Dr Despina Demopoulos is an intensivist in an intensive care unit who has been working on the frontlines of the battle against Covid-19. She is full of praise for the her healthcare colleagues, who are working long hours as they struggle to find beds for ill patients. There’s a strong sense from her of the famous South African “make a plan” mentality – but she also speaks of the terrible loneliness which can accompany the disease. And she is grateful for the ban on alcohol (even though she also likes a glass of wine). – Alec Hogg
The last time we spoke with Dr Despina Demopoulos was in April this year. A lot has happened since then. I know you’re on a number of committees, you’re very close to what’s going on with Covid-19 and as an intensivist, you would have been seeing it from a front-row seat. How are you guys holding up?
We definitely are in a different place than we were two, three months ago. It’s been very difficult for everyone but we keep going. My colleagues have been absolutely fantastic, everybody’s been trying to help each other and it’s been amazing to see.
When we last spoke, it was early days and you were warning how important it was that PPE or private protective equipment was used by people in the medical frontline. It looks like that message must’ve gotten through because the mortalities haven’t been of the kind that one feared.
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Yes, absolutely. It’s been amazing because in the hospital, the doctors have been fantastic with their PPE and we are only sitting with 3% of healthcare workers being admitted. What’s happening more is infections in the community more than in the hospital.
How are you seeing that increase? I’ve had the first friend that I know who’s passed away due to Covid-19, and I’m hearing other people as well having similar stories that something that was so far away is now very close to home, but with you seeing it upfront, what’s happened, for instance, on your new admissions?
The number of admissions related to Covid disease has increased remarkably throughout the ICUs. We are full with Covid patients.
Before we’d have one or two in the ICU. Now, every hospital has got three or four wards full of Covid patients and most patients in the ICrU are Covid-positive, and mainly adults.
There’s definitely been a huge increase in the number of admissions related to that. The other admissions have decreased because we’re doing less elective surgery, people are scared to come to the hospital. Covid has mainly filled the hospital’s, private and state.
Are the facilities holding up?
So for now, we are in the private sector. The state sector is a bit difficult. I don’t work there currently, but just discussing with colleagues of mine, they’re definitely running out of beds and they are opening new wards. For now, we still okay and there are certain facilities that have opened up like Nasrec and in the Cape there are other facilities. We’re okay, but I think we’re almost not okay if you understand what I’m saying.
Getting close to capacity.
We are getting close. There have been times where there’d be no ICU beds for patients in the last couple of days. I sit on one of the groups where intensivists around the country have been asking if anybody’s got a bed because they’ve run out of beds, and this was in the private sector. We’re reaching them.
I was talking with Dr Ross Hofmeyr from Groote Schuur, he said that everybody’s jumped in. He said he’s getting gynaecologists working next to him in ICUs, etc.. Is it a similar thing happening here?
Not yet. There has been a call now in the state hospitals to ask for non-ICU doctors to get involved, like radiologists, gynaecologists, everybody who hasn’t been doing intensive care. In the private sector at the moment, we still okay with intensivists and anaesthetists. We are as you know, following Cape Town, they got it before us, the huge peak. I’m sure we’re going to follow in Ross Hofmeyr’s footsteps very soon.
What about your working hours, have they changed much?
What’s changed has been standing in for colleagues that are getting sick. We’re still doing our calls 24/7, one week, seven days a week, and we are swapping. What has happened is a couple of colleagues, for instance, in my hospital alone, about seven or eight that I know of, that become positive and then they cannot work. We randomly stepping in now and then it has been a bit disruptive, but we’ve had to make changes but we are managing, which is fantastic. More than just doing more hours on the floor, it’s been more like changing our timetables because our colleagues have been sick.
There’s been a more personal thing, we hear of those who’ve passed away through Covid-19 having a very lonely passing. Is there anything that you guys can do to make it easier for them, given that families aren’t allowed to see them?
The saddest thing I think about Covid has been that it’s been a lonely disease. What we are doing is we’re trying to say that the nurse or the doctors that are involved are there to not let the patient die alone, to hold their hand. We’ve often video-called to the families, where I work there is an iPad so we’re able to contact the family so that they can see their loved ones.
In many hospitals, the groups of nurses in that area will stand around the patients so that the patient doesn’t die alone. Recently I lost a fantastic nurse and I had to speak at her virtual funeral a week ago, which was exceptionally sad.
Then another colleague lost a wonderful nurse from the hospital down the road, and all the nurses stood on guard with their PPE as that nurse left the ICU. We’re trying to be there instead of the families. Obviously, it’s not the same, it’s very hard. It’s a very lonely death.
You’ve just mentioned a couple of nurses. Are people within the community getting infected and passing?
Yes. They definitely are. A lot of nurses have been infected from the community. Fortunately, most of them have recovered, both in Gauteng and in the Cape, because they’ve also had a huge increase in terms of nurses infected. Most are coming back to work but there have been one or two, luckily it’s not a big number, who have passed from Covid. Everybody seems to know one, which is quite hard.
They’re not picking it up in the hospitals themselves but in the community?
Yes, most people are picking it up in the community. When I had a discussion with the Cape Town group and with our microbiologist looking at our statistics, the majority are picked up in the community. Very few are actually picked up in the hospital. There was a time where before when there were still meetings in tea rooms and things like that, where there were one or two hospital transmissions, but mostly because of PPE, we’re not really picking it up from the patients. Even with the doctors that are now close to me, one out of the seven have been infected from work, but not actually from the patients.
How are you all reading this, you’re all in close contact through your various groups and the various committees that you sit on, how are you seeing this going forward?
I think it’s going to get a little bit worse before it gets better. Especially in Gauteng, we’re going to peak for a bit longer and then hopefully get better as colleagues in Cape Town are starting to breathe a little bit now, but we’ve still got another month or two where it’s going to be a bit hard. Then hopefully we’ll start easing off. The concern is that there have been places in the world that have had second and third peaks.
We have to be careful for the future. What we are doing in terms of doctors around the countries is just trying to make sure that we have space for everybody. Ideally, if we can just space out everybody getting sick. I know that sounds strange but that is what we are discussing as colleagues, you try not to get sick for the next few weeks because there are not beds.
The way we’re seeing it just to answer your question is that there’s probably going to be another month or so of a difficult time in Gauteng and that Cape Town is probably going to start turning the corner now.
We don’t know what’s going to happen in terms of a second and third peak. It’s obviously worse because it’s winter in South Africa, but we all are trying to stay positive. The health care workers in South Africa are just so amazing. They’re just trying so hard.
If there are no beds already and infections are rising, doesn’t that tell you that things are going to get pretty tough or have you been able to plan for this, has anyone been able to plan for this?
We’ve been able to plan in some places. Saying that, a lot of private healthcare are getting into doing a lot of home monitoring, oxygen at home, a doctor coming to the house and putting up drips and giving dexamethasone and that kind of stuff. What we’re trying to do is get the patients in for a little time when they’re critical, then move them out so the other patients can come in.
But some other institutions are not as fortunate. It’s very sad to say that I think parts of the healthcare industry will be okay because they have backup plans, they have made space, but some other areas I think are not going to be okay.
We are going to have some situations likely when the Cape, where patients are coming and dying in the casualty because they won’t have a bed. Some of these field hospitals that have opened are hopefully going to help, but as you know, there was a problem with oxygen and things like that. The private sector is trying to do a lot of home care, but in the state sector we only have one or two field hospitals, so we are concerned about that.
You mentioned dexamethasone is that plentiful, is that freely available?
Yeah, that’s great. It’s quite cheap and there’s quite a lot of it. We’ve been using it in ICU for a very long time for many, many diseases. We’re quite comfortable with dexamethasone.
Have there been any other developments that have helped you? Any other drugs, perhaps any other kinds of treatments?
There’s ongoing research all the time, there are lots of anti-inflammatory drugs that are being used. There are a lot of rheumatological drugs that are being used, drugs that get used for autoimmune diseases. There are lots of drugs that are being tested and it appears that there are some breakthroughs.
Problems with a load of those drugs are that they’re very expensive and we don’t have lots of that. In South Africa, we do a Section 21, which is a lot of motivation and some medical aids are paying, some aren’t. The state sector is getting as a trial use but we’re saving that for the really sick patients. Those patients that are in ICU, those that are not responding to the dexamethasone, are then put onto those drugs.
You mentioned earlier that some people are perhaps going to die when they’re waiting in casualty. Why would that be, would it be because they’re too far gone, they come too late or there’s just no other way of treating them?
That has happened in some parts of the country and it can be numerous things. Sometimes it can be because there aren’t ICU beds, but some in many places, especially in the state sector they often come too late. There are also a small proportion of patients that get sick immediately and get really sick very, very quickly.
A lot of patients will get almost flu-like symptoms or myalgia or fevers or a whole lot of symptoms that take a couple of days. Then you get a small proportion of patients who get very sick, very quickly, and in a day can go from just a sore throat to gasping for air.
There is a small proportion of those and with that kind of thing, you need to be very quick to put them onto a ventilator and hopefully get a bed somewhere. Where we’re going to run into problems is there’s going to be more from not having beds available, then patients coming too late in to hospital.
Those who have died, is it primarily been people with comorbidities?
Yes. It’s been primarily patients with comorbidities, hypertension, diabetes, obesity. In children, there have been very few deaths and those have been mainly with comorbidities or related to something else and happened to have Covid. In the adults, there’s definitely comorbidities. There’s a very small proportion of patients that don’t have comorbidities and are getting quite sick in terms of even going to ICU, the 40 to 60 age group, but they’re actually doing okay. The deaths are usually the older and the comorbidities and unfortunately, a lot of the old age homes have been attacked by this virus.
I ask all of the medical professionals this, the banning of alcohol, there are many in the society who are not very happy about it but so far, every person in the medical sector has been celebrating.
Totally. I also like my glass of wine, but I can tell you that it’s opened up beds, which is the big thing. It’s sad to say that a lot of our admissions are related to violence and trauma and assault but those take a huge proportion of beds in the ICU and in the casualty and in the hospitals and also a lot of work for the doctors. It’s already one week in and we’ve seen an improvement again. If we can open up those beds and free those doctors, then, unfortunately, it is the way to go for now.
There are people who say, well, just turn them away if they come to the hospital when they’ve been drinking.
That’s easier said than done. There’s no doctor who can just turn away a patient, they’re in front of you and you are going to do something about it. There’s a lot of assaults and it’s really sad that alcohol does that to us but it’s really freeing up beds and now’s the time when we need that.
