Like a “blanket of fatigue” – Inside Groote Schuur’s long-COVID clinic
Inside his office at Groote Schuur Hospital in Cape Town, pulmonologist Dr Rubeshan Perumal gestures at his computer monitor where two lungs are etched in black and white.
“This is the right lung,” he says, pointing. “And here you can see the left lung, nearly absent. That is because it was destroyed by tuberculosis in her previous illness. And one can see how somebody so disadvantaged by a previous episode of tuberculosis is really going to be in trouble when they come up against COVID, especially as severe as she had it. These are the complexities that we face in this country. Perhaps she wouldn’t have struggled as much if she had not lost so much of her lung due to prior tuberculosis.”
Perumal is discussing one of his patients at Groote Schuur’s Post-COVID-19 Lung Disease Clinic. A first in South Africa, the clinic, hosted at the hospital’s Division of Pulmonology every Friday, help patients suffering long-term effects stemming from acute COVID-19. Each week, five pulmonologists and other healthcare staff see five new, and between ten and fifteen existing patients. Patients are treated for persistent respiratory symptoms which include shortness of breath, chest pain, and fatigue.
“This woman, whom we’re seeing today,” Perumal continues, “had COVID in May last year. She spent some time in the ICU [Intensive Care Unit] and she had recovered, or so she thought, and so did we. But a year later, she’s still on oxygen at home and she’s given up all of her recreational and occupational activities. She isn’t able to care for her family, she’s barely able to take care of her own needs. But we’ve been able to offer her specialised further investigation, which helps us identify small opportunities to improve her condition and even trials of treatment. In fact, subsequent to one of the treatments which we tried on her, she has been able to take a shower on her own. And perhaps most proudly, she said to us, she was able to prepare a meal for her daughter, after her daughter’s shift. See, her daughter is a nurse here, at this hospital.”
‘Blanket of fatigue’
As he speaks, Perumal’s breath is misting up the spectacles above his face mask. Breath is of course key to his work here.
“Patients were struggling with a few problems, which plague them in ways that didn’t allow them to return to a life of meaningful quality,” he says. “And that was concerning to us. They were tired. They often described this blanket of fatigue that was really impossible to escape. In their fatigue, they were losing motivation to recover. There were complaints of persistent shortness of breath. And you know, the desire to breathe is strong and one wants to feel comfortable doing it. And when one can’t breathe comfortably, there’s a great deal of anxiety. We find that these symptoms, while they might seem to originate in the lung, are often multifactorial and may also take their origin in the brain, heart, muscles, and often with a complex interaction between these systems. Often even the psyche, a perception of breathlessness. And so these are the problems for which we were being contacted.”
Globally and in South Africa scientists have noted that many patients suffer COVID-19 related complications long after their acute illness is over. Within a context of great uncertainty as doctors continue to study the phenomenon, Groote Schuur’s Post-COVID-19 Lung Disease Clinic looks at what might cause patients’ symptoms and then suggest treatment plans. Due to its limited capacity, strict referral criteria are followed to prioritise patients most in need.
“Even when no medication is indicated, we can still offer reassurance,” says Perumal. “And the effect of this reassurance cannot be underestimated. Patients know they have a place to express their fears, their concerns.”
‘I can breathe again’
Further along the corridor, Dr Gordon Audley is treating Shireen Chetty, who has made a remarkable recovery after being intubated on a ventilator for 42 days at Groote Schuur’s ICU, while her husband passed away at Victoria Hospital in Wynberg. Speaking to Spotlight, tears roll down Chetty’s cheeks as Audley touches her shoulder.
“I’m fine now. Finally, I’m fine. I can breathe again and live normally,” says Chetty. “I am so grateful to the staff here at Groote Schuur for everything. But I’m not over my husband’s death, you know, it was just such a shocker. He had a cough at home. We took him in because he wasn’t looking well, but he tested negative. Then three days later, we noticed that he was just getting weaker. So they sent him to Victoria Hospital. He went in on the Thursday and that Sunday morning they phoned to say that he passed away. I was at Groote Schuur, the day he died was when I was put on a ventilator.”
Good days and bad days
In another room, Dr Quincy Gurirab is assessing patient Kim Japhta, who was admitted on January 21, and who has been taking oxygen ever since. This included 38 days on high-flow nasal oxygen [HFNO], a technique that delivers heated and humidified oxygen at a maximum flow rate through a nasal cannula. (See Spotlight’s previous reporting on HFNO here.)
Speaking gently, with Japhta’s permission, Gurirab says: “So this young lady, who had one or two co-morbidities prior to her diagnosis of COVID, had severe COVID, requiring respiratory support. She spent 38 days on high-flow nasal oxygen and a total of eight days in ICU. She is now more or less five months post-COVID with a good recovery. She’s gone from requiring eight litres of oxygen per minute, down to about one to two litres. She’s got some residual lung injury, but we are very happy with her progress, and also very hopeful that the progress is going to be good.”
Japhta has been back at her home in Mitchells Plain for a month now. She was discharged from Groote Schuur with an oxygen tank and an oxygen concentrator. “Even now I have good days and bad days,” she says. “Today, I feel so much better. The way the doctor explains things plays a big role.”
Speaking in the corridor, the doctors agree on the life-saving importance of oxygen supply. Audley notes a paper he co-authored in the South African Medical Journal, which details oxygen use at Groote Schuur during the pandemic.
The study entitled “Prolonged treatment of COVID-19 pneumonia with high-flow nasal oxygen: A story of oxygen and resilience,” notes that 343 patients were admitted with COVID-19 acute hypoxic respiratory failure at the hospital from 7 May to 26 August 2020. These patients were treated with up to 34 HFNO machines. The paper adds that oxygen supply to Groote Schuur is priced at R8.73 per kilogram of liquid oxygen.
Using a 55-year-old woman who spent 40 days on HFNO as a case study, the study shows the success of prolonged high-flow treatment: “Despite the large amount of oxygen used, costs for this inpatient treatment were relatively low,” it states. “An approximated cost analysis of this patient’s oxygen consumption equates to R26 600 while on HFNO.”
In an adjoining room marked “Lung Function”, another patient is breathing into a towering piece of equipment. Leading the way into the room, Perumal explains: “This is the lung function division, which includes technicians who are trained in conducting lung function testing and exercise testing, and other studies really crucial to helping us understand the lung and its problems better.”
Concluding, Perumal tells Spotlight that for all the grief and challenge of their work in the ICU during the pandemic’s peaks, being able to provide aftercare to COVID patients is a privilege.
“There are a lot of repairs to be done,” he says. “Even on psychological and emotional levels. But before then we will likely have to prepare ourselves to be submerged in another wave of COVID-19.”