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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
Posted on by basilBLOGinc · 27 Comments

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
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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.

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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.

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Conversations with Hippocrates

Long before I had an inkling that I wanted to study medicine and then be a doctor, when becoming an orthopaedic surgeon was still occupied in that part of my brain by a desire to become a game ranger, I dislocated my right shoulder. The injury dated back from primary school and was recurrent, popping out every few months. It was painful when it happened but my mother learnt how to put it back without hurting me, doing a gentle manoeuvre that engaged the joint and let it to slide back into place almost painlessly. Much further down the academic line and after putting other’s dislocated shoulders back I came to know that my mother was in fact using a well established technique, the Kocher Technique. Like all things in medicine, it was named after him because he published it in a journal, but in fact it was first described in Egyptian hieroglyphs 3000 years ago.

One year when I was fourteen I participated in the school gala. Everyone thought I should be a good swimmer as I was a good runner, but halfway down the lane at the municipal pool my right arm caught the floating lane divider and my shoulder popped out of joint. My father was there, talking to Rod Conacher, the principal of the school, but he was not watching. When my arm came out of joint it would stick up like I was asking a question in class. That is how I tread water in the middle of the pool. My mother jumped in to save me, because she was astute enough to see I could no longer swim and that my shoulder was out of joint.

As they waded toward me my mother later told me that Rod Conacher asked my father if Olga was also swimming in the gala. My father, who normally took every detail in at any function, had not noticed me floundering in the pool nor my mother wading toward me, clothes billowing in the water.

The worst part was when they got me to the edge of the pool and all the rescuers lined up, reaching to pull my dislocated arm that was asking the proverbial question in class. I screamed in pain and then remember resting against a small retaining wall, while my mother supported my arm. She was waiting for the spasm to subside before attempting a reduction, but before I knew it an orthopaedic surgeon, a big rugby type, a parent of one of the children, arrived. He promptly placed his foot in my armpit and pulled so hard I cried with pain and because of the spasm he struggled and worked up a sweat getting it in. He used the Hippocratic Technique but he had no feel for it. Normally the pain is reduced by some sedation. I heard the joint crunch into place and limped away sniffling with pain and from the near drowning.

Rod Conacher offered to give my mom a prize for life saving at the school prize giving later that year, but she declined. I thought they should give the orthopaedic surgeon a prize for butchery, but they declined.

The new Umhlanga Storm Water Pier