"We're on skeleton staff. We are quite anxious, because one positive case will be a catastrophe. If we have people from Sydney coming and we just get one case, we're in big strife. If we had a positive staff member, it would shut the whole hospital down."
Those are the words of Samantha Gregory-Jones, a delegate for the NSW Nurses and Midwives Association (NSWNMA), who works in a tiny hospital one hour's drive out of Orange in the state's Central West.
The hospital has 10 acute beds and an emergency department. During the day there are only three nurses working, and two during the night.
Ms Gregory-Jones is one of many frontline health workers in small communities fearful that when people start moving around NSW, it will spell disaster for their health services and patients.
They are concerned that health services in regional, rural and remote areas of New South Wales will be particularly vulnerable in the face of the State reopening when enough people become double vaccinated against COVID-19.
"We're all sitting here waiting for the hammer to fall," says Dr Rachel Christmas, a GP and obstetrician in Temora in the Riverina district, and vice president of the NSW Regional Doctors Association (RDA).
"There's a degree of inevitability, and everyone understands we can't keep people isolated forever."
In interviews with doctors, nurses and paramedics, they all say the same thing - it only takes one COVID positive person, or even a close contact, to present at a doctor's surgery or hospital to shut all health services down in those small communities.
"Rural health is very fragile. It just takes a tiny push to knock it over," says Dr Hamish Steiner, a GP in Cooma.
"A lot of small towns with only one practice, if they (had to) shut, there would be a real disaster for the area for two weeks while they're shut."
It has already happened in Cooma, a town that has two GP practices. One has been in lockdown for the past two weeks because they had a close contact through the surgery.
"It means half the doctors in town have been taken out of action, and they work in the hospital as well. The hospitals had to get locums and scramble around to keep services going," Dr Steiner says.
"It's a real eye-opener. Suddenly half the doctors on the hospital roster are taken off. Half the GPs are taken out; they can still do phone consults but they can't do a lot of other things.
"It made it fairly obvious if both surgeries were taken out, it would be a complete disaster.
"No-one can get anything done, the hospital is completely unable to cope with the workload."
This non-emergency stuff, it was crippling us before COVID. I don't know how we're going to start dealing with it once we start opening up.Tim McEwen, Australian Paramedics Association delegate
Taking general practitioners out of the equation means more people will present at local emergency departments.
Not only does this put extra pressure on hospitals, but ambulance services as well.
Tim McEwen, a paramedic based at Yamba on the North Coast of NSW, and delegate for the Australian Paramedic's Association (APA), says paramedics' workloads have increased and changed.
"Since COVID started (in 2020), barring a couple of two-week periods, it's been Christmas-busy. It's been absolutely relentless," he says.
He suspects NSW/Queensland border closures may be to blame for a large part. On the north coast, people are largely reliant on specialists in Queensland.
"All of a sudden, people have either been cut off from specialists or are too scared to go up to Queensland, worried they're going to have to isolate when they come back, or not be allowed to come back.
"We've found people haven't be accessing their specialists either as regularly as they should, or when they need to, if there's an exacerbation of a chronic illness," Tim says.
Also, Yamba is heavily reliant on tourism and has a large population of "grey nomads" regularly passing through, putting more pressure on local health services.
A large percentage of regional and rural areas in NSW have faced a chronic GP shortage for many years.
An influx of people moving from the city into regional and rural areas has seen populations boom in many areas, with infrastructure, and in particular medical services, unable to cope.
There's never enough staff. We are so short staffed it's not funny. ," president of the NSWNMA's Port Macquarie Base Hospital branch, Mark Brennan says.Mark Brennan, president NSWNMA Port Macquarie Base Hospital branch
Many GPs have closed their books to new patients, placing further stress on ambulances and hospitals.
"When people can't get into GPs and their specialists, then it falls back on NSW Ambulance (to take them to emergency)."
Tim says NSW Ambulance is often being used as a "taxi service" by people with minor ailments, or for patient transport.
"If you have a town that only has one ambulance, and you take them out of the equation because they need to transport a patient that's not necessarily acute or needing a paramedic's intervention, then that town is uncovered and there's no fall back.
"This non-emergency stuff, it was crippling us before COVID. I don't know how we're going to start dealing with it once we start opening up.
"COVID has exacerbated what we've been saying for years and years, that the system is barely coping."
Paramedics have the same concerns as doctors and nurses - if one person in a crew becomes infected or needs to isolate, that might mean you're taking out 25 per cent of the workforce in a small town.
Scott Beaton is the vice president of the APA and a paramedic working in Gilgandra, west of Dubbo.
"We've seen an increase in workload, obviously in Dubbo and those areas where there are high amounts of COVID positive patients," Mr Beaton says
"So we not only have our normal workload to deal with, but then we're topped up with more problems from the extra patients requiring hospitalisation or transport to the hospital for COVID issues."
Mr Beaton says paramedics arriving at Dubbo Base Hospital have been facing the same bed lock or ramping issues that are happening in metropolitan areas, where ambulances have to wait in line to offload patients.
Doctors and nurses say a chronic shortage of nursing staff is crippling regional and rural services.
"There's never enough staff. We are so short staffed it's not funny," president of the NSWNMA's Port Macquarie Base Hospital branch, Mark Brennan says.
We desperately want the vaccination rates up, that's the only solution we have, is vaccination.Dr Rachel Christmas, vice president NSW Regional Doctors Association
He says as far as he is aware, the hospital is "ready to go" if it gets COVID patients.
"But again it boils down to staffing issues. We don't have the staff."
Dr Christmas says the lack of nursing staff is "killing rural areas".
"We know that if we get coronavirus out in the community before we've got those protective vaccination rates, our small hospitals aren't going to cope, because we're already on skeletal staff," the Temora-based doctor says.
"We also worry our referral hospital (Wagga Wagga) is going to be inundated and won't have the ability to cope."
Dr Steiner also worries about the capacity of the State's hospitals to cope. At Cooma hospital, he says, they don't have the ability to look after patients sick with COVID.
"There is no capacity to look after someone who's really sick and needs ventilating. It's never going to happen in small towns.
"As long as the cities like Canberra are able to accept patients, that's fine, but if they get busy they often say no to us.
"And that's our concern - if things do get out of control, the ICUs get full and we start getting patients, we'll find it very difficult to get them out to other hospitals. We already find that difficult with non-COVID patients," he says.
Local health districts are banking on higher vaccination rates keeping the majority of people from contracting COVID, or those who are vaccinated, at least, from needing to be admitted to hospital.
Consensus seems to be those not vaccinated in our community will pose the biggest threat of all to the health system.
"We desperately want the vaccination rates up, that's the only solution we have, is vaccination," Dr Christmas says.
"And until we get those vaccination levels up, we just don't want to expose ourselves to any more risk than we have to.
"When unvaccinated people are a proportion of the population, they do pose a risk, because they're more likely to get COVID, they're more likely to transmit it, and more likely to get unwell from it."