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.