Gunter Schleicher
Critical Care and Pulmonology, Wits Donald Gordon Medical Centre, Johannesburg, South Africa
On early identification of high-risk COVID-19 patients:
A small percentage of patients infected with SARS-CoV-2 virus develop severe illness, characterized by a “cytokine storm”, severe pneumonia, ARDS and multi-organ failure (MOF). These patients must be identified early on their disease course by using risk-assessment tools, serial biomarkers and pulse oximetry. The timing of life-saving interventions such as high-acuity monitoring, immunomodulatory therapy (e.g. corticosteroids, tocilizumab, Polygam) and high-flow oxygen therapy can prevent the need for intubation, progressive MOF and death.
On the pitfalls of evidence-based medicine:
The dogma of practising strictly evidence-based medicine was tested during the COVID-19 pandemic as treatments changed rapidly and unpredictably. Clinical trials often lagged behind clinical practice, which had to evolve rapidly based on clinical judgement, personal experience or local group discussions. In the end, good medicine, dedication and perseverance, an open mind and hard work saved more lives than international guidelines.
On human nature:
This pandemic has taught many of us more about human nature than any previous life events. It has brought out the best in us, and sometimes the worst. Our collective and individual behaviour will be forever changed as this new virus persists in our communities for the foreseeable future.
Guy Richards
Division of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Chronic COVID-19 (COVID Long Haulers):
Some 30% of patients who have contracted SARS-CoV-2 may suffer from a constellation of protracted symptoms that include exhaustion, cough, anxiety, palpitations, shortness of breath, muscle and joint pains, headaches, cognitive dysfunction (COVID fog) and, particularly if having had more severe disease, pulmonary fibrosis, post-traumatic stress disorder and ICU-associated weakness.
The mechanism by which this syndrome develops is uncertain but in many ways it mimics the chronic fatigue syndrome. Our hypothesis is that both the severe acute manifestations and the prolonged symptoms are related to a deficiency of nicotine adenine dinucleotide (NAD+). This molecule along with zinc is essential for the activation of the sirtuins, an ancient family of proteins that regulate cellular processes and regulate the production of pro-inflammatory cytokines. In any inflammatory state such as diabetes, ischaemic heart disease, obesity and the ageing process, as anti-oxidant defences decline, there is depletion of NAD+, and in so doing predisposes to more severe manifestations of COVID as well as having the potential to cause many of the features of chronic COVID mentioned earlier. Therapy with nicotinic acid has in many cases improved the symptoms of chronic COVID and it, along with zinc, is included in our treatment protocol for acute COVID.
Yunus Moosa
Department of Infectious Diseases, Division of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
COVID-19 unnerved the medical fraternity with the challenge of a new disease with significant mortality and scant evidence of effective treatment. The response was a flurry of treatment options on social media ranging from home remedies to repurposed drugs to novel therapeutics. Many practitioners responded by treating patients with several cocktails of medication using the argument – the absence of evidence is not the evidence of absence. The question that begged answering is how should one respond in a sea of uncertainty. In such a situation, everyone needs to be reminded of one of the most important promises in the Hippocratic Oath, “primum non nocere,” “first, do no harm”.
Colin Menezes
Division of Infectious Diseases, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
Learning to manage emotional reactions : It was clear that the thought of facing one's own mortality once I became infected with COVID-19, as well as having to deal with the anxiety, panic and anger of staff – not only doctors and nurses but clerks, porters and cleaners as well. This impacted patient care and the use of personal protective equipment (PPE).
The rush to establish the COVID wards’ corridor required a coordinated and multidisciplinary approach between hospital management, nursing and the department of infrastructure development. This required quick learning on our part about the dos and don’ts of infrastructure planning and resulted in the re-engineering of sections of the hospital.
The importance of rapid turnaround time for the COVID-19 test results was a critical factor in the triage and clinical management of patients – fortunately, we had access to rapid testing provided by the Respiratory and Meningeal Pathogens Research Unit where results were accessible within 24 h.
The issues around PPE were often a matter of debate with conflicting recommendations in the early phase of the outbreak. Disagreements on the interpretation of the guidelines with the actual situation on the ground and confusion about droplet versus airborne spread made the situation worse. However, adjustments were made to our hospital guidelines as things evolved to ensure adequate staff protection.
Jean F. Botha
Wits Donald Gordon Medical Centre, Johannesburg, South Africa
COVID-19 and transplantation
We learnt that the transplantation programme did not need to be completely suspended during the pandemic and a pragmatic approach enabled us to continue to provide life-saving organ transplants. At a practical level, we were able to house transplant recipients in a geographically separate part of the hospital, and medical and nursing staff taking care of these patients were not permitted into parts of the hospital where patients with COVID-19 infection were being looked after.
Surprisingly, we discovered that paediatric organ transplant recipients appear to be very resilient, and despite some transplanted children contracting the virus, none succumbed and most were asymptomatic. With regards to adult recipients, again we were surprised that being an organ transplant recipient did not appear to add to the risk of developing severe disease anymore than the known risks of age, obesity and diabetes. A number of these patients (both adults and children) were taking steroids as part of their immunosuppressive regimens and one speculates as to whether or not this may have offered some form of protection against severe disease.
Mervyn Mer
Department of Internal Medicine, Divisions of Critical Care and Pulmonology, Faculty of Heath Sciences, University of the Witwatersrand, Johannesburg, South Africa
The past many months have been taxing and tantalizing, eerie and enthusing, intrusive and illuminating, demanding and distinctive, as well as being rewarding.
Preparation is pivotal:
We had the gift of time to prepare as efficiently as we could, relative to many other regions. We got a team of relevant role players early on to engage and after our first meeting had already devised a working protocol which was later refined and widely adopted. This allowed one to address and overcome several of the challenges faced, often in the setting of very real adversity.
Communication is paramount:
This was and always is an absolutely essential component in all interactions – engaging, polite, constructive, inclusive with all parties and at all times. In our own unit, this approach overcame many significant challenges, including fear, panic and anxiety which were so prevalent at the outset. A daily staff interaction during the day and at night was initiated with all the role players involved in the functioning of the unit, and where everyone had a voice. This was enormously time-consuming but so worthwhile and beneficial.
Evan Shoul
Milpark Hospital, Johannesburg, South Africa
On analysing literature:
The pandemic shifted all efforts, energy and attention away from our usual work towards the coronavirus. With that came a torrent of literature investigating every angle of the pandemic, from the macro-level factors of health policy and international travel to the micro level of patient management and molecular pathophysiology. The urgency of the outbreak and our desperation in working out how to manage these patients lent itself to the erosion of our usual powers of data interpretation and analysis. Leaked non-peer reviewed pre-prints, papers with fraudulent data collection and pharma releasing early drug or vaccine efficacy results to the press all became blindingly bright, shiny distractions away from a core pillar of our practice, that of evidence-based medicine. This pandemic has reminded us to critically review all aspects of research and the significant implications of the results before incorporating it into our knowledge base. This has been one of many humbling experiences we have all shared during the COVID-19 pandemic.
