Covid ICU in govt hospital

The lockdown had begun.That meant shutting down the clinic and one visit a day to the hospital to see a few admitted patients.Like all interested clinicians,I was reading every word printed on Corona.The news channels were full of just one news :The epidemic.Everyday the news of people falling like nine pins were pouring in from GOVT HOSPITAL at PUNE.It was feared we were in for a LOMBARDY like situation.I consider myself a decent Intensivist.I was growing increasingly restless.How can I sit at home when I think I might be of some use?I registered on NITI AYOG website to enroll as a volunteer to work in any COVID ICU.Alas,there was no response from them.When we got a call from Government Officials saying I am to join ASAP at the designated Govt Hospital,I was happy.I don’t want to look back at my life and think I could have made a difference but I didn’t.Plus I was fresh from reading Dr Taru Jindal’s book which spoke of her experiences of working in rural Bihar in a Rural Hospital as a Obstetrician.It is an inspiring book on how one individual can make a difference  in a rotten system if he decides to stand up and get counted. I was all charged up.

    At the meeting called by the OSD and Dean collectively,we were twenty eight intensivists. Of these, twenty  were literally in mourning. I realised that these are reluctant participants who have come here only on government order and don’t give a hoot to what is happening around them.They were asking questions like “Why us?” when I was thinking “If not us,who?”.Some of them had brought along certificates saying they were Diabetic or had Rheumatoid and hence immunosuppressed and should be exempted.Adversity often separates the men from the boys and sad to say,there were just a few men around.I was one of the first ones to volunteer  .Fortunately ,two people who work with me at my hospital were also amongst the twenty eight.I convinced them that we four should  join as one group so that we have better  co ordination .Immediately the Senior people working in Department of Medicine came down for a apparently friendly chat.

“We have limitations you see”

“Patients are presenting too late”

“You will have to work in protocol we have set”

“Its Government up,you can’t get a 2D ECHO done for everyone!”

     This should have given us some hint of the hostility we were to experience. But I can be incredibly naive at times beleiving that the world is full of do_gooders.We felt they were warning us on what not to expect.The next day,armed with a suitcase  and very high hopes,I landed up at the hotel .

“We don’t have any instructions to give room to you”the front desk person at the Hotel told me tersely

“But I was asked to check in here”

    I called the person from Govt Hospital who was coordinating this thing 

“Hello sir,Dr XYZ here.I am at the Hotel but they don’t have a room for me”

“Oh .There is some mistake.Let me check.Please call me back in ten minutes ”

   I called him back nervously in ten.

“Oh,Dr XYZ.Sorry.You are put up in another hotel .”

 He gave me details and we trudged my luggage to another hotel.After settling down,I bid goodbye to hubby and prepared to walk to the hospital 

     With N95 on my face(which has become so permanent a feature of my face,I don’t recognize myself anymore without it)I pressed the button for the seventh floor.

“Use your elbow not your finger”someone donning a PPE reprimanded  me.PPE is the ultimate equalizer after death.You recognize no one.Everyone from HOD to Mama looks just the same.I had forgotten what it is to get yelled at.Bruised but not rattled I thanked him

“Kidhar kidhar se chale ate hai.Kuch protocol nahi pata “the person in PPE was talking about me to his colleague.

       I got out of the lift to find that 7C which was the Covid ICU was on left.Flanking the ICU was a small anteroom where three senior sisters were seated, chatting away merrily ,without a care in the world.

“Sister.Mi Dr XYZ. Covid ICU madhye duty ahe.PPE pahije”

“Kon Dr XYZ?”

“Mi Intensivist ahe”

“Intensivist?”

“Ho.ICU tadnya”

“Mhanje intern?”

“Nahi.ICU dr ahe”

“Amhala tumhala PPE denyache kahi circular ala nahiye”

   I had hit a wall.Without a mobile phone,I didn’t know how to wriggle out of this situation.

“Aat round kon ghetay?”

“HOD Medicine che”

“Tyanchyashi bolu ka?”

“Bola.Konashi pan bola,amhala kay!” 

   I was able to get him on line.To his credit, the senior clinician walked out and introduced himself.He directed the staff to give PPE to us “outside doctors “.He took me to the ICU,  pointed out to a protocol which they were following for all patients.With that,he said with a hint of sarcasm

“Ok,over to you now.Manage”

What he really meant that we probably were not going to  be able to walk the talk.

     Taking an ICU round in my unit is a pleasure.A resident will summarize case history.I have to just look at the nursing chart where every single patient parameter is meticulously charted.Every single drug either given as stat or regular order.The patient cant even fart without it being mentioned on the chart.I looked around cursorily wondering where to start from.I usually start with the most sick patients. I headed to the beds of patients who were being ventilated.I was reading the case file when someone in PPE nudged  me;

“This patient is dead and so is the one next to her”

   I must have been taken aback but she couldn’t see my face.

“So why don’t you disconnect the ventilator?”I asked in irritation 

“We haven’t declared death yet”she answered nonchalantly 

“Why not?”

“Relatives are not allowed near this building.So it takes a while to get hold of them”

“Oh .I see.When did they pass away?”

“Sometime, yesterday night”

“It’s been ten hours!”I said incredulously 

“So?It is  Govt Hospital. Now getting a Mama to do hypochlorite spray and the two layers of body wrap is going to take another three- four hours.By the way,who are you?”

 So yours truly did the introduction round again.

        As I stepped near the next intubated patient, I checked his pulse first to make sure he is.He was.In this ventilated patient,all that was put up for monitoring was a saturation probe.

“Mam,I am JR3 ANAESTHESIA.I am posted here”

“Hi.I am Dr XYZ .Accha listen,can I ask you something?”

“Sure”

“Why are the cardiac  chest leads not connected to this patient?The  monitor seems good”

“I am not sure”

“Can we get chest leads and connect the monitor?”

“Yeah, if you say so.Staff where are the chest leads?”

“I don’t know .Go search them yourself.I have lot of other things to do “Pat came the reply

    Both of us got searching and found the chest leads sitting comfortably near ECG machine.We opened them,removed the plastic from the monitor and hooked the patient to the monitor.We repeated the same process with everyone.Small beeps and alarms started buzzing.It made me feel  like I was in a real ICU.Without the background noise of alarms and monitor sounds,no ICU sounds like one

“Will you help me with rounds?You know case history and progress?”I prodded the anaesthesia JR3.

“I am sorry mam.It is my third duty here.But we don’t see patients or put orders We help with intracaths,lines,ABG and intubations”

“Oh,I didn’t know, sorry. Who would know?”

“Medicine JR3 ”

“And where would he be?”

“He is at the console near the step down unit ”

   I walked to the console,greeted the fellow and asked him if he could help me out.

“I want to but can’t ”

“Sorry?”

“Yeah.I am completing paperwork for the deaths.It’s a nightmare, this paper work.So many forms to fill!”He waved a bunch of papers at me

“Oh,you continue.I will find my way around”

    I began with scanning each patients file.I noticed that many of the drugs were going on for just too long because no one had kept a tab on the number of days.Steroids were being given at a terribly high dose not consistent with any international guidelines.I confronted the HOD on the same

“These are our guidelines.Follow them ”

  I was so stunned ,I couldn’t react at all.I have spent most of my career reading and trying to put into practice various widely accepted guidelines.Evidence based and not eminence based guidelines are sacrosanct.I didn’t want to antagonize anyone so soon,I let that pass.I found the kidney function tests deranged in couple of patients 

“Staff,put in a urometer for hourly output chart”

“We don’t have them here”

“Can’t you indent?”

“You will need to speak to someone higher up.It might take weeks”

“So how do we monitor urine output?”

“If you want ,we can change urine bag at each shift”

“No ,no .that would be such a waste of resources” 

“Then don’t monitor.Send CREATININE everyday if you need to monitor ”

   The staff nurse was schooling me on monitoring kidney injury.Retrospectively,she was just letting me know how things stand .The Medicine JR3,the one busy with paper work,rushed in a breathless patient from the ward

“Mam,have a look”

    I saw that the patient was in obvious respiratory distress with Sats around 80.I went through his file in quick time.The old man had a background COPD. 

“Mam,we are going to intubate him”the Anaesthsia JR3 told me

“Are you telling me or asking me?”

  I connected him to a NRBM Oxygen 

“It’s in the protocol.Anyone with breathlessness and sats less than 90 on oxygen,we intubate”

  I didn’t want to lecture her that intubation is a big decision based on individual characteristics of a patient and not just on a number.I plea -bargained with her

“Can I try and settle him with drugs?If he doesn’t,we intubate him”

“You take responsibility for this.I will call my HOD and tell her.If this guy succumbs without intubation ,she will get mad at me”

“You make the call .Let me handle this”

    I yelled at the sisters to get hydrocortisone and magnesium and lasix 

“Madam,his intracath is out.How can we give drugs with no intracath?”

“So put in a new one!”

“That’s not our job.Call the Anaesthetist ”

    Exasperated ,I barked at them

“Give me one.Let me put it in”

“It’s on that trolley.Go and get it yourself “she replied calmly.

    It slowly sinked in that I was back to being a JR after fifteen years.I had no time to get angry.I somehow put the intracath (with poor visibility due to face shield).The staff pushed the medicines I had ordered.In fifteen minutes, the patients breathing was better,the sats had picked up to a comfortable 92 and I too was breathing easy.The Anaesthetist was back from the call

“Mam,my HOD asked me to put in a tube.I have to listen to her”

“Have a look again at the patient.Intubate, if you feel we must”

  I moved on to other patients leaving her to decide.That was just a COPD exacerbation in a Covid patient.Not all Covids get breathless due to COVID.They still have to deal with COPD,LVF,Diabetic ketoacidosis,anemia.Since people ,who haven’t really had a good look at the patient when he deteriorates ,were making treatment decisions ,it was easy to understand why the mortality just kept climbing each day.A decision to intubate must be taken only by a person who has seen the patient and has the know -how to make a decision on sound clinical data and judgment.That was clearly missing. 

     While the lasix kind of settled that patient,he needed to pee urgently owing to its diuretic effect.As the patient kept yelling for a urine pot,I realised he didn’t have a catheter.My mistake .You can’t give lasix to a breathless patient with no catheter in ICU. I understood that putting catheter would be again a job of neither the sister nor the Anaesthetist.I channelled my inner Zen and gathered all the equipment I needed to put in a Foley’s .I was putting in a catheter after years.

   That was also an epiphany.Some patients were without catheters.If we aren’t letting ICU patients use the loo because they might collapse,how were they peeing?Curious,I asked an awake patient ,who was in ICU due to a possible myocarditis ,about the same

“Kya bataye,mujhe diaper laga diya hai.Isme Kaise karenge?”

“Are,aap pot mang sakte ho!”

“Dene Keliye Mama nahi hote Madam”

      In fifteen years,the apathy of the class four workers had still remained the same.Not showing up for work or not doing anything when present was their work ethic.I guess,some things in the world never change!Diaper for a conscious, young ,adult male?Knowing fully well but not wanting to believe I engaged with the Mama

“Aap unko pot do”

“Nahi de sakta”

“Kyun nahi?”

“Time nahiye.Ek mama.Itna patient.Kaisa karega?Hum sabko diaper hi bandhega.Faltu ke kaam ke liye time kiske pas hai yahaan?”

    I had completed my round.Most patients were diabetic and sugars were pretty high.They were being monitored infrequently. By this time,I was learning the tricks of surviving the ICU.I asked  the Anaesthetist casually

“Who does sugars?You or Medicine guy?”

“Neither.We have a dermat resident posted here.She does it.She must be collecting lab in adjoining step down unit”

“She collects blood and lab reports,right?”

“Yes ”

    I walked down the hallway and asked for Dermat resi.She was busy with the PC,tracing reports

“Hi.I need you to do sugars on these patients ”

  I handed her a list

“Like right now?”

“Yeah,right now ”

     The sincere ,petite girl set about the task diligently and handed me the numbers in quick time.Most of then were pretty off target.

“We need to start insulin infusion for these patients “I was now talking softly to the staff 

“Next shift.Our shift ends in five minutes ”

   Oh,it was already close to eight! I hadn’t realised ,six hours had passed by.

“Just hand over the insulin.I will give it”

“Ok”

“When is dinner served for these patients?”

“All of them are nil by mouth”

“But why?”I was aghast.Most patients could eat except intubated ones

“I don’t know.There are no orders ”

     I silently marched to each bed and put food orders for all patients 

“These will be carried out from tommorow. Who will send dinner for ten patients last minute?We haven’t informed pantry “the staff informed me

“Ok”I didn’t have a choice

“Mam I need your help to extubate that patient”It was the Anaesthesia JR3

“The dead one?”

“Yeah”

    I had no idea what help she wanted.It became apparent immediately.Most of these patient had passed away hours ago and the body was in Rigor Mortis.Extubating was going to be tough.I tried pulling out the tube with all the force I could muster.Not good enough!Finally,I just cut it letting a part of it stay in the oral cavity. This was the final assault on my composure.My colleuge,who had arrived to take charge from me,didn’t know what had gotten to me.

“This is unreal”I was nodding my head furiously,a thing I do when I am nervous.

I gave him a overview of patient condition and left after doffing .

    I was in  a state of catatonic shock.I couldn’t believe that a set up this pathetic ,was part of a huge teaching hospital which had been entrusted by the administration to handle these very sick patients.With no monitoring,no individualization of treatment decisions and inexperienced doctors at helm,these patients had no chance.Covid is a heinous disease which affects the lungs in ways we still have to fully comprehend.Even in the best setups mortality was terribly high as it seemed from American and Italian  data.No setup is perfect, yet this was too imperfect. I went back to the Hotel in complete panic.I had to do something. This was surreal, but in a ugly way.

       The officer on special duty for COVID,whom we had met at the meeting,had given us his personal number for any issues.I spent some time in indecision.Should I call this person I had met only once?It was almost nine p.m.I threw caution to the wind and called him.

“Hello Sir.Dr DXYZ here.We met yesterday at the meeting.I am part of group of doctors that joined today”

“Oh yes.Tell me.Hotel,food all ok?”He had assumed I was calling to complain about the hotel

“No that all is great.I wanted to speak to you about patient management ”

“Go ahead ”

   In my nervous excitement I described in detail how things worked.I sensed he was as shocked as me.

“We provided them with whatever machines they asked for.All equipments are State of the Art”

“Unfortunately Sir,machines don’t save patients.The brains behind those machines do”

“You mean to say that the hardware is in place and not the software?”

“Yeah”

“Can you come down to meet me at the Collector office tommorow One pm before your duty?”

“Sure ”

  I called up with a few renowned doctors working in big institutions asking them to intervene in the nick of time.Perhaps these big names could step in and do something. 

  At breakfast,our entire team of doctors was shaken.This was apathy of highest order.No regard for lives!No dignity in dying!We were appalled by the whole setup.I mentioned to my friends about this scheduled meeting and some of them agreed to accompany me.We waited for the OSD sahib at the appointed hour.He escorted us straight   into the Collector’s cabin.

“Sir should be here in some time.You can speak to both of us”

    An important looking man flanked by security personnel entered in some time.He was speaking on his bluetooth and was obviously hassled.

“Sir ,these doctors are working with the Government Hospital since yesterday. They want to speak to you”

“Yeah sure.”

     I found my voice as I always do when I am passionate about any cause.

“Sir,this ICU is fifty years behind any ICU from good private setup.We can’t bridge this gap in eight days or even three months.We can’t save very sick patients here”

    He removed his bluetooth and asked me to elaborate .I briefly explained him how modern ICUs function.By getting patient data by close monitoring and anticipating and averting complications based on it.Good monitoring and good nursing staff is  the backbone of any good ICU .Without that support ,it was impossible to turn things around.He probed further into specifics and I think he understood what I was trying to say

“So what do you suggest?”

“The government is spending  way too much.You can ask patients to seek care at private hospitals and foot their bills.That should be cheaper ”

“I get what you mean but we can’t do that.What is next best option?”

   I suggested we needed more autonomy in decision making,more staff at the least.He assured me to do his best.My second day was as bad as the first one.I had tried but this was beyond me.Afterall ,what can a small person like me do?I can’t stem this rot,could I ?I felt completely defeated by circumstances.I had been a idealistic fool again.Will I ever grow up?

     The third day, I walked in with a resolve to do whatever little I can for maybe a few patients.It was not my job to re organize a faulty system.I was greeted by the HOD

“Ah,Dr XYZ. There you are.Staff,Dr XYZ is in charge of ICU for this week.You better listen to her.They are going to save these patients ”

   I ignored the obvious sarcasm 

“Try and stay within our protocol ”

“Sir,I will stay within internationally validated protocols.I assure you that”I was at my defiant best

    Expecting complete noncooperation from all stake holders,I began my round.When I needed a sugar,I did one .If I needed a ABG, I got one.I changed  the “out” intracaths.I wrote new orders for every single patient.I carried each file to the staff asking them to follow what I had written.I put few awake patients in prone as I had read a great deal about how it improved oxygenation for them.The staff was all looking at me like I had lost my mind.Honestly,I had and I didn’t care anymore what they thought.After a thorough round,I got down to the business of checking urine outputs and making changes in  fluid orders when needed.I haggled with the MEDICINE JR to get 2D Echo for a couple of patients.He agreed and got busy mobilizing it.Instead of sitting in the console,I busied myself walking the breadth of ICU,talking to patients,chiding then to put oxygen on and so forth.The entire PPE clad staff and junior doctors were housed in the nursing station.I felt less unsettled that day.I had done whatever I could.And that was that.

     From the next day,there was a gradual change in the staffs attitude.I arrived in the ICU to see sisters wishing me ‘”Good Afternoon “Oh!It had to be a good omen.The visit to Collector office hadn’t been pointless.I began my rounds ,ignoring everyone.To my surprise,the dermatology resident handed me a list of sugar readings

“I will do one more round for sugar for the ones who have above 250 in 3 hours”

  I smiled for the first time in days

   The Anaesthethesia resident was a post MD guy today .

“Can we take combined rounds?”he asked

“Sure”Any respite from hostility was welcome.

Soon we were taking rounds.Sensing a shift in momentum,the staff were more receptive to drug orders.Food was being served to patients.I shifted out a couple of patients who were doing well .Claustrophobic from PPE,I sat at the nursing station for a while

“Mam,Bed 2,4,7 Creatinine  has increased “It was JR3 from medicine 

“Show me”

  He showed me the numbers.We made a several changes in drug orders and fluid orders.

   I had sensed that I couldn’t order them.I had to do it first myself for them to follow suit.I had to make patients better before they started believing in me.Eight days was short time but I had to try.Fortunately all my colleagues were extremely devoted people,working with the same zeal as me.

     So in couple of days,we had managed to make the place look like a ICU.All patients had monitors,lines and catheters.We had put in a protocol to monitor sugar,urine output,oxygenation and XRAYs .The unit was now functioning like a team.We had actually managed to shift out a few patients.What perhaps was lacking was leadership or process ownership which we were providing. To my delight,the residents and nurses had reacted by raising their own bar instead of pulling our bar down.

        A patient who was being ventilated on fifth floor with a PEEP of ten and FIO2 of 0.9 was shifted on a Bain circuit with oxygen cylinder and arrested on arrival.Since with Covid ,policy is no CPR,we did the next best thing,pump atropine and adrenaline.In  a near miracle ,we got a rhythm.

“Dopmanine staff,quick ”

    Dopamine drip was started in minutes.This was one of the sickest patients yet .Oxygenation was poor with sats hovering around 80s on 0.9 FIO2.We had to do something.In a moment of despair, we decided we need to prone ventilate this patient.This time,instead of disbelief, the discussion was on  how to arrange this.My Anaesthesia person got someone to fetch two ring pillows that we need.Since we were short on vecuronium,I was anxious to prone.No paralysis increases the risk of extubation many folds.Somehow, the staff got hold of the drug and we managed to make the  patient prone .The improvement in oxygenation was there for everyone to see.It was a watershed moment for the staff.Patients didn’t have to die on a ventilator.Something they hadn’t seen with  a single Covid patient till then.Inspite of concerns of aerosolisation, we put two patients on Noninvasive ventilation to avert intubation with excellent results.

   The residents were now more forthcoming 

“We were doing it all wrong mam.Intubating right,left centre based on numbers alone!.Just last week we intubated a patient who was clinically stable but sats hovering around 85 based on numbers alone ”

“We were ventilating patients on a jumbo oxygen cylinder in our makeshift ICU.The alarm for low oxygen didn’t sound.We lost a few due to no oxygen ”

“So these patients can survive with good care,Mam?”

“Tell us more about how to decide on ventilation ”

“Why are we giving LMW heparin to all?”

“Why prone ?”

“Seems steroids are working!”

“So we defer intubation in everyone!They are tolerating low numbers on sats pretty ok”

    I was more than happy to answer.In seven days, we had shifted out seven patients,two were maintaining on NIV and one was sick but hanging on with proning.We had managed to arrest the free fall.The staff and residents had their chins up.A lot needs to be done probably There were no urometers till the time we left.Each subsequent incoming set of doctors will probably help to make things better.On the last working day,the staff and residents requested for a selfie.With PPE on, it made no sense but we did  a photo session anyways.I guess, adulation can be shown in numerous ways.

     I came back home today feeling more alive than ever.I am a  tiny speck in the universe really but I can make a difference if I put my heart into something .The issues are much broader and not a part of my immediate mandate.I will live better knowing I didn’t remain a mere spectator in this unfolding catastrophe.Afterall, one is only answerable to one’s own conscience.You can choose courage or you can choose comfort, not  both !Any given day, I shall choose courage !!

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