'Patients on death's doorstep': Groote Schuur Hospital discharges its 150th ventilated Covid-19 patient

Groote Schuur Hospital staff reached a major milestone this week after discharging their 150th ventilated Covid-19 patient.

They had earlier suffered one of their “lowest lows” when a young surgeon died with Covid-19 on January 18.

But the hospital's critical care director Dr Ivan Joubert said it was days like Monday when their hard work resulted in sweet victory.

“For us the significance of it is looking at the 150th discharge of a particularly sick group of people and it’s excluding all other successes such as from the high-flow nasal oxygen treatment — the low-hanging fruit — that’s why we were very proud of it,” said Joubert.

The reality, said Joubert, is that patients who need to go on to ventilation are practically on death's doorstep. “It’s the very last lifeline and caring for ventilated patients is an extreme task, it’s just about the most intensive form of care available.

“Most ICUs across the country will tell you what their outcomes are of high-flow nasal oxygen patients and ventilated patients together where high-flow patients do much better because they have a better prognosis,” he said.

“Ventilated patients are all patients who have failed all other forms of therapy available to them. In other words, they’re the very sickest of the sick Covid-19 patients.

“When we ventilate them we put them on a ventilator, they get incubated, they have a tube put into their trachea, their windpipe, and we get a ventilator to breathe for them,” said Joubert.

“We give them a muscle relaxant so they are paralysed, they can’t move any more, and they have sedation so they are deeply unconscious. And essentially they get what is the same as a very prolonged anaesthetic and for some of the patients that sort of anaesthesia has lasted three to four weeks, during which time you have to do absolutely everything for the patient,” he said.

Ventilators have been the subject of social media myth since the start of the pandemic with people claiming they cause death among patients.

“What has made Covid-19 different from a medical perspective is the fact that unlike any other disease we’ve dealt with before, Covid has been managed in social media, on Instagram and Twitter,” said Joubert.

“That’s where the public got most of their information and perceptions from and this idea of 'ventilators kill people', 'ivermectin can save everyone', 'hydroxychloroquine is the drug we need' ... There have been many waves of these kinds of things going through social media and unfortunately it hasn’t been very instructive to the public.

“Unfortunately there was a perception that if you get on to a ventilator you will die, ventilators kill people. That’s not true, if you get on to a ventilator you are already very sick and the reality is you would have died without it, and a ventilator offers people a change to survive.”

The origin of public anxiety about ventilators and intensive care units in general is not unfounded, however. If you are sick enough to land up in ICU or on a ventilator the life-saving treatment you require will be invasive, radical and possibly traumatising.

Psychosis, delirium and post-traumatic stress disorder have been diagnosed in patients coming out of these treatments, though Joubert said these side effects are temporary.

“A number of patients who’ve been through what our Covid-19 patients have been through have an element of post-traumatic stress disorder, they may have delirium and so on, which settles down and they recover,” he said.

“A lot of the public say, 'Oh, that sounds terrible,' and certainly it’s not pleasant for the patients at the time, but the flipside is you would just be dead. All of those Covid patients we’ve put on a ventilator here, if they hadn’t been ventilated they would just have died where they were.

“With ICU if you look at the side effects and these unpleasant things, the delirium, the psychosis, you have to weigh that up against the alternative which is death.

“When you look at it from that perspective, though treatment in ICU does have some undesirable side effects, what we’re looking for are functional survivors. We want people to come out of ICU and go back to their every day lives and enjoy a good quality of life.”

Groote Schuur is famous for performing the world’s first heart transplant. The government hospital also performs lung, kidney and liver transplants and is the only public sector hospital in the country which performs heart transplants. It also offers extracorporeal membrane oxygenation, a specialist therapy needed to keep lung and heart transplant patients alive.

“I think it’s encouraging. I think if we could build other state hospitals up in this country we could be doing really well. Just because we’re state sector it doesn’t mean we can’t achieve,” said Joubert.

“There’s too much lethargy in this country — that because it’s state you can’t get this done — but that’s not the case. Getting big teams of people working all the way from top management down to clinicians and front-line workers, that’s how you make a success.”

Public sector hospitals get a bad rap and there are many examples of hospitals in a deplorable condition around the country but there are also hospitals like Groote Schuur providing a world class service.

“Here at Groote Schuur Hospital we are very privileged to have five intensive care specialists working in ICU plus the trainees, people specialising in intensive care, which I know if you look about in intensive care units about the country, you have the biggest number of intensive care specialists here at Groote Schuur, so we run a very good service,” said Joubert.

“If you get admitted to your average ICU in private or whatever, you’re going to have a physician look after you or a pulmonologist, maybe an anaesthetist, but there are very few of us who are actually specialist intensive care doctors.

“It’s one of the unfortunate things in SA — we have a very small number of intensive care specialists.

“I think there are many things that we do that we know we can do better than the private sector can do and we pride ourselves on it. Our outcomes with Covid now is one of the things we are really proud of.”

Joubert said despite the long, hard journey through the pandemic there were moments of triumph to balance out the bad days.

“It’s been a long journey. It’s been quite emotionally wrenching, with a lot of very low lows but equally some nice triumphs and good moments,” said Joubert.

“When I tweeted earlier this year, that was a medical doctor, a colleague who passed away and it was obviously very sad for all of us. It’s been a lot of ups and downs, but the ups stand out very nicely.”

Joubert said the battle for health-care workers is far from over but since the rollout of vaccinations started on February 17, 73,000 have been vaccinated, providing a new set of armour and a much-needed morale boost to fight the pandemic.

“Without a shadow of a doubt, it’s had a very positive effect,” said Joubert. “Knowing that you’ve been vaccinated adds just an additional layer of protection to you in a work environment and I think that added layer of protection just gives people reassurance, it just settles them down. Their anxiety is way less,” he said.

But he cautions that the portion of South Africans being vaccinated is “tiny” and if the public doesn’t “stick to the rules” a third wave is already in the making.

“The fact that the vaccine is getting rolled out is fantastic and we should be encouraging South Africans to be vaccinated, however the number we’ve rolled out so far is insignificant if you look at it as a percentage of the total population.

“The starting steps are in the right direction but we haven’t vaccinated enough people for it to have any meaningful affect on a third wave. It’s tiny numbers.

“The last thing I would say to the public as we await the arrival of the third wave is to remember that these waves are not driven by the virus; they’re driven by our social behaviour. If we want to avoid a third wave, the only way to do it is by social distancing, wearing masks, and playing by the rules.”

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