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 …