Prof Ian Vlok on Covid-19 frontline: Keeping death rate down at Tygerberg Hospital

Professor Ian Vlok, neuroscientist and neurosurgeon at Tygerberg Hospital, follows up with BizNews founder Alec Hogg about the management of Covid-19 infections at Tygerberg Hospital in the Western Cape. During their previous discussion in May, Prof Vlok explained how the hospital had been preparing for the anticipated tidal wave of Covid-19 infections. Now, with the Covid-19 wave upon them, the specialist is cautiously optimistic that Cape Town and the Western Cape have plateaued, albeit in the form of a 'table mountain type' curve. Praising the nurses as the 'absolute real heroes', Prof Vlok says the collective effort within Tygerberg Hospital has been as good as it can be. Discussing the low mortality rate in South Africa, Prof Vlok suggests that perhaps it is partly because South Africans are 'just a bunch of tough guys' who have been primed for this by decades of perpetual illness which has plagued our society. Prof Vlok also explains why the liquor ban is applauded by health workers. – Nadya Swart.___STEADY_PAYWALL___.Professor Ian Vlok gave us time on the 9th of May. Professor, I remember at that stage you were saying that we are now as ready as we are going to be (the lockdown that had gone up to that point) and that the country needed to move on and that you could handle what was going to be thrown at you. There must have been times that you felt there at Tygerberg Hospital that the wave might be a little too high to handle? .Absolutely. Thanks for having me again. It's an interesting thing. Everybody's been making predictive models about what's going to happen and who's going to die and who's going to make it and what the volumes are going to be. And I wouldn't say we were all surprised. I mean, you can only prepare up to a certain point. But I think the collective effort within at least Tygerberg Hospital and surrounds was actually excellent – as good as it can be. .We can never say we have enough resources. We hardly ever do because of the sheer volume of patients we have. .But with what we had, we actually managed very effective patient streams, effective testing, and identification of patients to the extent that our fatality rate is actually much less than what is reported in some of the first world countries. .The explanation for that? I'm not exactly sure. But we dealt and are dealing with it head on, and I'd like to think we're plateauing at the moment. It's a little bit too early to say, but it seems like the wave is on us, but it is not increasing, at least..When those increases occur – how difficult is it to keep morale up? Because I guess at some point you must think, 'when is it ever gonna end'?.Yes, I think some of the biggest challenges were the patients that did not have Covid. Remember, we're still serving a massive population that's got inherent disease: there's cancer, there's trauma, violence – which is a co-epidemic or pandemic in South Africa – that we still had to deal with. So now we've got a lot of resources and gear towards Covid and managing that and keeping everybody safe. .Also read, listen to: The Editor's Desk: Lockdown, PANDA, damned lies, & statistics.But in the meantime, there are these continuous – let's call it – waves of other patients that are arriving. What we did a lot is learn on the spot. When there's a Covid positive patient who needs hospitalisation – there's a very clear pathway for them. But then, you get somebody who comes in who, perhaps, is comatose, who's injured and has a head injury, but now you don't know – are they, in fact, Covid positive? .And if you're going to put them amongst, let's say, Covid-free or ideally Covid-free ICU: are you going to be infecting everybody else there and creating a lot of mortality and morbidity related to that patient? Do you have the time or the luxury to wait for testing, or do you just go ahead and go full PPE and operate them in a separate theater – which takes a whole lot of resources itself. .So all these different pathways of management started popping up. We had to find solutions for all of them and every single person was under stress. Everybody is tense and probably overworked, but put anxiety into normal work and you immediately get overworked. And yet, a lot of people pulled together, and if you appreciate that the guy you're dealing with – the anesthetist, the other surgeon, the ICU staff – everybody is under the same pressures and a cohesion developed that actually ended up creating a lot of synergy within the facility. .We are managing with the very acute cases. I think the people that are taking the strain are the semi-acute and less acute, but symptomatic, patients – somebody who might have a disc herniation in the back, for example. A lot of pain, but one must ask if it is validated to bring them into an environment that is not that safe for them. So, we learned on the spot and we dealt with problems as they arose and we are seemingly getting through it. .It's interesting – the point made about the low mortality rate here versus other parts of the world. Now, many people are trying to find reasons for it. This cohesion, this all hands on deck approach might well be quite a big part of that? .I think a lot of it is also our patient population. We definitely have a younger average age of patients being admitted and age is definitely a risk factor for mortality. And the numbers we can compare with are Italy, of course, the predecessors – the guys who kind of set the benchmark for us. If you look at the United Kingdom, for example, they've got tremendous fatalities related to testing. I think they tested about four times the amount we're doing at the moment. So their numbers certainly aren't underreported. .Also read: Covid-19 curve leads to recession curve: Prof Alan Whiteside.The synergy perhaps plays into the way people are referred. We start managing patients when they become symptomatic in the ward already. The system is set up in such a way that we don't carry a lot of mildly symptomatic patients. So, everybody that's admitted into hospital at any point (about 150 patients) are all very deserving candidates for that bed. .No people are being shown the door. There aren't people that are told that they're too sick to come in or too old to come etc. We are managing through it and our numbers are turning around about 60% fatality for people that reach ICU, that need ICU care. .And again, our ventilatory strategies have differed from those internationally, and we've learned a lot of things – high flow oxygen, etc. – that seem to have made a big impact. .Whether it's that or, like I said, the younger population or the fact that South Africans are just a bunch of tough guys – we are used to disease and it's a very strange concept, but people are perpetually ill and living in small living spaces. And as much as that transmits it – perhaps it has primed us in some way. That's very anecdotal, but still – we are doing well under the circumstances compared to what is out there. .You mentioned patients arriving comatose. When the hard lockdown ended and liquor sales came back in – there's been a lot of discussion by amateurs and by outsiders on this – how big an impact did that have on demand for hospital services? .I don't have formal figures to give you, because we will be releasing all of these. We're looking at all the numbers, but anecdotally – about a four times increase in trauma within the first week of alcohol being released. But part of that, particularly, is actually the curfew. If you can sit and drink at your own house, sure – that doesn't help much for domestic violence – but it certainly helps for perhaps gang related or gathering violence where things could just get out of control. But we certainly saw a four times increase. .Now you've got all these patients coming in and again, you've got a confused patient, you can't screen them properly, you have to assume that they are positive because of the impact they could potentially have. Remember, if somebody is intubated or coughing all over the place, it can have a devastating exponential transmission. So, it burdened us a lot. I think I might have said it last time – let the people smoke, but keep the booze out of it. But the curfew may be even better. .We've been scolded now by the principal and we've been sent to our rooms without our drinks. It's sad that those things had to happen, but the figures don't lie. I've been taking the stance that everybody affected by Covid has got a very valid point: the businessman, the restaurateur – everybody's got a point of argument. But standing on our side of the fence, where you're looking at the actual patients, that single intervention has certainly made a massive difference. The alcohol. .And I think as citizens of South Africa, we know who's manning the frontline right now, and surely the support that they require – the way you've put it there – is something that every citizen or everybody can help with. What about the infections of healthcare workers at Tygerberg – them being exposed to Covid-19 patients – have you managed to have better returns, as it were, than elsewhere in the world? .Very difficult to say. Those types of figures aren't released as openly as one would like to see it. But I can tell you, for example, in our ICU – we had one nurse test positive, then her immediate contacts were quarantined. So, suddenly it takes seven or eight people out of your nursing pool. And I'll tell you, the nurses are the absolute heroes here, because they are really, really doing so well in terms of service delivery for our patients. .When you suddenly take seven people out, you are asking more of the remaining people to cover shifts and keep maintaining beds. You ask people to do more and more. That has got a significant effect, particularly the people that might need to be quarantined to prevent further infection. So, we've had several incidences where somebody tested positive and their immediate close contacts were quarantined. .From a doctor point of view, we've had several doctors test positive within our environment. Fortunately, to my knowledge, most have recovered well and haven't really been dramatically ill, but certainly taken out of the management pool, which then immediately knocks on the burden. .I do think that the nursing complement being affected hits us the hardest, because we are nothing without our nurses. They need a massive shout out. .Then there are also the staff that are staying behind – that actually just crunch up and double up and just get the job done. So, yes, it does affect – particularly if somebody gets ill – the general service delivery and you've got to go and beg, steal and borrow from other services to make up your ICU numbers, for example, which has a knock on effect on how those services get managed. .The medical students at Stellenbosch University – have you been able to recruit many of them to assist? .So there have been several volunteers. We haven't actually put a mandate on them, and maybe I speak under correction, because I've seen quite a few around in the ICUs. They have been phased back into the training. They are called student interns – the final years. So, they are actually working within a hospital environment, working in the departments and divisions. .And there have been volunteers, particularly in the screening environments and the primary care environments. So, the students have come back and they are not at full complement, but the clinical groups have returned and they are phased in more and more. A lot of them have stepped up and volunteered..You've been through the fire. It looks like it might have plateaued and at least in the near future, may start declining. But other parts of the country, other provinces – which are perhaps not as well resourced as the Western Cape – are going to be looking for resources, for support. Amongst the medical fraternity – is that something that you can do? Can you send doctors? Can you send nurses to, say, the Eastern Cape? .That's very difficult, because you're going to have to have a willing buyer, willing seller, isn't it? You can't really force people, I would imagine, to go into those environments – particularly if they're grossly understaffed. And, you know, we all see social media accounts of what's going on in different areas of the country. Typically, the worst of the worst. So it is difficult to really judge the global picture. .Cape Town and the Western Cape seem to have plateaued, as you said, and that is still one week, maybe 10 days worth of data. So, let's not break out the champagne yet. It's going to be a table mountain type curve – it's going to take a long time on the plateau before it starts dipping down. What we currently have is certainly not light. .Some of the solutions that we had in the year are on plan – we implemented synergy with the broad practice where the private facilities would be able to take patients in. .And we had the CTICC, sort of the intermediary step-down top facilities that are available. I'm not sure to what extent those facilities are available elsewhere, but I would imagine now – looking at the way things are skyrocketing almost out of control in some of the parts of the country – that they are going to be leaning way heavier on those plans that we perhaps do in the Western Cape. .But that will probably be the first resort – to have the private and public total bed complement being optimised prior to bringing people in. And if you're going to bring people in, logistically – why would somebody do that? There is a lot of goodwill, but they're certainly not sitting twiddling their thumbs down here. So, people are going to be reluctant, I think, to go. That's just my honest opinion. But they are in for a rough ride. .We had the benefit of the fear factor after the hard lockdown. Everybody had a significant fear factor. We were told to do things, we were forced, there was a lot of police presence, everything was locked down. And then, the Western Cape started having their surge. .Now, the surge in Gauteng, Eastern Cape, KZN – whether the fear factor is there, I don't know. People have too much time and too much social media access which leads to having too many conspiracy theories: so there's 5G and crystals and all sorts of things going on that's 'the real cause'. The reality is the laxity in terms of the very simple things to which people are not listening, and that laxity is now paying dividends. It's honestly biting really hard. .Honestly, to have 100% capacity in taxis (maybe everybody wears their masks, maybe that don't), but you can just understand how exponentially transport systems can be affecting these things. I can't be too critical because part of this is maintaining the economy, and I'm literally standing on one side of the fence. I do understand that there's way, way, way more to this than that. .But the solution would have been (I think) a sort of a phased lock out. I do like the concept of being very strict on people not adhering to PPE: wearing their masks, that sort of stuff. If you can police it like you would a primary school (I don't think you can) – you still demand a lot of people's common sense and cooperation. I'm not sure, but I think we're going to feel it rather than listen. That's just my sense.

Prof Ian Vlok on Covid-19 frontline: Keeping death rate down at Tygerberg Hospital

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