I decided to write short notes and thoughts on my cell phone during the Covid-19 pandemic as both a form of a diary but also a written recollection of a medical historical event, the likes of which have not been seen in the last century. This writing captures some of the shared experiences and emotions that many of us experienced during the covid-19 pandemic.
I was “fortuitously” scheduled to do my rural/outreach medical registrar rotation in the sleepy town of Klerksdorp, to coincide exactly with the peak of the Covid-19 pandemic. The region's Covid-19 battlefield is a small township hospital in Tshepong, just a few metres from the matchbox houses and shacks of Jouberton.
Entering a ward entailed the time-consuming donning of personal protective equipment (PPE); a series of jump suits and coats, masks, hats, boots and visors to serve as armour against the invisible enemy. Sometimes it felt a bit like being in the film Gladiator. The PPE being our armour, and instead of the wild beasts from distant parts of the world that Maximus Aurelius had to face, our enemy was a microscopic and invisible organism and more deadly and which could innocuously cross any nanometre void in the armour and attack you through the lungs. A pathogen that needed no puncture wound to kill, but opportunistically enters the open portal for life sustaining air. An ingenious way to harm and injure.
Covid-19 taught me about deception. At medical school, we were always taught to inspect thoroughly, and that so much of a diagnosis can be made from looking at the intricacies of a patient, including the hands and faces. Covid-19 brought this whole idea into question. Inspection as the basis for triage could not be used. Patients with oxygen saturations less than 50% were walking and talking and reassuringly comfortable. There was no air hunger with respiratory rates in the 30s when the body tissues were almost completely starved of oxygen. I could no longer rely on the eye or a hunch to quickly assess the severity of sickness. My saturation probe became almost more important than the observing eye or the stethoscope to help assess the severity of the Covid-19 infection.
Perhaps I am naive, but the lack of severe dyspnoea may have been a mercy from God. The lack of dyspnoea often reassured me about delaying intubation and mechanical ventilation until absolutely necessary, which may have improved patient outcomes. It also was easier at times to see a patient more comfortable, with less laboured agonal breathing as they demised.
Early in the rotation, there was a covid-19 outbreak at a nearby chronic care facility. In the following days, we received chronically ill patients with intellectual disability, paraplegia, stroke patients with fixed flexion contractures. Covid-19 often tolled the death knell for these patients. Then came the orange wave; the colour of prison garb. For a week or so there were several prisoners walking in with shackles with very low saturations, a sure sign of Covid-19 pneumonia. Possibly a guard infected with Covid-19 brought the mini outbreak to the local prison.
Then there were the good Samaritans. Teachers from Stilfontein and Jouberton, nurses from Alexandra who travelled to a funeral in Klerksdorp, farm workers from Hartbeesfontein, miners from Sibanye Stillwater and street vendors from Khuma and Kanana who also had severe Covid-19 pneumonia. The names I cannot recall but the stories, faces and often the sadness, on Covid-19 diagnosis disclosure still remain vivid in my mind.
Disclosure became an issue in itself. When informing the patient the positive results, they often gasped with shock and uttered quick prayers. I disclosed to a frail old lady her likely positive diagnosis. She asked: “Will I see my family again.” I lied through gritted teeth and replied: “Perhaps”. Her oxygen saturation was 62%. She asked: “When will I be discharged?” A fleeting thought crossed my mind: “Perhaps never”. It felt sometimes as if we were medieval apothecaries or plague doctors. Our beaked masks were our N95s. Our only arsenal for treatment was encouraging words, prayer, vitamins, corticosteroids and enoxaparin.
Deprived of reliable covid-19 severity index scores or mortality prediction calculators predicting patient outcomes became more difficult. Two patients of similar age and comorbidity profile would end up having vastly different outcomes. The unpredictability was frightening especially when tasked with rationing coveted Covid-19 ICU beds. It was a humbling reminder that death, sickness and life are from God. All the supposed knowledge and technology we assume we have can sometimes be insufficient to avert an inevitable death.
The two weeks of the worst surge were met by the frequent sight of funeral parlour staff in PPE loading white body bags into the hearse. On one day I counted seven trips; a lot for a small town hospital. Not all our colleagues escape unscathed. The entrance to my Covid-19 ward had a poster pinned up. It was a memorial announcement with a photo of a smiling senior nurse who died in a private hospital ICU.
Two calls (24-hour shifts) I did with a couple of intern doctors were chaos during the peak of the pandemic. We admitted 25 to 30 patients each day. The stretchers and wheelchairs kept rolling in. We hurriedly made notes and examined before another five patients arrived, the new lot sicker than the old; oxygen saturations in the 30 to 50% range. Interspersed among these, a young asthmatic with severe bronchospasm that could barely speak. Another patient with massive pleural effusion that needed emergency intercostal drain placement. Fortunately, both responded to treatment. At some point we ran out of oxygen wall points and had to try procuring oxygen cylinders from other wards to keep patients alive.
We were working at maximum pace but still not keeping up. Tea and toilet breaks were postponed in an attempt to clear the wards before the inevitable next wave of patients. The silence in the wee hours of the morning, as we hurriedly worked, was broken at regular intervals by a cacophony of coughing. Three somnambulists toiled through the night, fuelled by adrenaline. A rough introduction to medicine for these junior doctors. Some patients arrived near moribund and were rushed to the Covid-19 ICU, and one died on arrival at the hospital.
However, like all misery and horror, it was certain to end. Every doctor knows the relief of the sun rising through the ward windows. It heralds the coming of a fresh day, new recruits, and with it a sense of catharsis. The fear, anxiety, stress and hope of the evening shift to make way for the relief of rest and respite until the next 24-hour shift. A much needed interlude to regroup and recoup strength.
There were also stories of hope and encouragement that served as lifebuoys for distressed health-care workers in this Covid-19 sea of despair. This week our first ventilated patient was successfully weaned off a machine. Tshepong Hospital had remarkable interdepartmental collaboration and camaraderie among colleagues that helped to reduce work strain and fatigue. Local town's people consistently offered messages of support and meals at the end of a hectic shift. New ventilators and high flow machines were procured which will serve a lasting legacy for critical care patients.
Perhaps we are all met with that same relief seeing the inflection point in the national Covid-19 statistics. The long-awaited deserved downward trajectory, and the hope that we over the worst phase of the pandemic and we can all return to some semblance of normality. We are better prepared with the armour of new knowledge but the enemy still lurks silently.