“This is probably the cleanest place in the world right now,” says associate professor Ross Hofmeyr. The ward in which we are standing, in the “new main building” of Cape Town’s Groote Schuur Hospital, was formerly an isolation ward for cancer patients recovering from radiation treatment. Now, it is an isolation ward for Covid-19 patients.
A team of clinicians wearing goggles, gowns, gloves and masks huddle around Hal, a R500 000 life-size dummy whose vital signs appear on the monitors next to the bed. The team is taking part in a simulation exercise. In this scenario, Hal is a Covid-19 patient with respiratory failure.
Hofmeyr seems relaxed and happy with the way the simulation is going. Unlike the clinicians huddled around Hal, he is wearing only scrubs. He gives me a brief rundown of what is happening in the room, every now and then turning his attention to the clinicians. They are anaesthesiologists, experts at what they do, and yet there is tension in the air. One of them complains that their goggles are fogging up and wants to remove them. Hofmeyr asks them to continue working with the foggy goggles and problem-solve as if they were in a real-world situation.
The anaesthesiologists taking part in the simulation have not yet intubated any Covid-19 patients. But they know that very soon they will have to, and they are training to be as well prepared as possible.
The airway team
Hofmeyr is the airways lead in the anaesthesiology department at Groote Schuur. Midway into January, he suspected that the virus wreaking havoc in Wuhan, China, might end up being responsible for the next global pandemic. He kept a close watch on how China responded and started thinking about how South Africa could respond if the coronavirus made its way here. When the pandemic exploded in Europe, it was clear the country would not be spared.
Critically ill Covid-19 patients need “airway management, ventilation, organ support and close monitoring, all of which fall within the core skill set of anaesthesia,” says Hofmeyr. Anaesthesiologists have a part to play beyond their usual theatre and intensive care unit (ICU) work when it comes to the virus. But fulfilling that role safely requires careful preparation as the procedures they will have to perform come with a high risk of patient-to-clinician transmission, intubation carrying perhaps the highest risk.
According to Hofmeyr, South African state hospitals need more medics to meet the “basic benchmarks” at which we should be operating. “We can 3D print ventilators and crowdsource CPAP machines,” he says, referring to continuous positive airway pressure machines. “But we can’t 3D print more personnel.” Healthcare workers infected with Covid-19 need to go into isolation for a number of days before being allowed to work again, putting pressure on the remaining healthcare workers.
Hofmeyer drew on the responses of countries hit before South Africa and lessons from the Sars outbreak in 2003, adapting these ideas to develop an approach to intubation and airway management for South Africa that would keep his team safe and working. He used Groote Schuur’s simulation training system to develop step-based simulation exercises to train clinicians, and put out a call on 17 March for volunteers to join the Covid-19 airway team. This team will take on all high-risk Covid-19 cases that require intubation and ventilation.
Sacrifice and preparedness
“The department is buzzing with anxiety,” says senior anaesthesiologist Felipe Montoya-Pelaez. “Part of that anxiety is being channelled towards preparedness, but people are concerned. Some of us are afraid.”
At 57, he is at a higher risk of developing a serious Covid-19 infection than his younger colleagues. When his wife, who is also a clinician, asked him why he was volunteering at his age, he answered that doing the training would make him safer. “At some point or other, we’re all going to be involved regardless … I might as well be … in the forefront as someone who is well trained and working with other well-trained people.”
A rolled up foam mattress has been leaning against the wall of his office for weeks. Like the others on the team, he is concerned about carrying the virus home to his family. “Once you can see patients are coming in and needing to go to ICU on a daily basis, I’m just going to stay here. Maybe once in a while I’ll ask my wife to put some food in the garage, and then I’ll go in and eat there and come back. I think maybe it’s overdoing it, probably, but psychologically for me and my wife and children, I think it’s the right thing to do”.
Dinell Behari, a specialist trainee in the anaesthesia department, was asked to join the airway team. He agreed wholeheartedly. “It’s a highly specialised team,” he says. “You go into every scenario fully prepared and with the backing of your colleagues.”
Behari and his wife, a doctor providing care to Covid-19 patients at a different hospital, don’t have children. While this makes their home life less complex, they are not shielded from the daily anxieties that healthcare workers face. “Something will happen at work, or somebody gets sick, or you’ll hear that the patient that you or someone you know was in contact with might be positive. You wake up again and realise what the risk is,” he says.
Specialist anaesthesiologist Karen van der Spuy joined the team out of a strong sense of responsibility and wanting to be as prepared as possible for working with Covid-19 patients. I wanted “to ensure my team and I obtained the correct equipment and protective gear and that we had a group of colleagues we know we could understand and trust in these high-risk situations”, she says.
Van der Spuy’s partner is an obstetrician-gynaecologist at a private hospital, who is also on a Covid-19 team. They are aware that the care they provide in their jobs could put their family at risk, and so have also had to make big sacrifices.
“One of the hardest things to have done regarding my commitment to my job and to my team at initiation of lockdown was sending two of my three kids to live with their other parent, and to ask our domestic assistant to move in with us, into a separate section of the house, to care for our toddler,” says Van der Spuy. “I miss the kids terribly. I can see by their curiosities and the questions they ask that they miss home, too, and struggle a lot with understanding this crazy time.”
It’s difficult not to invoke a wartime analogy in situations like these, but as Montoya-Pelaez says: “We are preparing for battle.”
No emergency in a pandemic
“There is no emergency in a pandemic,” says Montoya-Pelaez, describing the psychological shifts involved in dealing with these new working conditions. Thinking about “our safety first when going to a patient in need, we are going against our instincts as anaesthesiologists, as ICU practitioners, as health workers. If a patient needs to be intubated, we go without thinking. Now, it’s different.”
When clinicians intubate Covid-19 patients, they release tiny droplets called aerosols from the patient’s lower respiratory tract into the air. These aerosols, which could contain significant amounts of the coronavirus, pose a significant risk to the clinicians. To prevent transmission, clinicians need to don appropriate personal protective clothing (PPE) before making contact with the patient. The process of donning this PPE is critical and needs to be done meticulously. Only once they are certain everyone is safe can they attend to the patient.
Performing intubations in full PPE is not straightforward either. “Most of … my anaesthesia colleagues have put in hundreds of endotracheal tubes and they can do it in their sleep, mostly the patient’s sleep,” jokes Hofmeyr. “It’s a psychomotor skill that they don’t even think about any longer.” He describes the added layers of complexity in performing this task wearing PPE, “where your visual field might be impeded by wearing goggles, where there’s light reflecting off things, where your mask is causing you to fog up a little bit, where you’re physically restricted with two layers of gloves and a gown on, where your communication with your team is limited because you’re talking through your respirator…” All of this is also compounded by the fear of transmission and infection.
Once the intubation is complete and the patient safely hooked up to a ventilator, the clinicians have to remove their protective gear, which is covered in droplets and aerosols containing the virus. They do this in a sequence designed to prevent them from coming into contact with any of the contaminated PPE.
The training simulations are powerful tools, beginning with the donning and ending with the doffing of PPE. Hofmeyr explains that clinicians practice under the conditions they are going to experience, recognise their limitations and learn to work around them.
Has the training been successful?
Behari says he feels really protected doing intubations wearing full PPE and that simulating various scenarios allows them to maintain control when dealing with live patients. But he adds that there is a critical time factor that cannot be accounted for in simulations. The patients they see are physiologically unwell and have limited respiratory reserves. “There’s a time limit to the things you need to do, and you are acutely aware of that,” he says.
For Van der Spuy, even when everything goes smoothly, it can still be extremely stressful as she is constantly aware about having to take care of her own safety and, even more so, that of her team. “When I train and when I’m in [live] scenarios, it’s a very different situation,” she says. “I don’t think that one feels comfortable, ever.”
Although the anxiety may always be present, the simulation training exercises have given the volunteers on the airway team the ability to respond meticulously to a variety of Covid-19 situations. They now have a specialist understanding of the necessary safety precautions and confidence in their ability to perform safely under pressure.
Waiting for the flood
In the past few weeks, the airway team has performed almost daily simulation drills. Volunteers on the team have trained to lead simulation exercises for clinicians within the anaesthesiology department as well as for clinicians from other departments. They have created open-source training material that can be used in any South African hospital and is available through the South African Society of Anaesthesiologists. And they have successfully performed live intubations using their system, as have clinicians in other hospitals around the country.
The expected flood of critically ill Covid-19 patients has not yet arrived, but managing suspected or confirmed cases of the coronavirus has become a daily occurence. If two weeks earlier there was some doubt as to whether making all those sacrifices early on was premature, it is now clear they were not.
Hofmeyr knows that sacrifices will have to be made, but he is able to see the positives. “It’s easy for us to feel like we’re having a hard time. But on the flip side, we’re able to go to work and we’re able to get out of the house and we’ve got a great sense of purpose, which I think a lot of people at home are lacking at the moment.” It is “a marathon at sprint pace,” he says. “And we’ve been sprinting for weeks.”
Clinicians in hospitals working with the most critically ill Covid-19 patients are often described as working on the front line in wartime analogies. In terms of exposure to possibly life-threatening risk, this is true. But if we think in terms of lines of defence, they are the last line, and Groote Schuur’s last line is extremely well prepared. Whether they are overprepared or underprepared will be decided by how well we manage to perform at the front line.