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Elma and COVID-19

January 24, 2021 in Uncategorized

To our English-speaking friends, Elma has hit the Afrikaans media recently because of the work she and a dedicated team of caring people are doing.

So we translated the interview which had appeared first, on LitNet. Should you be able to follow Afrikaans, do also look up the interview with Elma in Rapport; and the myth-busting interviews I have done with Awie Badenhorst and my sis, Marianne Lomberg.

Elma overseeing the installation of the oxygen plant (Photo by Rosie Burton)

COVID-19: The clinical manager of a 200-bed field hospital tells her story

Original article in Afrikaans at https://www.litnet.co.za/covid-19-die-kliniese-bestuurder-van-n-200-bed-veldhospitaal-vertel/

Elma de Vries is the clinical manager of a 200-bed field hospital that was opened at short notice to treat COVID-19 patients.

You are involved in a field hospital that can serve 200 patients who have tested positive for COVID-19 and are in need of care. It was established within two weeks. Why was it necessary to suddenly open such a facility?

The second wave of COVID-19 has resulted in an increase in the number of people needing hospital care, with hospitals bursting at the seams. The large numbers of COVID-19 patients in emergency units in hospitals contribute to patients waiting longer for a bed in a ward. The leadership in the Western Cape Health Department realised that it was necessary to make more beds available to accommodate the large numbers of patients who need hospital admission and oxygen.

Many people get Covid and then have to stay at home for a few days. Why then do you need so many hospital beds?

This is a strange virus. With ordinary flu, only 1–2% of people will need hospital admission, so 98% can recover at home. With COVID-19 it is different, with about 14% becoming seriously ill and up to 5% becoming critically ill, possibly requiring intensive care.

The Western Cape government also operates the Brackengate Hospital of Hope as a field hospital – which has been open since the first wave. How does the care that you and other field hospitals can provide differ from the type of care that can be provided in intensive care units, such as at Groote Schuur or Tygerberg or in the private hospitals?

Most patients who become very ill with COVID-19 can be treated with oxygen in a regular medical ward. Only a small percentage need intensive care. Intensive care requires many human resources, especially nursing staff trained in intensive care. The nurse-to-patient ratio in intensive care is very different from in a regular ward or a field hospital. With COVID-19 pneumonia, ventilation is not always effective, and high-flow oxygen is often the best treatment. Field hospitals can administer high-flow nasal oxygen treatment, but not ventilation. The advantage of high-flow nasal oxygen is that patients are awake and can eat by themselves while receiving oxygen, while someone on a ventilator is totally dependent on nursing care.

Let’s look at the term field hospital. It is usually a military term for a hospital that can be set up anywhere at short notice. In peacetime, the term refers to a temporary, specialised hospital that provides assistance for a short period of time. Is this correct?

Indeed.

The private hospitals are also full, not so?

Correct. Both public and private hospitals are under pressure at the moment with large numbers of COVID-19 patients and other emergencies that are not COVID-19 related.

You are a specialist in family medicine. How does your job in a hospital differ from that of someone who specialises in lungs (a pulmonologist) or someone who specialises in, for example, internal medicine who then runs an intensive care unit?

General practitioners, or family medicine specialists, are trained to treat anyone, no matter how young or old they are, or which organs are affected. Nowadays, palliative care is also part of our training (care for people with life-threatening illnesses). This includes care at the end of people’s lives. Specialists are trained in a specific field; so a pulmonologist, for example, focuses on lung diseases. The COVID-19 patients we treat in the hospital often have multimorbidity, in other words several health problems. An example is someone who is on treatment for HIV, diabetes, heart failure and depression. And now COVID-19 pneumonia as well. A pulmonologist or intensivist will be able to treat the pneumonia with great skill, but may enlist the help of other specialists, for example an infectious disease specialist for HIV or a psychiatrist for depression, while a GP follows a holistic approach and attends to all the aspects, including communication with the patient’s family. I have a great appreciation for my specialist colleagues and find that we are cooperating even better in the pandemic than before.

You and Brackengate use the logo of the Hospital of Hope that ran during the first wave in the Cape Town International Convention Centre (CTICC). The CTICC was a symbolic space to prove the state’s commitment, but am I correct that your team is modifying existing infrastructure so that it can finally, in a post-Covid world, be used again by the state’s hospital services?

Yes, we are also now called a Hospital of Hope. It is much more effective in the long run to utilise existing infrastructure, and it is part of the Western Cape Government’s legacy to COVID-19. The wards of Aquarius Intermediate Care at Lentegeur could quickly be set up as a field hospital. The infrastructure adjustments were mainly oxygen points, a large oxygen tank as well as spaces for the staff to put on and take off protective clothing (known as donning and doffing). When the second wave is over, the infrastructure will still be there for continued use by the Department of Health. The management of Aquarius Intermediate Care has played a major role in making it possible to have a field hospital ready within nine working days.

Doctors Without Borders, or Médecins Sans Frontières (MSF), often set up field hospitals. I think of their work in war zones, also more recently with the Ebola outbreak here in Africa. Is MSF involved with Covid?

We are very grateful for the help of MSF. With the first COVID-19 wave, MSF operated a field hospital in Khayelitsha. When, in December, the Khayelitsha MSF team heard that we were going to open a new field hospital, they made staff with COVID-19 experience available to help. Their technical support as well as the human resources made a big difference.

You used to be the first chairperson of MSF in South Africa, but that’s a long time ago?

MSF established a South African chapter in 2007. I was invited to get involved because I used to be part of RuDASA (Rural Doctors of Southern Africa) who are activists for better health care in rural areas. To my great surprise, I was elected chairperson, and was later succeeded by Hermann Reuter, who became known as the doctor who proved in Lusikisiki that people in rural areas can use antiretroviral drugs responsibly. Those were the days of a battle against a virus other than this one. MSF gets involved where the need is the greatest; one of my MSF colleagues at the field hospital was described as a “tornado chaser”.

You were on holiday in KwaZulu-Natal when you heard that you had been appointed as the clinical manager of the new field hospital. After that, things happened rather fast, in part because you received a lot of support from the provincial government. How did you get people, trolleys, oxygen, drip stands, needles, nappies, food … and much more together in days?

It was a big team effort. The team from Klipfontein Mitchells Plain substructure that had to start the field hospital was amazed at the support from all sides. A hospital is a complex system with many components. The management of Aquarius Intermediate Care has helped a lot with the logistics and human resource management, and their existing kitchen staff provide the food for patients. The province’s infrastructure team, medical technology department and laboratory services all contributed their share, and this over the festive season! Mitchells Plain Hospital’s pharmacy helped get the necessary medication ready. The emergency medical services have registered the field hospital as an ambulance destination on the system, and provided the inter-facility transport for patients. The management of Brackengate Hospital of Hope also helped us a lot, with both advice and supplies. The Klipfontein Mitchells Plain substructure has dedicated people who really went the extra mile over the Christmas weekend and New Year weekend, to make sure everything is ready to admit our first patients on January 1st. These are people with passion who serve the community unselfishly. The leadership of the Health Department has supported us in the process and is always available to listen and help when there are challenges.

You need scales, for example. Why? There are so many things I would never have dreamt of.

About 40% of hospital patients with COVID-19 have diabetes that is usually not well controlled. When calculating insulin dosages it helps to know how much the patient weighs. Fortunately, we were able to make use of Aquarius Intermediate Care’s existing equipment, such as beds, drip stands, monitors and indeed a scale.

How many staff members are involved in a 200-bed hospital?

It’s hard to say exactly – we’re still hiring staff so we can operate the full 200 beds. In addition to nurses, doctors, physiotherapists, social workers and dieticians, we also need clerks, cleaners, warehouse staff, kitchen staff and porters. A hospital is a complex system, and each category of staff fulfils an essential function.

Doctors, and you are one, suffer from catastrophilia. I get the idea that many of the younger doctors in your team realise that they will never get an opportunity like this again and therefore approach the incredibly long hours with a degree of satisfaction. Am I right?

Yes, some people thrive when there is a catastrophe. It makes us feel needed, that we can make a difference. Some young doctors feel that this is an opportunity to be part of a historic moment. It is desperately hard work, but as a colleague recently said after an exhausting Christmas weekend: “I have a job.” We have the privilege of getting job satisfaction – more than 80% of our COVID-19 patients get better and go home, back to their families. The smile of a patient who is better gives us strength to keep going.

However, I hear that the younger doctors are suffering do to the high mortality rate. Why?

The interns are struggling. We older doctors have filled out many death certificates over the years, but for the younger doctors this is all rather new. The death rate at present is much higher than the average before the pandemic. Senior doctors do provide support to the younger doctors, helping them to accept that death is part of the picture, that we cannot always heal, but that we can always support. To me, this is the wonderful thing about a palliative-care approach, that we as health workers can make a difference to people’s last days and hours, to strive “to cure sometimes, to relieve often, to comfort always”.