🔒 From Quintin ‘the robot’ to how prepared we are for a Covid-19 tidal wave – Tygerberg Hospital’s Prof Ian Vlok

Alec Hogg engages in a dynamic discussion with Professor Ian Vlok, neuroscientist and neurosurgeon at Tygerberg Hospital, who introduces us to Quintin – ‘the robot’ with the potential to decrease the risk for medical practitioners while increasing their virtual presence with patients during the Covid crisis. Professor Vlok furthermore believes that the lockdown has granted the medical professionals at Tygerberg Hospital with time which they have utilised in order to be as prepared as they can be for the anticipated tidal wave of Covid-19 infections to come. – Nadya Swart

We’ve been tracking down Professor Ian Vlok for quite a while and it’s good to have you with us, Professor, to talk about this incredible development at Tygerberg Hospital with robots and how the robots are now going to accelerate the treatment of Covid-19 patients. But for people who are coming for the first time to the medical world, what is the relationship between Stellenbosch University and the Tygerberg Hospital?
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Thanks for having me. Effectively, it’s a single platform where the University of Stellenbosch runs the training part or the education part of medical doctors (undergraduate) and then specialists (postgraduate), as well as all the ancillary sciences – the physiotherapists, OTs, there’s nursing, dietetics, etc. So it’s called the Faculty of Medicine and Health Sciences and, obviously, the practical component of that is Tygerberg Hospital where they join each other and ultimately – the practical training happens within Tygerberg itself. 

Would you call it a teaching hospital?

Yes absolutely. So, it’s called a tertiary level hospital so we have all the very super specialised facilities and then obviously, a public hospital for training and teaching. 

You’re a professor at Stellenbosch University, but you’re actually a neuroscientist who operates on spines?

Yes, so anything soft that conducts electricity. So, basically a neurosurgeon. So we do brain surgery, spinal cord surgery. So most of the neurosurgeons end up building themselves up in a specific part of neurosurgery – my specific interest is the spine and, particularly, the cervical spine (so, the neck part). Within the collective there’s vascular surgeons, tumour surgeons – so we all have our niche, but at a facility like Tygerberg, where we have so much pathology, we are all effectively ‘jacks of all trades’. We do the basics of all the pathologies we see and then ultimately focus in on the very nasty stuff – on our own super speciality. 

So, Covid-19 – getting to that; now, the robot’s – Quintin and Salma (as you call them) – how did you find out about them and what exactly are they going to be doing? 

So, at the University of Stellenbosch – Division of Neurosurgery – we developed a skills lab about four years ago in 2016 called Sunskill (and you’re welcome to have a look at it – Sunskill.co.za). This is a world class training facility and inside we’ve got equipment to be envious of – it’s really phenomenal. But what it does is it creates a platform for our registrars and trainees to practice their surgical skills – everything from suturing to endoscopic training to whatever you actually can dream of. We can actually simulate it in the lab and then ultimately improve them and translate them into the practical environment, which is a phenomenal way of teaching any surgical skill. Part of Sunskill is that we have this double robot. Now, what it is – it provides us an opportunity to tap into the knowledge of our colleagues and world class specialists that might be sitting in the US or UK or wherever they are. So, we’ll dial in and they’ll be there in a virtual presence and talk to our guys and give a lecture or actually just walk around the lab with the robot and give a bit of guidance.

It was initially and still is a teaching tool and then once the Covid crisis started, Coenie Koegelenberg – the guy who runs the Respiratory ICU (so he’s literally the guy standing in the front at the top of the pyramid) – he contacted me because his wife had actually done some practical stuff within the lab and said she thinks that might be a great addition and nobody could argue that, so immediately (the following day) – we transported Quintin (as they so fondly call him – which I think is a little bit of a play between Quentin Tarantino or Quarantino). So, Quintin was deployed right away and immediately made an impact.

We have spoken with ICU doctors on this program in the past and there’s great concern about the mortality rate for those who work in the ICU, although clearly they’re hoping that with the protective equipment that is now available to doctors in South Africa that they can reduce those ratings. The expectation that we were given was that elsewhere in the world it’s as high as 20%, because of repeated exposure to Covid-19. Using Quintin and perhaps also the other robot – is that part of the thinking as well to try and get your frontline soldiers less exposed to this horrible virus?

Absolutely. So part of the people – if you think about the very sick patients (the ones that are in ICU – ventilated or perhaps on high flow oxygen, whichever way), they’re managed by a team – it’s physiotherapists, nurses, doctors, specialists. So it’s a whole team of people that need to be present and it’s not like you just can put him into a space and then think, ‘this is now what we’ve done’. It’s a very dynamic situation in terms of ventilator settings and observations of how the body responds to certain interventions, so it demands a certain amount of presence. And this is one thing we want to emphasise – that the robots don’t decrease the amount of human presence, but it increases the amount of visitations to the patients. And to be able to relay not only if the patients for example are not ventilated, to relay the patient’s own experience, but also to look at ventilator settings, observations etc. and to interact with the patients.

And then, sort of a hybrid thing between – where the whole team perhaps does not have to be there. For example; a few days ago a team entered, but deliberately the registrar (the trainee) who actually admitted the patients throughout the night stayed outside the unit, did not have to enter, and could actually relay all the patients by virtual robots. He was actually speaking to Dr Koegelenberg and his team at the bedside but it actually decreased the exposure of the doctor. So, ultimately the amount of contact – the really risky environment – is decreased. Also, if for some ad hoc situation you need to pop in there – it’s really quick, you sign in, control it and when you get there, it’s sorted. 

Intensivists have told us that their colleagues over the age of 60 are being kept away from Covid-19 patients, because of the risk. Because there’s clearly quite a lot of experience and skills there, would they be able to use this robot in any way to make a contribution?

Absolutely. This is also one of the options that it really provides. Let’s say Coenie, for example, falls ill (or any of the major decision-makers); you’ve got to understand the dynamic – everybody’s got an exceptionally crucial role within the team. He can actually sit in from home if he’s quarantined or if he’s not completely incapacitated. He can actually manage the robot from there. So his presence is not lost. And again, the same holds if there’s a second person deciding. So ultimately, if there is a high risk group of people that needs to be part of decision making – this gives them the option to actually be there in a virtual sense.

Read more: Robot Quintin to the rescue at Tygerberg Hospital for ICU rounds

What does Quintin look like? 

I don’t know if you’ve ever seen a Segway scooter – this is almost like a mini Segway. It is really tiny – it is about 20-30 centimetres in width and then it’s essentially like a pole and then it’s like an iPad on a Segway. So, it’s got quite a thin profile, it doesn’t take up a lot of space, and it can turn on a nickel. And he ultimately docks in a little docking station –  always ready to go. That’s him. He can become higher or lower depending on how fast you want him to move. He’s about eye-height. So, he’s literally like an iPad on wheels.

Can he talk to the patient?

Yes. So, it’s like a Skype interview. The doctor who is using Quintin – his face is actually on the screen and he’s in control, so he can turn around and talk to whoever he needs to talk to. The little camera module at the top is dynamic, so that can actually zoom in or turn around so he’s got a sort of optical range that he can work with. And again, the controls are fairly simple; it’s like up down left and right. You rotate and you move forward and backward and it is quite sensitive and self-righting, which means that if somebody were to knock it or it drives into a bed, for example, it doesn’t fall over. So it’s very clever tech. 

Professor Vlok, is anyone else using Quintin look-alikes elsewhere in the world or elsewhere in South Africa?

If you look at the tele-presence for one – it is usually a static type of entity, but there are products like this available – there are a couple of makers. This is a product from what is called Double Robotics – they are highly rated in the world. There are a couple of other ones, but I haven’t seen any in South Africa. I do believe there is an engineering company here who is busy designing a solution for local South African costs to product – hopefully to actually do this, to actually give people the option to sign in and decrease their own risk where they need it in high risk environments. Our own unit – we’ve got a ventilated unit and the moment you start dealing with a patient that’s unknown – there’s a fear factor amongst everybody and again, it’s probably sometimes unfounded – but that’s the reality of everything that’s been going on around us. So, to be able to substitute yourself (whichever management team you are a part of) is a wonderful privilege. 

How are you guys feeling at Tygerberg Hospital about Covid-19 and the tidal wave that we’re told is coming?

We adapt. There’s this fear of what’s coming. Then it arrives and then you just start dealing with it. So yes, we are slowly seeing the numbers increase. I had a good chat with the Head of Occupational Health yesterday. We have very good testing principles – contact tracing – so the testing is done very, very thoroughly (at least in our environment, I understand). That leads to a lot of numbers, so we are picking up the positive patients. This is an unavoidable condition. It’s beyond any restrictions and it can’t be contained. So, we have to deal with it. And I think at the moment we’ve reached that level where – from the feedback that I get from the stats guys – it’s like a consistent volume at this point in time. We constantly have patients in ICU where the Covid wards are fairly saturated, but there is a dynamic within them – patients are getting better, we are getting better at treating them as well. We have learnt a few things and I think that’s a good place to be in – where people are getting used to being careful (if you can call it that). And ultimately, that kind of settles the nerves a little bit.

I think that if there’s a double wave of what we’re currently seeing – that will be the next set of uncertainty. But for now, the wheels are turning and we’re managing to contain it and at least manage patients and everybody has now figured out their role – there’s special pathways going to Covid theater, special radiology pathways etc. The reality is – trauma is still around; whether it’s a lack of alcohol or ‘skelm’ alcohol. But it seems to be that the lockdown has decreased our trauma significantly, but now it’s creeping up again. So the standard workload is still upon us and we have to manage that within the Covid processing. Well, from a neurosurgical point of view – people that come into our unit are typically very ill and need quite urgent intervention.

If you could go back six weeks; when the lockdown was brought into South Africa… had that not occurred, had we done the Swedish route for instance – how would our medical practitioners have coped?

I think the Swedish model – the herd immunity model – has become quite topical, because most people are becoming saturated – they are now done with it. People are now actually in a lot of trouble economically and I won’t dare express my opinion there too much. But, I’ll say this – our country is not like Sweden where there can be an announcement and everybody will wear masks and everybody will perform social distancing. Ours is not a first world country – whether that makes you more compliant, I don’t know – but in Sweden, it’s easy to decrease something and have it be followed. At the same time, you’ve got 3,000 fatalities already. Depends how you look at the percentages; if it’s per million – okay, they’re on par with a lot of other countries. But, if it’s per test – they are not doing very well. But ultimately, they have achieved – or it looks like they’re going to achieve what we ultimately are also aiming for.

You can ask – what did we benefit out of the lockdown? Firstly, it’s getting systems in place. If there was going to be a flood of patients amidst the singularity that is our usual work, that is an entity that is just an epidemic bigger than anything else – the trauma and the extreme pathologies – we would have tanked (at least in the public service – it would have been too much). And right now, we’ve managed to contain it. We’ve managed to do that.

I think our lockdowns biggest benefit was education. I think people are aware, people are wearing their masks, they are performing social distancing. You can’t uniformly apply that – there are the skeptics. There’s the people who always believe they can buy themselves out of problems. And here, there’s no solution – you’ve got to follow the rules. It is effectively a very nasty flu or influenza, from which people also die. But in this case there are very clear high risk patients, so the way forward – isolate those people; high risk patients, older people. Make very sure that they are not exposed, and for the rest of us I would be an advocate of fairly rapidly introducing business as usual – with masks and social distancing and ultimately, create that Swedish model. But now it’s on our terms and in hindsight – if we didn’t do it, I think we’d be in disaster. We are getting into disaster as well, not from Covid, but from many, many other things. But I don’t think there was a win-win in this hand of cards – it was always going to be trouble.

As a scientist looking back on it – you’ve had the opportunity to prepare. Can we get any better prepared than we are?

I don’t think so. Our colleagues in private facilities have all got their things going on. I think in the public service we are as jacked up as we can be. We’ve got high turnover, we’re managing it nicely. Well, look I’m only speaking from my facility, at least. So we are as ready as we can be and if we’re gonna get flooded – the people who suffer from the flooding are the people who have the near-fatal conditions, but not the fatal conditions. We can only see that impact in time, but as it stands – for now we are coping. Also, from our neurosurgical perspective – our operating slates have been cut down, but still to an extent where we can manage our emergency services – our emergency services are still functioning very well. And now, we are also learning, we’re looking at the numbers – Western Cape seems to be picking up, looking at a peak in June, July (as has now been suggested). So, we’re all kind of taking it day by day. But the system is still functioning amidst the lockdown.

I think what we’ve gained now is perspective. Having dealt with it, it’s been exposed, we are now dealing with patients (as I mentioned to you). The anxiety level has dropped a bit and we’re getting better. I believe that people who are in companies who are now just opening up –  they’re screening forms every morning, but three days in a row there was a case of somebody coughing and having a headache – so they screen, but there’s no action. So, people are not jacked up as to how to implement that. And I think this gradual release from that, hopefully, will implement these types of screenings and get everybody to the level of a less anxious state and just get on with things. Now, ultimately it’s inevitable, but now it’s on our terms (I believe).

Have you got enough protection as medical practitioners?

I think so, yes. So all our SOPs are in place, there’s face shields, masks, N95 masks. But it’s all about you. If you have a mask and you have social distancing – your chances of getting this is extremely low and if you have a child that’s got the flu, you’re not going to take him to grandma. So, your common sense has to apply. And I think people are kind of seeing this as Ebola in a way – like it’s one touch and it’s over – and that’s not the case. That set amount of common sense needs to apply. And again, I might be taking a bit of a less rigid opinion on this thing, but we’ve reached a point (like I said) – that we’ve dealt with it now, the anxiety is a bit less, and we actually have to move forward.