Editor's note: This series will focus on the difficulties faced by the medical fraternity at COVID-19 hospitals, their duty hours, access to protective gear, facilities they get during quarantine, how are their families coping with this new reality across different states in the country. This is the tenth part of the series.
The fervent hope of Dr Bhuvana Krishna, professor and head, Department of Critical Care at St John's Medical College Hospital, Bangalore is for normalcy. The normalcy of what she terms as the “hustle-bustle of the ICU pecked now and then by emergencies’. And in the midst of this hope is the day the doctors, nurses and the paramedical staff can walk in their normal clothes, donning just their overcoats and working ‘unarmoured’. There is poignancy in the way the doctor describes her life and of her team members at the hospital.
Early February, the hospital had begun preparations to deal with the growing pandemic. She recalls how the world changed for them swiftly with the arrival of coronavirus suspect case into the COVID-ICU on 21 March. Now that date and month seem like an aeon as time since then has been rapidly folding in on itself with healthcare professionals continuously caring for COVID-19 cases, suspects, and nothing else.
Krishna listed a slew of missed familiar routine—“no classes, no lunchtime gossip, coffee lounge moved into a small room where no more than four can sit and hungrily gobble the bun dipped in sugary warm water.” Then there is the oft-said and borne pressures of wearing the Personal Protective (PPE) kit. “Enduring physical discomfort from tight, well-fitting PPEs, to ignoring hunger, thirst and nature’s call, in an effort to save precious PPE. Long days with no weekend offs makes one struggle to maintain sanity within and outside,” Krishna said.
Assisting doctors in patient care are nurses who fear not being able to do ‘enough’ for their patients. A full PPE which they have never used before, includes one or more gowns or coveralls, head coverings, masks, goggles, gloves, shoe covers, and face shields. Once anyone gets into a PPE, it's hard to hear, and unbearably hot, said Dr Manu Varma MK of the Department of Critical Care. He said the summer heat can make one feel the sweat pouring down the back. Looking after COVID-19 patients is physically demanding work and he related what nurses had told him of their experiences.
“The goggles fog with every breath, all sense organs are blurred. One finds it difficult to feel the cold peripheries of a patient, cannot see the numbers on infusion pumps and monitors easily; writing with a pen is no more fluent and distinguishing the look-alike drugs is difficult.” What’s worse for the hard-working nurses is to hope they don't feel the urge to sip water or take a toilet break during the 7-hour shift. “A lack of hygiene would transmit fomites from COVID-19 confirmed patient to a suspect,” Manu Varma MK said.
Doctors recalled how they were caught off-guard when the first COVID-19 suspect walked into the hospital. St John’s first COVID-19 suspect case was a Chinese national from Wuhan.
“I clumsily wore my PPE kit. I wasn’t still adept at it as we had just started practicing how to don and doff it,” said Dr Sanjiv Lewin, Chief of Medical Services, the first contact doctor. “The Chinese national asked me for directions to the centre he had to go for tests and gave me his phone so I could pinpoint the place on Google Maps. I had taken off my gloves by then. I took the phone from the COVID-19 suspect and gave him directions on the map. After I returned the phone, I realised the seriousness of what I had done. I self-quarantined myself and prayed for my well-being as I was terrified of infecting my family and colleagues. I had a big smile the day the period ended without any complications,” said Lewin.
St John’s is proud of how the 1,350-bed hospital with over 800 doctors and 1,000 nurses prepped themselves to meet with the outbreak of coronavirus when patients--COVID-19 positive and the suspects--trooped in and more importantly segregated their care while continuing to provide treatment to non-COVID patients. A charitable tertiary care hospital attached to a private medical college since 1963, St John's hospital mainly caters to the middle class and poor, especially rural and the underserved population.
The most crucial gear for healthcare professionals--the PPE kits are in a short supply at the hospital since the outbreak of coronavirus. This meant the hospital could not afford isolated individual rooms for COVID-19 patients. Lewin said, “We have no isolation individual rooms but 90-beds are distributed as cohort isolation wards. We also have to segregate the Acute Respiratory Illness patients who are susceptible as they have lung issues, and have triages with segregated areas for care never mixing the two.”
What makes Levin furious is the lack of PPE kits, the fear of running out of quality masks, gloves, gowns and the challenges of disproportionate distribution of these important gear by distributors -- government and private. He said over 80 percent of healthcare in Bengaluru is taken care of by the private sector with many hospitals charging exorbitant fees for their services even during prevailing challenging circumstances. The poor and the middle class cannot go to these ‘corporate style care’ hospitals, and the government hospitals are blocked for COVID-related patients, Lewin said.
“Access to government-private supplies of kits, etc., for COVID-19 appears to be disproportionately distributed to these hospitals who do not have full-blown COVID-19 cases. It is not uncommon for many of these to say they do not have space and thus turn away SARI—Severe Acute Respiratory Illness patients that end up in hospitals like ours with no warning or referrals, thus risking manpower further," he said.
So far, St John's Hospital has screened over 831 patients as on 16 May, swabbed 351 and have had four COVID-19 positive patients so far. "I have hardly enough kits and masks to last me for the next three weeks and it is being monitored on a daily basis,” Lewin said.
The hospital has had one coronvirus-related death and that was due to other complications of an underlying heart infection and also because the patient was diabetic.
“A patient was on the ventilator for three weeks and the bill was Rs 6 lakh. But he refused to pay and just left. What do we do with them? How does one sustain operations in these circumstances?” Lewin asked.
The revenues of the hospital are linked to footfalls and occupancy which has gone down to 29 percent since the outbreak of COVID-19. Average outpatient footfalls pre-COVID-19 would be 2,400 patients per day and occupancy wast 80 percent. Since the hospital started treating COVID-19 cases and suspects, the number of patients have gone down. With 39 percent occupancy and massive drop in patients to less than 500-1,000 outpatients per day, 'naturally income and revenues just don’t match', Levin said. “We haven’t even hiked our charges,” he added.
Levin said the hospital has been actively participating in government efforts to contain the epidemic, but yet its pleas for access to quality, affordable, rate-controlled PPE-like kits have been unsuccessful so far in spite of inspections of its facilities. He said that he has attended every meeting and had written to authorities for supplies (PPE kits, masks, etc).
“We are admitting patients that other hospitals refuse. Since 10 February, we have not received a single surgical mask. We have a responsibility to serve, but our healthcare workers must be protected to enable the continuation of all services,” he said.
When sanitisers ran out at the hospital, its biochemists came up with one. The hospital has recently started a laundry and tailoring unit to make masks and PPE kits. Lewin said the hospital has no alternative than to make them as prices for these items have gone up. In normal times a three-ply mask would be a available for Rs 1.40, but now its price is Rs 12 to Rs 14.
The pandemic is bound to change medical practice going forward, cautioned Lewin. The gross inadequacies of the health budget and the fear of endangering health workers will take its toll, he said.
Illness versus public health
There is another group of people who are angry at the way COVID-19 has been allowed to gather fear and lead to panic and in extreme cases, violence. Public health specialists are angry that the government hasn’t done much to focus on the Panchayats or work itself from bottom-up to create awareness.
Public health is about prevention of disease and hygiene, they said. What has COVID-19 got to do with medicine? There is no medicine as such for it now. COVID-19 is a public health concern, said Prasanna Saligram, a public health and community health researcher with Jana Swasthya Abhiyan Karnataka.
The Jan Swasthya Abhiyan (JSA) was formed in 2001, with the coming together of 18 national networks that had organised activities across the country in the lead up to the First Global Peoples Health Assembly, in Dhaka in December 2000. The JSA forms the Indian regional circle of the global People’s Health Movement (PHM). At present, it is the major national platform that co-ordinates activities and actions on health and healthcare across the country.
Saligram said, “Public health is ignored. The medical fraternity can do little to treat COVID-19.” So what should people do then? “It is important to create awareness. Fear and stigma is triggering attacks on healthcare works,” Saligram said.
Talking to Firstpost, another public health specialist raised the issue of the recorded messages cautioning the caller when he/she makes a call. “What does this constant messaging do to the listener besides increasing their angst? What about those who are not literate and struggling--without being able to work, and have to take care of their families? This constant messaging is going to create fear.”
The government has not factored in, feels Saligram the different strata of society in its one-message-fits-all communication regarding prevention of spread of COVID-19. "When you ask people to wash their hands to protect themselves, is that possible for a section of society for whom water is a scarce commodity," he asked.
“For the many others who have to depend on tankers or on public resources—what does this constant washing of hands mean to them? The other thing that is spoken of in the government's communication is social distancing—isn’t this akin to Brahmanisation where the dominant caste has been trampled upon and kept at a distance since ages in India? The word to use would be physical distancing instead,” he said.
But physical distancing is an impossible task for someone living in an 8x10 room with other family members. So what would Saligram suggest? He said that the state governments in India should follow the Kerala government model. “Kerala activated its Panchayats. Decentralise power and give authority to those organisations that know the pulse of the people. Kerala is not looking at the Centre to take care of the health of its people,” he said.
Healthcare professionals suggest three ‘fundamental’ things that should be followed:
Testing, contact tracing and more tests. “Test every citizen,” they said. Those with other health complications—heart, kidney, cardiovascular, among others are more susceptible to COVID-19. The virus does not kill directly but it can attack any part of the body which is susceptible and then the illness become COVID-19-related.
Saligram said, hardly 2-5 percent of the population has had COVID-19 but the rest of the population has been shut indoors due to the government announced lockdown measures.
He suggested the government identify hotspots and not allow people to enter these places. Let the rest of the population to move out, Saligram said.
For the large majority that do not have access to water, soaps and sanitizers, soap bins for communities would work well. There should be an awareness created instead of fear as is being felt by most people now, said Saligram. Write messages with photographs/drawings on walls from the village-level so that people can understand the symptoms of the pandemic and be able to protect themselves. Stage street plays to create awareness about safety and prevention of the illness, he said.
The government has perhaps not realised the mental havoc it has created with lockdowns and the COVID-19 se bach ke rehna messages, said Saligram.
The government has not been able to provide adequate protective gear to healthcare professionals It has also not been able to transmit the message to the public in a manner that citizens are not alarmed. The lockdown has kept the public reined in and that has mental consequences, said mental health experts. Unlike Kerala which has become a model for critical care and prevention of COVID-19, the success of that state has not been replicated any where else in the country. The government has thus exposed the underbelly of the inadequate medical system that it runs.
Updated Date: May 20, 2020 23:58:02 IST