The very thought spelt excitement. Our Superintendent of Hospital called me to form a COVID-19 Emergency Task Force.I was thrown in at the deep end of the pool but I was thrilled.I thought to myself I will be able to help the people who are feeling so helpless.
From my early days in administration. I had seen the appeal of being a team leader, able to communicate my enthusiasm for my subject, not just to COVID Nursing Incharges but to all those involved in this project across the Hospital.
I don't remember very much by way of preparation and support in advance of taking up the role. I think the view at that time was that if you had enough about you to get such a post, you had enough about you to work out how to do the job effectively.
Little did I know what I was getting into?It was a Herculean task. Let me recount all our challenges.
We were given a team of thirty nursing in-charges who would then have 15 nurses under their charge. I took stock of the situation. We had 25 wards at our disposal initially and 450 Nurses and 20 Resident Doctors. I started getting all the wards of our Hospital evacuated. We had to turn our team of simple health care workers into COVID care super specialists.
We started a teaching programme for all nursing in charges to help them understand the methodology and treatment protocols. Time was not on our side and we had to rush. Each ward already had patients of different diseases and these to be had discharged.
We started spending 14 hours every day. Then came the big bad breaking news. Our Head of department tested COVID Positive. I was stunned. How was it possible? I was with him throughout and attended all the meetings with him. All contacts were traced and the police came calling at my doorstep. Everyone in our colony looked suspiciously at me.
“Am I allowed to feel this?” It was a confusing time, I must prepare myself to the possibility of being infected. My family did not take this well at all. I felt conflicted between my loyalty to my employer and my responsibility towards my family. Take leave, respect your family’s wishes or work, because the patients and your colleagues will face many new challenges and might need you during this time.
I felt guilty for having feelings. Was I allowed to feel feelings? As Critical care specialists we are trained to think rationally and ethically towards our patients. To stoop in during crises or to serve the public. As a member of my family, I felt pressured to do the opposite, put myself first to ensure that I protect my family.
My initial test results came back after 3 days, thankfully I tested negative. I must be tested again due to the window-period of the COVID-19 virus. Now I can take this time in isolation to process what happened and deal with my trauma. This is an opportunity for me to practice what we teach our patients. Reframe what happened, practice mindfulness and prayers.
Incidents that shook me to the coreI would like to mention one specific incident. One day while on rounds I saw that a patient was running around in the ICU. I remembered that this patient was intubated and on a ventilator. How come this patient was running around. There was a major commotion inside the ICU.
How come this patient had snapped the endotracheal tube, IV lines. I called the nurse and demanded an honest explanation. She admitted that she did not put the paralyzing injections in the drip and did not go to attend the patient in her duty of 8 hours. Why! Why! Why! I asked her. The nursing staff said she was pregnant and did not want to go near a ‘COVID Positive’ patient. She wanted to protect her baby. I had no words. I did not know how to react and what to say.
Another incident that affected me. On one of my night rounds I was told that a doctor had refused to intubate a patient. To my amazement I saw that all the Resident Doctors were hesitating to intubate the patient as both their faces would be too close. I thought to myself. How can I help our health care workers from getting infected?
Innovations in times of COVID ERAI made two Innovations. I devised the automatic Cardiopulmonary Resuscitation kit and an Automatic Ambu Bag. These were a big success. I am so proud of our hospital’s performance and our team.
Me and my team began working in earnest following the sequence of actions on patients. Deployment of Rapid Response Teams (RRT), Surveillance, Surveillance in containment zone, Contact listing, Mapping of the containment and buffer zones, Active surveillance, Surveillance in buffer zone and Perimeter Control.All beds had to be separated by one meter from each other.All monitors to be placed alongside each bed.Four ICU had to be prepared along with a severe acute respiratory infection ward and an acute respiratory Illness ward. Protocols for Doctors & patients duty list were made.
Everyone was fearful and anxious during the first month. We quickly realized that. One of the most important issues with caring for COVID-19 patients is proper use of personal protective equipment (PPE) to prevent the caregiver from getting infected.We started inviting tenders for for PPE's, Masks, Sanitizers. Every day we met Company heads to check the quality of all the items related to the COVID 19. Then Resident doctors and other health care staff had to be given accommodations in different hotels. They would stay in the designated hotels for 7 days and do their duty and thereafter they would be quarantined for 14 days.
Medically speaking
• Clinical PresentationWe started examining our patients and collecting statistical data. Mild disease, observed in 81% of patients manifests as self-limited respiratory symptoms typical of a viral pneumonia, including fever, cough, dyspnea, sore throat but also, interestingly, anosmia and dysgeusia. Severe disease, accounting for 14% of the cases in the same cohort, included florid pneumonia which may progress to acute respiratory distress syndrome (ARDS) along with cardiogenic or distributive shock.
Mortality rates associated with severe COVID-19 are high (8-25%), despite aggressive supportive measures including mechanical ventilation. Individuals most vulnerable to developing severe and critical disease included those of advanced age or with significantcomorbid conditions, such as cardiovascular disease, chronic obstructive pulmonary disease, and hypertension.
• Impact of Cardiovascular Disease on Clinical Outcomes among Patients with COVID-19It was revealed that the prevalence rates of hypertension, cardiovascular/ cerebrovascular disease and diabetes mellitus was 17.1%, 16.4% and 9.7%respectively among patients with COVID-19.Importantly, patients with severe disease and those admitted to intensive care units (ICU) had 2-3-fold higher rates of baseline cardio-metabolic conditions than non-severe/ICU patients
• Cardiac InjuryEmerging data suggested that SARS-CoV-2 infection may culminate in serious cardiovascular injury or worsening of existing cardiovascular disease.
Most of the myocardial injury seen with COVID-19 patients is likely related to effects of disease severity, cytokines, vasopressors, hypoxia, and disseminated intravascular coagulation (DIC).Patients with COVID-19 have also been shown to have abnormal coagulation parameters. This includes elevated levels of fibrin-degradation products and D-dimer.
• Heart Failure/ArrhythmiasAnother apparent cardiovascular sequela in patients with COVID-19 is heart failure. Heart failure was reported in 44 (23%) patients and was significantly more frequent among non survivors (52% vs 12%). Furthermore, differentiating heart failure from ARDS is often challenging and further studies, particularly utilizing invasive hemodynamic measurements, are needed.
Cardiac arrhythmias have also been described in patients with COVID-19. In one report, 16.7% of hospitalized patients experienced an arrhythmia (of any type). The development of an arrhythmia also correlated with greater odds of an ICU stay.
I will share the most important insight into some of the do's and dont's during the Covid outbreak.
DO'S & DON'TSDo's
• Hand wash
• Cover Your Mouth& Nose
• Consult A Doctor If Sick
• Stay Indoors
DONT'S
• Avoid close contact with anyone
• Do Not Spit
• Avoid Using Public Transport
• Do Not Use Over The Counter Medicines
• Don't Panic, Take It Easy
• Don't Touch Your Face
We started following the TIME LINE of this virus(lab wise):- Day 0: infected
Upto Day 5: Onset of symptoms
Day 7: IgM positive (D7- D 21)
Day 14: IgG positive
Days 1-28: SARS CoV2 RNA & Antigens will be positive
Day 21: IgM disappears
Day 28: SARS CoV2 RNA & Antigens disappear
D0 - D5: Asymptomatic Phase
D0 -D7: Window Period (Only PCR is positive in this phase)
D 14- D21: Decline Phase (Still Infective)
D 21- D28: Convalescence Phase (PCR may be positive but not infective)
COVID Treatment Protocol : simplified. 1) All covid positive patients
* Tab HCQ 400 twice a day for 1 day. Then 200 twice a day for 4- 9 days.
* Tab Oseltamivir 1-0-1 for 5 days.
* Tab Ivermectin 12mg twice a day for 2 days.
* Tab Doxy 100 twice a day for 5 days.
(In case of fever add Tab Azee 500 twice a day for 5 days, add only for young patients without co morbidity. For those with co morbidityadd Cefixime 200 twice a day/ 5 days or Augmentin.
2) To all Patients on Oxygen
a) * All the above PLUS
b) * Inj Clexane 0.6 cc OD /BD for 5 days ( BD in seriously ill)
* Inj Methyl prednisone 40- 500 mg BD for 3 days (500 in seriously ill)
(instead of Inj methyl: use Inj Dexa 8mg tds in Diabetes patients)
3) Salvage treatment: (To take permission of consultants immediately)
* Inj magsulf 2gm iv tds diluted for 2 days
* Inj Methylene Blue diluted once may be repeat after 8 hours.
4) High end Drugs: (depends on availability and permission of consultant)
a)Inj Tocilizumab: 300-400 IV infusion. Stat only SOS repeat after 12/24 hours.
To all patients with pneumonitis requiring Oxygen. (ideally to those with IL6 levels more than 20)
b) Tab Ibrutinib 3 tab of 140 once/ day for 5 days
5)Supportive treatment * Vitamin B with Zinc, * Vitamin A and D, * Cough Syrup, * Paracetamol, * IV Fluids/ Others
6) Antibiotics- Mild to severe: ceftriaxone - piptaz- meropenum.
II) Prophylaxis byICMR: * Tab HCQ 400 twice a day for 1 day then once a week for 3 weeks (patients)
* Suggestion to add: * Tab Ivermectin once a week / 3 weeks.
* Tab Doxy 100 once a week / 3 weeks.
We evolved a Brief Severity Scoring SystemSeverity class Criteria Triage
Asymptomatic to mild No symptoms or common cold–like symptoms Community treatment centers
Moderate Body temperature 37.5°C and cough Community hospitals
Severe Suspected severe pneumonia (body temperature over 38°C Tertiary hospitals
lasting more than 3 days, respiratory symptoms)
Critical Suspected critical pneumonia (shortness of breath for Tertiary hospitals / ICU care
more than 1 day, respiratory rate of 30 breaths/minute or
more)
Severity class was determined by physician volunteers who interviewed patients by phone. The severity class and subsequent triage could be modified by factors such as age, co morbidities, end-of-life status, and dwelling in a long-term care facility.
ConclusionThis deadly killer cannot be stopped until we figure out a vaccine. However, maintaining good hygiene such as covering your mouth while coughing and sneezing, use of the hand sanitizer and wearing and anti-pollution mask will do you good. Say yes to hygiene and stay safe. Over three billion people in the world are quarantined or in social isolation.Border closings and restrictions on transportation are in place, among others measures.
As a result, widely used information technologies have become the main way that people interact and communicate. We realized that teleconsultations are a safe and effective way to assess suspected cases and guide the patient's diagnosis and treatment, minimizing the risk of disease transmission.
COVID-19 has already stressed our nation’s health care system.COVID-19 is not going to leave quickly, and if the public abandons wearing a mask and social distancing, then it will return.
New medicines are coming rapidly in the market.
Of this:
1. Cipremi Remdesivir.
2. Steroid Dexamethasone.
3. Favipiravir.
The above will be coming in the market soon. They will surely help ease the burden. We are entering a dangerous phase of this covid pandemic. Number of infected people are rising alarmingly. In this phase we have to be responsible for ourselves and for others around us.
I am allowed to be both human and a critical care specialist. To have feelings and rational thoughts. I am allowed to feel this, and by feeling this, I will heal from the trauma and emotions caused by this Pandemic.
When thinking about life, remember this. No amount of guilt can solve the past, and no amount of anxiety can change the future.
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The author, Dr. Tarun Lall is Senior Professor, Additional Nodal Officer Incharge & Medical Officer Incharge OT & ICU, Trauma Centre, Sawai Mansingh Hospital, Jaipur
