Covid-19 is still with us. The South African curve is not flattening, and the number of new cases and deaths continues to rise.
I am seeing my first Covid-19 positive patient at Netcare Kingsway Hospital. He is fortunately well. Unfortunately the surgery for his broken arm will be delayed for two weeks. I am not prepared to risk spreading the New Corona Virus in my theatre if it can be avoided. This said, if we needed to operate my team would do it safely.
I have consulted and seen other patients with Covid-19 before our hospital was closed and then reopened last month. But they had been admitted under other physicians, and were not strictly my responsibility. Although ownership may be a better word. We bear great responsibility as the doctors of these patients.
I was prompted to write this piece by Laurel Braitman, a professor and the Director of Writing and Storytelling at the Stanford School of Medicine at Stanford University. She hosted an emotional online writing workshop this weekend. The prompt was to write something for a time capsule that would be opened by future generations.
Back to my patient:
He was the last patient I saw on my ward round.
First I see green patients, then yellow patients, and finally the red patients. Negative swabs, awaiting swab results and positive swabs respectively.
Besides being red my patient is also black, and I am white. Yes I notice that. Especially after all the other colors in my hospital. We are both born in the same country, but we come from different cultures. We are the Rainbow Nation. Diverse and rich in color and ethnicity.
Our categorization of the disease in South Africa is also divided into race, as it has become all over the world. Black and white. I say this with great respect as America burns with human rights protest.
To save on PPE (personal protective equipment) I took him his breakfast. This meant a nurse would not have to don a special N95 mask, visor, gown, apron, hood, booties and gloves. No more pleasing hostess serving patient’s food on a tray with plates and cutlery in the hospital. Just a polystyrene container with food heated in the microwave. Delivered by an already tired doctor.
South Africa has always had constraints, and we all live in fear of not having enough PPE. So being able to serve the patient his food was my way of saving PPE for the tsunami we are expecting. It also allowed me to connect with him. I had to explain the delay in surgery. I reassured him that it was not going to jeopardize the ultimate result and clinical outcome of his injury. We also spoke about his work. His family. And Covid-19. We are all facing the same storm, yet each of us is in a different boat.
Then my ward round was over. I spent thirty minutes with the nursing team going over the donning and doffing processes to be sure they were safe. Then I changed in the large change room the hospital has created for staff dealing with Covid-19 patients. I changed from hospital scrubs back into the new scrubs I wear to work every day.
At home, after a shower, I changed out of those scrubs into shorts and a t-shirt, and started my sanitized day.
Surgery is a privileged profession in so many ways. But under the cloud of Covid-19 I discovered a new profound privilege.
I had to operate on a 16 year old girl. She had injured her knee before lockdown and we had planned a knee ligament reconstruction. She was due to come into Kingsway Hospital with her mom and be treated with care and attention in our orthopedic ward.
We had to delay surgery because of lockdown. Then the hospital closed and re-opened, and at last we were able to schedule surgery for this past Saturday.
Surgery is not about the incision. It is about the healing: people entrust their bodies to the surgeon to remove, repair or relieve. There are moments on the path that the surgeon and patient walk that stand out. There is the introduction, understanding who they are and what they want to become. Assessing them clinically and then interpreting the investigations. Discussing options and guiding them to what you believe is the correct choice. Then the surgeon has to engage about the details and obtain consent. The capacity to make choices about your body, even as a child, is enshrined in our constitution, so it is good to engage with minors although their guardians have to sign the consent.
I had an new responsibility on Saturday. In the consultation we had decided that her mother would not come into the hospital with my patient. It would be an additional cost for her mother to be tested for Covid-19, and there was also the small risk of possible exposure.
It felt awkward at the time to exclude her mother from her hospital admission. She would be in hospital for a little over 24 hours. Even so, I had never done this before.
That meant my patient was taken to the front entrance of my hospital by her mother. There she would be left to enter alone with a clerk showing her the way to the ward.
This whole thing had been preying on my mind for days.
I saw her pre-operatively in the ward. She was alone in a normally occupied three bed ward. As healers we have had touch taken away as part of our skillset by this virus. Our faces are guarded by plastic visors and hidden by masks. Intonation and smiles are lost, and breathing and speech is difficult. Communication fails even though the need to care is heightened.
Over the years I have had children with injuries whose parents have given telephonic consent for emergency procedures to be performed. So seeing a teenager alone in bed was not something unusual. Yet the knowledge that her mother would not be allowed in as we had decided not to have her tested for Covid-19 meant that my patient was alone because of new policies and requirements to contain the possible spread of the disease.
I felt a sense of loss in that some of the humanity of my profession was gone. When she was wheeled into my operating theatre I realized I was entirely responsible for her. She was in my care in a manner beyond my commitment to my patients before this pandemic.
It was a new sense of responsibility. It was almost as if she was my child for that moment.
The seven days that Netcare Kingsway Hospital was closed completely became a long week.
There were moments of self-doubt. Finding calm in the moments that made up the closure of our community hospital was difficult.
I was paralyzed during the week my hospital was closed. I limited my news intake, and as I don’t use social media, I was spared the barrage of funny videos, false news and frustrated outbursts that we all experience under lockdown. My paralysis left me unable to read documents that were important to the functioning of a hospital, and further, the functioning of an orthopedic surgeon in a hospital. No hospital, no function: paralysis.
It was late Friday night that I heard that we were allowed to open. The weekend would be taken up by dusting off everything and ensuring that all the things that are vital to a hospitals functioning were working. This meant checking things like oxygen, air, vacuum (for suction) and back-up generators were all working.
Then we had to meet to train. We had to appoint new key players in new departments that make up the new normal of working in a hospital during the Covid-19 pandemic.
So after a week of mental paralysis how do you focus when you seem to be starting in the beginning again?
My mind races and there are many answers to the many questions. The answers that ground me are not technical. They are the emotions that will enrich us: empathy, gratitude and answering the question why for this period.
Firstly we need to have empathy, as each one if us has been to dark places in the last month. No one knows exactly what path anyone else has tread, but caring for each other is important. We need to be kind-hearted, concerned and considerate.
Secondly, and equally important, we need to be grateful for everything we have and everything that has happened to us. We need to be grateful we had time to slow down and recalibrate. We are now all more grateful to have a place of work. More than that we are grateful that the public trust us to take care of them in our place of work.
Lastly, we need to answer the why of what has , is and will need to be done. We can easily answer the what and how, but why will reveal the foundation of our plans and protocols so that the team can incorporate them as part of their fibre. United in understanding we will achieve much more than just with protocols and procedures.
An extended period of closure for any business can be devastating. For a hospital, closure speaks to a further loss. The feeling of failure settles easily on your shoulders if you don’t stand tall. Stand on your foundations of empathy and gratitude, and answer why it happened.
Then what we do in the new normal will be greater than we would have done before.
Toward the end of last year I was reading an article on disruption from Singularity University. The writer challenged businesses to think how they would respond if their customer base was suddenly lost. The challenge seemed to be based on climate change extremes and technological advances. It was a good article, and I thought about it.
My hospital, Netcare Kingsway, is set in the lush coastal bush of a tall dune on the South Coast of Kwa-Zulu Natal. I thought that even with a significant rise in sea level we would not be affected. The dune is at least seventy metres above current sea level.
So what could else cause me to lose my patients? The answer is clear four months into the new year: the economic and political chaos that has followed the Covid-19 pandemic.
I have seen fewer patients during lockdown than the fingers on my surgeon hands. For one week in April, the Medical Centre (a building adjacent to the hospital housing over fifty doctors) in which I work was closed. It underwent a deep clean by professional cleaners brought in by our hospital management. This despite there not having been a patient or doctor or receptionist who works in the Medical Centre testing positive for Covid-19.
Since the deep clean a handful of doctors returned to consulting in the Medical Centre during the last week of lockdown. They were seeing a fraction of the number of patients they normally see. Seeing these patients during the pandemic is difficult with protocols in place to enforce social distancing, wearing of masks and visors as well as increased hand hygiene for all. With the adjoining hospital still closed we cannot use the laboratory or X-rays department to help us make diagnoses. Worse still, we cannot admit our patients for treatment, be it medical or surgical
The patients we have cared for feel that we, the doctors, have abandoned them. I have cared for over twenty three thousand individuals and families during the two decades I have worked at Kingsway.
My last operation was on Easter Monday, over three weeks ago. Shortly after that the hospital was closed to contain a Covid-19 outbreak. My patient was a ninety-two-year-old lady who shattered her thigh bone. The theatre staff and I were in full PPE (personal protective equipment) to protect her and us from Covid-19. She was discharged from Kingsway last week. Her thigh bone was fixed and she did not get infected with the New Corona virus in hospital.
I am pleased lockdown has been lifted in phases. I am not sure if I will be able to send her flowers for her ninety-third birthday next week.
I believe that Netcare as a group has been proactive with policy and protocol before Covid-19 was declared a pandemic by the World Health Organisation. Kingsway Hospital management has upped their game: they spent on more PPE, created more negative pressure ventilation cubicles, paid staff even though they are not working, converted a day ward of twelve beds into a Covid changeroom for staff, allocated only one patient to a cubicle even in three or four bed wards. This management team ran the hospital efficiently before Covid-19. Now they are risk managers as well, dealing with unimaginable crisis after crisis that has become the hallmark of this pandemic.
We have ongoing cleaning of the hospital including with an Ultraviolet Robot since we were closed to new admissions. We have emptied the hospital of all patients and closed the Medical Centre again from the end of April and have repeated the deep clean. We have trained staff and doctors in Covid-19 protocols. We have taken a team that has always cared and been cautious, and have made them better.
All of us are dealing with all the unknowns of the Covid-19 pandemic. For us at Kingsway Hospital an additional unknown is when our hospital will be re-opened. We have lost a great part of what defines us as doctors.
In another world I would have been an engineer sitting behind a computer solving other management problems.
But thanks to an inspirational ICU nurse I changed from engineering to medicine.
Now in this world, as a doctor, I am a humble part of the team at Kingsway Hospital that is managing the Covid-19 threat.
We are all, the public and health care workers, faced with the stress of the effect of the pandemic. There are economic fears of retrenchment and real money issues. Then there is the psychological stress of losing our right to move as we please, and with whom we please.
Covid-19 is a disease whose spread we cannot control. Even worse, some patients who get a severe infection cannot be cured, and will die in our care. I ask the public to think about the precautions we have to take to reduce the spread of the virus in our hospitals. We have to be vigilant: anyone can spread it in the asymptomatic carrier stage. We screen endlessly. We wash our hands so often our skin cracks. We live in masks, and as the risk increases we spend the day and night in uncomfortable protective gear. I challenge any member of the public to watch a video on the donning and doffing of our PPE (Personal Protective Equipment). Some of this process is not entirely new to people exposed to the operating environment. But I can tell you, as a surgeon, the new processes are not easy for me, and are much more demanding and tiring.
The nurses have been forced to learn so much that is new. This is not like dealing with a superbug in the sense of the word before Covid-19. Superbugs like MRSA and CRE remain a challenge for all hospitals. The management of those is difficult, and we have extended and increased our systems of safety and control for the Corona Virus at least a hundred fold.
Some of our nurses have been in isolation, and fewer have actually been ill with the virus. Thank you to them for taking time out of your life to keep us safe. Thank you for accepting sometimes blunt orders from your hospital. I understand the trauma you have been exposed to.
Some of nurses have temporarily lost the job they were so good at. I think especially of the theater staff, where no operations have been undertaken in over ten days. I know you want to contribute. The only way we can contribute is to train even more to deal with this threat.
Other nurses with great clinical skill have been put on point duty to man sieve and screening areas for 12 hours at a stretch, exposed to the elements. Durban is not such a mild place if you are outdoors all day. Thank you for being so patient with the public that still come in needing our hospital.
We all have to pay so much more attention to detail. The equivalent performance by a sportsman or woman would be a hole in one or an ace with every shot, or a goal with every penalty shot in soccer. There is no one that can do that. Let’s not beat ourselves up about failures from which we can learn and do better the next time.
I know we all use Facebook to stay in touch with each other. A lot of good comes out of being in touch with people far and wide, and being able to share your life with them.
What’s happening with the negativity toward nurses by some members of the public on Facebook is just not right. But Facebook gives strength to the weak, and should never be the judge of the calling you all hold dear to your heart.
What is happening in our community with nurses being ostracized in public and common areas speaks to the lack of understanding of what we face with this pandemic.
Those people, like us, need to learn to manage their stress and ask for help. There is no need take it out on the nurses who will care for them when they are sick.
Our nurses are the superheroes of our new world. Take some time to acknowledge them.
They will be the ones looking after your loved ones in hospital.
For those patients that die in our care the nurses are the closest they will have to family. They will be with them when their family members who want to be close, cannot. Many of the nurses will feel the pain of their passing as keenly as family, with the added weight that they may feel they failed. They have not failed.
The disease is the killer. Not the nurses. That’s the simple truth about nurses.
I am so proud of all of you. You have applied yourself to everything that is new. You have patiently listened as we explain protocol after protocol, and then frustrated you by changing it the next day. I am proud of how you showed care to my 99-year-old patient whose hair is perfectly coiffed and her makeup is ready for a BBC interview.
Like you I don’t know what day it is. I need to check a calendar to see if it’s a working day or a weekend. Not that it makes any difference to you, working shifts and three-day weekends every second weekend.
I try, and yet I fail to talk to you in the corridors and in the nurses stations and in your offices in management suite.
I failed to act ten days ago when someone asked me to write something motivational for you. This is a time when failure is commonplace: the only solution is to acknowledge it, learn from it and move on. With this letter I hope to move on.
We are facing a global crisis in our little hospital that has always served our community to the best of our ability. It seems sometimes that nothing we do is enough for our patients, our hospital, the whole world. But we have not failed!
The sense of failure, the fear of not being in control, the quarantine, the concern for our families causes us all to feel anxiety.
Feeling anxious about things in today’s world is completely normal. Although I am no master, I’d like to share with you how I have learnt to deal with my anxiety over the years and what works for me now:
We need to deal with it. Learn from our failures. Consolidate and move in a new direction with calm and strength and compassion. I believe we all, and especially you, have this ability.
In our medical training and our experience at the workplace over the years we have all faced stressful moments: a patient’s death, a complication, a disagreement with a colleague. Think back to those times. Now empower yourself by reminding yourself that you dealt with those crises before, and you have the tools to deal with this crisis. You have achieved so much, and will continue to achieve.
Over the last decade I have been blessed to meet many wise and caring people who have helped me deal with fear and anxiety. The essence of their help for me can be distilled into three words:
Remember to breathe (even if it is behind a suffocating mask).
Breathing is the essence of life, and we can control it. In the beginning just acknowledging your breath is enough. Start to feel the place where your inbreath gently fades into your outbreath. Feel your diaphragm move. If you want you can pause, and count to four at the end of each breath.
It is as simple as that. Now you have something you can control. In controlling that you can reduce your fear and anxiety.
I salute you all. For once the world is recognising your calling. They are appreciating your service for the greater good of humanity. They understand your sacrifice.
Six weeks ago I was placed in self-isolation by my hospital for ten days.
“I had a dream that you asked me to polish your shoes” my maid, Londiwe, messaged me a few days later. Now you should know I have never asked her to shine my shoes. Erasmus does my shoe shine at the airport regularly (I fixed his shoulder years ago so please look out for him at King Shaka Airport after lockdown). I had asked Londiwe to stay away from work until I was cleared of a possible Covid-19 infection. Londiwe in Zulu means “protected or kept safe”; I truly hope that both of us stay safe.
I knew immediately what her dream meant.
It has been a long journey and we are still in the early hours of the first morning of the months that will unfold in social and economic upheaval. I have found it important to choose my words carefully during this time. This pandemic is a global crisis but I believe it will change who we are and how we do things for the better. At a price, I know.
Yesterday at the screening entrance of my hospital I saw the matriarch of a Zulu family with her daughter and twenty-year-old grand-daughter. They were tense, as most people are now, and were huddled too close around the Perspex shield protecting the nurse attending to them.
In my surgical mask outside the hospital I introduced myself, and then asked them to move apart and stand two metres behind one another. There was a sense of loss and fear in their eyes, from old to young.
“I’m sorry” I said, “we need to keep social distance to protect each other.” They didn’t move apart and I stopped myself from being authoritative.
“Can I help?” I am saying that many more times than I used to. I act on it many more times as well.
I cannot remember what the nurse said. I should. It was important. But it was a blur of “they have come to see or pay last respects” to the grandmother’s husband who had died in ICU.
No visitors are allowed into the hospital now. No one can be at the bedside of a dying family member, and no one can gain closure by seeing or touching the cold lifeless body of the departed.
“Please wait here. I’m afraid we cannot allow you in. I will find a manager to help you”. You have to speak clearly and loudly in a surgical mask in order to be heard. That removes any tone of sympathy. The assistant nursing manager grasped the urgency and went out immediately to explain. As I turned to look back the daughter and granddaughter walked away, their souls battered by the new normal. The next I saw was the nursing manager opening a big official book, with carbon copies, for the matriarch to sign away the body of her beloved outside the hospital.
I was shattered. Even in my first world hospital I had once seen a young man reverently carrying a branch of the Mpafa tree, the Zulu Tree of Life. A Straight thorn points to the future, while a curved throw connects us to our past. He was taking a branch to the ward where his father had died. He would rest it on the on the body and capture the soul of the departed and take the branch home to tuck into the eaves of the homestead. On the way home he would buy a ticket in the taxi for himself and the spirit in the branch.
In this dream in the time of Covid I thought we could allow families to bring a branch of the Ziziphus mucronata, the Mpafa tree, and we could put it in yet another safe plastic bag, and leave it with the body. They would never be allowed to take the branch home. It would burn or be buried with the body.
Londiwe, may we be kept safe, had a dream to prepare my shoes for this long journey. A dream in the time of Covid.
Photography teaches good philosophy if you are aware of what is happening in your life: try taking pictures with a 35 year old camera and use space age paper to make instant pictures. For me, in the beginning, it is indeed impossible.
I first heard about Polaroids still in use in Italy from Willem Oets, when he attended his first TPW (Tuscan Photographic Workshop) in 2011. I have played around with developing and printing black and white film in My Darkroom in Africa and love watching a picture come to life. After my tantalizing introduction to instant photography I knew it was a lifestyle I wanted to explore. In this age of instant gratification instant photography is actually not instant at all. Even the modern Fuji Instax film takes a minute to show a washed out image and ten minutes to mature. Furthermore, although a picture appears on paper, there is no instant digital sharing option, and the picture really is one of a kind.
In July this year at TPW I met the master of light and prints, Enrico Borgogni and have now embraced instant film cameras and love it. When we all presented our digital portfolios by way of introduction at TPW this year, Enrico passed around large prints of his masterpieces. Seeing and touching a masterpiece is far more sensual than looking at a good quality digital projection.
The new Polaroid film made by the Impossible Project needs to be kept dark for 4 minutes after exposure and then there are still chemical defects caused by the old rollers on the camera that set the chemical cascade in motion to reveal the picture. These add a timeless aura to the picture. Using the old Polaroid camera is not easy. There is no light meter, no histogram and no live preview. The exposure compensation ability is crude. Worse still my current camera (Polaroid CL600) seems to have a sticky shutter and the curtain is not moving out of the way fast enough. When I get my pictures right they will have a unique identifying shadow feature on each side.
In this day and age of instant mass production isn’t that what we strive for: to be unique.
The Impossible Project is teaching me patience; and allows me to be unique.
There are two special moments in darkroom work: the first is when you unroll the wet film from the black developing tank and see the negatives, and the second is when your first full size print comes to life in the developing tray and you see the image in the red light.
It was a hot and humid day in Durban and I loaded the film into the reels and developing tank in a small windowless and airless room under the steps at home. Then I set about the chemistry of mixing the DF11 Ilford film developer, a homemade stop with vinegar and the Ilford fixer. The temperature of the developer is critical and fortunately Ivor Ginsberg had sent me a thermometer that fitted in the irrigation spout of the developing tank.
Using the Durst “Made in Germany” mechanical timer and Mike as a time keeper, I poured the developer into the tank like a celebratory glass of champagne and agitated the mix every minute until I poured that out and poured in the stop to cease the developing process. Then a few minutes in the fix, and after the first wash, I opened the tank lid and peeped at the negatives. My heart sank initially as I had exposed Mike’s film by opening the camera back as we had forgotten how to rewind the film in his “automatic” Minolta 500i. The OM1 was much easier with a manual rewind lever. But the negatives looked alight.
I used dishwasher rinse as a wetting agent, then dried the film with a chamois, as I only had an old squeegee that would scratch the film because the rubber had perished. Ivor had sent original film hanging clips so we left them to dry in the shower and had lunch.
After lunch I set up the spare room as darkroom. I placed the Meopta enlarger and timer and the Patterson enlarging “computer” ( just a simple exposure meter) on a table. After a few test prints, as I had no idea of what time to use, we found some images appearing. When I changed the enlarger bulb to a full 150 Watt light things really started happening. Ivor had sent some old (from the fifties or sixties) Agfa Bronica paper. This was not a resin paper and dried badly without a proper drier or press. Then we started using the Ilford Mutilgrade resin paper and my first picture was born.
The equipment was working well enough to plan a darkroom party at Costa Calla.