FROM THE COVID-19 FRONTLINE

Doctor's diary | Camaraderie, the deceptiveness of Covid-19, politicians' greed

14 August 2020 - 11:45 By Dr Imraan Kola
Dr Imraan Kola is a physician registrar who worked in Covid-19 hospital wards during the height of the pandemic in SA.
Dr Imraan Kola is a physician registrar who worked in Covid-19 hospital wards during the height of the pandemic in SA.
Image: Dr Imraan Kola/Supplied

A physician registrar who worked in the coronavirus wards at a small town hospital for two-and-a-half months shares his personal experiences throughout Covid-19 and its peak in SA.

I decided to write short notes and thoughts on my cellphone during the Covid-19 pandemic as both a form of diary but also a written recollection of a global historical event, the like not seen in the last century.

I always asked my granddad what it was like to live through the World War 2. His mentions of food rationing and soldiers searching the house for stockpiled food always stuck with me. It brought the human touch to the black and white clips of Normandy I used to watch on the History Channel.

I hoped that some day when my grandchildren asked, “Grandpa, what was it like to live/work in the time of the Covid-19 pandemic?," I would have a written recollection capturing some of the smaller moments and the essence of the pandemonium when the memories had grown hazy and the horrors had been softened by the rose-tinted glasses of retrospection.

The phrase that kept rolling on my tongue at the start of the Covid-19 pandemic was the words of Wilfred Owen's poem “Dulce et decorum est pro patria mori”, describing the horrors of the battles of the World War 1 in screeching detail. The rough Latin translation is: “It is sweet and fitting to die for the homeland.”

Seeing news flashes of health personnel from Europe who had died, it served as a form of sarcastic encouragement for the winter of discontent I knew was to follow.

I was “fortuitously” scheduled to do my rural/outreach residency rotation to coincide exactly with the peak of the Covid-19 pandemic. I would leave my family and home support to the sleepy town of Klerksdorp.

I think its important to get an idea of this rural setting, a far cry from Johannesburg. It's a small, quiet interior town built on two sectors — farming and mining. Along the road to the town there are constant reminders. Mining shafts several storeys high and ugly grey and brown mine dumps the height of small sky scrapers for kilometres. This breaks the monotony of the brown veld and mealie plantations.

Your entrance to the town is marked by the region's Matlosana mascot in a glistening metal statue. A sort of metallic conglomeration of man and woman, one holding an ear of wheat/corn and the other a mining shovel  as symbolism of the foundations of the region.

It's a small town where doctors and patients often worked on the mines or farms.

I heard several times the story of a mining accident in the mid 1990s. A locomotive in a deep shaft mine had crashed into a mining elevator shaft, snapping the supporting cables and leaving 50 plus miners dead after plummeting in the elevator. One of the doctors at the hospital attended to the trauma victims, and another patient was the mine hoist operator at the time. A very horrific tale that clearly left a gaping indelible wound in the region's psyche.

Walking the Checkers Hyper aisles you hear Afrikaans music in the background, and the entrance board with store management photographs has a notable absence of black faces. The rural interior is clearly still lagging behind on affirmative action and employment quotas.

A morning commute to work is accompanied by the soundtrack of Radio OFM, where presenters skip between English and Afrikaans almost seamlessly. The news, business and sports report concludes with an agricultural report. The social feature for the morning is shortlisting candidates for Boer Soek 'n Vrou, a local Afrikaans reality TV show on which farmers seek love and a wife.

The region's Covid-19 battlefield is a small township hospital — Tshepong — a few metres from the matchbox houses and shacks of Jouberton.

The road to enter the township is covered with potholes, and there are often burning tyres and the smell of burnt rubber near the entrance of the hospital. This is a typical apartheid-designed township hospital. No multi-storey building of glistening glass like Milpark Hospital, or concrete like Charlotte Maxeke Johannesburg Academic Hospital. A mishmash of 30-bed wards interconnected by corridors with corrugated iron roofs open to the elements on the side. Several wards had been repurposed to serve as the Covid-19 frontlines.

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 more deadly that 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.

There were no crowds cheering “Maximus, Maximus” to raise morale in this fight.

Not infrequently patients or nurses would shout your name saying, “doctor, when next am I going to be seen, I have been waiting hours,” or nurses calling you for another patient who had arrived with extremely low oxygen saturation, or to certify a patient as deceased. This became the crazy chaos for a few months.

We were working at maximum pace but still not keeping up

Covid-19 taught me about deception.

My dad would read us Sherlock Holmes when we were children. I marvelled at the astute detective skills of Sherlock. He would find subtle signs in the hands or faces of people that would lead to identifying a suspect, or his work to piece together a case. My dad would always say Sir Arthur Conan Doyle was a trained medical doctor, and being an observant physician brought these detective skills into his writing.

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.

Covid-19 brought this whole idea to question. Inspection as the basis for triage could not be used. Patients with oxygen levels less than 50% of normal were walking/talking and reassuringly comfortable. There was no air hunger with breathing 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. The media-popularised term “happy hypoxic” was definitely true.

My saturation probe became almost more important than the observing eye or stethoscope to help assess Covid-19 severity.

Perhaps I am naive, but perhaps the lack of air hunger is a bit of a mercy from God. Usually for doctors it is that air hunger, when the patient can't complete sentences, that is a strong impetus to quickly intubate a patient and put them on a breathing machine (ventilator). Covid-19 patients often lack this, and now we know it improves outcomes if we delay machine ventilation. I felt like patients sometimes looked more comfortable as they died. The usual terminal agonised breathing of patients is painful to watch. Instead, here a more peaceful transition to the after world.

One patient would walk out well after a few days, the other would be on a ventilator. The unpredictability was frightening

Initially we asked about the suburb of residence (hotspot areas) and Covid-19 contacts as screening tools to identify who might be infected with the coronavirus. We asked about coughing, shortness of breath and fever. But Covid-19 deceived us in the patient's history. Symptoms were as varied as diarrhoea, vomiting, headaches, heart problems and strokes in Covid-19 patients. A virus that would have multi-systemic effects. The coronavirus even infected the bed-bound who never left home for months and had no known Covid-19 contacts. True deception.

There was a Covid-19 outbreak at a nearby chronic care facility. In the following days we received chronically ill patients with intellectual disability and spinal injuries, stroke patients whose joints were fixed in flexion deformities due to prolonged immobility. Covid-19 often tolled the death knell for these patients.

The thought did occur to me that if we running short of oxygen ports, I would have to deprive one of these patients of oxygen to save another. Fortunately, it did not come to that.

Then came the orange wave. The colour of prison garb in SA. For a week or so there were several prisoners walking in with shackles and very low saturations. A sure Covid-19 pneumonia. Probably a guard infected with Covid-19 brought the mini outbreak to the local prison.

Then there were the good Samaritans. Teachers from Stillfontein and Jouberton, nurses from Alexandra who travelled to a funeral in Klerksdorp, farm workers from Hartbeesfontein, a school bus driver from Lichtenberg, 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 are vivid.

Disclosure became an issue in itself. Initially patients would pray their Covid-19 test was negative. When telling the patient the positive results, they often gasped with shock and uttered quick prayers.

Inevitably, the questions that followed involved: “Will I live?” A question I often couldn't answer with any degree of certainty.

Staff had to be restationed as every day another colleague would test positive

During the early days of my Covid-19 rotation 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”.

Doctors are used to severity index scores or  mortality prediction calculations that help us decide on patient outcomes and the rapidity and aggressiveness needed to treat the condition. This time we were left without these tools. All we often had were reassuring words, a prayer and some comfort.

It felt sometimes as if we were medieval apothecaries or plague doctors. Our beaked masks were our N95s. Our only arsenal for treatment were encouraging words, prayer, vitamins, steroids and blood thinners.

The morning round often became a similitude of comorbidities in the presentation. “Diabetes, hypertension, central body obesity now severe Covid-19 pneumonia with low oxygenation.” It almost sounded like a 100% rehash of the story of the patient in the next bed. Only there was no way I could accurately predict the outcome of these seemingly matched patients. One would walk out a few days later feeling well, the other on a ventilator. The unpredictability was frightening.

Sometimes this lack of predictability made choosing candidates for the coveted Covid-19 ICU beds difficult.

It was a humbling reminder that death, sickness and life are from God Almighty. All the supposed knowledge and technology we assume we have can sometimes be insufficient to avert an inevitable death. Often it felt like reassuring words for patients or prayer were the strongest medicine.

The Covid-19 days were punctuated by fresh news and WhatsApp messages. A professor at the hospital  had fallen gravely ill with severe Covid-19 pneumonia. A cousin is now admitted. A colleague/friend and fellow registrar had tested positive. Most worrying, my mom and gran were the latest Covid-19 test statistics. Fortunately, both cases were mild.

Staff had to be restationed because every day another colleague would test positive. There was genuine concern for the health of a colleague and a scramble to try to rearrange rosters to cover their allocated shifts during quarantine.

Even a day off break to escape to the local fish and prawn restaurant for a quick meal was accompanied by concerning news. The waiter said my order was only the fifth for the day at 7pm, and tips had virtually dried up. A tangible reminder of the economic catastrophe of Covid-19.

There was a second plague that dawned with Covid-19. The plague of stigma. Patients coming to the swabbing clinic would hide if they encountered a neighbour. They made me swear not to disclose their result to their relatives or neighbours.

The stretchers and wheelchairs kept rolling in. We hurriedly examined patients before another five arrived. The new lot sicker than the old.

One middle-aged lady with heart failure began crying uncontrollably when I told her she had Covid-19. I reassured her that hers was moderate disease, and God willing after a few days of oxygen she would recover.

She said she cried not because she had Covid-19, but from the time she was swabbed, no-one would bring her water for fear of infection.

She had slipped through the cracks and was admitted to the non-Covid-19 admission wards. Rightfully, nursing staff felt trepidation about entering without the necessary PPE. I thought about the stigma she faced as a modern day leper.

Later that week a Covid-19 patient died on arrival from a small peripheral hospital before being assessed by a busy doctor. A post-mortem swab was done to confirm the likely suspicion that she died from Covid-19 pneumonia.

The lab requisition form that confirmed the Covid-19 diagnosis had a single letter spelling error in the name. The family refused to accept the result and death certificate diagnosis. I was summoned three days later to reswab the woman's corpse at the local mortuary to appease the family that it was certainly Covid-19 that killed her. Perhaps it was the denial and grief of mourning a sudden death that led to this madness, or perhaps it was the community stigma of a relative dying from a highly infectious disease that bred denial.

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.

We heard the story of a patient who died the day before. The fourth death in the household in less than two weeks. She had lost her daughter, son-in-law and her husband to Covid-19. She succumbed to Covid-19 pneumonia.

Two calls (24-hour plus shifts) I did with junior 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 50s, some in the 30s.

Interspersed among these, a young asthmatic with such severe airway constriction that  he could barely speak, another patient with massive lung fluid collection that needed emergency placement of a chest drainage tube. Fortunately, both responded to treatment.

At some point we ran out of oxygen wall points and had to try get 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 to try to clear before the inevitable next wave of patients. The silence in the early  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 end 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.

Perhaps we are all met with that same relief seeing the inflection point in the national Covid-19 statistics. The long-awaited downward trajectory. The stomach knot provoked by daily new infections in the 13,000s of mid-July have been replaced by a collective sigh of relief at the lower numbers. The first peak has been climbed, and surely now we are rolling down a deserved descent.

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.

'It is sweet and fitting to die for the homeland', as the poem states. But not for a homeland in which the ruling elite borrow funds and then pillage and misappropriate

The Covid-19/internal medicine department at Tshepong Hospital is a miniature United Nations of medicine. There are many astute specialist consultants up to date on the latest medical literature.

The doctors include black, white, Indian and coloured staff members of all ages, and also excellent clinicians and specialists originally from Kenya, Cuba, Eritrea, Sudan and Libya. Some of the staff are Afrikaans speakers, others English speakers. Some others are of Scottish, German and Congolese decent. Somehow there was a great camaraderie and collective resolve to address Covid-19 medical issues.

Senior departmental clinicians were always approachable and had creative solutions to try to resolve coronavirus issues. They fought tooth and nail to ensure  all staff and areas were equipped with the necessary PPE. To date we never had to resort to clothing ourselves in rain coats or plastic bags as a form of PPE as many had to do in the developed world.

Specialists taught us a lot of medical lessons and educated us about the social determinants of disease and injustices of the past.

Interdepartmental collaboration helped to reduce the strain and ensure enough doctors covered all Covid-19 areas. Very few doctors complained about working extra-long shifts or additional unpaid overtime hours to help fight Covid-19.

Covid-19 upgraded a lot of regional services, including the acquisition of new ventilators and high flow oxygen machines. Additional staffing was arranged at relatively short notice, and new wards were opened as the need arose.

Town's folk were extremely hospitable. My family members provided home-cooked delicious meals daily which were much appreciated at the end of a hectic Covid-19 shift. Town residents constantly sent offers of food and words of encouragement.

Dulce et decorum est pro patria mori.” It is sweet and fitting to die for the homeland. But not for a homeland in which leaders and the ruling elite borrow funds and then pillage and misappropriate. The audacity to profit during a health and economic pandemic. In a climate where civil servants have been offered no pay increases and where unemployment is fast approaching 50%.

This arrogant contempt for the poor masses and the enormous debt accrued for future generations cannot go unpunished.

Perhaps a gleaming beam of hope from the pandemic surge is the exposé of the pandemic of greed, corruption and cronyism among the ruling party, and the need for change.

Impunity for corruption and mismanagement will not be tolerated, and this pandemic needs to be stopped before it stifles the life and prosperity of our hard-fought for democracy.

Dr Imraan Kola is an internal medicine registrar/resident at the University of the Witwatersrand.


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