We have probably by this week run out of capacity to treat people. And it makes you feel useless as a doctor to have to say that to someone. But there’s nothing else we can do.
It’s been drilled into our heads as health-care professionals that in a pandemic there is no emergency, which is difficult to get your head around when working in an emergency department. Really, it’s about the greater good for the most number of people.
What you can do as an individual is protect your neighbour, friends and colleagues by staying away from them, keeping your mask on and washing your hands. There’s not much else you can do other than that, really.
Some people are going to get it, other people aren’t, and the doctor’s job is to limit infection rates as quickly as possible so our hospitals are not packed to capacity as they are now.
When case numbers were low, we as doctors had a sense of peace with the fact that we would all get infected. As the lockdown lifted, the reality set in that our PPE was not going to be enough to protect ourselves or patients. We could finally feel the pandemic, and it was a new and uncomfortable feeling. We each have different ways of coping, as all people do, but the anxiety in our normally jovial working environment has become palpable. We aren’t smiling that much any more, but behind the masks, that doesn’t seem to matter. Most of us realise we have an important job to do; we are avoiding our personal feelings and bracing for the impact.
“We could finally feel the pandemic, and it was a new and uncomfortable feeling”.
As the SA situation has worsened, we have been thinking more about our families. Everyone is ridiculously overburdened. In the beginning we had pay cuts and reduced shifts. I’m lucky that I work in a private hospital as shifts are 12 hours. But now we are seeing patient numbers we are not used to. And those patients are generally more sick than before the pandemic. My colleagues in the public hospitals have it worse. All SA doctors have experienced the long, unforgiving hours in their careers, but from what I hear, this pandemic has brought a new level of exhaustion.
Some doctors are rather flippant. Others are militant in their PPE protocols and taking measures to protect themselves. If you do test positive, the worry is you don’t know if you’re going to get a more serious illness. I also have the added anxiety that if I am asymptomatic, am I going to unknowingly infect my friends, colleagues and patients?
You hear a lot of people say that working in emergency rooms takes a different kind of person. We know we are the cowboys of medicine. But part of the thrill of being on the front line is making an immediate difference.
Last weekend I lost my sense of smell and taste while at work. I asked the lab technician to swab me because it’s one of the symptoms. On Sunday I learnt I was positive.
Remarkably, I’m feeling pretty good, so I feel a bit stupid stuck at home for two weeks. But it is what it is. I’m asymptomatic. Realistically, we all expect to get the virus, so I’m glad to have the mild symptoms rather than the more serious ones.
Part of my job requires me to be on call for a few different emergency departments around Joburg. On-call days used to pass uneventfully, and often I would forget I was even on call.
Last week I was on call twice. I was called out on both days, to different hospitals. This is not normal. With a fellow doctor and a clinical associate — who were already there — I struggled for the better part of those days to stem the flow of a pandemic that had finally hit. We have been waiting for this, so we aren’t particularly surprised.
What did surprise me was the attitude of the people I helped. I understand this is scary, and I acknowledge we’re all learning on the fly. Anyone who says otherwise is a danger.
I entered one emergency room after rushing as fast as I legally could. My call-out activation was for “three P1s”. A “priority 1”, or “red”, patient requires immediate life-saving intervention. It’s a pretty important thing.
I walked into the Covid resuscitation area. The doctor who was already there was intubating one of the patients. I started sorting out the others. The patient who was tubed was a “private” patient. That’s someone who doesn’t have a medical aid who presents to a private hospital. Our job in that situation is to stabilise and provide any required intervention that will save a life. He was stabilised. The next step was to transfer him.
This is where it gets dicey. Of the nine possible government hospitals that have the ability to manage a ventilated patient, none of them had space. There are no beds. That patient then qualified to be ventilated in a private ICU because, as much as people may vilify organisations or people who make money from health care, we are still driven by our need to help people.
While the staff were frantically calling around, I saw a patient with mild Covid symptoms. This patient was nowhere near meeting the NICD criteria for admission. This was a “treat at home” patient. I prescribed the treatment required and explained the situation. The patient nodded and left. A few minutes later I was called to reception where a family member of the patient wanted to speak to me.
“Of the nine possible government hospitals that have the ability to manage a ventilated patient, none of them had space”.
He insisted I admit his brother, saying “we pay medical aid for this service”. My soul crumbled behind my N95. Here we are, struggling to find machines to breathe for people, and my biggest challenge of the day is a young lawyer flexing his degree.
I tried to explain that a global pandemic meant we were struggling. I agreed that in any other year we might admit the patient, but it just wasn’t possible now. There was no clinical evidence for us to do that. Just because you have Covid (as many people do) does not mean you qualify to take up a bed. That is the stark reality. We are not a hotel. We are in crisis mode, and we are saving bed space.
My words didn’t make it past the visor I was wearing. The family member refused to leave until the patient was admitted.
“How can you just send us home to die?
“You’re a disgrace. You don’t know how much this is going to cost you in court. I’m a litigator! Get me someone else to talk to, find a real doctor. I will not leave until you admit my family member.”
After working every day of the week, a mishmash of day and night shifts, being called out, working extra hours to make sure patients got assistance, that was our thanks.
This incident caused me to be at the hospital for an extra four hours. People forget we are people too. As much as we wear the PPE and try to protect ourselves and our patients, we are exposed. We are in the thick of it, and we feel it.
I realise times are tough and life is stressful. Doctors get pay cuts too. And we miss our friends and families. We appreciate the signs in Woolies saying “essential services skip the queue” even if that doesn’t happen. We love the billboards saying “thank you”. We love our jobs.
But the bottom line is this:
We are only just beginning and it’s not going to get better soon. It is difficult for all of us.
There. Are. No. Beds.
The thing with private health care in SA is that everyone with access expects a hotel situation — you pay your money and you are admitted. All SA doctors work in government hospitals early in their careers, so we’re quite used to telling people that the resources are limited. But private patients are not used to being told no.
In these past two weeks we’ve been doing a lot of that. I understand it’s difficult to have someone tell you no if you’re used to paying your exorbitant medical aid every month. To then find out what you think you’re paying for is unavailable because of the pandemic can be terrifying.
“Those decisions are sometimes difficult but they aren’t influenced by a medical aid card or a bank statement”.
Beds aren’t guaranteed for anyone regardless of who pays monthly or what kind of money you have. Medical aid gives you an option, not a guarantee. It’s our job to make the decisions as to who qualifies for those beds. Those decisions are sometimes difficult, but they aren’t influenced by a medical aid card or a bank statement. Unfortunately for people who expect access to unhindered world-class health care, you expect to always have that available to you. And the difficulty is saying, on medical grounds, this is what you qualify for. In the private sector, we have grown quite used to saying we’ll do anything to make you happy. We have maybe fallen into the trap of seeing our hospitals as hotels rather than as what they are. Hospitals are there for the sick.
Resources are absolutely stretched. Realistically, the resource that’s most stretched are ICU beds rather than general wards. But that’s essentially what you need if you’re admitting someone with Covid: access to the oxygen and ICU.
So it’s not that hospitals at this stage are completely full, and I think a lot of people are confused by that. I’ve had friends call (responding to my post) and say: “That’s not accurate, I work in a hospital where we’ve only got 20% capacity.” But the thing is, their ICUs are still full. So if you need hospitalisation for a respiratory problem, you can’t get it at the moment, although if you fracture your ankle you could probably be admitted without a problem.
There are probably a few cases previously where we would admit people for oxygen therapy — nasal prongs — but we’re not doing that at the moment because we’re trying to save bed space. But I think that is a hospital-by-hospital decision; people have different ways of going about that, and beds are more plentiful in different places.
I spoke to one of our specialists in one of our hospitals early on in the pandemic when I had a patient come in who required oxygen. He said we’d admit that person now, but we shouldn’t count on that being the case later because we were changing our criteria as the situation deteriorated.
As a doctor, I am used to dealing with difficult situations. Part of our training is called “breaking bad news”. I have lived through periods of my life when almost daily I told mothers their children wouldn’t survive. I am hardened, and I know I am cold, but to hear that the specialists I look up to for advice and support are feeling the pressure has me rattled. It is scary, and to have people who are used to dealing with “scary” acknowledge fear should be sobering for the rest of us.
Sitting at home in quarantine, waiting to hit the ground running, I feel as though I am letting my colleagues down. Our WhatsApp groups have changed from roster discussions and playful gifs to requests for assistance and offers of support. Doctors are good at helping, even if it sometimes means we need to take a step back and help each other. We know the surge is coming, and we aren’t sure we will handle it. For a health system that was struggling before Covid, things are about to break. There’s very little way to sugarcoat it, and I am a relatively optimistic person. We won’t stop though. It’s why I’m proud to be a SA-trained doctor. We know adversity and we thrive in it.
Most people are acutely aware they are sitting in a global pandemic, and some of them are willing to accept that the facilities that were available to them then aren’t now. Whether you are a patient in one of the few private facilities or someone who relies on what our government can provide, you will probably feel the squeeze as capacity dries up. I don’t think any of our patients are expecting that things will go back to normal in the next few months. The reality is, it probably won’t ever go back to like it was before.