WITH A NOD to those jokes about Tasmanians (yes, you know the ones), it's been said that as a Tasmanian girl I did fine community service by going offshore to find fresh genetic material. And not only that, I also increased the island state's population by bringing the bloke back here to live. For better or worse my West Australian-born husband is a Tasmanian now, and it's likely an irrevocable conversion. John can't go home unless he wants to leave behind his wife and kids, his tractor and his acres, a share in a beach shack, and a big and colourful cast of in-laws. Besides, having been a Tasmanian wage earner for a decade he'd have to pull off a miracle to buy back into the bloated property market of mining boom WA.
John made a choice – and did so knowingly – but you can't say the same for our three kids. We are making them Tasmanians, fitting their early years to the heart shape of the island and filling their horizons with all the privileges and problems that come with being of this place. It's rare for me to think that this could be a mistake, but just every now and then I wonder, and worry, about the choice we've made on our children's behalf. If my personal tipping point has a street address, then it's 48 Liverpool Street, Hobart.
ALMOST TWO YEARS ago, when our son Finn was two years old, he got sick. He had a constellation of unexceptional symptoms: fever, runny nose, a rash across his back, pain.
'Sore tummy,' he said, over and over again.
'Where, exactly?' I asked, and he pointed at his belly button.
Late on a Friday afternoon, just as the city's general practice clinics were swinging their 'CLOSED' signs and the paediatric specialists and their log-jammed appointment books were shutting for the weekend, Finn went from bad to worse. His temperature and his distress escalated beyond the control of infant paracetamol and cuddles. Just in the nick of time I got hold of the receptionist at our regular general practice clinic. Our GP was away, I was told, but if I was really worried (I was), then a locum would squeeze us in before she went home. In the waiting room, Finn stopped crying, went limp and began to grunt with every outgoing breath. The locum was careful, thorough, and very concerned.
'I don't like it. He's going to need to be monitored,' she said to me.
And to him, she said: 'It's the Hotel Royale on Liverpool for you, I'm afraid.'
On the spectrum of euphemisms, 'Hotel Royale' hovers somewhere between those such as 'Vinnie's Boutique' and the Frenchified pronunciation of Target (tar-jay) – where the light-hearted intention of the doublespeak is to simultaneously acknowledge and defray the déclassé reputation of the subject – and those more like 'Hanoi Hilton', where the desirable is made to stand in for something downright repellent. The 'Hotel Royale' is the Royal Hobart Hospital, a neglected and often troubled institution that has become a prime focus for concern over Tasmania's overburdened health system.
Probably, there are few people who love hospitals. Other than in their maternity wards, hospitals offer little reliable expectation of joy, and their business has nothing to do with pleasure. A cancer survivor once described to me how he felt each time he drove past the hospital where his chemotherapy treatments had been administered years earlier. He only had to look at the building to feel nauseated. He would sweat and his arms would ache in a manifestation of his body's memory of the needles and the poison. I have a similarly Pavlovian reaction to the Royal: just looking at the place today makes me feel powerless and afraid.
I suppose that if you live in a place for any length of time, the local hospital will gradually accrete a set of fairly grim associations, and this is how it is for me with the Royal. The only two dead bodies I have seen were those of my grandfathers, and I saw both of them on beds at the Royal. I spent quite a few visiting hours at the Royal after a friend of mine collected a serious head injury; in his addled state he had to be strapped into a chair, like a toddler in a car seat, to prevent a repeat escape. In his first breakout, wearing nothing but a gaping hospital gown, he had made it out as far as the Argyle Street exit where heavily pregnant patients in their quilted dressing gowns stood smoking at the doorway. Later, when my first baby threatened to be born much too early, I was wheeled into the Royal's neonatal intensive care unit to be familiarised with the sight of tube-covered babies weighing in at seven or eight hundred grams, just in case I shortly had one of my own.
On 28 April 1996, I drove past the Royal on the way to work an afternoon shift at Hobart's daily newspaper, The Mercury. When I saw that the streets immediately around the emergency entrance had been cordoned off with flashing orange lights, I felt cold. In the office, the editor was striding through the cubicle farm, more hyped than I had ever seen him, giving loud orders in a Scottish brogue.
'What's happening?' I asked, overhearing gunman, Port Arthur, death toll.
The editor said, 'We're at the centre of the fooking universe today!'
The rest of my afternoon and evening was spent camped like a ghoul at the mouth of the ambulance bay. Choppers landed at the nearby Cenotaph, ambulances screamed in, and one or two shell-shocked paramedics came outside to breathe the night air and try to forget what they'd just seen.
BUT NONE OF this explains why the Hotel Royale frightens me still, and why it makes me worry for my children. The reason is that every time I have been to the Royal, either as a patient or as the advocate of somebody vulnerable – somebody old, somebody young, somebody seriously ill – it has been a battle of perseverance, tactics and sheer bloody-mindedness to get the care that is needed. This has never been because of laziness or ill intent on behalf of any of the hospital's staff.
At the Royal there is not enough of anything to go around: not enough doctors, not enough nurses, not enough beds, not enough supplies, not enough elective surgeries, not enough energy, not enough hours in the day. The good people who work there end up tired beyond measure, flattened from their overexposure to a broken system that fails to care adequately for their patients or for them. The rubber bands that have been holding the institution together have all snapped, and the Band-Aids that long ago lost their stick were bought from a Chickenfeed bargain store in the first place. Perhaps the Royal is no worse, or not very much worse, than any other public hospital in the nation. But for Tasmanians, as for other Australians from small and regional communities, the problems of the local public hospital are intensified by a dearth of healthcare options. To the Hotel Royale, the locum was telling me, I would have to take my son, usually such a brave little boy – robust and easily consoled, but now lying in my arms grunting as if every breath agonised him – because there was nowhere else to go.
The last time I'd had a child admitted there was when my eldest daughter was eighteen months old and had picked up a particularly virulent strain of gastro. She spewed green bile in the Department of Emergency Medicine waiting room for hours, and hours, while the triage nurse told me that because my daughter was still taking sips of water, she was a low priority for care.
When we at last got to the Paediatric Ward, Xanthe was fitted with a naso-gastric tube as a means to try to rehydrate her, and then we were shut in a quarantine room and forgotten. Xanthe was determined to pull out the tube that had been inserted during a fairly stressful and unpleasant procedure, and since I didn't want her to go through that again, I took seriously the advice to hold her arms tightly. I held her while she vomited, and – after the bug took hold in my gut – while I vomited too, aiming as best I could over the arm of the chair. Though we rang the call bell, for several hours no one came. It was change of shift the following morning before anyone came to check on her progress.
When your children are very ill, whether or not you have private health insurance becomes inconsequential. If you take a sick child to the emergency room of one of Hobart's private hospitals, someone behind a reception desk will patiently explain to you that their hospital can offer no paediatric services, and send you off to the Royal. Or, they will have you sit in their waiting room until a doctor is free to explain to you that their hospital can offer no paediatric services, and send you off to the Royal, charging you a non-refundable $190 for the courtesy. Of course, all of this is irrelevant to the half of the Tasmanian population that must do without expensive private health cover.
'Can you at least admit us directly to the ward?' I begged the locum, desperate to avoid Finn having to suffer through the wait in Emergency.
The locum shook her head.
'You'll have to take your chances,' she said.
THREE TIMES OVER the course of the next thirty-six hours I arrived at DEM with Finn feverish, distressed and grunting. Each time he and I waited for four or five hours before being shepherded through the swinging doors and into the care of lovely, bright, helpful, well-intentioned and seemingly inexperienced young interns, and the occasional harried registrar.
'Sore tummy,' Finn would tell them, and they would gently prod the area around his belly button, and frown in concern. The first two times, they sent us away with the diagnosis that it was probably a virus and the advice that we should give Finn maximum doses of infant paracetamol and ibuprofen and see what happened next. I was frightened because I had never seen my son so lethargic and in so much pain, and I was angry because it seemed that there was no real help or relief available for him. It was now the weekend. None of the private hospitals could help and if we went to the after hours clinic in Derwent Park we would only have to sit through a long wait there before being sent back to the Royal.
Finally, on our third attempt, Finn was admitted to the Paediatric Ward. The difference, this time, was that one of Hobart's most experienced paediatricians, who is also – in true Hobart fashion – the partner of a teaching colleague of my mother, strolled through DEM to see one of her patients and stopped by to see why we were there.
'That child has pneumonia,' she said, glancing at Finn, before explaining to our latest intern that children often describe lung pain as tummy pain. Finn was x-rayed, then taken up to the ward where he got some pain relief and was started on a course of intravenous antibiotics. Before too long he had stopped grunting and fallen asleep in my arms.
SINCE CHILD PATIENTS must be kept safe, you don't just stroll in and out of the Paediatric Ward; the doors close and lock behind you. The ward is on the third floor, but the lack of natural light gives the place a subterranean feel. There are bright coloured friezes and murals although they do little to alleviate the dingy grey of the walls, ceiling and floor, or the prison-like quality of the ancient metal cots. Finn was given a bed and I was allocated one of the red vinyl recliner chairs in which many a parent has spent a fitful, neck-sore night, though I mostly sat on Finn's bed, holding him while he slept, or – if he was awake – stopping him from pulling out his drip needle.
Over the next few days, we got to know the stories of the patients sharing the room with us. Across from us was a young girl who'd been hit by a car some years earlier. She'd been crossing the road, following her mother and siblings, when she'd tripped. Now, and not for the first time since the accident, cerebrospinal fluid was leaking from her ear. Beside us was a teenage boy whose flawless olive skin and long dark blond hair might have made him beautiful had he not been emaciated from an eating disorder. Nurses watched him while he ate. Since the bathroom was off-limits to him, his toilet was a bedpan behind a curtain. For the first part of our stay, another teenager with an eating disorder occupied the bed opposite him, but she was moved after the two started sharing tips on cheating the weight-gain system. Her bed was taken over by a little boy with autism, a self-harming habit, coeliac disease and pneumonia. Aged six, he weighed less than my two-year-old. Not one of us, not the children, not their parents, wanted to be staying at the Hotel Royale, and yet our talk revealed that we had all had our separate fights to get a reservation. Now, though, there were other battles to contend with.
A nurse sorrowfully confiscated my phone charger when she saw that I'd ignored the signs (and, I have to admit, her first warning) and plugged it into a bedside power point. The device couldn't be plugged into the hospital's electricity supply, apparently, because it had not been electronically tested and tagged. My phone battery spent now, I had no way of contacting John, or anyone else. There was a hospital telephone by the bed, but in order to use it I had to go downstairs and pay for a phone card, but since I couldn't leave Finn – who would scream for fear of abandonment if I stepped out of the room – the phone card was out of my reach anyway.
'You know Schapelle Corby?' one of the other mothers asked me. 'Well, we're all a bit like her. Better off if you've got someone on the outside.'
She was an experienced campaigner, so nothing surprised her any more.
'We have to be here,' she said, meaning the parents of sick children. 'They're too short staffed to look after our kids without us, but that doesn't mean they bring us food or anything.'
She was right. Without John to bring in meals, I would not have eaten anything but Finn's leftovers for three days. Soon I learned what it took for me to go to the toilet. I had to put Finn on my hip and hold him with one arm while pushing the drip stand with the other, and walk this way the full length of the ward (the toilet opposite our room was out of order). I had to squeeze myself, Finn and the drip stand into the toilet and do the business while keeping his free hand away from his cannula.
On the third day, I thought it might be an idea for Finn to have a wash. And just quietly, I wouldn't have minded a shower myself. I asked a nurse where that might be possible and after she had shown me the way, she gave me a tin of powdered Ajax that might have been purchased in the 1970s, along with detailed instructions on how to scrub the bathtub when I was done. She was apologetic about it, as she was about the fact that she had no time to change the sheets that had become a bit soiled. The no-name nappies the nurses had supplied for Finn didn't fasten properly, and I'd forgotten to get my man on the outside to bring more Huggies.
Like everyone we met in the hospital, the nurses were good people. They were kind and they were tired. Their talk was of double shifts and overwork and falling standards. A doctor came each day, flanked by a tribe of earnest, well-heeled trainees. Finn, on his intravenous cocktail of drugs, improved. On the fourth day he was still far from well, but pressure was building from downstairs. Beds were wanted and a plan was presented to me that would enable Finn to go home and free up some space. It involved upping the dosage of his antibiotics, and pushing these mega-doses through in one swift hit. I knew our regular GP would be back from leave by now and that I could probably better look after my boy on the outside than I could on the inside. So I agreed.
'This is what they do in America, when they can't afford to keep poor people in hospital,' the doctor said grimly, signing off on the dosage.
Three hours later, Finn was discharged without a prescription for any further medication, or any recommendations for future treatment. God bless America.
RIGHTEOUS INDIGNATION IS a heady brew. Addictive. There's guilty 'first world' pleasure in having a good whinge about how long you spend on hold with Telstra before you get a result, or just how delayed was your Jetstar flight. But when it comes to hospitals, the stakes are much higher than crappy service and late planes. I know that I am lucky: I have healthy children who only rarely require the last resort of a stay at the Hotel Royale. Children with chronic illnesses, and their families – and poorer people who are wholly dependent on the public health system and who lack the connections to fast-track or short-circuit it – are more often subject to its grim reality, and for longer periods of time. Doubtless, those familiar with the hospital's other wards have their own worrying stories to tell.
There's nothing particularly terrible about the story of Finn's stay at the Hotel Royale, except for two things. One: his experience is normal. Two: it happened in 2011 at around the time the state government announced that it would cut the Tasmanian health budget, including the operational budget of the Royal Hobart Hospital, to the marrow. I wondered what they planned to economise on. Beds? Staffing levels? Nappies? Cleaning services? Tins of Ajax? Meals for parent carers?
It's easy to see why funding for the Royal Hobart Hospital was on the top of independent MP Andrew Wilkie's shopping list when he negotiated his allegiance to a minority government, but it is less clear what will be left of his $340 million deal after the GST clawbacks it will attract ($59 million for the first year of the four-year deal). At the Hotel Royale, a major redevelopment is planned and some of the capital works are underway. Meanwhile, however, the Australian Nursing Federation last October claimed that, because of the high number of nursing jobs lost in the funding cuts, nurses at the Royal had over the course of the previous two months done 420 double (seventeen hour) shifts.
Independent health policy analyst (and former ABC journalist) Martyn Goddard has said that $40 million of the Wilkie windfall will be directed not into operations and patient care, but into a 'fourth administrative redesign of the Tasmanian hospital system in eight years' that he suspects has little prospect of succeeding in solving the inefficiencies that the three earlier investigations have largely failed to remedy. He also questions what will happen to health care in southern Tasmania after the four years' worth of extra funding runs out.
A storm brewed up in a teacup in late 2011, almost literally, when it was announced that the wards of the Hotel Royale would close the pantries where patients could make themselves a hot drink outside of meal times. Of course, the dispute was more complex than the headline (the closures were apparently driven not only by budget cuts, but also by questions of whether or not nurses should spend time rinsing out tea cups) but that didn't change the fact that the vending machine operators have never looked back. Amid the outraged online and talkback chatter that followed the decision – chatter in which the Royal was called 'third world', 'an embarrassment' and 'a joke' – one commentator from the suburbs asked: 'What do you expect? It's a public hospital, not a café.'
What do you expect? A wise question, and close to the mark, but I think the real question is: What can't you expect?
Here we are in Tasmania, where our fat-free state budget decrees that services of all kinds must be pared back to the quick; where we are being characterised not only as the poor cousins of the nation this time, but also – thanks to WA Premier Colin Barnett – as its 'mendicant[s]'; where on the nightly news we have the spectacle of our poor unfortunate health minister becoming increasingly tight-lipped as she pursues the euphemistic 'savings targets' that are required to balance the Department of Health and Human Services budget. 'We have to live within our means,' she says.
So, perhaps what we can't expect from our public hospital is the level of health care that we have come to regard as 'first world'. Maybe we can't expect little niceties like clean sheets, cups of tea, meals and someone else to clean the shower after we've used it. No Qantas for us, Jetstar all the way.
Far more seriously, if staffing levels remain as perilously low as they currently seem, we may not be able to expect to sustain the lives of all those people, ill and injured, whose lives we might save if we were better off. We might, at the end of the Hotel Royale's upgrade, have some shiny new buildings in which patients can take their chances. And I suppose it will now fall to our health ministers, state and federal, to find a euphemism for that.