Covid-19 has put an unprecedented focus on New Zealand's intensive care units, but day-to-day capacity hasn't improved since the pandemic began and often struggles with "business as usual" demands.
Official documents obtained by the Herald and interviews with frontline health workers outline how years of under investment has meant hospitals had capacity problems even without any Covid-19 patients.
There's an expectation that if the public comply with level 4 restrictions then ICUs won't be swamped by Delta cases. However, the health system is running at full stretch, meaning there's little ability to absorb more patients without knock-on effects such as delaying surgeries.
New Zealand has fewer ICU beds per capita than other developed countries. Middlemore Hospital is particularly short-numbered - an alarming weakness given it serves more patients with underlying health conditions, who are most vulnerable to Covid-19 infection and serious illness.
There are currently 284 fully staffed ICU beds across public hospitals, and 629 ICU-capable ventilators, with 133 in the national reserve if required.
However, more important than the number of beds or ventilators is whether there are adequately skilled and trained staff to treat the patients using them.
ICU nurses provide individual, one-to-one care to each patient, and their numbers can't be quickly increased - such nurses have five years of specialised training and are in demand internationally, with better pay offered overseas.
In winter the numbers of people needing intensive care jumps, and viral illnesses also mean the limited pool of staff are more likely to call in sick. In a pandemic those absences become worse, when any potential transmission means workers are stood down.
"We now have more equipment compared with 18 months ago, but we actually have very few extra staff, and in some instances, we've got fewer staff," ICU doctor Craig Carr told the Herald this week. "Actual resourced bed capacity on a day-to-day basis, in terms of a bed with a nurse and a ventilator and all the monitors, that has not risen, to my knowledge, in the last 18 months."
Capacity problems were bluntly stated by DHBs when they sent recovery plans to the Ministry of Health around this time last year, and after the first lockdowns had successfully stamped out Covid-19 in the community.
The plans set out how quickly huge backlogs for planned care, including electives, could be reduced. They noted that ICU units were full - even without any influx of Covid-19 patients - and that had a flow-on effect.
"Our ICU is currently at capacity with four long-term ventilated patients. We currently are unable to schedule these patients as we are not in a position to have access to a postoperative ICU/HDU bed. ICU capacity is constrained in all NZ DHBs," Bay of Plenty DHB told the ministry, in documents obtained under the Official Information Act.
"We are regularly at capacity and need to cancel planned surgery as a result for those patients with complex health issues requiring postoperative access to ICU."
All New Zealand's DHBs have plans to scale-up intensive care capacity if a Covid-19 outbreak spreads significantly.
These differ by hospital, but will generally involve steps such as using operating theatres to expand the ICU physical area for patients. Anaesthetists and anaesthetist nurses would be seconded and do the work of their intensivist colleagues, under close supervision and support. Patients would also be sent to private hospitals if necessary.
Exhaustion and fatigue could be an issue. Covid-19 patients who have poor oxygen levels despite ventilation are often shifted into the prone position for 16 hours at a time. Safely turning them like this commonly takes eight people. Slighter shifts are needed every couple of hours to relieve pressure and avoid bedsores.
That physical, demanding work is done in layers of PPE and under strict infection protocols. Any breach or suspected breach would result in more staff being stood down and tested.
Having all hands on deck in the intensive care unit would have a serious impact on patients elsewhere, because the service does crucial work across other areas of a hospital, including helping resuscitate and stabilise patients in other wards, and detect any deterioration in their health.
A widespread outbreak of Delta in a country with relatively low levels of vaccination would quickly swamp hospitals and ICUs, even if capacity was much greater than in New Zealand.
In early 2020 and as the first waves of the pandemic overwhelmed Italy's world-class hospitals, a group of New Zealanders developed a world-leading piece of software designed to help if such a situation happened here.
The "1000minds" software would give each Covid-19 patient a score, calculated from criteria including underlying medical conditions, and extremes of weight and age. That number would then help ICU doctors decide who should get the next free bed if there aren't enough for every patient needing intensive care.
The software currently sits with the Ministry of Health for sign-off. Dr Andrew Stapleton, one of the intensive care specialists involved in designing the tool, said issues around equity were still being worked through, but he no longer expected the software would be needed, in the current outbreak or in the case of future ones.
That was because level 4 should contain the current outbreak, he said, as long as the public complied with the restrictions.
And in the future, once everyone who is willing has been vaccinated, Stapleton believes the Government won't allow a situation where hospitals and ICUs can't cope. (In countries like the United States, the overwhelming majority of Covid-19 patients in intensive care are unvaccinated.)
"I suspect the national strategy, once everyone is vaccinated, will be to continue to use lockdowns in a localised manner to try and prevent individual hospitals being overwhelmed. The goal would be to avoid situations where the triage tool would ever need to be used."
That view is supported by a new study, published in the Lancet Regional Health yesterday, that estimated reopening New Zealand's borders without hard measures like lockdowns could lead to more than 11,000 hospitalisations - and more than 1000 deaths - even if we manage to vaccinate nine in 10 of all Kiwis.
If the current lockdown contains community spread, hospitals will again turn to trying to clear the backlogs of people who had their treatment or appointments postponed.
Earlier this month and before the current lockdown the Herald revealed nearly 30,000 New Zealanders were already caught in delays for hospital treatment.
Recovery plans sent to the Ministry of Health by DHBs around this time last year had estimated how quickly delays for planned care could be reduced. Some services haven't made progress as fast as hoped, but the ministry couldn't provide more detail.
According to the recovery documents, clinicians feared that those needing treatment could suffer serious consequences. One major DHB warned that delays in its ophthalmology service could result in people going blind.
Sarah Dalton, executive director of the doctors' union, the Association of Salaried Medical Specialists, told the Herald the current Delta outbreak would only add more pressure.
Staffing problems were so bad even before the outbreak that planned care including elective procedures and surgeries was being delayed in many areas, she said.
"There were some DHBs that were pretty much unable to deliver any planned care. There are some severe strains on the system. North Shore Hospital was doing planned closures of one or two operating theatres at a time, just because of staff shortages.
"Sometimes things were having to stop if people were calling in sick. Because there just isn't the workforce. They are running on empty."
Emergency departments are already full, with patients needing admission waiting too long, the Australasian College for Emergency Medicine warned this week.
The Government is working on an ambitious overhaul of the health system, including doing away with DHBs. Days before the Delta outbreak, Health Minister Andrew Little told Newsroom he was frustrated that despite billions in extra funding, "the same pressures that were evident three years ago are evident now".
Issues like increasing skilled and specialised staff are difficult to fix in the short term, particularly because of border closures.
Dalton said one thing that could be done is more transparency about where the pressure points are, including by region.
"Look at being more flexible about offering people the chance to get care that might be a bit further from home but which might mean a shorter wait, if there's regional variation in waiting lists. I understand that's happening across the northern DHBs already."
Thick black smoke can be seen across the city.