Cytokine storm – A Life changing experience

It was 12th May 2020 when I started my second round of obstetrics Covid Ward duty along with my team.

We did three lscs of Covid suspect on the first day itself. Out of which first patient turned out to be positive for Covid-19. We were also managing one Covid suspect post LSCS day one – case of ante partum eclampsia. She was monitored by us and on 13th May 2020 her report came to be Covid positive.

I had some myalgia and burning micturition from 12th itself. The myalgia increased over the next few days. I thought it was due to UTI. I did my urine culture and started antibiotics. On 14th my weakness and myalgia started increasing further so I decided to take rest at home. There was no cough,sore throat, fever.

However I developed fever,mild sore throat on 17th so I started HCQ. I was already taking HCQ prophylaxis for Covid 19 so I started the dose of 400mg od along with tab azithromycin.

I was monitoring my temperature, pulse, respiration and SPO2 at home. Over a period of time the fever kept on coming and subsided with antipyretic.

In the mean time my wife Ashwini also developed mild symptoms of Covid-19(Fever, body ache and sore throat). However she recovered in three days by 19th may 2020.

I developed fever with chills and rigors from 19th and as fever started rising my oxygen saturation started dropping to 92 to 94%. Once fever subsided it went back to 96% – 98%.

On 20th may 2020 morning the saturation started to drop further to 90-92% then I realised that now I need oxygen therapy and need to be admitted.

We decided to go to VMGMC solapur. I got admitted in Covid block and was kept in the Covid ward.

All the residents and the staff on duty were very cooperative.

I was put on Oxygen therapy by non rebreathing mask.

I was examined by Dr.Prasad Sir Head of the department of Medicine. He reassured me that all will go well as I was maintaining saturation on the non rebreathing mask at a flow of around 10 – 12 litres per minute of oxygen.

I was also examined by Dr. Jamadar sir the Head of unit 3,Medicine.

They started me with inj.piperacillin tazobactum antobiotic, injection vit C, inj clexane and injection pantoprazole. My baseline blood investigation and ABG was sent which was not so good.

In the mean time the administrative machinery decided to shift me to Yashodhara hospital in the evening as there was no bed in the ICU.

I was shifted to Yashodhara hospital where Dr. Yogesh Rathod reassessed me and admitted me in their ICU. I was put on oxygen by nasal prongs and monitored.

They started on inj azithromycin (which was painful), inj Teichoplanin, Meropenem , methyl prednisolone, inj glutabest,inj ascorjet, inj thiamine, HCQ and Ivermectin. My blood investigations and ABG was sent again.

In the mean time Ashwini was in touch with all my friend circle and UG batchmates. Especially my close friends Dr.Sunita Chopda/Patil and Dr.Rahul Patil from Daund. They all initiated the plan to shift me to Pune – Deenanath Mangeshikar hospital (DMH). Dr. Manish Dastane and Dr.Ashwini Joshi my UG batchmates from Pune who practice in DMH helped a lot in reserving the bed in DMH ICU and coordinating the whole transfer and management in ICU. Dr. Jignesh Shah – intensivist at Bharati hospital pune also helped in the decision making.

In the mean time there was a plan to shift to Ruby Hall clinic.

Our Dean Dr. Sanjiv Thakur Sir and Dr.Sunita Tandulwadkar madam – IVF and laparoscopic consultant at Ruby hall confirmed a bed for me at Ruby hall. Both the institutes are world class however multiple calls from my friends insisted for DMH – they said Vijay just come to DMH and we will take care of the rest. Many of my batchmates and seniors practice in DMH so it was all more easy for me to go to DMH. We finally decided to shift to DMH in the morning.

Meanwhile in the morning I was put on BIPAP by Dr.Rathod for some time before shifting to DMH.

The cardiac ambulance was arranged by Dr. Manik Gurram Sir – courtesy Markandeya Rugnalaya and I was shifted to DMH Pune on oxygen and non rebreathing mask. We were joined by my friend Dr. Sunita Chopda/Patil from Daund on the way from Patas.

We reached DMH at around 3 pm on 21st may 2020.

I was immediately taken into casualty once the bed was available.The basic evaluation investigations and stabilisation was done. I was admitted in the ICU and put on non rebreathing mask. Provisionally diagnosed as covid suspect pneumonitis.

Dr.Sunita Patil was along with Ashwini till all the admission formalities were completed.

I was started on HCQ, methyl prednisolone, LMWH as per guidelines. Antibiotic Piperacillin Tazobactum was started. High dose Vitamin C 500mg three tablets three times was given.

Tab colchicine (anti inflammatory agent used here for its action similar to tocilizumab) and CARP (Covid awake repositioning/ prone protocol) protocol was started i.e I was asked to be in prone position, left and right lateral recumbent and 60 degree propped

position.

On 22nd may 2020 I was started on high flow nasal oxygen. I was started at 60 litres per minute.

My investigations were suggestive of cytokine storm since IL-6 was raised (10 times normal), inflammatory markers were elevated,no fever, procal was normal,trop I was negative. It was diagnosed in consultation with Dr.Parikshit Prayag.

So I was given injection Tocilizumab for Cytokine Storm on 22nd may 2020 evening. The senior consutants were present in the ICU when the injection was given to me. Next day HFNO was reduced to 40 litres per minute and FiO2 of 40%. The methyl prednisolone and Tocilizumab probably did the trick.

Post Tocilizumab, the inflammatory markers were raised – which was due to Tocilizumab.

After further waxing and waning it was reduced to 30 litres per minute and FiO2 of 30 on 27th may 2020.

The same day I was gradually shifted back to non rebreathing mask with O2 of 10 litres per minute for one day and then on 28th may 2020 I was put on nasal prongs with 6 litres Oxygen.

In the afternoon I was shifted to ward and gradually over a period of two days Oxygen was tapered and stopped.

I was started on chest physiotherapy in the form of spirometry( by Respirometer) and

Tablet Aspirin 150 mg HS was added.

I was discharged on 3rd june 2020 after repeat swab for Covid 19 came negative and passed the three minute walk test.

The whole DMH team of Dr.Sameer Jog, Dr.Balasaheb Pawar, Dr.Parikshit Prayag, Dr.Bhagyashree Bhurke, Dr.Amit Walimbe, Dr.Vishnidas Telbhare and there junior collegues were extremely efficient. Special need to mention about the ICU nursing staff extremely efficient and caring –which makes the difference. They took nursing care, blood collection, monitoring, charting, giving medicine on time, food and water on time.

Encouraged the patients. Special mention is the maintainance of myintracath which was inserted on 20th may 2020 in solapur was maintained patent without thrombophlebitis till the time of discharge. I removed it myself on 1st june 2020.

This teamwork really helps the treating physician, as his focus is on treating the patient and not on managing the staff, mama/maushi, food and sanitation. This is often seen in some hospitals where the doctor plays multiple roles of physician,manager, blood collector and fills in the shoes of any other person if he or she is not available or does

not do their job.

So it’s a TEAM WORK and not the job of doctor alone.

I came back home the same day and remained home quarantined for 7 days.

In the mean time when I was in the ICU, Ashwini was fighting the battle on another front.

As she was exposed to Covid 19 she needed to stay alone. Our batchmate Dr. Monica Paratane/Patil came to her rescue. She arranged for her stay at her hospital in Warje. Next day Ashwini got admitted at DMH for repeat swab which came negative. After discharge Dr.Sunita and Dr.Rahul gave their empty flat near Amanora and Honda City car for travelling to and fro. Dr.Rahul came all the way from Daund to deliver the car and counsel and convince the society chairman to allow her to stay in their flat. This is also a big problem as people are scared to allow covid suspects to stay in their area.

It was possible to stay in Pune all thanks to Patil couple. Otherwise the other option for her was to come back to Solapur.

I would like to thank from the bottom of my heart to all those who helped me recover from this crisis.

Special thanks to

• Mr.Milind Shambarkar – Collector Solapur

• Dr.Sanjiv Thakur Dean Dr.VMGMC

• Dr. Prasad Sir HOD Medicine Dr.VMGMC

• Dr. Dhadke Sir HOU Medicine Dr.VMGMC

• Dr.Jamadar Sir HOU Medicine Dr. VMGMC

• Dr.Anita Bandichhode, AP Medicne Dr.VMGMC

• Dr.Vaibhav Lade, Assistant Professor Medicine Dr.VMGMC

• Dr.Pritam Assistant Professor Medicine Dr.VMGMC

• Dr.Piyush Tak Resident, Medicine Dr.VMGMC

• Dr.Darshan Vithakar , Resident Medicine Dr.VMGMC

• Dr.Rajan Talele Resident, Medicine Dr.VMGMC

• Dr. Pradeep Kasbe Associate Professor Surgery Dr.VMGMC.

• Dr.Agraja Warerkar/Chitnis ART incharge Dr.VMGMC

• Dr.Sachin Bandichhode – AP Medicne Dr.VMGMC

• Dr.Audumber Maske Medical Suprintendant, VMGMC

• Dr.Rajesh Chowghule Assistant Professor PSM

• Dr.Vidya Tirankar HOD OBGY Dr.VMGMC

• Dr. Prabhakar Gawandi Associate Professor OBGY

• Dr.Pradeep Jadhvar Associate Professor OBGY

• Dr.Chandrakant Jadhav Assistant professor OBGY

• Dr.Shweta Kallurkar Assistant professor OBGY

• Dr.Shruti P Assistant professor OBGY

• Dr.Sahana K Senior Resident OBGY

• Dr.Drishti Doshi Resident OBGY’

• Dr.Monica Mallipatil Resident OBGY

• Dr.Rajani Saini Resident OBGY

• Dr.Gunwant Kamble Resident OBGY

• Dr.Sudeep Sarda President SPHOA

• Dr. Nitin Toshniwal

• Dr.Santosh Nawale Medical officer health SMC for assisting and

shifting me to Yashodhara Hospital.

• Dr.Yogesh Rathod Intensivist Yashodhara Hospital

• Dr.Vijay Shivpuje Yashodhara Hospital

• Dr.Manik Gurram sir for supplying the cardiac ambulance from

Markandeya Rugnalaya.

• Dr.Sameer Jog Intensivist DMH

• Dr.Balasaheb Pawar Respiratory Medicine and Intensivist DMH

• Dr.Parikshit Prayag Infectious Disease consultant DMH

• Dr.Bhagyashree Burkhe Intensivist DMH

• Dr.Amit Walimbe Physician DMH

• Dr.Vishnudas Telbhare Physician DMH

• Dr. Bharat Purandare Infectious Disease Consultant.DMH

• All the on call residents of ICU at DMH

• All the nursing staff of DMH

• Dr. Sunita Tandulwadkar IVF and laparoscopy consultant Ruby Hall.

• Dr Sumeet Saxena Plastic Surgeon Ruby hall.

• All the members of SOGS, SPHOA and VMGMC faculty and residents

for there blessings and prayers.

• Mr.Abhay Dongre ACP Solapur.

• Dr.Arun Kumar Intensivist Ashwini Rugnalaya

I would like to thank few of my UG BJMC 1995 batchmates who helped me in this crisis.

• Dr Manish Dastane – Orthopaedician DMH – coordinated in DMH

• Dr.Sunita Chopda /Patil – OBGY Daund

• Dr.Rahul Patil – Orthopaedician Daund

• Dr.Ashwini Joshi – Physician DMH

• Dr.Aditi Khurana / Dastane – Molecular Pathologist DMH

• Dr.Milind Phadke – Cardiologist LTMMC Mumbai.

• Dr.Jignesh Shah – Intensivist Bharati Vidyapeeth hospital Pune.

• Dr.Monica Paratane/Patil – OBGY Pune.

• Dr.Sachin Patil – OBGY Mulund .

• All the batchmates of BJMC batch 1995 for there prayers and blessings.

In the end I would conclude by thanking all my famiy members especially my parents, sisters, brother, sister in law , brother in law, my children and my wife Dr.Ashwini Saraf/Pawar for supporting me and boosting my moral during my stay in DMH. I would also like to thank our family members from pune Dr.Sanyogita Naik – HOD Anaesthesia and Dr.Vijay Naik Physician ESIS hospital pune for supporting me and Ashwini in Pune (They are in laws of my youger brother Ajayy).

Learning lessons

1.You can get infected even if you wear PPE, as there are so many asymtomatic patients,doctors, staff with whom you interact day in and day out.

2.Learn to have the habbit of not touching the face. All should see the movie Contagion. It gives a fare idea of what a airosol borne pandemic pans out. Available on amazon prime.

3.Report early to covid centre for treatment. Even if you are a doctor/physician don’t take self medication. That was the mistake I did. Fear of getting admitted in COVID ward.

4.The pneumonia / cytokine storm strikes suddenly, so plan and identify a place where you will get admitted in case of an emergency before hand. See that the hospital has the facility of Non invasive ventilation including HFNO. Adequate staff – doctors, residents and trained paramedical workers.

5. I am not an intensivist but what I understand is that -NIV and delayed intubation is the key in Covid 19 crisis. Delayed intubation is possible only in institute who have round the clock monitoring by trained physicians and facility for immediate intubation. Where these facilities are not available delayed intubation cannot be practised. We are aware that morbidity and mortality with intubation is high. So do keep this point when you have a covid patient and needs admission in ICU. It will help in deciding the hospital.

6.Take care of your health, it helps during the crisis if you are physically and mentally strong. Post covid I understood the importance of Pranayam.

7.Have a positive attitude always, never ever loose the moral and allow negativity to enter your mind.

8.When I was put on HFNO it requires full focus on your breathing. Consious breathing and deep breathing is important. Each breath is precious and takes efforts. It taught the value of oxygen which we take for granted. I concentrated on each breath and talked to myself Breath – Breath – Life – Life.

9.Limb physiotherapy to prevent DVT.

10. All the ECG leads are attached to the chest so if you think you are getting admitted to the ICU see that the chest is shaved, it’s a pain when they remove and stick the ECG leads on the chest daily unless you are comfortable with waxing.

11. Maintain hydration, I used ORS and Nimbu sharbat and lots of water.

12. Follow the instruction given by the treating doctor especially the CARP protocol. It’s a bit cumbersome to sleep in prone position with all the leads and tubings attached. So frequently change the positions, but do it religiously.

13. Smile, greet and thank the treating doctors paramedical workers and the other ICU staff. Gratitude helps. They need it and is reflected in our recovery.

14. If you develop any new symptom never ignore, immediately inform the on call doctor.

15. Most of the ICU don’t give you access to mobile phones so be mentally prepared to be away from mobiles – its total social isolation, can be depressing for some.

16. Don’t be afraid, face the situation head on and pray to GOD and express gratitude.

17. All the blessings of your near and dear ones help.

18. Life is precious – live it well. Do self introspection and course correction as you never know if you will get a second chance or not.

19. Have a good friends circle who will go out of the way and help you. Also when the need arises you should help others in need.

20. Now our private hospitals are also gearing up for facing the COVID 19 challenge, but just in case you decide to shift to a higher centre then its better that you shift early before O2 requirement as once the swab report comes positive and you are on O2

support/ BIPAP a cardiac ambulance will be required. It is an herculean task to arrange the ambulance and the accompanying doctor for shiftng covid positive patient.

21. Ask for help,don’t shy away. All your family and friends are always ready to help. You just need to ask for it. There will be some people who will not answer or block your or your friends mobile calls in the time of crisis. Accept it they will have there own reasons for those actions. Forgive and forget. Don’t have grudges against any one. It helps to heal yourself.

22. Post discharge there was weakness and dyspnoea on exertion. So take it easy. There are chances of DVT and pulmonary embolism so maintain hydration, move around don’t just lie in bed.

23. I started exercising gradually monitoring my pulse and SPO2. Target is 100 bpm and SPO2 of 96%. The moment the pulse crosses 100 bpm or spo2 goes below 96% I take a break.

24. Lung physiotherapy is important so spirometry has to be continued. I started Pranayam and Meditation.

25. Managing the Stress – your Mind, body and Spirit should be aligned. Any misalignment in these three leads to bad stress. So here meditation help. And what is meditation- its focussed breathing.That means you have to focus on breathing which I did in ICU.

26. Sleep – in the ICU they used CARP protocol so practice sleeping in prone position. Sometimes it a bit uncomfortable so if you are accustomed to it then it will help. Anyways sleep in the ICU is difficult due to constant noise of the alarms. Sometimes due to sleep your deep breathing stops and the Spo2 starts dropping. The sister on duty wakes you up and asks to do deep breathing.

27. Insurance and expenses – You should have a good mediclaim policy with zero percent copayment. If you already have then please check whether it is active and not expired. Otherwise the expenses runs in lacs. I spent around 4 lacs in 15 days.

These are the thoughts that I experienced during my journey through the covid crisis. If I forgot to mention anyone I apologise for the same.

I have shared my experience so that whatever mistakes I have done should not be

repeated by others who may land in this crisis.

Apologise if anyone felt hurt because of my article.

If anyone needs any help regarding COVID cases especially shifting to

Pune, I can help.

Dr.Vijay Pawar

Associate Professor OBGY

Dr.VMGMC Solapur

With inputs from my wife –

Dr.Ashwini Pawar

Consultant, SIMS fertility centre, Solapur

Consultant,Sunrise Hospital,Solapur

Director – Omkar Nursing Home Solapur

Please share your critical reviews on whats app – 9665481664 or

drvijaypawar@gmail.com

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