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 Note for Future Generations

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.

Thank you to Laurel Braitman for the inspiration.

Durban beach baptism

A New Sense of Responsibility

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.

Antarctica is the only continent free of Covid-19.

So Now Your Hospital is Open…

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.

The Simple Truth About Nurses

Dear Nurses

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.

Winner of the 2014 MPS/ SAMA Photographic competition

Stay safe..

Dear 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. 

Stay safe.

Ask for help if you need it.

Best wishes

Basil

Sunrise over the Indian Ocean …