The 7th of April is World Health Day: a global health awareness day celebrated annually under the sponsorship of the World Health Organization and other related organisations, and a day which has been celebrated annually since 1950. It is seen as an opportunity by the WHO to draw worldwide attention to the importance of global health each year.
And never has global health been more important or relevant than now. As we find ourselves locked down in our homes, relying on our healthcare workers to hold the line against the COVID-19 pandemic, they have risen to the task. All around the world healthcare workers are consistently showing up, going - in many cases above and beyond the call of regular duty - to keep us safe. On behalf of the general public, we thank and salute you.
And so in honour of all our health workers - in every possible field - our Ask the Expert column today is a chat with a local GP about her experiences working in a suburban Cape Town practice during the COVID-19 pandemic.
Q: Please introduce yourself to our readers: a little bit about your background, where you studied medicine, where you practice etc.
My name is Karen van Kets, I’m a GP in the Southern Suburbs of Cape Town, which is also where I live. I'm married with 2 children, and this is my 20th year of doctoring. I studied medicine at the University of Cape Town, and also hold a Post Graduate Diploma in Family Medicine as well as Paediatrics. I split my time between two practices in the southern suburbs.
Q: Are you still working through lock down?
Both the practices at which I work are still open, and we are working throughout the lockdown. We have, however, reduced our opening hours as there is definitely less of a need for us to be open for quite as long as usual. Everyone is being responsible in the lockdown and our patients are staying home and only going out if absolutely necessary.
We have also reduced our hours to allow our support staff - our receptionists and administration and cleaning staff - to be able to get to and from work safely.
Q: What procedures have the practices at which you work put in place to ensure that both you and your colleagues - and the patients you are treating - are as safe as possible?
We are trying very hard to keep our practices as safe as possible, so that our patients feel comfortable to come and see us if they need to come in. We don’t want our patients to be at home - ill, unwell or anxious - when they should actually be coming in for a review, check up or treatment.
To this end we have changed how we work during this period quite substantially. Firstly, we are offering telephone consultations for things that we believe don’t require a face to face consultation. If, during the telephone consultation, we feel that the patient may have a condition that isn’t safe to manage over the telephone, we’ll arrange a face to face consultation.
Any patient that we consult with over the phone and which we feel may have a Coronavirus-related problem will be referred for a screening test at one of the laboratories. If that test is negative and we know that the patient does not have Coronavirus (and the illness is something we should see in a face to face consultation) then at least we know that we have kept our practice and rooms as Coronavirus-free as possible for our other patients.
We are also conducting every face to face consultation - regardless of whether it is a respiratory case or not - with what we call basic “droplet protection”. This means that we wear a surgical mask and gloves for every patient we examine regardless of the reason for their visit, purely because we don't really know who does or doesn't have an asymptomatic Coronavirus infection. Our respiratory patients are obviously at much higher risk of having a COVID infection and one practice has a dedicated room to examine any respiratory case we feel is high risk. This room has a separate entrance and waiting area to limit possible exposure to other patients. There is one doctor assigned to that room for the day, who will take further more intensive precautions, such as wearing more personal protective equipment and use dedicated equipment for examining the higher risk patients. They will not be allowed back onto the general examination and waiting area until they have changed out of their PPE and washed any exposed areas of skin.
We are making sure that both practices are cleaned regularly with appropriate sterilising solutions and that any equipment we use for consultation is cleaned between each patient.
Our practices have also made the decision to have patients wait in their cars to minimise the exposure of patients to each other in the waiting room. If patients really feel that they would like to wait inside, chairs are placed 2m apart.
We have also ensured staggered appointments so that everyone will be able to park outside our door. When the doctor is ready patients are notified to go directly from their car to their doctor’s rooms. On leaving, patients can pay at reception if their card has a tap facility, otherwise we will email the invoice so that they can do an EFT.
At one of the practices, we have nominated one of our doctors to do house calls for our elderly patients in old age homes. This is because they are a very high risk population and we need to limit their exposure to us as much as possible. We notify each other if we have a patient that is frail and unable to come to the practice, so that one doctor can see as many of these patients on a single house call.
Q: Have you treated/ diagnosed any COVID-19 cases yet, or done any COVID-19 tests?
Fortunately I haven’t had to treat any patients with COVID-19 - yet!
I have, however, seen and sent for testing quite a number of patients who fitted the epidemiological and clinical criteria for COVID testing. Fortunately none of these have actually been a Coronavirus infection.
My colleagues, however, have had a few cases that have tested positive, and those patients have mostly been managed at home through telephonic consultations every day or two. We have had one patient whose condition deteriorated enough to require admission to hospital.
Q: How are you finding the telephonic consultations?
Having a patient sitting in front of you is very different to having a patient on the other end of the telephone, we are taught to start our consultation from when we call our patients in from the waiting area. The first part of an examination is always an inspection of the patient or area to be examined before we touch our patients. This is of course not possible so we rely fully on verbal communication only. When the patient is at the end of the phone, you worry about them, their family, and how this is going to impact them should it turn out to be Coronavirus. And then you mentally check all the things you will need to do if they DO test positive: notify the NICD, follow up with the patient every day to ensure that they are clinically well, and support them through this emotionally because we can’t be with them physically.
When the patient is physically sitting in front of you, you still think about all of those things, but you also think about yourself. You think about what you may have been exposed to, and my thoughts go to my family. I’m very aware that I could bring home a virus that could make them ill.
Q: How do you avoid “taking your work” home with you?
I make sure that when I come home I take off the clothes I was wearing that day immediately and put them in a separate bag for washing, and then shower immediately. I also disinfect anything I may have touched or held on the way home (keys, cellphone, handbag) and make sure they are sterile before I enter the house.
Q: How did you feel when you realised that the patient sitting in front of you was potentially infected with COVID-19?
One of the first patients that I sent to be tested was a patient who was very, very scared because they had an underlying condition (HIV). The fear in this patient’s eyes when I told them that their symptoms could be related to a Coronavirus infection really hit home with me. They were worried that they could have infected their spouse and their children as well as being worried for themselves. This patient had not travelled anywhere and could potentially be in a very serious position medically because someone else had gone out when they were unwell. It made it very real to me that this is a community issue and a community problem, and the solution lies within the community as well.
My patient wouldn’t have potentially been exposed to Corona if the person they stood next to on the bus or in the shops had stayed home when they felt unwell. So it was an emotive moment for me because this is a patient I have looked after for a number of years and have a good relationship with, and their fear and worry was something that really got to me that day. Fortunately, their test was negative, and their illness was caused by one of the hundreds of other viruses that cause the common cold but that are not as serious as the Coronavirus infection.
Q: Have you performed a Coronavirus swab test yet?
I’ve performed one swab test on an elderly patient in a frail care nursing home. She couldn’t have picked up the virus whilst travelling (because she can’t travel) but had developed acute symptoms in keeping with the clinical picture of Coronavirus. We were very concerned that if it was Coronavirus then one of the healthcare workers or staff members at the nursing home could have been an asymptomatic carrier, spreading the virus throughout the nursing home.
We tried to arrange for one of the labs to come and test our 93 year-old patient, but they refused due to the fact that she had not travelled, and therefore did not meet the testing criteria (at that time, the criteria have since changed). We felt strongly as a practice that we needed to ensure our patient was tested, so I decided I would do it.
We put together a full PPE kit with a head covering, a face shield, N95 mask, gloves, a gown, and scrubs, and thus prepared with all the gear and the swabs, I went off to the old age home to do the swab test.
And again, it was fear that I saw. Not so much in the patient’s eyes this time (she was quite unwell and didn’t really understand why I was garbed in full PPE) but there was definitely fear in the eyes of the nursing staff and assistants who are used to seeing me in “civvies”.
Fortunately, that patient’s test was also negative, and we didn't have a silent wildfire on our hands. If it had been that she was unwell from COVID-19 then the whole home could have been affected. I shudder to think what that would have done to our large, elderly and frail population.
Q: How does it feel to do a consultation in full PPE?
When I walked out of the change room in full PPE kit, I was very aware of how hard it is to breath through a mask and a face shield, and how slowly and carefully you have to move. Everything you touch and everything you do could potentially expose you (and other people) to a potentially lethal infection.
So I was very aware of having to do everything very slowly, and very carefully, and having to follow all the correct steps in the right order to ensure that the swab is done correctly. And also to ensure that I remained protected and that I protect all the staff that work in the care home and the other residents.
Q: If you had to suggest only one change that our readers could make to keep healthy during the COVID-19 pandemic, what would it be and why?
The best way to stay healthy is to STAY HOME! If you don’t go out, you can't get sick.
If you do need to go out, please take all the precautions that have been advised, the Golden Rules:
- Keep a good physical distance from other people
- Wash your hands immediately after coming home (if you have had to leave the house)
- If you touch anything, disinfect it and your hands at every opportunity you can
- There is now a big movement towards the general public wearing cloth masks when going out. Understand though that a cloth mask is more to protect OTHER people from you (based on the assumption that everyone is potentially an asymptomatic carrier) than to protect you from getting an infection. So when wearing a cloth mask consider that “my mask protects you from me, and your mask protects me from you”. Any mask should also be treated as part of your face or skin and should NOT be touched or adjusted once put in place.
While you are at home, things to do to stay healthy include sleep. Sleep is very important, as it’s linked to the immune system and so you need to sleep well, and sleep enough. Also consider your nutrition, and try to limit your alcohol intake and the amount of unhealthy snacks (I know this is hard on lockdown!) Maintain your exercise routine as best you can - 30 minutes of moving, and connecting with other people outside of your home every day if possible - and include some quiet time in your day. Keeping a good balance is the key to maintaining a healthy mind, healthy body and strong immune system.
Q: What are your thoughts on the public stocking up on gloves and masks?
There has been a lot of discussion on the GP WhatsApp groups that I belong to about this, and there seems to be more and more anecdotal non-researched evidence, as well as some emerging researched based evidence to support the notion that cloth masks are a good idea.
We all know that N95 masks are the best, and if everyone could have access to one, that would be amazing. But that’s not the reality of our current situation. N95 masks should therefore be reserved for people in high risk scenarios: those taking COVID-19 swabs and dealing with Coronavirus cases either at hospital or at home, for health care workers in clinical practice.
Surgical masks are the next best option, and they should be used for someone who is coughing and unwell. Then there are cloth masks. As mentioned before, cloth masks are better at stopping oneself spreading the virus unknowingly, than for preventing oneself breathing it in.
If you do choose to wear gloves and face masks when you go out, you need to treat both as if they were your own skin. You must NOT touch, move, or adjust your mask with unsanitized hands. And gloves can spread contamination in exactly the same way as hands do. Just because you wear gloves, it doesn't mean you are immune, and the gloves themselves are a potential source of contamination.
I would like to say a HUGE thank you to Dr van Kets for taking the time to share her experiences with us. Whilst our local GP’s may not be swab testing for COVID-19 every single day, rest assured that it’s as much on their minds as it is for healthcare workers in hospitals.
For more on glove usage, please take a look at our article Gloves on or Gloves off or subscribe to our blog for tips, information and industry trends. You can find updated information on COVID-19 services here.