By Dr GK Singh, COVID warrior. In memory of Dr KK Aggarwal.
When whole world was bidding adieu to 2019 and planning year end extravaganza in their lives; locality around Wuhan Institute of Virology in China witnessed unusual spurts of pneumonia which we now know as COVID19 caused by SARS-coV2.
India imposed one of the most stringent lockdown measures in April and May 2020 to contain the spread of virus, which was quite effective for our existing health care resources. Even though, India passed through very bad economic crisis where livelihood of poor migrants workers were impacted harshly, world praised the efforts of our country to contain the disease and its fallout on human lives.
Things were gradually settling down, statistical data from hospital were also suggestive of that. But it is the things that you least expect that hits you the hardest. The rampage of mankind by second wave exposed our understanding of pandemic as a nation. Its widely described as onslaught by the mutant B.1.167 of SARS-coV2 but only time will tell about possible bioterrorism by rogue and powerful nation.
India, which was thumping her chest after successful containment of first wave, was actually on knees and mercy of God and friendly countries. I witnessed this pandemic closely as a patient, as an attendant of my close relative and a doctor managing covid patients.
It has shaken me completely.
Therefore, it is my sincere and honest efforts to bring you the nuances of all the aspects as I witnessed. Sole aim of writing this diary is to educate the readers in subtle ways and highlight some ground level fallacies which are usually ignored by policymakers with the hope theses might get some place in their guidelines.
As a patient:
My hospital, name is not important, is one of the tertiary referral centre of Dermatology of entire North India and runs one of the busiest OPD of the hospital with annual footfall of 150 thousand cases. Due to ongoing pandemic, facilities of skin department, were converted into part of Covid care centre. Our OPD was running on ad hoc basis with the bare minimum resources.
By the end of March 2021 we started witnessing the pre-Covid status of OPD load. In a small, overcrowded place this was a disaster waiting to happen. Forget about the policymakers, people, media; we doctors and healthcare providers on the ground were taken off the guard due to prevailing low Covid cases from the previous month.
Administrative authority was gearing up for possible closure of the covid centre. Even the unofficial gossip was that we might get our department back by the end of March.
Like a self proclaimed, clever doctor I took vaccine slightly late after I got convinced that it is safe. I received my second dose on 22 March 2021. I did have mild muscular pain at the site of injection and very minimal feeling of lethargy which was totally resolved by day three.
Day five, post vaccination, I had noticeable calf muscle pain which I conveniently blamed on post vaccine myalgia and carried out my routine activities. But this muscular pain gradually started increasing and spread to my spinal muscles. Even though, I did not have fever or breathlessness, I was not feeling well.
On 1 April, 2021 afternoon, in post lunch academic session, I had unusual thirsty feeling and apprehension. I could sense my heart beating very fast. I immediately sought help of physician who examined me thoroughly and advised ECG. Considering my previous healthy state, finding of dry tongue, sinus tachycardia (normal but fast heart rate) in ECG in the backdrop of absence of fever, upper respiratory tract infection, I was advised measures to correct dehydration and take rest.
But being doctor, I was knowing that just after lunch I might not have dehydration. I insisted for COVID test. 2 hours later, geneXpert result conducted from nasal swab reported positive for COVID19. The initial euphoria of correctly predicting my disease clinically despite atypical presentation turned into horror when I thought about the possible complications.
I was one first specialist doctor who contracted this infection in early second wave. This has started my journey of patience, panic and grim. I was isolated in house in one corner while in other room my wife and daughter were staying who were not vaccinated yet. So near, yet so far! There was constant fear to spread the infection to close one even after taking mandatory precautions.
I realised the unconditional love and literal meaning of better-half, who constantly remained by my side, looking after every minute requirements even after knowing the contagious nature of the disease. My clinical presentation was not usual as most commonly mild covid features are of upper respiratory tract infection in the form of throat-ache, running nose, sneezing, low grade fever, body-ache etc while moderate to severe may develop features of pneumonia in the form of high grade fever, breathlessness, extreme weakness.
I developed mild nasal dryness, loss of smell and taste subsequently but it was extreme weakness which was quite bothersome. I never had fever and breathlessness, my SPO2 varied between 93 to 95 but even minimal movement like going till toilet, cleansing mouth used to feel like running a marathon in summers with a 30 kg bag-pack. My heartbeat used to be 130-140/min with feeling of sense of grim and gloom. Six minute walk test did not bring down my SPO2 level below 93 but used to increase heartbeat till 140-150/min.
Stricken by panic of high pulse rate, I used to be lying on the bed most of the time thinking of future of self, wife and small daughter. A bright light, an endless tunnel or Yamraj on buffalo. Mobile was constantly ringing from friends, colleagues asking about my health but simultaneously teasing on my good times with Netflix, Amazon prime movies. How could I tell them every time that it was not like last year when people of Covid infection in home isolation had really good times watching those stuffs. Here, my eyes were more concerned of reading of heart rate and oxygen level in pulse oximeter. In fact, I had started seeing oximeter readings in my thoughts and dreams.
I got really scared thinking about my heart issues, sought consultations of Cardiologist, Pulmonologist and Physician. I have undergone baseline test like CBC (complete blood count), LFT (liver function test), RFT (renal function test), blood sugar, Chest X-ray PA view along with inflammatory markers like CRP (c-reactive protein), serum ferritin, d-dimer and test for cardiac status like CKMB (creatine kinase myoglobin) troponin T/I and ECG. CRP, d-dimer was mildly raised, ECG showed sinus tachycardia, rest other tests were essentially normal.
I was not prescribed oral steroids. However, I did take tab vitamin C, zinc, aspirin. I was worked up for possible myocarditis or micro thrombi in lung tissue for persistent tachycardia (high pulse rate) by echocardiography and CTPA (CT pulmonary angiogram) respectively but fortunately these tests were normal.
Silently, I prayed to God for taking care of me. Even after three weeks, I remain covid positive by RTPCR with excessive weakness. I lost 4 kg of weight by the end of month, and continued to have tachycardia varying between 96 to 106 on rest to 120 to 130/min on mild exertion. I was prescribed tab ivabradine and tab metoprolol to control my heartbeat but I could not tolerate even single dose, so stopped thereafter. Both the drugs gave sense of sinking feeling and doom.
Ultimately, I tried to find out the doctors who had similar episodes following Covid 19 infection, luckily I got few of them. They all assured me that it will settle down gradually of its own over 06 to 8 weeks. At the end of 08 weeks my weakness has improved, I regained 3 kg of lost weight but resting tachycardia in the range of 92 to 100 is still persisting which still bother at times.
As an attendant
When, I was recovering from Covid my brother became symptomatic on 19 April with low-grade fever, nasal stuffiness, mild throat ache and progressive weakness. He was maintaining SPO2 within normal range. Due to heavy load on laboratory, his RTPCR report was delivered after four days with surprisingly negative report (found in many cases of covid infection in second wave); but results of baseline test (CBC, LFT, RFT, Blood sugar) and inflammatory markers (CRP, Seem ferritin, d-dimer, Il-6) were very much suggestive of Covid19 infection.
His conditions started deteriorating, his SPO2 declined to 94 on room air, he was positive for 6 minute walk test (SPO2 declined 5 point on walking for 6 minute). On day 6 of symptoms, I recommended him to undergo CT chest scan which revealed typical features of Covid pneumonia (ground glass opacities and consolidation on bilateral lung field mainly lower and middle lobes) with CT score of 11/25 (moderate involvement).
Since, he dealt with medical equipment, he could manage one oxygen concentrator for himself. He was on telephonic consultation and maintaining oxygen of 96 on oxygen concentrator. He was started on tab favipiravir, injection dexamethasone, injection enoxaparin along with Govt recommended covid protocol medications (Via C, zinc, paracetamol, Ivermectin).
His conditions further deteriorated, now he was maintaining oxygen at 94 on oxygen concentrator. On 28 April 2021, I realised that it will difficult to manage him at home, so the search for hospital bed started. This was the time, I realised how difficult was to get a bed in the hospital. Forget about the large corporate hospital, a small nursing home which had oxygen facility was not available. To add to the agony there was news all around of patients gasping at the gate of hospital, dying in ICU due to shortage of oxygen. I could sense imminent danger to life of my brother.
It was do or die moment. Being doctor in the Govt service, I requested my administrative authority to help in admission. Our authority was kind enough to facilitate admission. My eyes were filled up with tears when I got the news that one bed has been arranged for him. That guilt ghosts of not able to help my own family member despite being a doctor myself were laid to rest. My actual experience as an attendant started now.
Shifting patient from Indirapuram (residential locality in Gaziabad near Delhi border), required an ambulance which had oxygen facility. To our surprise it took almost two hour to manage one ambulance with oxygen. Few saw it as an opportunity and demanded unusually exuberant price of twenty five thousand that to be without oxygen. I took my brother to designated ward where bed was arranged.
Hall was full of patients in agony, atmosphere was gloomy, some were on masks, some on ever noisy machines and few were gasping for breath even on machines. Two beds had mortal remains which needed to be shifted to hearse van to mortuary. I was told that van is on way, mortal remains would be cleared so that it can be allotted to my brother. As a doctor, it was not very unusual scene for me but imagine the psyche of patient who was overlooking the bed which he was going to occupy after its cleared of mortal remains. Apocalyptic is an understatement.
Healthcare staff were overstretched, there was no bed vacant, almost one fourth of patients were quite critical requiring constant monitoring. Attendants used to plead to the nurse, doctor on round to do something as oxygen level is falling. But, in their heart they were knowing nothing much can been done.
Ventilators were limited, and could not be withdrawn from the patient to put on others. Small issues which could be so detrimental, I realise as an attendant. My brother was put on high flow oxygen but he had to walk around 15 meters to use toilet. He became restless and rush to his bed to realise that his oxygen level has dipped to 70. Luckily, he was in condition to ring me up, I came running, arranged for diapers and instructed not to move at all.
He could not pass urine for one day, as adult is not used to diaper. I could arrange one old bucket where he could pass urine. Out of fear he could not pass stool for 5 days. In doctors circle we had come to know that there had been couple of death of covid patients while going to toilet, as their oxygen level dipped too low to be revived on time.
Next late night, I got a call from my brother that he is being shifted to other ward and reason was not explained to him. The ward had old pattern of oxygen supply through jumbo oxygen cylinder which have to replaced manually every time it finishes. So, there used to be time when ward used to have low pressure of oxygen. I ran to the hospital, realised the wise decision of physician who wanted few patients to be shifted where oxygen pressure and flow is constant.
It took three hours from 12 o’clock to 3 o’clock in the night to finally get the bed in other ward. Similar, incidence followed there as well, we had to wait for the bed while mortal remains needed to cleared by house keeper. The oxygen supply in this ward was connected with liquid oxygen plant. Even he felt the difference in breathing, overall well being.
There was huge restriction on the attendant. Being a doctor in same hospital, still I had difficulty in reaching to the ward. During normal circumstances, I would have lost my temper but reaching to him was more important than to argue with security staff. On many occasions, I administered the intravenous fluid, essential injections to him after realising that duty nurse had forgotten.
They were many critical patients whose attendants were not there. They were at mercy of our paramedics. Food was served on the time but there were many unfortunate one who did not have attendants who could feed them. They were not in position to take the food. If they remove mask their oxygen level would fall and become restless. Some body needed to fix nasal prong instead of NRBM (non rebreathing mask) to avoid such circumstances.
Medications are important but equally important is nutritious diet, hand holding and emotional support by the close ones in such a difficult time. I felt the pain of attendant who had to really plead to authority to extend his or her visitor pass to look after near and dear one even after realising the eminent danger of contracting the fearsome disease. It was not humanly possible to constantly monitor oxygen flow, feed, change the diaper, change the posture, motivate, hand holding of each and every patient by our already overstretched health professionals.
In normal circumstances many such patients could have been saved by close monitoring, timely intervention but this pandemic created unprecedented crisis in health infrastructure where precious lives had lost value. Everyone, was not as lucky as my brother whose attendant was a doctor and could sense danger in the parameters and influence the treatment.
He started showing sign of improvement after 5 days of methyl prednisolone pulse, subcutaneous low molecular weight heparin, intravenous high end antibiotic like meropenem and teicoplanin along with covid protocol medication. His oxygen saturation gradually improved. Gradually, he was shifted from NRBM to oxygen mask then to oxygen concentrator.
Finally after ten days of hospitalisation, he was discharged with oxygen concentration of 92 on room air with advise to taper oral steroid, tab ecospirin, deep breathing exercise and review by Pulmonologist after fifteen days. I can never forget those tears of indebtedness in the eyes of my brother when I made him sit in the car to take him to his home as if he is trying to convey he could make it because of me. He is recovering well.
As a doctor incharge of covid ward
I was on leave recovering from Covid but was re-called as there was an order to follow from the higher authority so that the health professional crunch in one of the busiest Covid Centre of NCR can be augmented on priority. Wearing of PPE (personal protective equipment) in the hot summer of India is torturous. But, I had the practical experience when I had near choking feeling after one hour of wearing.
I was made in charge of of 50 patients distributed over two wards out of them 12 were critical on NIV (non invasive ventilator), nine were on BiPAP (bilevel positive air ways pressure) and rest others were either on NRBM or gradually improving from NRBM to oxygen concentrator.
When you take dermatology as subject to practice one of the unexpressed fundamental is to avoid emergencies and frequent call from the hospital so that you can enjoy quality time with your family.
Since last 10 years, I was actively practicing pure dermatology which is quite different from intensive care. As a dermatologist, we do see critical cases but when it requires airway management, fluid electrolyte balance we tend to seek help of our critical care specialist who look after ventilator, intravenous access, fluid electrolyte imbalances etc.
This explains a medical joke that has been going around a while about COVID prevention : If you don’t want a dermatologist to intubate you, please wear the mask and follow social distancing. Fortunately, when I was suffering from Covid, I tried to study different aspects of the illness.
I had working knowledge of different guidelines, protocol which were updated timely by ICMR (Indian Council of Medical Research), MoHFW (Ministry of Health and Family Welfare) and AIIMS (All India Institute of Medical Sciences) Delhi. Last year, I had an opportunity to even go through the SOP (standard operating procedure) of our hospital on handling Covid cases while writing an article.
First day, in the ward was unusually different. I was finding myself in bit awkward position as I was not knowing how to operate these equipments. I was briefed that any issues with these equipments, I can communicate with anaesthesia resident on call. But, I knew patient won’t give that much time. By the time resident will reach we might loose the patient. Therefore, I understood the operating principle of NIV, BIPAP by junior colleague from other wards, physician who used to take round and also augmented knowledge through webinar videos.
By third day, I was knowing every patient by their name and their management plan. I started enjoying my new commitment like a new intern placed in a job that he loves. I found great sense of achievement to temporarily save precious lives.
For a moment, I realised that what I practice was very shallow but I console myself that this pandemic is not going to be perpetual. Life will be back so be the world of Dermatology.
I could counsel the attendant, patients, set the parameters of NIV depending upon present clinical conditions. On many situations, I was able to place patients on NIV successfully. I felt the tears in the eyes of relative when oxygen used to dip. At the same time felt the sense of joy when oxygen used to return to normal range with minor intervention in setting of NIV or simply checking the fitting of mask.
Even though there is guideline and protocol but there used to be differences in the approach of treating physician. Younger lots were more aggressive, never used to hesitate in giving much higher dosage of injectable steroid, high end antibiotic, drugs like tocilizumab (interleukin 6 inhibitors), remdesivir, plasma therapy etc, while experienced lots were not chasing too much to inflammatory markers, rather they were more interested into clinical improvement and following well established evidence based therapies.
First week of hospitalisation was very crucial for the patients. Thumb rule, which I had observed those who could not maintain oxygen concentration on NRBM required either BiPAP or NIV support, 80% of them deteriorated and finally succumbed to death. My ward had mostly female patients in their late forties. Those with pre-existing diabetes, obese had very tough time.
Once they required NIV or BiPAP support, they usually succumbed to death. Even though, professionally, it was new experience for me, I had a great sense of satisfaction that I could come of some help to the nation when situation arose but at some corner of my heart it shattered me, made me philosophical of knowing how lives can be so priceless at times.
Lucknow’s famous Shayar Chakbast Brij Narayan’s lines made so much sense to me in these testing times: “Zindagi kya hai, anasir me zuhur-e-tartib; Maut kya hai, inhi ajza ka pareshan hona.” Meaning, “What is life, if not elements in order; what is death, if not the chaos that make them fall”. Virus is just a medium to cause the chaos. I realised, how important is to have one doctor in a family who can guide you without any prejudice or favour.
Jai hind.
(Author is a dermatologist posted at Govt Hospital in National Capital Region, New Delhi; Views expressed are very personal and not intended to harm any individual or any Institute.)