the better) through mouth-to-mouth, mouth-to-pocket-mask, or bag-valve-mask ventilation is absolutely essential in preventing death due to drowning. Roughly ten percent of drownings will have a shockable rhythm when found, so getting an AED and applying it is still important, but for the majority, prompt rescue and prompt ventilation is the key.

Hands-only CPR may be useful if a rescuer is unable or unwilling to do rescue breathing/ventilations, but this is not the recommended practice for a lifeguard or other first responder. Hands-only CPR is acceptable in primary cardiac arrest, ie, for an adult seen to suddenly collapse unconscious on land. But SLSNZ in every case recommends the same response: DRSABCD with head-tilt and chin-lift to open the airway and hold it open, bag-valve-mask ventilation with two rescuers (one holding the face tightly sealed up against the mask, and the second rescuer squeezing the bag), chest compressions for anyone who is unresponsive and not breathing normally, and defibrillation with an AED as promptly as possible.

Concussion

Concussion does not require the patient to get ‘knocked out’. 

A simple headache, ‘seeing stars’, slower than normal thinking, nausea, blurry vision, or mood changes can all be signs of a concussion. Even one of these in the setting of a head injury are enough to suspect a concussion, remove a participant from patrol, competition, or training and place them on an immediate standown, initiating a 21 day graduated return to play scheme, including mandatory medical clearance prior to a return to play/duty. 

By contrast, an actual loss of consciousness, vomiting, or trouble standing or walking are all signs of a potentially serious brain injury/brain bleed and need to be assessed by a medical professional immediately. Call 111 in any such case where a critical brain injury is a possibility.

Methoxyflurane

It’s effective. It’s generally very safe. But in extremely rare cases, it can be the cause of malignant hyperthermia, a disorder that is sometimes fatal. 

The green whistle, also known as Penthrox or methoxyflurane, is an inhaled anaesthetic that relieves severe pain. It is a prescription-only medicine, prescribed by the SLSNZ Medical Director and used under their medical license. The Ministry of Health allows specially trained and vetted lifeguards to administer methoxyflurane under a “Standing Order”. If administered to the wrong patient, ie someone with a personal or family history of malignant hyperthermia, there is a chance the patient could die despite medical treatment. Make sure you know the contraindications that preclude the use of methoxyflurane before you even consider its use.

Pulse oximeters

Very unreliable in drowning. 

The facts are that pulse oximeters are extremely inaccurate in wet patients and cold patients. Wet and cold are how most drowned patients will be found when rescued, meaning pulse oximeters are almost useless in the very patients we are most concerned about. In testing, cold and wet volunteers will have grossly inaccurate blood oxygen readings about 50% of the time. Before you use a pulse oximeter, know the limitations. And never rely on a single test or observation. Assess the patient yourself and see if the test results fit with your findings.

Bleeding management

Stop bleeding first. 

DRSABCD is a wonderful mnemonic (memory aid). But it is not perfect in every case. One of the few times it falls down is in the management of massive haemorrhage. In major trauma with external bleeding (ie, bleeding that can be seen, and often controlled), time is of the essence. Blood must be kept inside the patient as a priority. It makes no difference if the patient’s airway is opened, and their breathing assisted with ventilations, and an AED placed on the patient if they have lost so much blood that they become unconscious, lose their blood pressure, become unable to fill their heart, exsanguinate, and die. Ambulances do not carry blood, and there is no replacement for critical blood loss immediately available on scene. A patient who has bled beyond a critical amount (around 2-4 litres in an adult) will likely not respond to CPR or survive resuscitation. Therefore, once you have taken steps to protect yourself, place firm, direct pressure directly on the bleeding wound and maintain it until bleeding has stopped. Do not merely pile on more dressings which will soak up more blood, these are wholly ineffective at stopping serious bleeding. Apply firm, direct pressure directly to the bleeding site in the wound.

Hope this helps. Kia rite!

Dr Gary Payinda

Medical Director Surf Life Saving New Zealand

Emergency Medicine Specialist

Lifeguard, Ruakaka Surf Lifesaving Club

Of course we don’t have enough ICU beds. (You never can.) Denial will get us through.

In any emergency, need outstrips supply. That’s one of the definitions of an emergency. Our Intensive Care Unit beds in NZ are few in number. In Northland for example, there’s a little ICU in Whangarei that is said to have 7 beds. But beds don’t save patients, nurses do. To get an ICU nurse requires many years of training and experience and money.

They don’t grow on trees, and there aren’t enough around to staff all these ICU beds we say we have. ICU patients are often 1-to-1 nursing. Do you think we have 7 nurses in Northland available to staff 7 ICU beds across three shifts a day, 7 days a week? Fuggedaboutit.

The reality is of the 334 ICU beds NZ MOH says we have nationally, we don’t have anywhere near enough nurses to operate the vents, turn the patients, give the medicines and fluids, and suction the breathing tubes. I would be surprised if we had robust, 24-7, Covid-ready staffing for half of those number of beds.

Even more unrealistic is when the ICU number is boosted from 334 to 450 or so, by adding in all the spare ventilators we can find, magicking up the idea that the anaesthesia machines used in theatre for surgery, can be turned into ICU ventilators for dying Covid patients. Yes, technically they can do double duty, but you need anaesthetists and theatre nurses to operate them 24-7. And out supply of theatre nurses is challenged even during the good times, let alone the bad.

Are there ways around this: yes, but we must learn to accept compromises. You could call it substandard care, but if you’re dying of a pandemic surge and can’t get a staffed ICU bed, I’d call it a godsend.

There is no willingness by politicians and administrators to confront awful truths–better to slip into a catastrophic emergency ‘accidentally’ pretending that “no one could have seen this coming”…you see it with wildfires and the absurdly-named “100 year floods” that strike us every few years now. It’s a charade of denialism. It seems to be what politics operates on: pure theatre.

We should be doing some very sobering things: preparing to distributing thousands of cheap fingertip pulse oximeters to patients, so we can send all the quite sick-but-not-dying Covid patients home rather than overwhelming hospitals. We need to be honest with people in creating information sheets explaining we are sending them home because we don’t have enough room and that they should come back for oxygen levels that are consistently dropping below 94%. By the time we are hit, it will be too late to buy these $50 units that could decompress our hospitals.

We need to prepare tents that we can decant our hospitals into. The idea that we are taking respiratory infectious patients and putting them in waiting rooms, and indoors in rooms at all, is illogical. Ventilation is the key, and in a country gifted with mild weather, we should have moved our clinics, urgent cares, and fast tracks to semi-open tents and shelters long ago. My son was swabbed in a semi-open empty warehouse with four enormous garage doors open for cross-ventilation, while we sat in our car. Why isn’t more of our care done in sweep-ventilation systems like this? Why is my patient’s McDonalds junk-food given to her more safely in the drive-thru than her asthma treatment?

We should have oxygen concentrators ($500-$1500) and CPAP machines and bottled oxygen caches set up around the country: whether Covid, RSV, or pandemic influenza, this is worthy preparation. There will just not be enough of these lifesavers to go around.

We need to prep our staff with N95 masks caches and PAPRs ($2000) (clean air blower/filter hood devices that staff can work comfortably in). One doctor in a PAPR can stay safe and run an entire ward. Just like they do in the islands, just like they might well need to do here. (Or as they have in London, Milan, New York and elsewhere at various points over the past 18 months.)

He tangata, etc is on all our DHB walls as a value, but what will the tangata breathe when the hospitals are full of Covid? Our current plan is taking people off duty if they’ve had sick contacts, stripping some units of most of their staff. What about when the hospitals are overwhelmed, like in Israel currently, a country that has vaccinated 75% of its population compared to our…what?…27%

We need to plan for when our staff are sick and infected, our wards are full, and we’re desperately putting two to four people on a single ventilator, managed by not an ICU nurse, but a regular ward nurse who doesn’t know what she’s doing (because we’re not taking the time to upskill her now or at any other point in the past 18 months), assisted by a junior doctor who feels they know nothing, but is now managing the mini-ICU set up in the surgical theatre recovery room in the basement of the hospital. We need to be practicing for worst-case scenarios, not best case scenarios. We don’t ever talk about a real state of emergency, because like death and child abuse, we don’t want to go there until we are forced to go there.

At some point we’ll get a big bad outbreak, and even if we someday get as well vaccinated as Israel (we likely won’t), we’ll still be in a world of trouble, despite having been gifted more than an entire year to prepare for it.

https://www.nzherald.co.nz/nz/covid-19-coronavirus-delta-outbreak-have-we-boosted-hospital-icu-capacity-enough/BYKEKZQYWNBFKWQ5ZEE5Q5PWNE/

Stuff we’ve completely changed our minds on re: Covid treatment

In the past year and a half we’ve done a 180 on a lot of medical concepts.

We used to think intubating people really early in the course of Covid was good…we now know its bad, they are more likely to die. Save intubation for when we’ve tried everything else.

We used to keep people on high oxygen levels and high PEEP …not anymore.

We stopped recommending ventilations and chest compressions cause they were said to be Aerosol Generating Procedures…now we know these are trivial compared to patients simply coughing.

We used to recommend bleach injections (no, kidding, that was only Dr Trump). But we did recommend lots of different meds…and found resounding benefit for only one: steroids (dexamethasone or similar) in hypoxic patients.

We did discover things that work, that were important: checking blood oxygen levels (there are so many people who feel OK, but whose blood oxygen levels are dangerously low…and need oxygen); letting mildly hypoxic patients go home with pulse oximetry followup in the community or at home; lying patients prone, even before they became severely ill, to utilise more of their lungs in oxygen exchange. Nasal prong oxygen, CPAP, high-flow oxygen. These are all methods that took us from mortality rates of 10% initially in some health systems, to less than 1% overall in most wealthy countries even prior to vaccination.

Good lessons that the simplest interventions are what will save you: oxygen, masks, vaccinations, and physical distancing. Not fancy expensive medications, ECMO, or ventilators.

This was a good warm-up run for when the next Covid variant blossoms, or when pandemic influenza comes back.

Decrepit concepts in medicine: #647 : Aerosol-generating procedures

In just a year doctors have fetishised “Aerosol Generating Procedures” as the bogeyman. Docs now routinely avoid various aspects of non-invasive ventilation/cpap/bipap, preoxygenation/high-flow nasal oxygen, parts of intubation, CPR, nebulisers for asthma and COPD treatment and suctioning out of fear of spreading Covid. The evidence to support this is weak, but that hasn’t stopped it from becoming universal dogma.

We act at though AGPs are well-proven Covid vectors, and that prohibiting AGPs saves provider’s lives… when the evidence suggests otherwise.

What evidence we do have suggests the greatest risks, by far, are our patients: coughing, singing, and talking loudly.

Simply coughing creates 500 times more aerosols than intubating a patient.

Covid + Vaccine Q+A with Dr Gary

The good lawyers and legal aid workers of 155 Community Law Centre Taitokerau (https://communitylaw.org.nz/) provide free legal aid for non-wealthy clients in Northland. Their staff had some questions about Covid and Covid vaccination. I was more than happy to Zoom a medical Q+A session for them. I hope these questions and answers help you too.

Just a few of their submitted questions: Is this new technology? How does it work, and how do we know if it is safe? What about risks of heart inflammation? If I have a heart murmur am I more at risk from the vaccine/Covid? Will we likely need booster shots for different strains of Covid? What are the vaccine side effects? My experience after the first injection was a much heavier than usual period. Is this normal?

To summarise my advice in a few paragraphs (and save you an hour): Get vaccinated. The risk of vaccination is not zero. Nothing is ‘zero risk’ in the real world! But compared to our risk of Covid (the acute injury, the chronic damage, and rarely the chance of death), and even compared to our everyday health risks, the risk of the Covid vaccine is absolutely trivial. (5,290,000,000 doses and counting.)

Perspective. The Big Picture. You can’t just read headlines about blood clots or heart inflammation without understanding the baseline health risks we face every day. Medical perspective doesn’t come easily. You won’t readily find it on Facebook, because social media is optimised to make money: to create and sell outrage, sensationalism, and hatred to earn clicks and advertiser dollars. Perspective and understanding are dead boring and profitless compared to paranoia, rage and fear.

So, get vaccinated. Act as if you are part of a functional society of intelligent, interconnected people looking out for one another.

And once you are vaccinated, if there’s Covid in your community, wear a mask indoors to avoid spreading infection to others — and to avoid receiving Covid from others. Win-win.

If we could just do these three things: Vaccinate, Mask and Avoid crowded indoor places whenever possible, our communities would be in a stronger position to face this pandemic, new variants, the next influenza pandemic, or whatever the future holds.

Best wishes in health.

Kia kaha. Stay strong.

-Dr Gary

https://drgarypayinda.com

Kid’s Covid walk-in Vax in Whangarei available…NOW.

KID’S COVID VACCINATION IN WHANGAREI — walk in

ngati hine health trust 5 walton st is vaccinating kids 12 and over (with a parent/guardian accompanying them) now. tonight til7pm.
angela is the nurse leading the vax effort. nice lady.

she says:
thursday and friday, and all next week, hours are 9 to 4.
saturday 10-2.
fri and sat are recommended by angela for walk-ins.
see their website for bookings.

get your kids vaccinated. we certainly did.

delta variant is tearing through the unvaccinated abroad. their hospitals are loaded with sick patients, the vast majority unvaxxed (99% of covid deaths in some hospitals).
kids are safer than adults, but not fully safe. the odd one (healthy, no comorbidities) can become critically ill or die.

no time to waste. listen to (but then ignore), the paranoid nonsense out there.

if you get the chance to get a vaccine that prevents a vaccine-preventable disease that has killed millions, take it.

Covid is manageable. Facebook and social media disinformation campaigns are not. They threaten to be the death of our social democracy.

(Response to a post by Sir Ray Avery) I work in an emergency department in NZ and since you seem earnest but confused, I’ll respond to some of your concerns.

1) As a doctor, I have adequate PPE to treat Covid patients and suspected Covid patients. Thanks to the government, I am vaccinated. That doesn’t mean I’ll be perfectly safe, but it darned-sure helps.

2) No one is pretending we’ll eliminate Covid, we are trying to tamp it down long enough to get the majority vaccinated. Would I personally want to see mandatory vaccination aged 12 and over? Of course. Worldwide the willfully unvaccinated are harming the health of millions. Their irresponsible, selfish, and ignorant actions are equivalent to dousing our schools, shops, airports with petrol while we have a bushfire raging.

3) Eventually borders will open and Delta (or whatever variant is floating around that month) will flood in. (If it hasn’t already weeks ago.) It is our (and the government’s hope) that everyone who wanted a vaccine will be vaccinated by that point, so ICUs and the medical system aren’t overwhelmed. That’s the reason for the lockdown, surely you understand that.

4) Opening right now, which neither you nor any sensible person is supporting, would be harmful to New Zealanders.

“We are way behind with our vaccination program and don’t have ubiquitous use of face masks ,our own prime minister has said you don’t need to wear a mask if you are going out jogging.”

5) We are ‘behind’ on our vaccination, as far as I can tell, because we didn’t pay bribes, bully (US), overpay, commandeer other countries’ allotments (Europe, India) or do other despicable things. In fact, we gave tens of thousands of ‘our’ doses to protect our island neighbours who have no ICU-level care and few health resources. I just got back from helping support the Cook Islands vaccination program, one of the most successful programmes in the world (96% of eligible adults vaccinated in 2.5 months). The New Zealand government’s actions (Labour, National, the lot of them) were noble, effective, and awesome to behold. We have immunised medical frontline workers (doctors, receptionists) many months ago, but still have a long way to go. I agree with your feelings that we should be all done by now….but that’s just not reality. We got a great vaccine at a time when other ‘highly-vaccinated’ countries were getting lower-quality vaccines (Russian and Chinese).

6) Did the government do a good job? Yes. Can they have gone 100% faster, I do not know. They say no, supply was a limiting factor, and I believe them vastly more than I trust the Mike Hoskings of the world who gain financial benefits from sowing hatred, division, paranoia, and anger. Please don’t feed into that narrative, Facebook and dogwhistling political parties may ultimately prove a bigger harm to society than Covid.

7) Lastly, did our PM say you don’t need to wear a mask if you’re going out jogging? Good on her. You were a scientist, look at the studies on Covid spread: it’s largely a disease of dense indoor spread: ICU, hospital wards, nursing homes, bars, nightclubs, churches are extremely high-risk. Full stop. Well ventilated crowded spaces (airplanes) are dangerous, but nothing like a bar or crowded restaurant. Well ventilated non-dense spaces (supermarkets) are significantly less dangerous. Outdoor dense spaces (concerts, gatherings) pose a risk, but it is moderate, depending on mask wearing (which, of course, should be mandatory) and spacing.

When we get to non-dense outdoor well-ventilated spaces, the spread of Covid is negligible. Walking, running, bicycling by yourself? Come on now, sir. That risk is as close to zero as one can come. Surely you understand this.

To simplify: wear masks indoors, wear masks around people not in your bubble, wear masks and distance when around gatherings of people.

Please use your considerable talents, energy, money, and influence as a ‘game changer’ to support things that work: masks, vaccines, distancing, outbreak suppression, citizen cohesion, and the de-fanging of groups that seek to weaken our country through feeding frenzies of anger and misinformation/disinformation. We will surely see more variants and need a country that operates as an effective unit to respond to these challenges.

Regards, Gary Payinda

A thank-you to science teachers, and a congratulations to the kids brave enough to enter their work into ‘science fairs’ around the world.

Link to the video:

https://photos.app.goo.gl/1rSodh2xL6wFrS8x5

Dedicated to Mrs Phillipa Lauben, my science teacher at Hadley-Luzerne High School, New York, circa 1991.

This was supposed to be a speech delivered at the Central Northland Science Fair this week. But it was postponed due to Covid. It may still happen live, or it may occur in a digital format now that New Zealand is facing a Delta variant outbreak. I’m not great at public speaking, so maybe that turned out for the better….although apparently I’m not that much better on video either!

But ignore the messenger and listen to the message: science teachers are heroes, and the kids who enter their work into the “school science fair” will become our next generation’s engineers, technicians, doctors, and scientists.

Here’s a thumbs-up to kids building their scientific expertise, learning that science can be creative, and that it can be used to change lives and help people.

40+ religious schools in NZ won’t let students get vaccinated against cervical cancer at school. They don’t deserve taxpayer funding.

An open letter to our MPs:

As I understand it, there are more than 40 NZ secondary schools that prohibit vaccination on school grounds for HPV, the virus that causes virtually all cervical cancers, and many anal and head and neck cancers. 
Sadly, most of these claim to be Christian schools, which is ironic. It’s an exceptionally unchristian and inhumane thing to stand in the way of cancer prevention (in girls as well as boys) due to stone age thinking that vaccination encourages promiscuity rather than prevents cancer. 
We (and I don’t mean health professionals, or politicians, I mean ALL New Zealanders) can’t let this atrocity continue. Women will   needlessly develop cervical cancer when there is a extremely effective vaccine that can prevent it. 
People may not realise it, but most of these religious schools receive $1,000-$2,000 per student per year in government funding. For an average-sized school that means hundreds of thousands of dollars in taxpayer money annually. That money should not be used to obstruct cancer prevention. 
Some of these schools won’t allow Ministry of Health vaccination nurses to come on their school grounds to vaccinate kids (whose parents have approved of the vaccination), while I’m told others won’t even allow the mere distribution of cervical cancer information to students and whanau. This is insane. 
As a doctor I get to see the end result of misogynistic and backward practices like this: young women, often mothers, getting diagnosed with and sometimes dying from a disease for which a vaccine has existed for almost 20 years. 
A vaccine which every single 13-year-old boy and girl could and should be getting for free. A vaccine which would prevent literally hundreds of cases of head and neck, anal, and cervical cancer each year.
Cervical cancer is a disease which should be virtually non-existent in New Zealand. Instead it’s killing 50 of our wahine every year. 

Like most people, I wouldn’t want my taxpayer dollars going to organisations that stand in the way of cancer prevention.
If these schools want to put up roadblocks to HPV vaccination, then let them…but they certainly shouldn’t be rewarded with a single cent of taxpayer funding. 
If you have the power to influence this, please do. Cervical cancer is a vaccine-preventable disease. And schools have an obligation not to stand in the way of cancer prevention. 

Dr Gary Payinda

Emergency Medicine Specialist

https://i.stuff.co.nz/opinion/300271679/with-majority-of-cervical-cancers-now-preventable-we-should-already-be-halfway-to-eradicating-it–but-were-not
https://drgarypayinda.com/

Turning slum-houses into healthy homes, and educating school dropouts along the way.

https://www.facebook.com/levelconsults/

Shannon Reeves is an emergency nurse trying to improving housing and education for low-income New Zealanders.

I recently learned she had a side gig as a professional house-mover and asbestos-abatement specialist (she’s not your average person) and has turned that into something much bigger — a social-welfare passion that seeks to educate and house New Zealand’s neediest at a time when 1 in 6 New Zealand kids are living in overcrowded homes. Overcrowding is one of the biggest factors in our health scourges of rheumatic heart disease, meningitis, and other diseases of poverty. 25% of Maori and 35% of Pacific Islanders in Aotearoa live in significantly overcrowded conditions.

She and her team are taking neglected, tear-down ghetto homes, moving them onto lots, refurbishing them using high-school leavers guided by building trades tutors, and placing the refurbished healthy and warm homes into very-low income neighbourhoods. She’s working on 3 homes currently, but wants a chance to work on dozens more. These are the kinds of projects that government should adopt: no corporate boys’ club deals, just someone who can take a small amount of seed money and deliver the goods. Society needs to trial more initiatives like this: fund two groups and comparing their outcomes, then roll the next round of funding to the winner. You’d create a scaleable product optimised to create results in local neighbourhoods.

Quick background facts: *50% of landfill waste is from house building and house demolition. *Decades of state house neglect and ‘deferred maintenance’ (another word for neglect) have created 7,000 homes in Auckland alone which are slated for demolition. This runs into the tens of thousands of houses nationwide. *7-16% of these can be refurbished to create a new home for someone else.

We live in a throwaway society, but it has caught up with us. We throw away houses, our clean water, our young people’s potential, and our taxpayer money. Let’s support people who are actually doing things to change this. Not managers, not corporates, not politicians, but the people with dirty hands. The people who actually do things.

Ka pai Shannon! And good luck.

Lifeguard Call Out Squads (and their patients, and their communities…) will be safer from Covid!

https://drive.google.com/file/d/1qpElLNQga9aytSD2EOOplBzmarst8xHh/view?usp=sharing

Did you know some Surf Life Saving New Zealand lifeguards were working even during Covid lockdown?

Regional Call Out Squads (previously called Emergency Call Out Squads) get tasked by Police and Gov’t to respond to Search and Rescue events: finding missing rock fisherman, overturned kayakers, capsized boaters, surfers and swimmers in trouble, people trapped on cliffs and islands, sometimes body recovery to bring closure to families, and even missing persons searches along our harbours, mangroves, beaches and dunes.

They’re NZ’s surf/beach/inshore rescue do-it-all agency. If it’s too wet and dangerous for a police officer, or too close to breaking waves, rocks, or shore pound for the big Coastguard boats, they’re your volunteer heroes. They train for it year-round, participating in maritime search-and-rescue practice sessions and simulations.

A while ago I asked the Ministry of Health to consider them for expedited Covid shots, as frontline health workers. If they have to respond, and be prepared to rescue patients, ventilate drowned patients, and resuscitate people, they need to be as prepared as possible.

Allan Mundy, Adam Wooler, Paul Dalton and their team did a good job of getting them PPE (protective gear) even when it was difficult to source and today Ashley Bloomfield and his MoH have stepped in to provide the Regional Call Out Squad members with frontline worker/priority vaccinations. As medical director for Surf Life Saving New Zealand, I didn’t want them to push ahead of any sick and vulnerable patients…but I did want them protected as frontline workers.

I am so happy to see them get access to Covid-19 vaccinations. They’re frontline workers, they might save you from drowning someday, and they’ll be vaccinated. Safer for them, and safer for you and me.

Vaccination virtually eliminates their risk of dying of Covid or becoming seriously ill, in the event of community spread.

They will be able to do their work more safely….and protect the public too: once these squads are vaccinated the risk of them spreading it to others (or superspreading it) decreases hugely. Remember that people can spread Covid to others even when they feel perfectly fine!

I’ll say it again: You can feel completely healthy, while you’re spreading Covid to your friends, whanau, and patients…to the elderly, those with cancer, autoimmune disease, lung disease, and the many vulnerable people in our communities.

I’m proud these volunteers are being treated like the first-responders they are. These women and men are on call 7 days a week, around the country, ready to drive to an incident, don a wetsuit, take a small inflatable boat out in metres-high waves, and jump into cold water to help someone at the drop of a hat…in addition to working their day jobs…for nothing more than an occasional recognition, an article in the paper, and the knowledge that they’re helping their communities. These are the people that make NZ great.

-Dr Gary

Everyone should know how to *immediately* stop severe bleeding.

If you don’t know how to save a life in massive haemorrhage, have a read of this article I wrote for our nation’s 5,000 Surf Life Saving New Zealand (SLSNZ) lifeguards.

You never know when your child might put a hand through a glass window or ranch slider, or when you’ll be the first on the scene of a car crash where a patient is exsanguinating. If there is severe bleeding, there is often no time to wait around for help to arrive. An ambulance could take 5 to 40 minutes. You either know what to do, and get on with it, or you watch them bleed to death.

Along with knowing how to use an AED (defibrillator), and how to do chest thrusts on a choking person, these are the 3 essential first-aid MUST KNOWs, in my opinion. No time for an ambulance…it’s up to you.

Click on the link below to read the article:

https://drive.google.com/file/d/1vKTmQb7vtM133TE7CdUZALWg5SbtHXZy/view

Occupational therapists: is there anything they can’t do?

I want Northland kids to know there is more than just forestry and labouring jobs out there for them. There are lots of jobs in healthcare beyond being a doctor, nurse, or paramedic — jobs a lot of people don’t know much about, or maybe haven’t even heard of. The allied health professions do great work helping people lead their best possible life. This video is about the many facets of care that occupational therapists provide.

We couldn’t profile every health career/speciality at the upcoming Huanui Health Careers Night, so we’ve created some online videos.

This one is with Occupational Therapists Marie and Jesse from Whangarei Hospital. Even if you work in healthcare, it’ll amaze you to learn some of the things OTs can specialise in:

Stroke Rehabilitation, Assistive Technology, Seating and Mobility aids, Aquatic therapy, Neuro-Developmental Treatments, Autism Therapy, Aging in Place care, Brain Injuries/Rehabilitation, Diabetes education, Hand injury rehabilitation, Industrial injury rehab, Lymphedema (post-cancer) therapy, therapy for people with low vision/blindness, and others.

It’s limitless.

Bottom line: if you want to help people lead happier and more empowered lives this is a career worth looking into. The coursework takes 3 years and the job opportunities are good. AUT and Otago Polytechnic run OT courses at several sites around New Zealand.

See you at our first Huanui College Health Careers Night, at Huanui College, June 3 at 5pm. All interested Northland high school students are welcome!

https://www.careers.govt.nz/jobs-database/health-and-community/health/occupational-therapist/job-opportunities

https://www.aut.ac.nz/study/study-options/health-sciences/courses/bachelor-of-health-science-in-occupational-therapy

https://www.op.ac.nz/study/health-and-community/occupational-therapy/

https://www.northlanddhb.org.nz/ https://huanuicollege.school.nz/

On ‘Pee-Pees’, ignorance, and shame.

I have no doubt there are 9 year olds with a better understanding of the biology and terminology of their genitals than some adults.

It’s too bad so many kids don’t have an interested, knowledgeable, and unashamed parent or two who can teach them about their private parts. If a kid is old enough to know they have a “pee-pee” they’re old enough to start learning about it.

One common alternative is to keep kids and teens steeped in ignorance and shame, leaving them to learn about sexuality when they get an sexually transmitted infection, become pregnant, or get sexually mistreated or abused.

Shame has been such a big part of sexuality and sexual manipulation and control throughout the ages…and still is today in so many religious groups and other male-dominated institutions. The Dark Ages are unfortunately still alive and well, they’re just hiding under the banner of ‘traditional values’. Its no accident that self-confidence, human rights, financial and legal power, education and health come together as a package deal. And it all starts when we’re kids, with the adults around us either being honourable and brave enough to answer our questions honestly. Or BS’ing us.

‘For our own good’, of course.

“Tū whitia te hopo, mairangitia te angitū!” Feel the fear and do it anyway!

A quick chat with Dr Pip Stuart (Ngapuhi, Ngati Kahungunu ki Wairarapa) about growing up in Northland and ending up an emergency medicine doctor. (Yay.)

Pip and about ten other health professionals will be talking to Northland high school students about health careers in nursing, dentistry, veterinary medicine, medical imaging, physiotherapy and others. We will be there to help advise and inspire kids who might be interested in a health-related career.

The health careers night will be held at Huanui College on Thursday 3 June, at 5pm.

ALL INTERESTED NORTHLAND STUDENTS are invited, regardless of where you attend high school.

“Doctors and nurses tell all”, June 3, 5pm.

We’re putting on an evening for high school students from all over Northland to ask a panel of great nurses, doctors, paramedics, medical imaging technologists, veterinarians, hospital managers, dentists, orthodontists and other health professionals probing questions: Is being a paramedic a good job? What’s it like to treat someone who is dying? Or to be a hospital manager managing hundreds of people and millions of healthcare dollars? Did you always know you wanted to be a veterinarian? Do you always love your job? How do I get into med/vet/dental school? What are the positives and negatives of the job? What advice do you wish you had been given when you were a student? What if I’m no good at maths? What was your backup plan?

In short it’s going to be a wonderful chance for kids who ‘might’ want to be in the health professions to ask some serious questions in a small group, very personal setting with a bunch of friendly health workers who know what it’s like to be a kid facing a big life choice!

I helped put this event together to expose Northland students to a range of health professionals from a variety of circumstances, emphasising rural, Northland, and Maori backgrounds, recent graduates, and non-traditional educational paths. Many of these professionals have inspiring life stories, and they’re all interested helping advise kids on the path to meaningful, productive careers.

It is my hope that this group of health professionals can inspire students who might never have thought the health professions were for them.

Please spread the word. All are welcome. This is held with the strong support of Huanui College…but it is for ALL Northland kids and their whanau.

Cervical cancer is almost completely preventable. So why are we failing?

We could have essentially eradicated cervical cancer by 2040.

We’ve had the “miracle” vaccine for 13 years. We’re still nowhere close. What is to blame?

Religious extremist paranoia about “promiscuity” that would see a woman die of an almost completely preventable cancer rather than ensure every 12 year old girl (and boy) gets vaccinated.

A very small minority of profoundly backwards thinkers is holding the public’s health hostage. And they’re doing it with our tax dollars.

https://www.tvnz.co.nz/one-news/new-zealand/sexual-health-experts-concerned-drop-in-number-young-people-getting-hpv-vaccine

12 years ago, handheld ultrasound allowed medical students with 2 days training make more accurate diagnoses than specialist cardiologists with decades of experience. Why has virtually nothing changed in the 12 years since this study?

“The diagnostic accuracy of medical students using an handheld ultrasound device after brief (18 hours) echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.”

https://www.ajconline.org/article/S0002-9149(05)01111-2/fulltext

I have to look at this article every now and then to remind myself of the power of technology and the limitations of our “traditional methods”. I read it and feel amazed at how far science has progressed in taking medicine from the age of quackery and patent medicines, to the era of bedside ultrasound, where even a med student with just 2 days training can look deep into the body and figure out its story. With greater expertise than an expert cardiologist.

Then I remember that this article is 12 years old! And I realise that our medical students still get only the most minimal education in ultrasound. The don’t come out of med school comfortable, or even proficient. Even our most advanced trainee hospital registrars often don’t learn to perform ultrasound competently before leaving training.

And that’s when I remind myself that tradition and arrogance go hand in hand.

“This is how we do things here.”

The very people that set the agenda, the ones that build the curriculum, head the departments and medical schools, and make the big decisions, are almost by definition the ones who have been there the longest and mastered the old ways. They are entrenched. Whether those old ways are better or worse, they are not keen to change them.

What’s the answer? A/B testing.

This is a concept that comes from the loathsome world of marketing, where people learn to manipulate people to sell things and make money. But the A/B test concept is a good one.

Set up a mini-experiment with Group A trying the old way, and Group B trying the new way. See which one “wins”. Then bring in another new idea, to compete against the winner. It’s cheap, quick, and effective. And we virtually never do it in medical education. Or hospital administration, to be honest.

If we set up mini experiments more often we could answer questions quickly and accurately. Which method leads to greater accuracy? Which traditional training techniques work? And which ones just have seemed effective all these years but actually aren’t.

We could apply A/B testing everywhere. Which methods of documentation are faster and more efficient? Which consent forms are more easily understood by patients undergoing surgery? Which tests are useful in our specific setting, and which are a waste of money, pain, and time?

A/B testing allows us to figure out the answer to a question in real life. What we do instead in medicine is to almost always leave it up to the most senior doctors, educators, and administrators to come up with their best ideas and write them up in a policy.

A policy that never gets tested against anything else. Madness.

https://www.ajconline.org/article/S0002-9149(05)01111-2/fulltext

Commentary: Euthanasia drugs article in the NZ Herald.

Unapproved use of an approved drug is often called “off-label” use. This term can mean that the drug is:

  • Used for a disease or medical condition that it is not approved to treat, such as when a chemotherapy is approved to treat one type of cancer, but healthcare providers use it to treat a different type of cancer.
  • Given in a different way, such as when a drug is approved as a capsule, but it is given instead in an oral solution.
  • Given in a different dose, such as when a drug is approved at a dose of one tablet every day, but a patient is told by their healthcare provider to take two tablets every day. (source: fda.com)

I’ll be talking to 1News this week about religious schools not allowing cervical cancer vaccinations.

Is there anything more spiritually bankrupt than putting roadblocks up to teenage girls’ vaccination, ensuring some of them will needlessly get cervical cancer decades later?

If this is true (I just learned of it last week) — that religious schools taking PUBLIC funding are not allowing the Ministry of Health to give out cervical cancer vaccine information, and not allowing them to vaccinate kids at schools, there is only one answer: yank their funding. Immediately.

Religious schools can get hundreds of thousands of dollars of taxpayer funding each year. Yet some of them appear may be harming society, compromising public health, and causing women (and men) to get cancers that could have been prevented with a simple vaccination. It’s just not right and shouldn’t be tolerated.

You shouldn’t be allowed to contribute to cancer deaths AND take taxpayer money for it. That should be a law on the statute books, if not a commandment in a holy book.

“Thou shalt not take taxpayers’ money while allowing preventable cancer deaths,” and

“Thou shalt not create fear in order to control the women (and men) in your congregation.”

Cervical cancer: easily preventable. And yet we keep failing.

We have a vaccine that could have already eliminated the vast majority of cervical, anal, and head-and-neck cancers in New Zealand. Yet hundreds of our people continue to die every year…needlessly.

What is standing in our way? Religious extremism and misogyny. Fear and power.

Fear built up by manipulative religious leaders. These men literally want to keep the power to decide whether women will live or die.

Stone-age beliefs stay with us even now. Just look at modern religious fundamentalism and the antivaxx movement. Logic is a human tendency, sure — but so is paranoia and magical thinking. We are never too far away from witch-burning, hero-worship, and flat-Earthers.

Ignorance and stupidity will always be with us, but we can’t let these few people drag the rest of society down. They’re certainly trying to. And winning. Every year 50 women die from cervical cancer. Those deaths can be prevented — we’ve been able to vaccinate against cervical cancer for more than a decade. But we’ve missed the chance. Our vaccination rates are low. Everyone 9-26 should be getting the vaccine, but tens of thousands of Kiwis are not.

So 20 years from now, our daughters will still be dying of cervical cancers that were preventable. This should infuriate us as a society, knowing we could have prevented young women dying with a cheap vaccine, but didn’t.

The cervical cancer vaccine does not cause girls to be promiscuous, it just prevents them from dying of cervical cancer.