Light at end of Western Cape Covid-19 tunnel: Groote Schuur’s Dr Ross Hofmeyr

The Western Cape was hit the hardest when Covid-19 first appeared in South Africa. As of Thursday 16 July, 25% of all Covid-19 cases were reported in the province. More than 2,500 people have died in the Western Cape of the disease since the start of the year, which is significantly higher than in Gauteng where less than 1,000 have Covid-19 on their death certificates. Gauteng recently overtook the Western Cape for the rate of infections. Dr Ross Hofmeyr, an associate professor at the University of Cape Town who works at Groote Schuur Hospital, tells BizNews founder Alec Hogg that he is cautiously optimistic that the worst might be over for the area. – Editor.Dr Ross Hofmeyr is back with us after a three month or so adjourn. He is an associate professor at UCT, Department of Anaesthesia, and works at the Groote Schuur Hospital and has had a very interesting three months. When we spoke in April, you were preparing. That preparation presumably stood you in very good stead in recent times. .Feels like it's been a lot longer than three months and it's certainly been a very busy time. I think the preparations that we had been making when we last spoke, as you say, you have stood us in good stead. We've definitely learnt lessons along the way. We have the somewhat dubious privilege of being able to learn from those who had gone before us, particularly overseas. Hopefully, we in the Western Cape and Groote Schuur are able to hand on some of the lessons that we've learnt to other hospitals around the country. .___STEADY_PAYWALL___.Are you past the worst? .I'm tempted to say conservatively and cautiously that I think we are seeing light at the end of the tunnel. There has been a slight slackening in paces and an easing in the number of cases we're seeing each day. We have recently been able to decrease the number of extra ICU beds that we are staffing. .As of this week, we've actually decreased one unit, whereas there was a stage where we were opening up a new ICU unit just about every week. .While we think we may have gone over a peak, this is only really within the last week or so. We're looking very, very carefully at the numbers to make sure this is not just a temporary blip and things get worse again but the eye of faith and a bit of hope, we think that we might be over the peak and we might be seeing a slow, gradual decline from here. .What is an ICU unit? .Our intensive care beds around the hospital traditionally have been split according to different disciplines. We would have a cardiothoracic surgery ICU, we've got a neurosurgical ICU, we've got a general surgical ICU, and a respiratory ICU. When Covid started, we put our first cases into our isolation ICU, which is used for treating dangerous infectious diseases. Each of those ICUs can take a certain number of beds so isolation ICU can go up to seven patients. .When we filled that we started putting the patients into the respiratory ICU, where we originally had eight beds and that splitting into two units so two separate rooms. We actually expanded those rooms to six beds each and filled those beds. Then we by that stage, we tried to keep ahead of this. I must say our critical care team has been absolutely phenomenal, working with the hospital management and staying ahead of that increase..We would decant patients from other ICUs in advance to try and set up that the ICUs to start taking Covid patients, so it could happen pretty much seamlessly. We moved into what was our acute spinal cord injury unit and then we moved into our cardiothoracic surgery unit, then we moved into our first anaesthetic high care, then we moved into one of the neurosurgical ICU's. All the time, building extra bed capacity and moving those beds and those patients into other parts of the hospitals. .We went from an ICU capacity and the whole hospital of about 40 beds up to staffing and close to 50 Covid ICU beds, plus the other capacity. Really an impressive increase in capacity. I give a lot of kudos to my colleagues in the division of critical care for doing that. This came with the requirement to move a lot of staff around as well. We moved a large portion of our anaesthesia department, all anaesthetists undergo intensive care training, as well as bringing in people from other departments, such as surgery, into helping staff those extra ICU beds..Also read: My Covid-19 test is positive. What do I do now? MUST READ!.The big concern, if I recall, was that you were worried you'd have to turn people away from the hospital. Has that been the case? .No, I don't think any patient has been turned away from Groote Schuur. What did happen at a very opportune time was the opening of the Hospital of Hope at the CTICC, International Conference Centre. Which allowed us to send patients who just needed supportive care or who had a mild illness but couldn't isolate at home, allowed us to decant a lot of those patients to Hospital of Hope and keep our beds at Groote Schuur, our numbers under control. While we did escalate to quite a number of Covid wards, I don't think that any patient has ever been turned away from the hospital. .What about the medical staff? Have you had casualties of people getting sick, maybe dying? .Our staff compliment at Groote Schuur is about 4,500 and last tally that I saw we've had about 450 health care worker infections and we've had three deaths. In fact, one of our first Covid deaths was one of our very own porters. I was involved in his care, and it hits very hard. .We have had a hospital-wide infection control campaign to try and limit healthcare work infections. I must say, again, I take my hat off to our hospital management who have fought very, very hard to make sure that we have adequate quantities of PPE, hand disinfectant and campaigning to train the staff and to limit those healthcare work infections. .It's a matter of quite a lot of pride that we've managed to avoid any staff infections on our Covid anaesthesia team. I don't think we've had any of our ICU doctors who've been infected, giving their care. A lot of our infections have been amongst the nursing staff and that's because our nurses really are our absolute boots on the ground, front line workers in terms of providing the day to day care. .People forget what a physical discipline or career nursing really is, working with patients, helping wash patients, moving patients, lifting patients. We can be quite proud of limiting the healthcare working infections that we have to take cognisance of the health care workers who have actually given their lives in service of Covid patients. .Quite extraordinary. Within the ICU's, use themselves right in the early stages, given what happened in other parts of the world, that was a big worry. Clearly, all the preparation you did, those videos that you made about how to put on the protective equipment has paid off. .I can speak for my team. We are called in when the patients failed all other forms of oxygen therapy and need to be ventilated, need to be intubated and then transferred to ICU, as well as doing anaesthesia for patients requiring surgery who have Covid 19. We've as a team, over the last three months handled in excess of 400 cases, intubations and anaesthetics, and we've had no infections on the team whatsoever. .The message is that using appropriate protective equipment as part of an infection control policy and protocol, it's not just about having a gown or gloves or a mask or a respirator. It's about the package, making sure that there's a lot of handwashing going on, making sure that equipment is adequately cleaned. .We've turned that into a machine that actually is functioning very well and that's how we keep people safe, using the tools such as gloves and respirators, etc., but as part of an infection control policy. .400 cases. That's a heavy, heavy load. Is that the last resort, is that when people are really sick on death's door? .Those 400 cases include cases where we've provided anaesthesia for patients with Covid who require surgery because they have surgical emergencies that are ongoing. That includes patients who are already on a ventilator and need to have a tracheostomy, for instance. .That includes patients who are unknown, for instance, someone who's been in a car crash and comes in unable to give any kind of screening or any kind of history. We're involved in managing those patients because obviously we don't want to have a patient who comes in as a trauma victim, gets intubated in the emergency unit, goes to theatre and then later we discover that they're positive and a lot of staff have been exposed. We treat all cases as if they could be Covid positive. .We use all the protective equipment and that way, we've definitely dodged the bullet on a number of occasions of avoiding staff infections like that. Of the 400 cases my team has been involved in managing, about half of that, about 200 have been patients intubated to go to the intensive care unit. .Of those, what is our survival rate in South Africa better than elsewhere in the world? .That data is very difficult to call at this stage. The outcome data of ICU is such a challenge because the patients often end up staying in ICU for quite a long time. .Frequently they suffer other complications as part of being in ICU. The other problem with calling the outcome data too early is that a large proportion of the patients we're treating are still in ICU. We don't know what the eventual outcome is going to be. I think our mortality for patients who are intubated and lined up on a ventilator is going to be similar to that overseas, probably going to be in the region of survival between about 15% and 25%. .It's very, very serious and a disease with high mortality. What one must understand, taking those numbers into account, that's the absolute last layer of patients who are so severely ill that they lined up on a ventilator. .Certainly, the international experience and our own experience here in the Western Cape and within Groote Schuur, is that we do everything we can to stave off having to put someone on a ventilator. One of the great big breakthroughs in the management of Covid 19 has been the use of high flow nasal oxygen therapy. .A lot of patients, as their respiratory disease progresses and they're struggling to breathe, we first put them onto a special machine, which gives warm humidified oxygen and very high flow. It's up to 60 or 70 litres a minute via nasal cannula. We allow them to do what we call awake probing, which is where they lie on their side or they lie belly and then move around from time to time. .That helps improve the relationship between oxygenation in the ventilation and blood flow through the lungs. The good news is a lot of patients who go on to HFNO then do very well and don't need to be intubated. We see some vital signs that historically would have terrified us, patients whose oxygen saturations or sometimes in the 60s and 70s, where normal oxygen saturation somewhere between about 95 and 100. .There are people looking as if they're on the summit edge of Everest, but we hold in there and they actually cope. The survival of patients going on to high-flow nasal oxygen has been much, much better. It's a difficult message because we still get patients coming in who are terrified of being intubated because they hear if you get to bad and end up on a ventilator, the outcome is very likely to be poor. .We still need to try and rescue the people who are failing on high-flow cannula but we are certainly saving a lot of lives by using that therapy. That's been one of the breakthroughs and that lesson has been shared widely through the medical fraternity. .I'm sure recently you've also seen stuff about the use of steroids or dexamethasone trial showing that that therapy definitely helps patients who are requiring extra oxygenation or ventilation. .A number of these incremental gains, we are definitely in a much better position now, treating Covid-19 than we were three months ago and certainly, medicine has progressed rapidly since the beginning of the outbreak. .Certainly, that dexamethasone result is very uplifting. What about you personally, what kind of hours have you been working over these past few months? .I'm not sure what hours I haven't been working over the past few months. I can speak for myself and perhaps reflect on things that colleagues have shared with me. This will hopefully be the great health care crisis of our generation, I really hope we never have to do anything like this again. .For me personally, when we saw the storm coming, we recognised that this is going to be a season which we are going to be fully preoccupied with Covid and everything else must take a backseat. Most of us have cancelled all of our leave of the last few months. People are now beginning to talk as things slack a little bit, about whether we can get people to take some leave. .It's been a lot of very long hours and very long days, instead of traditional working hours to working shifts to staff all of these Covid wards. We've pulled staff from all around the hospital, from different disciplines who have not worked in acute medicine in 20 or 30 years sometimes. .It's been quite heartening and inspiring to pop into the ward to do an intubation and see a ward round of patients with pneumonia, but there is an orthopaedic surgeon treating patients alongside a gynaecologist alongside an ophthalmologist. Everybody has pulled together and has worked exceptionally hard. .Hopefully, we're all going to take a bit of a break when this is done. A comment was made that it's gonna be a marathon at sprint pace. We've been sprinting, the problem is that we've turned over a huge proportion of our hospital's efforts, staff, space and time to managing Covid. If we are over the hump, we've pulled through, which would be phenomenal but we have to acknowledge that at the same time, we've pushed a lot of our other work. .We've closed just about all of our outpatient clinics, we've stopped doing any kind of elective surgery, we've only been doing life and limb-threatening surgery. There is a huge burden of untreated non-coronavirus disease that's out there. Our health care system was already very strained, even here in the Western Cape where I think we fare better than some other places in the country. All of that work hasn't gone away..Those patients haven't gone away. They're still up there and are going to need that care. We're going to have to play a lot of catchup as well. There's a lot of focus right now on thinking about not how we go back to how things were before, but how we use this as a moment to pause and reflect on not returning, but on rebuilding something new and looking at our systems and a chance to reboot a lot of how we provide healthcare. That's quite an inspiring and quite an exciting time to be involved. Hopefully, we'll see some changes in how we do things, for the better that'll come out of it. .And morale is good?.I think a lot of the initial fear has passed as people have been trained and learnt to work with these patients and they've seen how good infection control practises can keep staff safe. There is there's definitely less fear. People are tired but as opposed to the first few weeks when things got really rough, when we weren't really yet seeing the survivors coming out of ICU. .When we were seeing incredibly sick patients demising in front of us and when we felt like the challenge might be insurmountable, I think that we've now seen how pulling the whole system together, working together and breaking down silos and putting our backs into it. .We've seen how that has benefited and patients are leaving hospital and patients are going home to their families. The level of tiredness is high, but I think the morale is actually good..For more on the Western Cape Covid-19 picture, see: Inside Covid-19: Insiders share life in the Western Cape frontlines – Groote Schuur, Tygerberg Ep61. LISTEN!

Light at end of Western Cape Covid-19 tunnel: Groote Schuur’s Dr Ross Hofmeyr

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