Covid-19 is not a single-specialty disease; everyone has to collaborate, parceling out work where resources are most needed and finding the best way to handle individual cases.
This is according to Dr Nicky Longley, a one-time University of Cape Town-trained infectious diseases Fellow, currently working in a London hospital that has just emerged from a bruising encounter with a flood of Coronavirus patients in a city that saw most of the UK’s infections and deaths. She was the special guest at a webinar attended by 1 500 South African clinicians and healthcare workers anxious to gain knowledge and insights from her in advance of their own surge in hospital admissions that will inevitably accompany local lock-down relaxations and/or lifting. The webinar, hosted by Discovery Health in conjunction with Medical Brief, was on Thursday, May 14th and Professor Linda-Gail Bekker, Deputy Director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT, and an erstwhile colleague of Dr Longley’s, facilitating. Dr Longley is an associate professor at the London School of Hygiene and Tropical Medicine and a consultant at London’s Hospital of Tropical Diseases.
She said South Africa had the advantage of foresight in having witnessed the pandemic sweep through countries like Italy and the UK and thus had the unique advantage of time to prepare and mobilize.
Risk stratification vital
“Nobody (no hospital) has enough isolation facilities or side-rooms to cope with this,” said Dr Longley, emphasizing how pivotal the risk stratification of patients was.
“You have to see who is most vulnerable in the population and work out how to shield them when they come into hospital,” she added.
Case definition swabs were vital but diagnoses not always as rapid as clinicians wanted. At the hospital entrance, patients were divided into those at high risk of transmitting the virus (put into the ‘dirty’ area), those unlikely to have Covid-19, but with underlying conditions which put them at a high risk of a poor outcome if they contracted it (e.g. the elderly, pregnant, or with malignancies) – put into a clean area, and then difficult cases that defied easy definition.
Dr Longley stressed the importance of a ‘buddy system’ when healthcare workers entered or exited ‘dirty’ areas such as ICU’s and high-dependency units.
“Somebody else watches you put on and take off personal protective equipment each time, because you’re stressed and tired and may also forget hand hygiene between each step when you take scrubs off and when you go home. Also, have a shower before you go home and leave your dirty crocks or shoes behind,’ she advised.
With 233 151 Covid-19 cases and 33 600 deaths in the United Kingdom at the time she spoke, Dr Longley said things were finally slowing down after a dramatically-effective but limited lockdown that allowed exercise, movement and shopping, with social distancing, hand hygiene and masks strongly encouraged. Her hospital went from being almost overflowing with operating theatres converted into ICU’s with extra beds, to being 25% full currently, which was lower than normal for this time of year.
Dr Longley said doctors had to realize that, ‘this is not a sprint, it’s a marathon – we have to be kind to our teams and ourselves.”
“As clinicians we won’t get it right all the time. We can step away. We’re used to being able to deal with, and know what we’re doing. Yet we’ve only been around this disease for some months – in some ways we feel helpless. It’s super important to realize that psychological impact. Our intensivists say this is not the normal thing they know. Your staff and patients are frightened. They’ve been told to stay away and self-isolate, and now they’re coming in. It’s reminiscent of the beginning of the AIDS epidemic. Nobody wanted to touch these people. There’s also fear from patients, ancillary staff and your own staff and their relatives when they’re read to go home,” she told her audience, which later peppered her with questions.
Dr Longley said people in isolation felt vulnerable being confronted with doctors and nurses suited up in intimidating personal protective equipment.
“They don’t see your smile. Instead they see your worried eyes. They’re without familiar things. We set up a library in the Covid ward, because they’re there for a long time,” she revealed.
Do I have it or not?
She said she and her colleagues felt guilt over being away from their families, scared they’d bring the virus home, fall ill and have to abandon their colleagues. A significant percentage of her colleagues were asymptomatic or quasi-symptomatic, or as she put it, “slightly under the weather.”
When stressed or tired they were never sure whether they had the virus or if they were suffering psychosomatic symptoms. An irony was that while healthcare workers were afraid of entering Covid wards, these were probably the least risky because everybody was on guard and took precautions. The danger came when working in so-called ‘clean’ zones where you least expected to become infected.
She said Covid presented with a host of unexpected non-pulmonary symptoms which made for a steep learning curve. A snapshot of 35 ICU patients showed that 60% had acute kidney injury while others had inflammation and direct invasion of the tubular system, needing continuous electrolyte replacement, having lost large amounts of phosphate, sodium and potassium. One third of scans showed pulmonary embolisms and some deep vein thrombosis. Those requiring high flow oxygen in ICU or on CPAP needed more anti-coagulants, though plasma-exchange studies were ongoing. Nervous system symptoms included a dramatic loss of smell, hypo-active delirium with deregulation of the autonomic nervous system, and strokes. Other unexpected variations included, (towards the end of the epidemic), a Kawasaki-like syndrome among a handful of children and young adults (treated with steroids and biologic therapy), myocarditis, diarrhoea and vomiting – associated with hepatitis, not respiratory symptoms.
Dr Longley’s advice was to treat conditions associated with Covid normally, as if they were presenting in isolation.
She emphasized that results were still pending in a 6 000-person London-based study comparing all the world’s highly debated drug therapies suspected to mitigate Covid-19. There was currently no significant evidence to say any worked. Biologicals were currently looking more promising than anti-viral treatments, but nothing had yet succeeded as a prophylactic.
She warned colleagues to be on the look-out for, (especially in elderly patients), straightforward presentations such as a urinary tract infection.
“Don’t forget to be a doctor – it’s not all Covid!” she said, citing two malaria deaths that occurred simply because the London-based former-travelers tragically self-isolated at home with fever-like or flu symptoms, thinking they had Covid-19.