In 1472, Dante Alighieri, in part one of the Divine Comedy, aptly named Inferno, wrote “lasciate ogne speranza, voi ch’intrate”. These words were translated in 1814 to “abandon all hope ye who enter here” – the famous words in the poem inscribed above the gates of Hell.
On the night of the 16 April 2021, the brave hospital staff who entered into the smoke-filled Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) could have been forgiven for imagining that they were following Dante's journey through Hell, Purgatory and Heaven. Many risked life and limb in the true sense of the Hippocratic took oath to rescue their patients from the fire.
The mood at CMJAH was upbeat in April. We had survived the second wave of the coronavirus pandemic, learnt more about the virus and saved more lives. We had been vaccinated to protect ourselves and those we care about at home, and a sense of a more normal future was approaching. What the pandemic had revealed was the true grit of a core of medical staff at CMJAH; leadership qualities in organising bed capacity, treatment algorithms and appropriate management to save hundreds of lives.
What none of us could have imagined were the consequences of the smoke that began to billow up from the lower levels of the blue block while we were on our usual grand round that Friday morning. By the late evening, the impact of the fire was evident, much to everyone's disbelief. We watched in horror as it became evident that we had to abandon our flagship hospital and as a consequence many lives were going to be on the line.
The focus initially was on the relocation of inpatients, but many of us were equally concerned for the well-being of our outpatients. At CMJAH, we see up to 1000 outpatients per day. With nowhere to be seen, nowhere to collect medicine and have necessary investigations performed, what was to become of them?
On the morning of the 17 April, our core of organisers began transforming chaos into order. Staff had to get to hospitals they had no experience of to provide care for our patients, I imagine with some anxiety. Some had transport, while others spent hours on buses getting to and from their allocated hospitals, often leaving home early and returning late. Some patients had been sent to some hospitals where necessary care was not available, like dialysis, and had to be moved again. Overall, considering the urgency with which it became apparent that the fire was very serious, and the number of patients that had to be moved, no unavoidable deaths occurred.
As in all stressful situations, communication is vital to allay panic and to allow for planning. A media briefing advised that CMJAH would be closed for 7 days, but rumours of severe damage were circulated. The site was declared unsafe and no staff were permitted to enter the building. This meant that we had no access to our equipment, patient records nor any results of investigations such as radiology. Through the Trakcare system, we could at least access laboratory tests, but it was evident that continuity of care would rely heavily on the memory of the attending CMJAH staff.
From a renal medicine perspective, we had unique challenges. While peritoneal dialysis (PD) can be managed with minimal infrastructure, haemodialysis provision is resource dependent and restricted to only a few state-run hospitals. This meant that our indigent outpatients now had to travel either to Chris Hani Baragwanath (CHB) hospital, some 20 km to the south of Johannesburg, or Helen Joseph Hospital (HJH), some 5 km to the west. These may not seem like large distances to those of us who are able bodied and employed with our own transport, but most of the dialysis patients at CMJAH rely heavily on SASSA grants for living expenses. Dr Davies, the head of the renal unit at Helen Joseph Hospital, was generous and went out of his way to offer the use of his dialysis unit to dialyse some 70 patients from CMJAH. Their daytime slots, like all state dialysis units, were full. This meant that the CMJAH chronic haemodialysis patients had to find their way to HJH in the late afternoon, spend the night there, as there is no transport available after hours. There was also no accommodation or refreshments available at such short notice. Thus, the patients initially spent the night sitting on chairs after dialysis. We are grateful to the Gauteng Kidney Association for their offer to cover some of the transportation costs of these patients.
We had to consider the renal outpatients, usually around 120 per week, as well as following up the 70 PD patients we care for. We had divided up our staff and arranged clinics for these groups of patients at HJH. Our PD unit staff managed to inform our patients when to attend for follow-up, but it took a couple of weeks to advise renal outpatients, through the media, what to do. As we do not have electronic records, staff relied on patients bringing old scripts and notes with them, and it is likely that mistakes in therapy may have been made.
We run an extensive renal transplant programme and look after about 800 renal transplant recipients. These patients represent a major socioeconomic investment on the part of the health services and they use a system of follow-up with an appropriate dosing of their immunosuppressive medications communicated to them, and they have access to a 24-h walk-in service if they are unwell. We emphasise the importance of follow-up and timeous presentation in the event of illness. In the blink of an eye, 800 transplant patients had no safety net. Also importantly, some of the immunosuppressive medications were not available at hospitals outside CMJAH.
Dr Mduduzi Mashabane, the head of Nephrology at CHB hospital, kindly offered us space to accommodate two admitted transplant patients, as well as space and a pharmacy service to see our outpatients each Thursday. This has worked well, but admissions for the transplant recipients are precarious, as most of them are admitted in the general wards. There they are exposed to opportunistic infections, as well as to patients with coronavirus infections, especially as the CHB COVID ward capacity was exceeded early in the third wave of the pandemic. Patients requiring critical care are not easily accommodated in ICU, and inotropes and ventilation are run in the short stay area of ward 20.
One of the important consequences of the fire at CMJAH is the negative impact on deceased donor transplants. Our number of transplants was already severely curtailed by the COVID pandemic in 2020, and currently we are not performing any transplants as the weeks after the fire passed by. Our indigent state patients with end-stage kidney disease have only one lifeline, and that is the freeing up of dialysis slots by the process of kidney transplantation. This means that more patients on the dialysis waiting list will die without dialysis.
While our hospital remains closed, we will not know how many patients will succumb from acute renal failure. Only a few Gauteng state hospitals offer acute renal support, and it is likely that some patients with acute renal failure will not be able to access dialysis due to the overall increased service delivery burden the CMJAH fire has placed on other hospitals in the region.
What are some of lessons that we can learn from the fire on 16 April?
First and foremost, we see that a hospital is not just a building. It is a place that provides multifaceted aspects of care to many patients, with far-reaching implications. As such, it is a precious resource and must be maintained and respected as such. I am very proud of the way my colleagues responded during and after the incident. To all staff travelling far from home for long hours in unfamiliar environments, I salute you.
Very importantly, we have learnt that continuity of care cannot rely on a paper-based system. We need to be able to access scripts and investigations on an internet-based system. Mistakes in care will be inevitable after the chaos of 16 April, but let us hope that they are minimal.
Communication from our health department and management structures during this crisis could have been more regular and specific so as to allay fears, prevent rumours and importantly to plan alternative strategies. Let us not repeat what happened in the early days of AIDS denialism. Let us have open and honest discussions and ask for assistance so as to avoid further poor press reports.
Lastly, it has been my experience that our health department seems to have a very “top down” management style. This seems to cause delays in responses to crises. Perhaps it is time to allow CEOs and HODs in hospitals to take important decisions; after all, they are the people on the ground who know what is needed and when it is needed. Health is not run like other businesses in which the top management individuals are often the most experienced and qualified; in health, many of the “factory floor” workers are highly skilled and educated professionals. Why not involve them in strategy planning, especially in times of crisis, as medicine after all is often about managing crisis situations, whether it be multiple ill patients or a larger scale disaster?
It is the first week of June and the hospital remains closed. I am hoping that Dante's journey through Hell will end soon.