The East Gippsland town of Mallacoota has a population of approximately one thousand people and is one of just two Victorian towns that are classified as remote. It is also the only population in Victoria that exceeds 800 people and is more than 30 minutes from hospital services or state-funded urgent care. The closest hospital is in Bega, a two-hour drive away.
In 2019, GP Sara Renwick-Lau and Practice Manager Marcus Renwick-Lau were part of the leadership team at Mallacoota Medical Centre, during the devastating Black Summer bushfires.
More than 100 homes were lost. Roads in and out of the town were closed for almost 40 days. Food and water shortages, power outages, and eventually the impact of COVID-19 complicated relief and recovery efforts in the weeks and months following the disaster.
Between the struggles of helping those affected by the disaster, Sara and Marcus needed to keep an eye on each other and their staff. Their aim was to make their practice a place where clients could come and feel safe when the fires were still ravaging the area.
After the bushfire disaster, patients and other members of the community came to the Mallacoota Medical Centre for much-needed care and support. We asked how Sara and Marcus worked to instil a sense of safety at their Centre, what issues they encountered and how they solved them.
The following are edited excerpts from the webinar held on 30 November 2021
Marcus: We ensured that people’s first point of contact, the reception staff, were open, helpful and well-trained. They were sensitive when talking to patients on the phone, as they never really knew what their experiences might have been. They were mindful to always be careful with patients.
Sara: Staff are trained in allowing a soft entry into the first opening up of the discussion when patients first call. They understand that for someone coming in with any psychological distress, the first interaction might be challenging.
So, staff ask, “How can we help you? What can we do for you?” And they help that distressed person through that process.
In the waiting room, if people look like they might be uncomfortable or are experiencing some sort of psychological distress, staff may take them to other rooms for patients while they’re waiting. We also use a nurse for triaging. So as soon as there’s an indication that there’s some psychological distress, then a nurse gets involved very quickly as well. And that’s part of our normal, day-to-day functioning when people attend the medical centre.
It’s also helpful that people see familiar faces around them. I think that when the patients present there’s often great familiarity with staff. However, it’s important that staff not engage in discussions that might lead to trauma disclosure or that increase the psychological distress in an unsafe environment, like a reception area. Conversations are kept quite short and polite so that people feel that they can safely come in without having to disclose the reason why they’re at the medical centre.
Sara: It’s really important to have as many networks as you can develop prior to the disaster and staying connected is really important.
You need to meet people, understand what their roles are, what they can provide, what their service is – is it a good service? If it is a good service you need to endorse it within your community, and let people know about it. And I think the ability to confidently connect people to the available services is invaluable for their access to care.
If you’re confident about the service you are referring to, then patients are more likely to access it. The medical centre staff are important for helping the community feel confident, as people are potentially accessing new or unfamiliar services. In a remote area there are a lot of fly in, fly out mental health services, and we want to be able to say, ‘look I think this person will be a good fit for you, I think it’s really important that you speak to them.’
Marcus: Recently we co-hosted a gathering of service providers in Mallacoota. There must have been about 35 or 40 people present from all different organisations. That was just trying to get all the service providers together, so everybody knew what each other was doing. Then when referring to certain people you knew who they were and what their strengths were. That was really important as well, and that’s still a massive amount of ongoing work that we’re doing to ensure familiarity of appropriate services.
Marcus: It was a very challenging environment. I remember walking back into the medical centre and I thought somebody had just picked it up and shaken it all around and everything was just, it was completely different. I didn’t know where anything was and we thought we were going to come back with all of this energy and we quickly realised our capacity was massively reduced, and so that was tricky.
I think everybody probably hit a bit of a slump a couple of days afterwards and so that was really challenging to work through. And I guess then it’s looking after each other, so that you’re in as good a state as possible to be able to look after the people who come through the door as well.
Then there were lots of challenges, like getting fuel. We’ve got a big diesel generator to keep the power running. Every day was a trip around the emergency services to see who was delivering the fuel and whether you’re on the fuel list and things like that. So it was a bit of a crazy time when we got back.
Sara: Everybody is heightened because they have been through this big event. When your town looks a bit like a war zone, it’s hard to do normal things like eat, or sleep, and you might have a chance to defuse and maybe connect, but then you turn around and you’re standing next to someone who’s heightened.
So, there’s not a lot of respite from that really, that constant heightened state, and I guess that immediate aftermath is a “bushfire brain”. A lot of people came in really worried about their cognitive function and wondering what was going on. It was good to be able to take the pressure off people when they came in feeling a bit confused. It was really useful to explain the process of what was happening to them, in that period of post-disaster.
Marcus: The clinic was also a safe space. A lot of people came out and came in just to be in the waiting room. It was somewhere where they could charge their phone. We’ve got some filtered air in here, so the air was relatively clean compared to the rest of the town.
The waiting room was somewhere where people came just to be, to be in the air conditioning, the clean air. Even just at that that sort of level it was a really important service we were able to offer.
We were open 24/7 so we ended up opening up a practice that people could come to any time, and had somewhere to come if they felt like they needed just be somewhere other than where they were.
Sara: Yes, even having the sense that they could attend at any time. There was always someone around.
Marcus: Look initially we tried to take as much pressure off our staff as we possibly could and we accepted lots of help from volunteers. So, for a while, the front desk was staffed by a volunteer because our reception staff were busy doing other things. Sometimes staff would come in and you’d see them come to work and they were kind of not really there.
Fortunately, we did get lots of assistance, and we accepted lots of assistance, and that was to allow our staff the space to do what they needed to do. Since the fires we’ve put extra staff on as well. That was the decision we made early on, just to have a little bit more capacity so that the staff weren’t pushed too much during that time. And that’s carried on with COVID and everything as well you know.
Sara: I think everyone would be familiar with the stoics in every organisation who take on a lot of work and don’t really leave themselves time and space. We felt it was safer to just assume that we needed twice the staff to do the same amount of work. There was this initial sense of wanting to regain control over the practice by getting rid of everybody. It felt easier if we could just bring things back to normal. “Let’s just get things back to normal. Get rid of the volunteers we’ll just push through” – that was when you’re running on adrenaline, that’s your initial reaction But we held back and we were able to kind of let go of that a little bit, and we listened to people who said ‘this is a marathon’ and we thought ‘how are we going to maintain this pace for that period of time?’
As health professionals, when there’s a disaster, there’s that sense of ‘I’ll just do whatever it takes. I’ll just keep working’. We really noticed that our staff also just continually turned up to work. They turned up every day and they still wanted to be there. I think that’s an important part of control and creating some normality and routine.
There were some people who were still defending properties outside of Mallacoota. So we chose to provide our staff with ‘casual with continuance’ pay during that month, and we said ‘we’re going to pay you the usual hours or whatever you’re working but come if you want to come. You know if you don’t come we’ve got you covered’. We tried to build in our staff an ability to check in on themselves, making decisions and having a little bit of agency over what they felt they were capable of doing. And I think that’s really helped with moving through this whole stage because people are able to come and say ‘actually I don’t have capacity for this’ and they’re comfortable to do that.
Marcus: The other thing I do is check in with our staff a lot. I use a traffic light system of checking on how staff are travelling. I always like to see how they’re travelling and where there’s problems or anything like that, and there’s good communication amongst the staff as well I think.
I do think we have a pretty good supportive culture within the clinic, so if somebody’s not traveling so well, then other people will pick up for them and help them out. So I think it’s important to have a good culture amongst your staff as well.
Sara: A very clear message to staff is that ‘you are really important’ because, as with any health service, it’s the staff that provide the service. The message is “you are really important, but we will manage without you if we have to. Your experience within this traumatic disaster response needs to be recognised. We acknowledge that it’s going to impact on your work function and we need you to manage that, so that you can still be here doing this next year and the year after.” We are supporting staff for the long game.
Having in-house mental health services also really made a big difference for us. We’ve worked quite hard in developing a mental health service, and having psychologists in the practice and in the building has made a really big impact for us as an organisation.
Sara: I think I’d probably say have a look at your organisation and its vulnerabilities and manage them now. Making it through a disaster and being able to support your patients and your staff will be harder things aren’t quite right. For example, if there is some staff conflict or role uncertainty, manage that now. Manage it right now, because the process that you go through in managing those vulnerabilities helps you develop good skills for building a trauma-informed organisation.
The other thing is being aware that you can learn. As health professionals we’re good at reading, we’re good at learning things, and even if it is something new, a new experience, you can find that information. Phoenix has been really fantastic, in particularly with the Disaster Hub, which I’ve already used a lot. There’s a lot of evidence out there and I think as doctors we’re used to dealing with evidence. In terms of good trauma care there’s evidence of what works in communities.
“I think I’d probably say have a look at your organisation and its vulnerabilities and manage them now. Making it through a disaster and being able to support your patients and your staff will be harder things aren’t quite right. For example, if there is some staff conflict or role uncertainty, manage that now. Manage it right now, because the process that you go through in managing those vulnerabilities helps you develop good skills for building a trauma-informed organisation.”
