The alert in Victoria has brought a newly urgent daily reckoning: in the chain of decisions, did the one I took help or harm someone?
“Get out of my way, it’s a code brown.”
“What’s a code brown?”
“You can smell it.”
Doctors of my generation grew up with a code brown that signalled an unfortunate case of faecal incontinence. The odour from the patient’s soiled clothes would engulf the ward only to be swiftly overpowered by the pungent hospital grade “air freshener”. The hassled nurse scurried in with glove and gown while doctors continued their rounds. Out of respect for the poor patient, everyone acted completely unbothered.
Last week, those same doctors and nurses witnessed the arrival of a real code brown in Victoria, an emergency alert usually reserved for mass casualties. In the face of rising Covid cases, the announcement aims to ease the burden on health services by streamlining systems and redeploying staff to serve the most critical patients.
We see patients not knowing when we might get sick, furloughed or redeployed
When the code takes effect, I am in clinic, doing what I have done for the last 20 years – seeing cancer patients. The past two years have been a nervous time, but some things have stayed the same. New discoveries have worked at keeping more people well for longer. Important surgeries have eased suffering. Vulnerable patients have defied prediction and lived to see another day. Gratitude and resilience haven’t receded from fashion.
Most of all, healthcare workers, from cleaner to consultant, have regarded their work as a mission and kept going.
But with an enduring pandemic now underlined with a code brown, the mood has changed. Physical exhaustion is remediable with rest but moral distress clings to you.
I receive an email “just letting you know” that a chemotherapy patient is still awaiting an urgent appointment. The details of one high-risk patient blur with another, my heart falters. In quick succession, my anxiety switches from the patient and the relatives to my duty of care and the nurse who needs my help to do her job safely. I squeeze in that patient but what about all the others? Who is advocating for them? What if they die from avoidable causes? It’s enough to lose sleep over.
Patients’ calls for help are increasingly desperate. When can they see a doctor? Will that doctor know their history? Does it matter that their scan is delayed? These questions aren’t new but after two years of interrupted care, they have taken on a new urgency. And with thousands of professionals away, no one is making bold commitments about timely or ideal patient care. Where once we pulled strings for our neediest patients, we are now reduced to worrying with them and apologising for our impotence. For doctors who have long harnessed their privileged position in the healthcare system for public good, this new lack of agency is an especially bitter pill to swallow.
A code brown entails moving staff at short notice. Taking a cue from another oncologist, I try preparing one of my oldest patients.
“Listen, if you come back next month and I am not here, don’t worry because our discussions are on the computer, and you can use a phone interpreter.”
Some years ago, I told her she had months to live. Then she responded to a new drug but is convinced that I personally vanquished her disease.
“If you go, I will follow you.”
“It doesn’t work like that.”
“I will empty my bank account to see you,” pleads her husband.
“It’s not about money,” I say, embarrassed.
“Then what are you hiding?”
I am hiding nothing – indeed, our dilemma is in plain sight. We see patients not knowing when we might get sick, furloughed or redeployed. Overnight, we discover that a ward has been closed or a theatre list cancelled. We are encouraging patients to stay at home, suspecting that it may not be the best place for them but hoping that home beats being in a tense hospital with limited staff and no visitors.
In the grip of a code brown, the wheels of healthcare continue to turn but every turn feels unsettling.
We know that the true cost of the pandemic cannot be counted only by lives lost or dollars spent.
For providers, the true cost includes the countless calls we made that didn’t feel quite right, the ethical dilemmas we grappled with, and the nagging thought that in a chain of decisions, the one we took personally helped or harmed someone. This daily moral reckoning we share with our colleagues around the world is the hardest work of all.
And still, amid the gloom there are embers of optimism because those who serve patients are generally committed and resilient and already thinking about the next challenge. The code might have brought us to our knees, but it is also a chance to rethink medicine. Aspects of the healthcare system struggled because they were never robust – and while it is easy to invoke a lack of funding for every problem, we must also consider a failure of vision and planning.
The pandemic may have been unforeseen but not so an ageing nation, a highly multicultural population with mixed needs, poor health literacy, scientifically naïve politicians, hierarchies that allow managers to overrule clinicians, and most importantly, a chronically poor nexus between community and hospital-based care. If we didn’t anticipate all these problems coming to a head together, we must never have an excuse again. The big picture of healthcare demands constant attention and background planning that is not the stuff of headlines but vital to good outcomes.
Case numbers may have peaked and this emergency will eventually expire.
One day in the future, a seasoned nurse will announce a code brown and a young doctor will grow pale at the memory of disturbance and dislocation.
Someone will smile and say, “No, it’s not that kind of code brown.”
We will relax, hold our noses, and keep going.