They might just walk in the door, oblivious to the fact they are carrying a virus which has changed normal life and killed millions around the world.

Others suspect they have it.

Qais Thalib, 28, of Dee Why, arrived like that.

Myself and photographer Chris Pavlich — dressed head to toe in Personal Protective Equipment — met him in the Emergency Department’s Respiratory Assessment Pod, where potential Covid patients are taken to be assessed.

He was suffering from chest pains and a fever, classic symptoms. Other signs of Covid are a cough, cold, sneezing and shortness of breath. The Delta variant has brought additional symptoms to the watch list including headaches, diarrhoea and vomiting.

‘We rely on patients being honest with us’

Jo Watts, nurse manager in Emergency, who lives in Queenscliff, said 60 per cent of patients they see have respiratory symptoms and are therefore potentially Covid positive. Managing that is “tricky”.

“We need to keep people away from each other,” she said. “It’s difficult in an emergency environment.

“A lot of it is relying on people being honest, but sometimes they forget. They come in and then realise, ‘Oh yeah I did have a headache a few days ago’.

“Then their management of where they are allocated has to change.

“Someone might come in with chest pain and we put them in a bed in the main arena and then 20 minutes later they go, ‘I did have some diarrhoea and vomiting and some headaches’. “And then we need to move them to an area away from people.”

Once they are in the Respiratory Assessment Pod, staff take their bloods and get a chest X-ray to find out whether they are positive and where they should go next.

Mr Thalib is lucky, later that day he finds out he does not have Covid and is able to go home.

When we were there, he and three others were being watched by five staff on duty on the ward on what was a ‘quiet morning’. Last week the ward was so full they considered going up to the next stage of their Covid plan and opening another.

That’s the reality of being in a pandemic, staff have no idea what to expect each shift.

Sweaty, tiring conditions

But what they do know is that there is a likely risk they will come into contact with someone who has the virus during their working day.

That’s why they have to wear PPE — which includes a plastic gown to go over scrubs, latex gloves, a mask which is individually fitted (and which invariably leaves deep grooves in the wearer’s cheeks) and a face visor or plastic glasses.

Staff continually ‘don and doff’ their PPE each time they move in and out of the ‘hot zones’, the areas of the hospital where there is a high risk of Covid, so as not to contaminate the ‘clean’ areas of the hospital.

PPE is not pleasant work attire. Among the complaints from staff are that it makes them hot and thirsty, it’s uncomfortable and working in it for 12 hours a day is far more tiring than usual. We only experienced working in PPE for a couple of hours and just the act of holding a notepad or a camera — which is nothing like physically caring for a sick person or actually trying to resuscitate someone — was enough to produce sweat, make the plastic gown stick to our arms and our face visors to fog up. Talking and hearing each other was also problematic.

And the unnerving reality for any Covid patient is that when they are most sick they don’t even have the comfort of seeing a reassuring smile on the face of someone looking after them.

In fact they may not see someone’s face for weeks on end if they are seriously ill.

‘Many arrive needing resuscitating’

Some Covid patients arrive by ambulance like a 38-year-old Collaroy Uber driver we met.

He was admitted two weeks ago, struggling to breathe and needing six litres of oxygen a day at first, along with other treatments to help keep him out of intensive care.

He did not want to be named for fear he would be stigmatised and unable to get work when he recovers.

He is an asthma sufferer whose condition suddenly worsened while at home. He’s a patient in Ward 4C, where patients go if they are diagnosed as being Covid positive, but are not so bad they need one-on-one care or a ventilator.

Those who come by ambulance, give Emergency staff the chance to plan their arrival.

The lengths they go to include closing down corridors when transferring the patient into the respiratory ward, so as few people as possible are exposed to the patient.

Others are so sick when they arrive they need resuscitating. At least a dozen Covid patients have needed immediate lifesaving treatment on arrival. However, the very act of resuscitating a Covid patient is high risk for staff because it causes the patient to forcibly expel a lot of air and droplets.

A specially designed resuscitation room — with its own air supply which sucks out the pathogens — is being built in the hospital’s Emergency Department, to protect staff and patients.

It’s a sure sign that Covid is not going anywhere soon.

‘Impending feeling of doom’

“I don’t think there is one clinician working in Emergency at the moment resting easy about what we are predicting for the next few weeks and months we’ve got ahead of us,” Ms Watts said.

“I think everybody has this impending feeling of doom.

“I think we had it last year, but personally I think it is a lot stronger this year because of Delta.“We’ve seen it spread so rapidly and so out of control.”

There are currently more than 1200 people in hospitals across NSW, with 228 in ICU.

But it’s not just Covid patients they’re having to deal with.

Northern Beaches Hospital saw nearly 6400 people arrive at Emergency in the last quarter, up a third on the year before.

Premier Gladys Berejiklian and Health Minister Brad Hazzard, MP for Wakehurst, have predicted October will be the worst month for Covid hospitalisations.

So the future is a little daunting for most healthcare workers

Their big fear on the beaches is seeing the numbers that they’re getting over at Westmead and Liverpool hospitals where hundreds of patients are presenting to EDs each day and it is difficult to isolate them.

‘Being in a pandemic is really surreal’

Every day, Dr Michele Franks, deputy director of Emergency, thinks to herself on the way into work, that she’s in for a ‘tough day’ and she’s worried it will get worse.

“We are not looking forward to the increase in activity which is coming,” she said. “We are gearing up for it.

“We recognise it’s going to be harder work.”

She said personally being in the middle of a pandemic was “really surreal”.

“But here we are, 18 months in. It’s difficult, very difficult.”

Like everyone, lockdown has meant sacrifices for Dr Franks.

She has not seen her adult son for three months because he lives in another LGA. The only person she sees is her partner and she is a single friend for her elderly aunt.

A swim at Manly, the suburb where she lives, and a socially distanced hello to fellow swimmers is her only relief outside of work.

Her main message is for people to get vaccinated so everyone can have some freedoms.

“When it is something you can prevent, it’s quite distressing to see people with no background issues, getting so unwell,” she said.

“We are used to seeing people dying from flu but they are usually older people who have got multiple health problems.

“Now we are seeing young, quite well people dying from this and it is quite distressing.”

Inside 4C – the typical unvaccinated patient

This is where our Uber driver has been for the past two weeks and where Covid positive patients go if they have generalised weakness, or some shortness of breath. He told us he doesn’t know where he got the virus from but suspects it was from a passenger.

He said he would love to know how he got it, but health authorities have not told him.

He is typical of most Covid patients — he’s unvaccinated and has an underlying health condition. He has asthma, a condition that affects around 11 per cent of the population.

He said his doctor advised him to get Pfizer and he only became eligible the day after he caught the virus. His dreadful experience of Covid has spurred him on to book the jab while still in hospital. His wife, who managed to avoid catching the virus from him, has also booked hers.

“My first symptoms were a tight chest,” the driver said. “I had a fever and headaches.

“My blood oxygen level was going down. That’s why we called an ambulance.”

By then, he was really struggling to breathe, which was causing him to cough a lot.

He admitted he never thought Covid would make him this ill and for a time not knowing what each day in hospital would bring was “scary”.

He’s warning to others is that Covid was much worse than he thought and for people to get the jab because “you can’t see it so you don’t know when you’re getting it”.

Patients range from 9 to 94

On Ward 4C the clinical educator nurse Kylie Stewart, who lives in Ingleside, has seen a range of patients aged from 9 to 94 since the pandemic began, most of them unvaccinated and from other parts of Sydney.

She said there has been a “lot of success stories”, including both their youngest and eldest patients. Incredibly, the nonagenarian is back running marathons.

Oxygen is available for patients on the ward, but only up to a limit.

Our Uber driver reached that limit with six litres a day and was on the cusp of needing intensive care.

When we saw him the staff were looking to wean him off the one litre of oxygen a day he was now on, so he could go home.

Happily, he’s another success for 4C to chalk up.

In ICU where patients are sedated and paralysed

While the Uber driver is set to go home soon, others need more care than the staff on Ward 4C can give.

At Northern Beaches Hospital, the ICU has been split in two, and one unit is now dedicated to caring for Covid patients. Most come from other parts of Sydney and are generally the most unwell.

Before entering we are warned by the press officer that the day before two patients had died and staff might still be “sensitive” about it. Losing a patient hurts.

Matt Morgan, head of the unit, explained that while some Covid patients “get a bit of oxygen and they get better, some people get a lot of oxygen and they still manage to get better, but some people get so sick they have to go onto a mechanical ventilator.

“That is what you see now,” he told us, pointing to a woman in her 40s.

“They need to be very, very sleepy for that to take place otherwise they might fight the ventilator which is trying to help them.

“Sometimes they need to be paralysed so they don’t actually move any part of their body so we can control everything.”

‘Some people will die, because this is a significant and serious disease’

Another patient, a man in his 60s, is lying on his front, a position studies have found can help Covid patients. He will be like that for most of the day.

He is connected to a variety of machines, including a dialysis machine. His whole body — not just his lungs — is struggling with the effects of the disease.

Dr Morgan said in some cases the staff have to “take over the kidney function, the heart function, the blood pressure condition, the lung function.

“And then we wait for the Covid medications to improve things and we wait for the time really and the patient to get better, but sometimes patients don’t get better from this disease despite all that we can do for them.

“And unfortunately, some people will die, because this is a significant and serious disease.”

New therapies used during this outbreak are helping to improve the chances of Covid patients surviving.

Like the male patient, the female patient will also be turned onto her front. It is called ‘proning’, a therapy which wasn’t used in Australian hospitals last year, but is being used during this outbreak after evidence based studies have found it to significantly improve the outcome of a Covid patient.

It is a simple therapy, involving the patient being turned onto their front and a pillow placed under their neck and pelvis to allow the chest and stomach to expand.

Covid treatments: ‘It’s not rocket science’

“We have big studies coming out of world literature that is helping guide some quite simplistic therapies actually, it’s not rocket science, it’s not an expensive drug, this is doing something relatively straightforward for a patient, putting them on humidified oxygen and getting them to lie on their tummy,” Dr Morgan said.

“From doing that from evidence we know, we save one in 14 patients from having to go on a ventilator.

“That’s an impressive thing. Sadly for this lady, although we tried these things, she got worse and that happens with Covid.”

Proning is still part of the therapy our Uber driver in 4C is undergoing. In his case, he can turn himself over and is now lying on his stomach for about an hour a day.

It is a far trickier procedure when a patient is on a ventilator, sedated and medically paralysed.

Dr Morgan said it takes five people to lift them into position, which is a huge resource.

While the male patient is spending almost all of his time on his front, so will the female patient who will be on her front from 4pm until about 8 or 9am the next day.

Other evidence-based therapies include drugs already available such as dexamathasone, a steroid, baricitinib and tocilizumab, which are disease modifiers.

‘I’m yet to see a vaccinated patient in my ICU’

Dr Morgan said he was yet to see a vaccinated patient in his unit. While there have been in other hospitals, he had not seen it at Northern Beaches Hospital.

“The general rule of thumb is that these people are unvaccinated, he said.

“I am yet to see in my practice a fully vaccinated individual in my intensive care unit.

“If you want to not die, get a vaccine, because that will stop you from dying if you get the disease and it is an even better vaccine than the ones you get from the flu.

“It works more effectively.

“So, we’ll see, I think, Covid becoming something that it is one of those viruses we get and we will see some patients in intensive care going forward, but hopefully not many because most people would have got their vaccine.”

Dr Morgan said his message was for everyone, not just the elderly or people with underlying health conditions.

“I have seen some very young, and very fit builders who are guys that are a lot fitter than me, training a lot and working in a more physical job struggling to breathe,” he said.

“I imagine they can lift more bricks or carry more weights than I can ever do and they are fit people, but they are ending up in intensive care on extra oxygen.”

Going into the tea room to cry

Dr Morgan said it was the nurses who did the hard yards, “doing the work, the sweating and the grit”.

“So if you’re out in the community and you’re having any hesitancy over getting a vaccine then think about the people working hard to keep your loved one alive and just get a vaccine,” he said.

Kim Smith, an ICU nurse educator from Bronte, and Rose Farber, the nurse unit manager in ICU, from St Ives, are two of those nurses looking after the sickest patients.

Apart from 12 hour shifts in PPE and being short-staffed — they are training up other nurses to work in ICU — the emotional toll of the job is huge.

Normally in intensive care the patient’s family are able to build a rapport with staff and are there with their relatives for their final moments.

But with Covid, the nurses are not just the patient’s carer, but are having to play the role of the relative too.

“We had a young patient, not so long ago pass away,” Ms Smith said.

“Witnessing the goodbyes of the family is, you know, the girls did an amazing job and it was, it’s just really hard because you just can’t help but think what if that was your family and it’s very sobering.”

“We’ve got a really strong team here and we know we can crawl into the office and have a cry or lean on each other in the tea room when we’re having breaks.”

Holding the hands of the patients who die

Ms Farber said recently she tried to get a nurse to go on a break, but she refused because she thought her patient was going to die.

“And I said, you need to go, I promise you I will stay with this patient and that I would not let them pass alone,” she said.

“The nurse would not, she’s a young girl and junior nurse and she just couldn’t go for her break.

“Really I felt so bad. She was so caring, she would not leave that patient to die on his own. I think that really hit me.”

‘We are pretty proud of ourselves’

Despite the grim situation, there is still humour on the Covid wards.

On 4C, Ms Stewart has a joke she likes to tell. “You’re probably safer here than in Woolies”, is what she tells people she meets.

Going by their track record, she’s right.

On her ward she has seen 208 Covid patients since the outbreak began, with no staff contracting the virus and no patient recontracting the virus.

“We are pretty proud of ourselves,” she said.

The strict protocols, which include nursing staff taking on the roles of “cleaners, kitchen staff, linen suppliers, all of those day to day chores and duties”, are the reason for the good statistics.

Cooper Wearne is an enrolled nurse and one of his roles is delivering meals to patients, which is much trickier and convoluted than in ‘normal’ times.

He has to ‘don and doff’ his PPE after going into every room, so he does not spread the virus from one patient to another.

That’s the same for every staff member who goes in to see a patient – which is often.

“I think we are actually more fortunate inside the hospital because we have the safe PPE and the safe environment, plus we get to go to work everyday, we are not locked up at home,” Ms Stewart said.

Ever the optimist she added, “So, I think we’re doing it a little bit better than some.”