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.