Some Good News

I have been distracting myself since the second wave. Our hospital has quietened down as far as Covid-19 cases go, and we started doing limited planned surgeries. After my last post which detailed the overwhelming and horrific difficulties we faced during the second wave, a friend of mine suggested my next post should be about some good news.

So I thought of telling you about a touching visit by a medical student to her grandfather. He had been admitted with Covid pneumonia and is now recovering at home. I also thought I would write about how we have resumed planned surgeries, and how it feels different to when we resumed after the first wave. In the background I have been working on a document detailing how Covid-19 has affected me as an orthopaedic surgeon. I think the latter post would not be good news.

But there is good news for this post: I received my Johnson and Johnson vaccine on Friday. It was injected into my left arm by a community clinic nurse at Prince Mshiyeni Memorial Hospital, a provincial general hospital in the south of Durban, KwaZulu-Natal.

There is so much to say about the vaccinations for Covid-19. The scientific endeavour and ultimate production and licensing is nothing short of miraculous. The first time use of mRNA vaccines in the Pfizer and Moderna vials is science exploring the envelope . The Pfizer story is worth reading. It details a humble event. Albert Bourla is a Jew born in Thessaloniki, northern Greece, who steered Pfizer as CEO to be the first to release and use a vaccine for Covid-19. The story of who was the first person to be vaccinated in Greece is where much respect goes to Mr Bourla. Mrs Despina, 95 years old and also of Thessaloniki, is a Jewish-Greek holocaust survivor. She received her vaccine in early January 2021.

The Astra-Zeneca and Johnson & Johnson vaccines both use the older technology of inactive adenovirus with the DNA of the Corona virus incorporated. Unfortunately the Astra-Zeneca vaccine gave less protection for the new variants of the Corona virus, including the variant which caused South Africa to explode in the recent second wave. The adenovirus DNA vaccines are more robust than the modern mRNA vaccines, whose cold chain storage at -70 degrees Celsius is difficult in a developing country. South Africa had already taken delivery of one million doses of the Astra-Zeneca vaccine as the studies unfolded about it not being as protective as we had hoped for. It was an disheartening blow to the nation’s health care workersw who were relying on a vaccine to give them real protection.

Before the dust had settled on the unused Astra-Zeneca vials ( which were sold to other African countries) South Africa took delivery of 80 000 doses of the Johnson and Johnson Vaccine. This is a single dose vaccine as opposed to the others which rely on two doses, given at an interval of a few weeks to a few months. Over the last week the Department of Health co-ordinated the distribution of the Johnson and Johnson vaccine under the umbrella of a trial for health care workers called Sisonke. Sisonke in Zulu means “together”. It is a Phase 3 (b) clinical trial which is pragmatic and set in the real world. Perhaps a little more real in Africa.

The Department of Health distributed the 80 000 doses between 14 state hospitals and used these initial doses to protect frontline health care workers. Their EVDS (Electronic Vaccination Data System) website allowed me to register as a health care worker. My hospital then stratified staff into risk levels, and then I was able to register on the Sisonke website to be part of the trial. Besides entering personal details this also involved digitally signing an informed consent. After this I received a voucher number and a booking to get my vaccine on Friday 26 February 2021 at Prince Mshiyeni Memorial Hospital. It was not all as simple as it sounds. 

The logistics of the vaccine delivery process has been difficult globally. South Africa has discovered the limitations of the public-private health care system. Some provinces allocated appointment times. When I received my invitation it was open ended: from 8 am until 4 pm. My heart sank as I thought of my visit two years ago to the Department of Home Affairs to apply for renewal of my passport. For that I arrived at 5 am to be close to the front of the queue. It could not be that bad, so I arrived at Prince Mshiyeni Memorial Hospital, 10km away from Netcare Kingsway Hospital, just after 7 am. I was relieved and reassured to see our nursing manager at the entrance welcoming and directing me. I was number 184 in the queue. Two hours later I received my injection. Then I had to wait the obligatory 15 minutes to ensure I did not suffer an adverse reaction.

I walked out feeling empowered. I had survived a mild dose of Covid-19 at the end of last year,  and now with the vaccine I was protected. As data comes in I will in turn protect others. But until a significant proportion of our population is vaccinated I will continue applying the appropriate precautions. We should all continue to wear masks, wash hands and maintain social distance. In the hospital and my office the minimum requirement remains a mask, visor, plastic apron and gloves. 

We still have a long way to go with this pandemic, but the vaccine is the most significant step in our battle to gain control of this novel corona virus.

I am grateful to the scientists who developed the vaccine and the South African government for choosing to protect us. Special thanks to the manager of Netcare Kingsway Hospital, Mrs Demetriou for her efforts to get her staff vaccinated.  Health care workers have seen a different reality to the rest of the population.

Thanks to Sister Nompumelelo Molefe

In Their Memory

I cannot find a title that encapsulates what has happened at my hospital without being alarmist. This is all about death. 

In early January 2021 my hospital was overwhelmed with Covid-19 cases as the second wave of infections hit our coastal holiday town with devastating force. 

The senior emergency doctor contracted the disease and was unwell. The remaining doctors were stretched to cover the extra load. Our infrastructure was stretched. My measure of how we were coping was based on a few rough gauges: 

How many people were lined up outside the emergency department on oxygen? 

How many people were in the emergency department waiting for a bed at my or another hospital? 

A few weeks later I added another measure: how many people were waiting for ICU? 

We were stretched, no doubt. So I went to see how I could help. 

The nurses and doctors knew what they were doing, but it seemed chaotic just because of the sheer deluge of ill patients. We had a ward that was empty and accessible to those needing urgent care for Covid-19 symptoms. But we did not have the staff.  

As I walked through the ward I discovered the real measure of how overwhelmed my hospital was. There was a dead body in each of many rooms. Out of respect for the departed our staff were leaving the dead alone in a room. Their desire for those in the afterlife was to rest in peace with space. 

I am not at liberty to give the statistics as they are part of the information that the Department of Health disseminates. But I can tell you how it affected us. 

To make space for sick patients I seconded a porter and we started moving all the dead bodies into one room. A holding area. As we did this I met some of my operating theatre staff who were delivering a shrouded body to the new holding area. Beds in the ward were at a premium so it was more efficient to move the body to a holding area where the many professional undertakers have taken them away timeously. 

4180. 

That is the switchboard extension the ward staff call to get the RIP (Rest In Peace) team from theatre to prepare and move the body.  

The RIP team is made up of skilled theatre nurses, scrub sisters, recovery and anesthetic nurses. Once they get the call on extension 4180 they go to the ward where the patient has demised. They check the paperwork. They ask the family if they want the clothes left on or removed.  Then they wrap the body in two layers of plastic, each layer with three patient stickers identifying the body. Then they shroud the body with a white bedsheet. The remains are respectfully transferred to the holding area. 

We managed to staff and open the ward the next day and take patients from outside on oxygen and put them inside in a bed on oxygen.  

The odd thing is the number waiting outside remained the same for many days.  

It was sobering that number of dead arriving in the holding area was much more than we ever anticipated. 

The Holocaust Memorial in Berlin

Sometimes I Think

Sometimes I think and nothing happens. That seems to happen a lot during this period of the second wave of Covid-19 that has hit my hospital. Netcare Kingsway Hospital is a community private hospital and has been overwhelmed in caring for patients with Covid-19.

Sometimes I think and something happens. That’s when a story takes shape and I wonder how I will tie it together to make it work.

Sometimes I think about the pandemic. I focus on the problems we face and work out solutions. I reflect on all we have done. I reflect on what we have learnt. Although we were all tired after the first wave, at least for the second wave we had systems in place. Systems to protect staff with PPE, systems to control the flow of patients and systems to deals with patients waiting outside and waiting for an ICU bed.

Sometimes I think that it is affecting everyone. It is affecting every nation. Uniting some and dividing others.

Sometimes I think that it is not only about the nurses and doctors and first responders. It is about the cleaners and security staff, about the porters and the kitchen staff. About the switchboard operator and the admission clerks. They are the ones that make up the scaffolding from which the nurses and doctors flesh out their caring and compassion. Without them risking close contact with sick patients health care workers could not do what they have had to do. 

Sometimes I think about the undertakers I see moving around the hospital. Death certificates in hand if they are lucky, otherwise their unfazed search for the source of that important document. I have seen families cry as a body has been transferred to the undertaker’s van. It was eerie to see a full length leg prosthesis pushed like a spare part above one body.

Sometimes I think about all of these people. I just have not written about them. Now I will write about them.

It may look like it’s only sometimes that I think about them. But today I walked out of my office holding a tray doughnuts. A patient brought them yesterday to celebrate his birthday with us. I didn’t save his life. I am just an orthopedic surgeon. I only fix bones as my clever anesthesiologist insists. I was grateful my patient thought of us but I never got round to having the doughnut.

Sometimes I think clearly. This time I took the doughnuts to the security guard that directs people in crisis to the back of the hospital for them to be triaged. He remains calm and polite and cares as much as any nurse or doctor. I know that because I see him every day he comes on duty. I wave as I drive in and he salutes me.

Sometimes I wish I could do more for them. The doughnuts for the security guard were a start.

Moving mannequins at a Durban outdoor market

Superlatives

I could use superlatives to describe our nurses at Netcare Kingsway Hospital.

There are fancy words like  unprecedented, incredible, amazing, unbelievable, conscientious and self-sacrificing.

But I will not.

I will just tell you what they do:

Our nurses work twelve hour shifts. They arrive early and leave late. They wait in line to  sign in with a thumb print for work. Then they log in on their cell phones to be screened for Covid-19 symptoms and checked for fever. They queue up to sign in. Then they wait to be screened. 

From there they walk to their ward. There is not as much noise as before. It is quiet as they put their bag and food in their locker. Before they used to leave their phones in the locker. Now the phone is a vital tool to connect. Not to social media, but to hospital and doctor groups. Orders, stats and death notices fill the small screens.

They don PPE to start work and care for their patients. They wear a mask, visor, gown and gloves all day. It gets hot. Their throats become dry.  Tea and lunch breaks are short and sometimes missed because they are busy. They cannot sit with friends. The tea rooms only allow two nurses at a time. I see them walking to their cars to eat lunch. There is no life in how they spend the time which is meant to recharge their soul.

The wards are full. We can give each patient an oxygen mask or rebreather. Not everyone can get high flow oxygen because our oxygen supply system will fail. This even after we installed a huge tank and free flow piping that we hose down every hour to prevent the freezing of the pipes. I do not need to explain the cap we face if we need to escalate breathing support. There are a fixed number of ventilators with a waiting list.

As I write this, the words seem without aim.

I have chosen my words to reflect the staccato world of talking through masks and behind visors.

Yet somehow richer words appear. The intensity of the ICU’s is cloaked in an almost church like peace as these highly qualified nurses work around the clock to save lives. When I talk to them all I see are tired eyes above the mask line, yet there is a gentleness and concern that pervades their every action.

My theatre staff have lost all sense of stability. They have to work in wards, ICU, the emergency department, triage or screening. They also call the families to update them of the loved ones condition. My theatre staff have another duty: they care for those we have lost. They do this with great dignity.

This week I got some grass cutting helmet visors (I am holding two in the photo) for some of the theatre staff. We all know they are the most comfy and safe as well. They are bulky and ugly. One of the nurses put her visor on and walked as if on a catwalk. She was showing off her new visor as if it was a designer handbag.

As she walked she tilted her head to show the large blue helmet with clear plastic screen and said “fabulous!”.

Now that is a superlative I did not expect to hear.

Holding the grass cutting visors in a stainless steel hospital lift. See my phone in a plastic bag.

Burials: We can’t keep up!

Those were the headlines in one of the Sunday papers.

He was around fifty years old and with his wife. They stood in front of me in the supermarket. He was in shorts and a light blue t-shirt, wearing beach flip-flops. Standard casual wear for the holiday beach town where I work at Netcare Kingsway Hospital in Amanzimtoti, on the KwaZulu-Natal South Coast of South Africa.

I could see him reading the headlines. Then he shook his head and muttered something to his wife.

“News” was all I heard. It was accusatory, devoid of any connection to the surge in Covid-19 infections we are experiencing in this province. 

I was not in my surgical scrubs. I too wore shorts and a t-shirt, although not as smart as his. Instead of flip flops I wore my Crocs. Every day at the hospital I wear closed restaurant Crocs that I wash every day with my scrubs. It was good to be in my beach and bush Crocs.

“It’s true, you know” I said. “ I can take you to Kingsway Hospital down the road and show you the people waiting outside.” I knew they were there,  sucking on oxygen from  battered black cylinders. They would have been triaged by a team of nurses, vital signs recorded and placed on the oxygen as they waited for a cubicle in our emergency department. A colored sticker on their shirt or blouse would identify them: BLUE for family members, YELLOW for non-Covid medical problems ( the minority) and RED for COVID-19 patients.

“I don’t believe it. I don’t know anyone who has it. I don’t know anyone who has died from it. I know hundreds of teachers, and not one has it. But I do know people who have been murdered in the last year.” He was calm and spoke his truth.

His words hurt me.

I chose not to argue. He would not recognize me when he came to the back of the emergency department. All he would see is my eyes above the mask and behind the visor. I would be unable to help him. Not because he did not believe that Covid-19 was a real problem. I would not be able to help him because there would be twenty other patients waiting for a hospital bed. Maybe he would get one on the other side of the city, or even in another town. I would not wish ill on him. But he should see the eyes of those pleading for care and attention. He should see their eyes when the person lying on a stretcher next to them dies. He should see all the bodies waiting in the holding area.

They are waiting for the undertakers who can’t keep up with the burials.

The nurses at my hospital can’t keep up either. I cannot keep up with how many get sick with Covid.

One of the emergency doctors steeled himself before a shift. “I can’t do this anymore.”

He was tired of seeing patients and not having beds for them. He was tired of seeing people die. He was tired because two of his colleagues were sick with Covid and he had to carry the extra shifts.

Still he went out to face the death and destruction that this disease forces on us.

The man in front of me at the supermarket que would not believe any of this.

The amazing thing is he would still be treated at my hospital like anyone else if he needed help. He would be treated by nurses and doctors who just can’t keep up. 

He may end up with a RED sticker on his blue t-shirt…

Begrafnisse: Ons kan nie voorbly – Afrikaaans for Buritals: we cannot keep up

Circles of Light

We had survived the first wave of Covid. The Covid admissions at my hospital were down and we had resumed elective surgery. Things were running as smoothly as they could in the new normal.

I washed alone in the darker scrub room. I always use this scrub time to focus on the case at hand. Surgery forces one to be very mindful, unlike other high pressure jobs where you may have to multi-task. In surgery all you have to do is focus on the next case.  

I looked through to my operating theatre, the room lights bright with the scrub sister positioning the brighter operating lights for me to make my incision. Over the decades these were the third ,and by far the best, set of lights to work with, I thought to myself. Was I thinking more today, or was I just more aware?

Surgery is a privileged profession, one which captivates and entrances. It is also a demanding discipline where failure stabs at your heart with no forgiveness.  But this morning I was captivated by the lights. For the first time as a surgeon I realised the operating room light is a representation of the primeval force of fire that bound humanity by giving light in the darkness. This light was the result of our forebears discovery of fire. Nothing less. 

Back to scrubbing. Palm to back of hand. Left then right. Then each thumb. Forearms then rinse. I always worry about the waste of water. I should change to a dry scrub. But I find the noise and sensation of running water soothing.

I glanced into my theatre. My eyes focussed and stayed there.

The light shone in a circle of circles, each emanating like a ripple in a pond from a stone thrown by some child. 

It is my twenty third year of operating here. I have survived a few medical mishaps of my own: a few kidney stones, a cardiac stent, amoebic colitis, surgery for arthritis to my thumb and now I think I have COVID.

It was as if I could see the virus now. There were halos I had not noticed before. Maybe it was from all the scratches of cleaning my visor. Last week I worked with a nurse in that same theatre for two days and they tested positive for COVID after that. 

It was five and seven days since my exposure. As a health care professional I could continue to work until I had symptoms. 

But the light does not shine on premonitions.

The next day I tested positive.

H.O.P.E.

Even as the postcards started arriving the signs of the second surge were present. The statistics are anywhere to be found but a retired colleague of my brother has done his own programming and has a useful site to look at the numbers if you need to: https://www.covibes.org

Back to the postcards. They are being collected in a box held at reception at Netcare Kingsway Hospital. 

I have collected twice and will check again next week. I feel like an old fashioned village postman.  It tugs at the memory of the film Il Postino, a beautiful film about how words can change lives.

Each time I took the pile of postcards to my office and left them in the corner of my empty desk. When my work day was over and I could focus, I sat alone and read each one. I cried easily at the intensity of emotions expressed about  how events had affected staff at the hospital. 

After each reading I went to the front desk where my receptionist Anina is protected behind Perspex barriers and shook my head in disbelief as I spoke  of the trauma. Anina scanned each one in so that the card was digitized, and from those files I was able to make the first collage that makes up the picture that accompanies this article.

One postcard ended simply: 

“No words.

Only emotions.”

There are so many emotions that we have all experienced to a greater or lesser degree, from closer or further than others. I could identify with all of them, from the anger to the zeitgeist of social distancing and lockdown of our new era.

The sense of loss is profound. Loss of family members and friends stab into your heart. The loss the nurses felt as they were the only ones to guide patients into the next world hurts so much that tears flow. 

There is anger. There is a sense of growth and achievement. There is an acknowledgement of lessons learnt. My writers have defined what is truly important to them. 

Despair makes an appearance but is won over by hope.

So why H.O.P.E.?

Hold On Pandemics End.

Keep hope alive by wearing your mask and social distancing. Think very carefully about your festive season travels if you really have to. Remember it’s as much about not contracting the virus as much as it is about not infecting someone else.

A Dream in the Time of Covid

Is this all a dream?

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.

A storm over the Indian Ocean, Friday 24 April 2020