A peek inside Covid war room: Tales from the ER – india news


When the pandemic began to grip Delhi in early April, the Lok Nayak Jai Prakash Narayan (LNJP) hospital was the first in the city to be declared a dedicated Covid-19 facility. So far, LNJP has successfully treated 3600 patients. Even as Delhi now has seven dedicated Covid-19 government hospitals, LNJP remains the biggest facility in the city, housing 522 patients at the moment.

LNJP is also a teaching hospital that houses the prestigious Maulana Azad Medical College (MAMC), and in the fight against the pandemic, the service of around 450 postgraduate students of the college — resident doctors — has been invaluable. They form the backbone of the medical force on the ground, taking care of the wards in 14-day shifts, of varying hours, at a time. The “senior residents”, or doctors in their final year of postgraduation, were to have appeared for exams in April, received their degrees, and got jobs by now.

But the pandemic put a halt to that, and they were pressed into service. This is the story of the experiences of two senior residents, Dr Saurav Kumar, 26, doing his MS in general surgery, and Dr Richa Narang, 29, doing hers in anesthesiology, as recounted by them over multiple phone calls.

The conversations highlight the Covid-19 journey from the viewpoint of health care professionals on the front line – their anxieties and challenges, and the emotional and physical load it has taken on them. It also highlights the shortcomings in the medical infrastructure and system — many of which, particularly at LNJP, have been addressed, improved and strengthened over the past three months, which these accounts also reflect.

Dr Richa Narang: During my first posting, I was very scared. This was in April. The hospital was unprepared. We had an ICU [intensive care unit] on the fourth floor with 15 beds, already occupied with patients, and then suddenly, Covid-19 patients started coming and we had to make another ICU. We scrambled to turn some disused rooms into ICUs.

The isolation was not proper at all and we were very scared. Our counter was right in the patient’s room. The PPE [personal protective equipment] kits were faulty. In those initial days, we did not have enough ventilators, oxygen masks, cannulas. It was chaos. We did not know who was doing what or going where, whom to admit, whom not to admit… then things got better.

Dr Saurav Kumar: The day we had to shift from the surgical block in the first week of April was very hard. Some of our friends who were working at the casualty called and said, ‘Today we will get around 150 Covid patients’. I said, ‘Boss that must be a rumour, we can’t possibly get that many patients in one go’… then they started to come, and we got a message that we will have to clear out the surgical ward. That’s 36 beds. I had been working in that ward for three years and I knew it like the back of my hand. In one hour, we were completely uprooted.

When the order came, the first thing we did was go around and ask patients who could be discharged if they wanted to be discharged and sent to another hospital since LNJP would become a Covid hospital. Some of them agreed. But we also had eight patients with open wounds or in post-surgical care whom we had to shift out. There was one diabetic patient whose foot and leg had become gangrenous and had to be amputated from below the knee. His wound was open and required dressing every day, his immunity was low, electrolytes were all over the chart, he needed close monitoring, lots of care. Shifting someone like him was so hard, but we managed, and he was safe.

But now (in the new ward) we did not know where the duty room was, where the nurse’s station was, where the toilets were.

PPE CHALLENGE

Narang: The day before my first posting, I got a message saying I was to be on Covid duty from the following day. In the morning, I attended a seminar at 11am on safety, basically how to don and take of the PPE. My first thought was, ‘When will I get to see my parents?’ We had our final exams scheduled for April, so I was busy preparing for it and had not gone home since February. Then the pandemic started, and all plans went out of the window, and now here I was, heading into a Covid ICU. I did not tell my parents about my posting.

Kumar: We took the place, which used to be our OPD [out-patient department] block in non-Covid days, to create a donning area. It is not connected to any Covid wards, so no cross-infection would happen. You change there, and then you go to whichever ward you are posted in. Four doctors are posted together on a floor with two wards (each floor has 72 beds), and we reach the donning area together and help each other. First we do our handwashing, then we wear the first layer of gloves, then the shoe covers, then the coverall, then an N95 mask and a surgical mask on top of that, then the cap, then a second layer of gloves, then goggles or face shield.

Narang: PPE suits are heavy and depressing. I felt suffocated; the headgear, the mask, the goggles, everything has to fit tightly. After a few hours, the goggles start to fog up and there is no way to wipe it, so you have to work with poor visibility. It is so hard to do anything. Imagine intubating a patient while wearing all of that, and sweating in that heat.

Communication was such a problem. No one could hear me unless I screamed. When you are handling critical patients, every word is important. So we put in place a system of hand gestures between the doctors and the nursing staff. Also, you can’t go to the bathroom after wearing your PPE, or drink water, or eat. ICU shifts were of six hours, so we had to endure that for the entire duration. There were times when I would be terribly thirsty, desperate to go the washroom, drenched in sweat and finding it difficult to see through the fogged goggles — all at the same time.

Kumar: May 13 was the first time I worked in the Covid ward. I worked for the next 14 days. That’s the first time I wore PPE. Within 15 minutes, I was drenched in sweat. It was like someone had poured a bucket of water on me. It’s supposed to be impervious to water, so it has a laminated layer of plastic. In May, with the heatwave on, it was terrible. After half an hour, sweat was dripping like a waterfall from my forehead. The donning area is on the fourth floor — we stopped using lifts, and we blocked off the walkways so that people don’t walk between the wards. So I wore my PPE, walked down four floors, out of the OPD building, walked 200 metres, and then climbed up four floors again to my Covid ward. As I was walking down the stairs, my first thoughts were: ‘Is this thing open from somewhere? Is there a gap I missed? Did I wear it correctly?’

When I reached the ward, the first thing I did was to ask the nursing staff to recheck everything. Then I was telling myself, there is nothing to fear, you have been here for three years, it’s the same hospital, there is nothing to worry about. I was reminding myself, that I am the kind of person who wants to volunteer, who wants to be challenged… But before I started my shift, I had spoken to a colleague who had already finished his. First thing I asked was: ‘How scared should I be?’

I was posted at the Covid ward in the surgical block, where the stable patients are housed. The conditions of patients at the Covid ICU and Covid medical block is worse; this is where they are shifted when they need oxygen support. My colleague told me, ‘These patients are stable, but they all have surgical elements, fractures, abscesses, some need dialysis, so treat the patient as a whole, don’t only think Covid, Covid, Covid’. He said, ‘Before you change into your PPE, you should know what you are supposed to do, step by step, when you enter the ward. Don’t plan after you put on your kit. The main work in the morning shift is to do the patient round, and to take samples that are listed for testing. Also, you have to be very cautious with Covid patient because they can deteriorate very quickly.’

SILENT KILLER

Narang: Covid is known to create Silent Hypoxia — oxygen levels decrease, but the patient is not symptomatic till the level falls to a critical value. Normally the oxygen saturation in our blood is 99-100%. If it falls to a level below 92%, you need oxygen support to prevent possible damage to your organs. Normally, when the saturation falls below 92%, there are symptoms like difficulty breathing, restlessness, drowsiness. But in Covid patients, the saturation can fall to 80% without the patient showing any symptoms. That’s Silent Hypoxia, that’s what makes this disease so dangerous. So one of our main jobs is to constantly monitor saturation levels.

Kumar: On my first day, one patient, a 58-year-old male, was not in a good condition. He was the only one on oxygen support at my ward. He was not able to maintain saturation, it kept dropping. After two days, I had him transferred to the ICU. On the second-last day of my shift, a 70-year-old woman was not maintaining oxygen saturation. We did an X-ray. It did not look too bad, but she was deteriorating. I spoke to another doctor, and then we decided that she needed to be given oxygen and monitored for 24 hours. After this conservative approach, her condition did not improve, and I had to transfer her to the ICU. She was also hypertensive and she had diabetes.

Narang: Patients suddenly develop critical symptoms when the saturation drops below 80%. We call this “air hunger”. Normally, we would intubate a patient whose oxygen saturation is so low without thinking twice. With Covid, we learnt that we need to keep a higher threshold, because we saw that once a patient is on a ventilator, there is not much more you can do, and very few came back from that stage. So we adopted an unconventional approach. First, supply oxygen through a non-rebreather mask. If that didn’t work well, then we use a technique called “awake proning” — put the patient on the stomach while continuing oxygen therapy. This opens up the lungs more. This is a technique used for ARDS (acute respiratory distress syndrome) patients, which is a critical illness of the lungs, a seizure form of pneumonia, and Covid symptoms closely resemble ARDS. I have had great success with putting patients in the prone position. I had a 64-year-old hypertensive patient, admitted with great respiratory distress. His saturation was 80% when he came in. We put him on a non-rebreathing mask and the oxygen saturation began to improve… 80 to 86, then 90, then 94. Two days later, his condition deteriorated again; this time I applied high-flow nasal oxygen — it provides oxygen at 60-65 litres per minute, compared to non-rebreathing mask which provides 10-15 litres. His condition stabilised for another 2-3 days but again began to deteriorate. At this point I started doing proning. The very first night, he felt so relieved that he fell asleep in the position; his saturation was at 97%. After 18 days, the patient was discharged.

Kumar: The first order of the day at my ward was always to take samples. The night shift keeps everything ready — swabs, vials, ziploc covers, pens, micropore, cotton and a chart with the details of who has to be tested. The samples need to be collected and ready before noon, because after 1pm, the lab will not receive new samples.

The way it’s done is an art. We had seen videos and demonstrations, but nothing compares to actually inserting a swab into a patient’s nose or oropharynx. There is a gag reflex. The patient might vomit on you, which happened to a colleague. Or the patient will grab hold of your hand really hard.

Narang: The first time I went to test a patient and I inserted a swab in a patient’s nose, the patient coughed really hard, straight at me. I was standing right in front of him because I had no experience of doing this. That first incident was scary.

Kumar: Once you put on PPE, you can’t be heard. I am screaming from behind my mask and shield, and the patient still can’t hear me. All the ACs had been shut down to prevent the virus from aerosolising in the central ducts; we had arranged for some coolers to run, and they make a noise too.

I line up the patients with social distancing, and call them one by one.

‘What’s your name?’ I shout, as if declaring war.

Then, at the top of my lungs, I explain the procedure. I tell them, ‘Now we will test you for the virus. This cotton bud here, I will put it inside your nose, and touch it to a place at the back of the nose…I will just dab it, I won’t hurt you, and then I will take it out again’ it will take 20 seconds. But when this swab goes in, you will feel uncomfortable, maybe nauseous, like stopping me or holding my hand, but if you can just bear it for a few seconds, it will be done, and you will get the right report.’ You get patients who are very calm, and patients who panic.

LURKING FEAR

Narang: In April, I had two mortalities on my shift. One of them was a lady who was there throughout my shift but died on my final night. She was 54, diabetic. She was on my mind for many days. I had become close to her. I used to stop by at the end of the day and chat with her. Her granddaughter’s birthday happened when she was at the ICU and she told me about it. To see her craving for oxygen, it was very hard. I had to do prone position with her every day, and her breathing was really improving. She was showing good signs. But in the last seven days, her X-rays showed that her lungs were deteriorating. We could not understand why or what to do. The last two days, she was on ventilator. Then on my 14th day, she passed away at 4am. I was there with her. I cried very hard.

In May, by the time my second rotation came, I was full of enthusiasm and excitement that I will save every person under my care. I was very affected by the way patients died on my first shift: unable to breathe, no family members around, having spent all the time in hospital in isolation without your loved ones. Under any other circumstance, you can have any disease, but at least you can meet your family and friends. Here you are lonely, isolated, disconnected. Isolation for a healthy person is difficult, for a suffering patient it must be doubly hard. It’s so depressing for us as well, we are isolated too. Nobody could meet us, we could not meet anybody — it was just isolation and quarantine (which every doctor must go through after a shift).

Kumar: There is one good reason to segregate patients according to the severity of their symptoms, so that those who are alright don’t get to see others in critical conditions. Then the patients who are stable start developing a fear. ‘Is this where I am headed? Will this happen to me in 10 days?’

For me, it was a different kind of exhaustion. For us, it was two doctors and four nursing staff working in a 12-hour shift for 72 patients. We had patients on dialysis, patients on drip, patients who needed bloodwork done, someone was anaemic, someone needed a wound dressed, an ECG [electrocardiogram], a X-ray, someone needed to be seen by a specialist. You are consumed by your work for those 12 hours, you think of nothing else. After sweating everything out, you get back to your room, drink lots and lots of water, or ORS, and just pass out. Those 14 days that’s all I did: work, sleep, work, sleep.

Even then, the most time -consuming thing was the paperwork. Why not take some of the paperwork off the doctor’s hands? Doing data entry can easily be outsourced and it will halve our burden. That way, patients would get much better care.

Narang: Most patients in the ICU were diabetic or had heart disease. We had 10 beds in the ICU to start with, then 15. We were two doctors, my senior and I,and four nursing staff; total shift was six hours.

In my May rotation, I did not have a single mortality while on duty. I was very proud of myself. There were mortalities — our own OT [operation theatre] technician, a 13-year-old diabetic girl, a patient with a kidney failure, an elderly patient with cerebral aneurism — just not on my shift. We’re the ones who go and declare the passing of the patient to the relative. For me, facing a crying relative is the hardest part of my job.

My first posting in ICU — that was in 2018 — was also the first time I had to tell a relative that we could not save someone. I remember two incidents. I can’t remember which one came first. Both were young, both were in RTAs (road traffic accidents). One was a girl, 10 or 12, and one was a man in his mid-20s. Both were on bikes. The man was riding; the girl was pillion on her brother’s bike. She had fractures all over her hips, legs, and spinal cord; her bladder was gone. The man’s face had been smashed, his skull fractured, and he bled profusely; the whole bed was soaked in blood.

We could not save them. I still remember the bed numbers; the man was on 3, the girl on 14. It was very, very hard for me to go and tell the relatives. My first feeling was intense anger. I want to take all the people who drive badly and give them a tour of the ICU and show them what it actually looks like and feels like to be in an accident. I don’t think they will ever drive badly again.

Kumar: Once a patient was brought in by a whole lot of men, aggressive, shouting, threatening us (to save that man)… on investigation, I found that he had perforations in his intestine, we needed to operate, we needed blood. We told that large crowd that we needed at least four people to donate blood, and most of the people vanished. One person came and said, here’s a thousand rupees, make some arrangements. Humanity comes naked to you when you are a resident doctor in a government hospital.

INDOMITABLE DRIVE

Narang: A time comes when there is no one except the lonely patient. I have a drive, I want to save lives, I want to keep trying. I have always wanted to be a doctor, ever since I can remember. My sister who is 12 years older to me is a doctor. We are four siblings, I am the youngest. The oldest is my brother, who is 15 years older. He is an advocate in the Delhi high court, like my father. My mother is 80 and she has polio so one of her legs doesn’t work, but through this entire lockdown, she and my father did everything by themselves in their house. There was no one else with them; I was very worried.

I grew up in a single-storey house in Karnal. Even though I have always wanted to be a doctor, it did not feel like I was living my dream when I started my MBBS. It was just studying, studying, studying, it was quite a nightmare! The first time I felt like I was living my dream was when I walked into an ICU. The rush of being in the ICU, where there is only thing to think about — save lives — is what drives me.

Kumar: I want to specialise in GI [gastrointestinal] surgery and liver transplantation. In three years you get to know what you want to do. For me, when I open the abdomen up, it fascinates me. Suturing a bowel is technically demanding. Imagine you have a puncture in a cycle.You patch it, if it leaks again, you patch it again. But here, when we suture, if there is a leak again, the patient will die. If you suture too tightly, the blood supply will get cut off. There is no room for a mistake. It’s fine work, very fine work.

When I was growing up, I was fascinated by farming. The harvest season was the best time: all the tractors, threshers, everyone out on the field. All day long, I would follow them. My ears would be tuned to hear if Papa’s bike was coming up the road. My father taught botany at the government college in Araria (Bihar), and he was a strict man. There was great discipline at home; even though we lived in a large joint family. I was the older child, and I was told that I must always lead by example. My brother is also a doctor, doing his internship at the Army hospital in Jammu.

When I got into MBBS, I was not just becoming a doctor; for me, it was a generational leap. In 26 years, I’ve seen two completely different lives, one in the village where I grew up, and one here in the city. And now I am experiencing being on the front line in a pandemic.

Narang: I like to look good, so I would go to the hospital nicely made up — even in my PPE, and even though the duty was exhausting and hectic. I would also go for 45-minute runs every day, inside the park at MAMC. When I went back to the hotel room (she was quarantined at the Hotel Lalit, which was attached to LNJP), I did more reading on Covid. I searched articles in medical journals, I asked my sister to send me articles, I attended a webinar. Then I referred to my own books to read up on ARDS and ventilators. By the end of April, I told my consulting doctor that I want to do a study on the disease. At this point, something horrible happened to me. Someone mirrored my phone pretending to be a bank executive and stole ~14 lakh from my account. That’s like a year-and-half of my salary. I almost gave up. But I was back on shift in May.

INFRA struggle

Kumar: At some point, just because of the exhaustion, because your body is aching, you are in pain, you start to feel like you are being punished. You start to forget life was different before this.

Before Covid, I spent lots of time on social media. I liked playing basketball, badminton, watching Netflix. Before all this started, a group of four or five of us friends would sometimes study or work late into the night, and then we would go out for a walk.

One place we liked to go to is Alam bhai’s Maggi point, which is next to Lady Hardinge [medical college], and is open all night. But things are very bad in Delhi now. The government can deny and say there is no community spread; but clearly there is. Also, our hospital conditions are as bad as they were decades ago.

Why is health and education not a priority? We have the worst doctor-patient ratio in the world. In hospitals, the biggest problem is the shortage of manpower. It’s not just about doctors but also nursing staff, sanitation workers, all of them are needed in the system.

Narang: The images of dead bodies lying around in wards at LNJP — that was at the medicine block. We don’t have enough nursing orderlies, they are the ones who have to carry out the bodies. If someone dies at 6pm, the body may be removed at 10pm, after repeated requests, after searching for the orderlies… The first death I had on my shift — I spent three hours trying to arrange for a nursing orderly, then an ambulance. This should have happened in 15-20 minutes.

Kumar: What people saw in the images was not the fault of health care delivery, it was a collapse of infrastructure. Actually government hospitals in Delhi are much better than the government hospitals in most other states.

Narang: But since there is so much focus right now on medical care, I think things will improve. They will spend more on health infrastructure. Just to tackle the pandemic, we have had to make huge improvements already, like in the number of ventilators, oxygen support, equipment…

Kumar: Right now I am talking to you from a park in front of the library; there is a slight breeze, and lots of trees so the heat is not unbearable. I tested positive for Covid, and I have just recovered. I was more or less asymptomatic, but I had a lot of fatigue, and also some joint pain. I was in Guru Nanak Eye Centre for five days.

There is a special ward for health care workers, it was really good; a fantastic set-up. For me it was just depression, being stuck in a room with nothing to do but watch the fan rotate… no Wi-Fi, phone signal was not good. I carried my books, my exams were supposed to start on June 16. I was fully prepared, I had my admit card, I knew the exam centre, and then on the 15th evening, they cancelled it.

Narang: My quarantine period is also over. We are very uncertain because our exams are not happening. Our contracts were extended till June 30. When will we get a degree? Where will I work? But we understand, the situation is grave. Anyway, I think I’ll go for a run now.

(The final-year students’ exams began on July 10).



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