They are widely seen as the soldiers on the front line and in at least two of the hardest hit countries in Europe and the world, the only line of defence in fighting the deadly Covid-19 pandemic. But what if that line of defence is so compromised they can’t do their job? In the UK one in four of the doctors are now sitting at home in self-isolation after they’ve contracted Covid-19 and globally many doctors and health workers have fallen victim to the disease, most famously the discoverer of the disease in China. Learning from expert colleagues around the world in countries that had the pandemic ahead of us, our health care professionals have been preparing like soldiers preparing for a war to keep SA’s citizens and our health care professionals safe. Dr. Ross Hofmeyr, an anaesthesiologist at Groote Schuur Hospital in Cape Town, who literally stares death in the face when he has to push a tube down the airway of an affected patient, tells Alec Hogg in this riveting interview about the hospital’s preparations that the frontline is definitely not them. It is people who need to remember to wash their hands. – Editor
We’re off to Groote Schuur Hospital now and welcome Dr. Ross Hofmeyr. I had the privilege of having a look at some of the videos that you guys have put together and it looks almost like soldiers preparing for a war. Obviously you’re not a soldier, you’re a doctor, but you guys are doing simulations on how to treat Covid-19 victims. When did you start doing this?
I’m an anaesthesiologist here at Groote Schuur at the University of Cape Town and we’ve obviously been watching this eventuality of the public health emergency – it’s now become a pandemic and a national disaster for us here in South Africa – we’ve had our eyes on it since early in January. We’ve been slowly and steadily making preparations which obviously now have been accelerating over the last few weeks. One of those things that we recognise – as anaesthesiologists – is that we are going to be very involved in treating these patients. As a hospital as a whole, there’s been a lot of coming together from different disciplines about how we’re going to manage if we have a huge surge in patients as our colleagues overseas have seen, and how we can prepare well for that.
In anaesthesia we recognise that our skill set is looking after critically ill patients and patients who might be Covid-19 positive who might need to come for emergency surgical procedures. We have – as a hospital – downscaled all of our elective surgery. We’ve been trying to empty our wards, empty our ICU’s and then on the anaesthesia side, we’ve been prepping very hard for treating these patients while keeping our staff safe.
We recognise that probably our most scarce resource in South Africa – in terms of the whole of medical practice – is our healthcare workers, our doctors and nurses and all the allied professionals who work with us in the hospitals. So keeping them safe, preventing them from getting infected – which would result in them being quarantined or landing up in hospital or ICU themselves – is a huge priority for us.
In the UK 1 in 4 of their doctors are now sitting at home in self-isolation after they’ve got Covid-19, so it’s a very real issue. We’ve seen quite a lot of doctors or health workers around the world who’ve died as a consequence of this – most famously the discoverer of the disease in China.
Yeah. This is a huge concern for us and there are a number of reasons for concern. One of them being that healthcare workers – working with critically ill patients – are exposed potentially to quite heavy viral loads and there’s a question as to whether that puts them at greater risk than people in the public who is exposed to sick patients. We’ve also seen a phenomenon globally – if we look at the Italians for instance – about 8% or 9% of their overall infections occurred in health care workers. So about 1 in 10 people who get sick and land up in hospital are healthcare workers themselves. That hits both sides of the system. It takes away from the practitioners that can care for these patients at a time of national need and it also adds to the burden of those that need to be cared for. So as health practitioners, we take this very seriously and we take protecting ourselves and our colleagues very seriously so that we can be available to care for more patients.
So that process – the set of videos that you put together – it starts off with what the healthcare worker needs to do to prepare themselves to come in contact with the Covid-19 victim?
Yes indeed. We need to be very careful and stratify carefully, what precautions are necessary for people in different situations who might be coming into contact with Covid-19 patients. One of our big concerns – and one of the problems that we’ve been seeing – is people who are in the community who obviously are concerned about being infected, going to quite drastic measures to prevent cross infection and actually using up supplies that are needed by the healthcare workers. So people are going to the shops, coming to contact with other people, are going to prevent infection by physical distancing, good quality hand washing, avoiding touching one’s face etc. With patients coming into the hospital we have got what we call our standard level of personal protection and that is if we’re working with patients who may be Covid-19 positive, or who are known to be positive, and then we know that the majority of the spread is through contact and through droplets. So we’re taking standard precautions such as asking the patients to wear face masks so that if they cough, the droplets are arrested.
We are practicing good hand hygiene, we’re wearing normal gloves, we’re wearing aprons – all of our normal contact and droplet precautions. There’s a very specific group of procedures which we call “aerosol generating procedures”, which generate airborne Covid-19 virus droplets. Those things include procedures such as intubation – which is putting in a breathing tube for someone coming for an operation – or someone who is acutely ill and needs to go on a ventilator. Those procedures we need to take very very strict precautions in order to keep our staff safe. Those procedures we’re using the highest end of the respiratory protection, the specialised N95 respirator masks – the disposable ones that you see us wearing – the head covers, the goggles, the full length gowns etc. What we’re trying to do is use the highest level of protection for very high risk procedures like intubation and then use stratify protection for other forms of contact that we may have.Â
We’re seeing – although there’s relatively few deaths at the moment in South Africa – that they are starting to grow and indeed also hit previously healthy people, so these droplets, or the transmission of the droplets, is a very significant part of the spreading of this disease.
Yeah, so we must remember that this is a coronavirus. It’s a lot like other flu viruses and the predominant methods of spread are droplets which are heavy particles which fall out of the air within a couple of meters and then come into contact with contaminated surfaces. So the person who is not wearing a mask or who doesn’t practice good cough hygiene, who might then wipe their face, get them on their hands, open the door using the door handle, it’s passed on. If there’s somebody coughing who is at least a few meters away from you, the risk of droplets is quite low. But this is why we’re suggesting that people who are sick and who are in the hospital, put normal surgical face masks on.
It’s those very fine aerosol particles that are generated when we do high risk procedures that require us to wear this additional protection like the N95 masks. This is an issue of national concern to us, that people might be inappropriately wearing the masks because they feel that confers better protection. It’s actually taking them away from the health care providers who really need them because they’re doing the high risk procedures.Â
I guess if you are in a hospital, the chances are people who come in because they’ve got Covid-19 symptoms, they are going to come into contact with you first. But just to take it a little bit further, these training videos, how widely are you dispersing them and did you make yourselves or are they models that you’ve been able to pick up from elsewhere?
We’ve made these training videos here at Groote Schuur with the support of our department – Amnesty International medicine – as well as the Groote Schuur hospital and the Western Cape Department of Health. The funding and the drive for this has come through the South African Society of Anaesthesiologists (SASA), which is our national body and SASA, who have been at the forefront of trying to raise the level of awareness. Right up to a ministerial level nationally has also been very involved with the sourcing of more PPE – personal protective equipment – with addressing issues such as the availability of ventilators and working very closely with the Critical Care Society of South Africa.
Fortunately we are connected to expert colleagues around the world, we’ve been in discussion for several months learning from the countries which have had the pandemic ahead of us. We’ve learnt from our colleagues and information coming out of China, we’ve learned from our colleagues in Europe. The Italians have been very efficient in sharing knowledge so as clinicians, we’ve had a lot of online discussions, we’ve had webinars and early publications. Fortunately we have networks of these contacts, for instance I’ve been able to pick up the phone and speak to my counterparts in the UK about their preparations.
There’s been a plethora of information – that’s featured in these videos – and a lot of expert consensus has gone into this. We’ve certainly been able to learn from people overseas and then we’ve also utilised our own local expertise. We’ve tried to come up with models that are available which can be used around the country. For instance, any practitioner in the country can go to the SASA web page, sasacovid19.com is the resource and our national guidelines for personal protective equipment for theatre work for Covid-19. What to do with older colleagues, how to gear up private practices, how to manage patients who are coming into private hospitals with Covid-19, all on how to train anaesthesia teams assisting with critical care. All of that is available on that resource and it’s open access – it’s shared online – and the training videos that you’re talking about went live yesterday. They’re available to be reviewed and to be downloaded and shared widely. We’re encouraging people to do that. There’s an aviation saying, “there’s nothing more useless than the runway behind you”. You just have to use what runway is left in front of you”. I think as South Africa faces the concern that we might be hit hard as our colleagues overseas have been, we all need to be making every effort that we can to prepare now. What we’ve tried to do is create those resources to help people prepare.Â
I guess the biggest concern or the greatest fear amongst ordinary citizens is that once they get this thing it’s tickets. Surely that’s not the case, surely there is stuff – although there isn’t a vaccine yet – there is help that medical professionals can give you?Â
Absolutely. People have been hailing the efforts of medical teams and medical practitioners – we’re on the frontline – but actually the most important message is, we’re not the frontline. We are the last line. The frontline stuff is in the community. The frontline is the people who are getting frustrated because they’ve been stuck at home for a week. The frontline is people who need to remember to wash their hands. It’s Joe Public – the citizens of South Africa and the world – who need to be reducing the spread, flattening the curve. The hospitals are the last line of defense. We know that this is not a very lethal virus, yes it’s not the normal flu – and people need to recognise that – we know, from looking at the models of the countries who’ve been hit harder before us, (particularly if you’re a young fit and well) maybe one or two in 1000 people are going to succumb to this virus.
We do know that if you take the whole population – maybe about 10% to 15% may need hospitalisation and they may need a little bit of support, maybe some oxygen and maybe some medical treatment, but the vast majority of everybody else who gets it, is going to be able to convalesce safely at home and is going to get over it like you would the flu. It’s only a small percentage – somewhere around 2% to 5% who are going to land up in hospital and who will be needing critical care, perhaps to go on a ventilator or to have some kind of respiratory support. But 2% of an entire country is a huge number of people and it’s way more than our health care system can cope with at one time, so that’s why we really need to slow down the spread of this virus – to allow us to spread out those cases – so that everybody can get the care that they need.
And also make sure that the medical professionals are themselves able to serve.
Absolutely. One of the biggest concerns at the moment – I’ll speak frankly – is that we as medical practitioners are nervous. We’re worried about ourselves, we’re worried about our families, we’re worried about taking the virus home and transmitting it to our elderly parents who live with us who are at greater risk. So yes, there’s a lot of fear and anxiety but with preparation and with planning comes the confidence to deal with this disease. The greatest problem at the moment is if people who are unwittingly exposed to the disease and need to be quarantined. If you take a couple of people off the floor in the hospital, that immediately puts everyone else at greater risk because they’re working harder, longer hours etc. So getting them the right protective equipment, screening for contacts, tracing the people that have been exposed, slowing down the spread, these are the things which are going to keep us safe and keep us working.
Sounds like Cyril Ramaphosa has been listening to people like you because what he’s trying to tell the country is exactly what you’ve articulated now.
Yeah. I have to say – with the greatest respect to our president and to his ministers – we were all calling for a lockdown early in South Africa. There was a petition that went around for medical practitioners to the president which called for an early lockdown. What we really need to do is to see people respect that as much as possible. A greater challenge and a great concern to us is that we recognise – because of the inequalities in this country – there are a lot of people to whom a lockdown is a huge challenge and a huge problem – in our underprivileged areas and to people who don’t have the resources to sit in a comfortable house in a leafy suburb – so how we can help our fellow citizens to isolate socially as much as possible, how well we can support people who are more vulnerable in this time, is really where business and where the citizenry of South Africa should be turning their eyes.
