Coronavirus Outbreak: In Kolkata, doctors on the frontline forced to make do with used gloves, raincoats for gowns
What entails without a proper PPE and shared by different medical professionals across the globe on social media has only triggered fear among healthcare professionals.
It's Saturday, 28 March, 2020. I googled the weather conditions in Kolkata. The temperature had reached 38°C on the higher side and the minimum had been recorded at 24°C. The precipitation was at 0 percent and humidity was at 38 percent, which essentially meant it was uncomfortably hot. How would anyone feel wearing a raincoat during this weather? Hell. Period.
In gross violation of the prescribed standards for PPE (personal protective equipment) by the World Health Organisation (WHO) — raincoats, poor quality surgical masks, used gloves — are among the items with which the West Bengal government is arming its doctors who are literally behind enemy lines to fight the novel coronavirus or the COVID-19 .
The WHO interim guidance issued on 19 March, 2020 on the Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19) states: "Health care workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask, and eye protection (goggles or face shield). Specifically, for aerosol-generating procedures (e.g. tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) health care workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant."
Shockingly at these times of such grave medical threat, doctors in Kolkata are made to beg for prescribed PPE.
"We have only one concern. We need proper protective kits. More so because we don’t want to affect ourselves and spread the disease more. We are staying in the hostel for many days and not going home just because we don’t want to affect our families too. But if we get infected, the hostel residents might get infected too. And everyone is a doctor," said a medical intern from IPGMER and SSKM Hospital who has been posted at the Infectious Diseases & Beliaghata General Hospital (ID & BG Hospital) in Kolkata. The intern preferred to remain anonymous and will be referred to as Doctor A in further references.
"What we were given instead of proper PPE was rainwear and some of it was even torn. In some cases, the gloves were also torn. We can't work in these conditions. We are more conscious because if we get infected we might end up spreading the disease to people who come to us for check-ups and are already immunocompromised. If we the healthcare workers or the doctors get affected, the chances of transmission are more and it will spread like wildfire," the doctor said.
At the ID & BG Hospital, the duty hours are long, with those posted in the Emergency Room (ER) working for 12 hours at a stretch. Their counterparts in indoor duties also have to work for 12 hours. Those in round duties work from 9 am to 2 pm. Doctors dealing with the novel coronavirus have not encountered this particular strain of virus before, making their task even more challenging, not only dangerous.
Whatever on the job training the doctors are getting at the ID & BG Hospital is also quite basic.
On Tuesday (24 March, 2020), a few interns from the Kolkata Medical College & Hospital who were posted at the COVID-19 ward in ID & BG Hospital, approached the medical superintendent cum vice-principal (MSVP) complaining about the absence of surgical masks only to be rudely told, "Dogs don’t need a mask. Why do you?"
Defining PPE, the Hospital Infection Control Guidelines of the Indian Council of Medical Research say that "PPE refers to a variety of barriers, used alone or in combination, to protect mucous membranes, airways, skin and clothing from contact with infectious agents. PPE used as part of standard precautions includes aprons, gowns, gloves, surgical masks, protective eyewear and face shields."
The document also clearly states the purpose of the use of PPE by health care professionals.
It says, "Using personal protective equipment provides a physical barrier between micro-organisms and the wearer. It offers protection by helping to prevent micro-organisms from contaminating hands, eyes, clothing, hair and shoes and being transmitted to other patients and staff."
The document also says, "The sole aim of universal precautions is to prevent transmission of infections from the patient to the health care provider."
The table below, which is sourced from the Indian Council of Medical Research, gives the summary of precautions to prevent the spreading and transmission of infections.
|Organism based precaution||MRSA, Clostridium difficile, lice, scabies||N. meningitidis, mumps, Pertussis, norovirus, influenza invasive group A Streptococcus||Pulmonary tuberculosis, measles, chicken pox, disseminated zoster|
|Syndromic precaution||Draining wound Diarrhea (not yet diagnosed) Infestation||Toxic shock||Fever, weight loss, cough, high TB risk|
|Negative pressure room||No||No||Yes|
|PPE- Staff||Gown + gloves||Gown + gloves + surgical grade fluid resistant mask||Gown + gloves + N95 mask|
|Visitor – PPE||Gown + gloves||Gown + gloves + surgical grade fluid resistant mask||Surgical grade mask|
|Transporting patient||Patient – No
Staff – No
|Patient – Yes
Staff – Yes
|Patient – Yes
Staff – No
|Cleaning||Precaution clean||Precaution clean||Precaution clean|
"We know the person engaged in the ER should wear an N95 mask according to ICMR guidelines. And the doctors and other healthcare workers working in other wards should wear surgical masks. These interns were demanding surgical masks but were forced to leave following the taunt from the medical officer," Doctor A said. "Next day after we demanded again, the surgical masks were provided but only after a wait of three hours. During these three hours, we didn't work. Also, we are being asked to reuse N95/surgical masks if at all they are being provided. Because the supply is scarce."
"My co-interns working at the ER in IPGMER and SSKM Hospital and the fever units of Sambhunath Pandit Hospital and Kolkata Medical College & Hospital are all given rainwear as PPE. Only one pair of a surgical mask with a fine single-layer has been provided and only one pair of gloves has been provided which is also very thin. In a proper PPE kit, there are four pairs of gloves. People have no choice but to continue working with those poor quality safety equipment," said Doctor A.
"It is very hot and uncomfortable to work in that outfit. I wore that PPE kit for an hour and everything I was wearing got drenched in sweat," said Doctor A.
The most worrisome part is when hoards of patients throng the hospitals every day it is unclear who might be a COVID-19 patient unless the tests are conducted. This increases the risks manifold for the healthcare personnel without a proper PPE and also to other non- COVID-19 patients. The less number of testing in India has only compounded the fears in the medical community.
"We are being posted in different hospitals due to this epidemic crisis. In these times the least we can expect from the administration is the availability of proper PPE kits. The thing is the material they are providing us with is no better than raincoats. The brand names of the manufacturing firms are put on the front and the item is marked as rainwear. It is like we are advertising them. There is a huge fault with them. There is a huge risk of exposure even when we are dawning the equipment. It would be wrong to say that not a single proper PPE is available but the people who need them most like the frontline health care professionals are not getting them. Unless we are protected we will be harbouring the disease and spread it to healthy patients who come to us for help. We will be essentially more harm than good in such a situation," said Doctor B, who is a resident post-graduate trainee at SSKM Medical College & Hospital and currently posted in the fever clinic of the institution.
The situation is no different in Kolkata Medical College & Hospital with a capacity of 3,000 beds which has been made as the apex institution or the nodal agency in West Bengal to deal with the novel coronavirus in the state which essentially means the institution will deal with COVID-19 patients only.
"Earlier I was posted in Beliaghata ID & BG Hospital which was previously the nodal centre for infectious diseases. Now I am back with my parent institution Kolkata Medical College & Hospital. The first few days we did not get any PPE which is a standard protocol in ER. We never know whether a patient is a positive or a suspect without screening. We did not receive the N95 respirator which is a minimum filter you need to prevent aerosol generated diseases. Our PPE is supposed to cover all the bare skin surface like your eyes etc. Nothing of that sort was provided," Doctor C, who is a medical intern, told FirstPost.
"Today (28 March, 2020) we had the training for using the PPE when the Kolkata Medical College & Hospital starts functioning as an exclusive COVID-19 medical facility from Monday (30 March, 2020). Even during the training, we were given raincoats and no N95 masks or goggles were provided to us. On Monday also we are supposed to get raincoats because this is what has arrived at the hospital and they are passing it off as PPE," said Doctor C.
Another doctor, whom we will refer to as Doctor D, expressed similar fears.
"Initially we thought they were having a stopgap mechanism but then over the last week, we have been telling the authority that it is not the appropriate PPE. As of today, we are still to get the right PPE. Since we are going to deal with the positive patients here at the Kolkata Medical College & Hospital all including nurses, doctors and other medical staff are apprehensive of the situation. Without the proper equipment for healthcare professionals, it is unlikely that it is going to start functioning from Monday. We have made it clear to the administration that without proper equipment we won't join work," said Doctor D.
Around 150-200 healthcare professionals at the Kolkata Medical College & Hospital will be dealing with the COVID-19 pandemic.
What entails without a proper PPE and shared by different medical professionals across the globe on social media has only triggered fear among healthcare professionals.
The death of Kious Kelly, a 48-year-old assistant nurse manager at Mount Sinai West in Manhattan, New York, may have been the first New York City nurse to die from the virus. This is what his sister Marya Patrice Sherron wrote on Facebook: "In time, the truth regarding the lack of PPE in his unit and hospital will come to light. Nevertheless, Kious served."
Diana Torres, who is a colleague of Kelly, expressed her outrage on Facebook over the absence of "PROPER PPE".
Response from the administration
Soumitra Ghosh, head of Department of General Medicine, IPGMER and SSKM Hospital, who is also part of the 12-member committee of experts formed by the West Bengal government to combat the epidemic spread of COVID-19 , said that the problem is not just limited to West Bengal.
"This is a problem across the globe and not just West Bengal or the Indian sub-continent. It is not the time to blame anybody. The issue should be raised that the healthcare providers are the biggest warriors against this pandemic and they should be protected. In New York also, they are reusing PPEs. Human resources are the most precious resources. Blaming will not solve the problem. However, it is also a fact that the biggest warriors are not being provided with adequate protection," Ghosh said.
"Wuhan was the hub from where the medical masks were supplied and 90 percent of the globe depended on them. Money is not an issue but the scarcity of the product is," he said.
Kolkata Medical College & Hospital, MSVP, Indranil Biswas accepted that there has been a problem with PPE but expressed optimism that things will change.
"The government is going to change that. They have initially ordered to one firm which has provided with these kits. We have conveyed it to the government that these are not ideal PPEs and are very difficult to use. So from Monday, we are supposed to get the ideal PPEs," Biswas told Firstpost.
Despite the shortcomings, the Kolkata Medical College & Hospital MSVP sounded positive that the institution will be functional from Monday.
"We have not started functioning as yet. All the doctors are post-graduate and they are very much interested in the effort. They have already familiarised themselves with the standard operating procedures on how to run this hospital for the novel coronavirus patients. These are the basic things and it will be changed. Government is trying hard to change things," he said.
The institution has not reached out to any corporates for support yet.
"Actually at present, it is not required. The thing is that even if you have the money to procure proper PPEs in such a large quantity is very difficult. The government has ordered for those. We are hoping for the best. Let's see on Monday," said Biswas.
He also sought to allay fears over the alleged lack of negative pressure wards where infected patients will be kept in the facility.
"This has changed. Now the entire building has been converted into negative pressure wards where only infected patients will be kept," the Kolkata Medical College & Hospital MSVP said.
He further assured that adequate steps are being taken to handle the biomedical waste in the facility.
"The handling of the biomedical waste will be as per WHO guidelines. We already have a proper biomedical wastage handling team. That should not be a problem," he said.
The Kolkata Medical College & Hospital MSVP did accept that they are "facing a lot of problems".
"Everything depends on the number of patients ultimately infected. If the lockdown is properly maintained then I think the problem will be minimum. We can only hope for the best," said Biswas.
Amrita Bhattacharya, who is a medical officer at the ID & BG Hospital, agreed that there were hiccups initially.
"There were a few packets of PPEs which were raincoats and other inappropriate gloves. Now this issue has been addressed at the ID & BG Hospital," said Chakrabarty.
Emails and WhatsApp messages were sent to West Bengal Health and Family Welfare department, Principal Secretary Vivek Kumar and Trinamool Congress MP Derek O'Brien seeking their response. The copy will be updated accordingly if they choose to respond.
Unique circumstances force replacement of standard PPE
Before anyone cites how healthcare professionals in Spain are using garbage bags as PPE, let this also be remembered that these are being used as the last resort "in hopes of protecting themselves against contracting the novel coronavirus ".
The grim situation is visible according to a story by The Associated Press and published on The New York Times: "He (Kious Kelly) worked at the same hospital where three nurses, frustrated at the scarcity of supplies, posted pictures of themselves on social media wearing makeshift garbage bag protective gowns, an image splashed on Thursday’s New York Post cover with the headline: “TREATED LIKE TRASH"."
"If we don't have proper PPEs just at the beginning whereas other states like Kerala, Maharashtra do, I don't know how the state thinks it can combat the disease till the end," said Doctor C.
What extensive use of proper PPE can do is also another story which was depicted by Alessia Bonari, an Italian nurse at a Milan hospital, with bruises all over her face.
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Sono i un'infermiera e in questo momento mi trovo ad affrontare questa emergenza sanitaria. Ho paura anche io, ma non di andare a fare la spesa, ho paura di andare a lavoro. Ho paura perché la mascherina potrebbe non aderire bene al viso, o potrei essermi toccata accidentalmente con i guanti sporchi, o magari le lenti non mi coprono nel tutto gli occhi e qualcosa potrebbe essere passato. Sono stanca fisicamente perché i dispositivi di protezione fanno male, il camice fa sudare e una volta vestita non posso più andare in bagno o bere per sei ore. Sono stanca psicologicamente, e come me lo sono tutti i miei colleghi che da settimane si trovano nella mia stessa condizione, ma questo non ci impedirà di svolgere il nostro lavoro come abbiamo sempre fatto. Continuerò a curare e prendermi cura dei miei pazienti, perché sono fiera e innamorata del mio lavoro. Quello che chiedo a chiunque stia leggendo questo post è di non vanificare lo sforzo che stiamo facendo, di essere altruisti, di stare in casa e così proteggere chi è più fragile. Noi giovani non siamo immuni al coronavirus , anche noi ci possiamo ammalare, o peggio ancora possiamo far ammalare. Non mi posso permettere il lusso di tornarmene a casa mia in quarantena, devo andare a lavoro e fare la mia parte. Voi fate la vostra, ve lo chiedo per favore.
Low number of tests sparks anxiety Doctor B also expressed concerns about the relatively low number of testing in India unlike other countries like the US, South Korea or China which have focussed highly on testing. "The testing should cover a wider base of patients. It is very restricted now. It is giving us a false sense of security. I know India has a relatively low number of patients compared to other countries like Spain, Italy, China or the US. We can't say for sure whether we are in stage 2 or 3. How do you expect to get the actual number if you are testing such a low number of patients," said Doctor B. This is what WHO also suggested as well.
We have a simple message for all countries fighting #COVID19: test, test, test. The most effective way to prevent #coronavirus infections and save lives is breaking the chains of transmission. And to do that, you must test and isolate. https://t.co/cOOs5wMCZE — Tedros Adhanom Ghebreyesus (@DrTedros) March 16, 2020
According to the India State-Level Estimates study conducted by The Center For Disease Dynamics, Economics & Policy, an organisation involved in multidisciplinary research to advance the health and wellbeing of human populations, "delays in testing are seriously reducing the ability of the population to self—protect."
"At baseline (without interventions), between 300 and 400 million Indians are likely to be infected by July. Most of these cases will be mild. At the peak (somewhere between April and May 2020), 100 million individuals will be infected. Of these, approximately 10 million will be severe and about 2-4 million will require hospitalization. This is the most critical period," the report said.
The way ahead
It is the medical fraternity which is the final frontier between the novel coronavirus and the apocalypse that threatens even as many corners of the planet have been filled up with legions of sick humans. For them, I dare say, contra spem spero (I hope against hope).
Red Cross comes through
The ministry of health took to Twitter on Monday to announce that 10,000 PPE coveralls donated by the Red Cross had been received and are being distributed. The ministry, in a long Twitter thread, said two domestic manufacturers are producing 50,000 N95 masks per day, which is expected to increase to 1 lakh per day within the next week.
The ministry also stated that 11.95 lakh N94 masks are in stock, that an addition 5 lakh masks were distributed over the past two days and 1.40 lakh masks are being distributed today. The DRDO will begin manufacturing 20,000 N99 masks per day within the next week, the ministry further said and that Agva Healthcare, Noida has been given an order to manufacture 10,000 ventilators within a month, the supplies of which are expected to commence in the second week of April.
Over 14,000 ventilators are earmarked for COVID-19 patients in various hospitals across the country. Bharat Electronics has been asked to manufacture 30,000 ventilators over the next two months in collaboration with local manufacturers. Automobile manufacturers have been asked to manufacture ventilators and are working towards this end, the ministry said.
The ministry said Maharashtra reported the highest number of daily cases at 31,643, followed by Punjab with 2,868 cases and Karnataka with 2,792 cases
The nationwide tally of COVID-19 cases rose to 1,26,86,049 while the toll increased to 1,65,547, the Union health ministry data showed
India reports highest single-day spike of over 1.15 lakh new COVID-19 cases; tally reaches 1,28,01,785
A total of 1,15,736 infections were reported in a day, while the toll rose to 1,66,177 with 630 new fatalities, the Union health ministry's data showed