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ISMPO Insights

Stormy days and soul-searching mind

Dr. TVSVGK Tilak1

1MD (Med), DNB (Med), DM (Medical Oncology), FRCP (Glasg),

Professor (Medicine) & Medical Oncology,

Department of Internal Medicine, Armed Forces Medical College, Pune, India,

Email ID: drtilaktvs@gmail.com

“I can be changed by what happens to me. But I refuse to be reduced by it.”
- Maya Angelou



The dreams at night. Again, the same ones. The hangars of the make-shift hospital. The cubicles full of patients. The alarms going off on many monitors. The ever-perplexing clinical scenario. Those hopeful looks of the caregivers in personal protective equipment (PPE) standing next to the patients on oxygen support or ventilator. The counselling which goes on through the hum of the large air conditioning ducts cutting across the length and breadth of the hangar along the roof.

It’s 05:50am. The bedside clock rings and says it time. It’s time for yet another day, to get ready for my morning shift. Mind is still muddled, sleep still incomplete, morning feels dreary. But there’s job to be done, task at hand and the mind adjusts to the same.

Time for planning the day. The breakfast as fuel, the amount of fluid intake to allow spending next 6-7 hrs with no break, no option of drinking water or eating anything during that time because of the PPE. However, once I enter the arena, donned in PPE, time moves nearly unnoticed.

The second wave is nothing like the last one last year. The cases are much more severe, majority young (less than 40 years). The manifestations also intriguing. Patients presenting towards the end of the second week with some treatment priorat home or other healthcare set up, seemingly improving patients deteriorating rapidly over 24-48 hrs from face mask to non-invasive ventilation and eventually getting mechanical ventilation for support. Common reasons for such worsening often eluded clinical assessment and evaluation. The chest radiographs show worsening and the arterial blood gases are not good either. The probable cause could only be assumed to be microthombotic events but usually all measures to improve the clinical condition failed- much to the anxiety of the attending staff. The outcomes in such cases have been fatal in majority. Peculiar clinical manifestations- disease related bradycardia, intermittent tachy-brady episodes, cardiac arrhythmias-mostly atrial fibrillation and paroxysmal supraventricular tachycardias, clinical and ECG evidence of pulmonary or coronary thrombotic events necessitating thrombolysis, with some having excellent responses. Acral manifestations were seen more often this time. Severe hypoxia with central and peripheral cyanosis wasseen more often. Agitated delirium with multifaceted etiologies, necessitating antipsychotics and physical restrain was bearing heavily on the health care providing staff.

This was my third deployment at a COVIDhospital since it all started last year, the role purely clinical this time. These hospitals are a joint collaboration between two large government agencies, a central venture. The set-up of the 500 beds is the classical Nightingale pattern, the numbers usually 250 in each large hangar, which was centrally air-conditioned via large perforated ducts. This led to a constant background noise adding to the sounds of various alarms of the monitors and the ventilators. The communication between healthcare staff as well as with patients was a challenge in this scenario. The other hurdle was recognizing the various healthcare workers, all looking alike in PPE. To find a medical officer, nurse, physician or an anaesthetist inside the large hangars was a task, unless the PPE they were wearing, had their names written on it. This was ensured every shift for easy identification. Thankfully the housekeeping staff was given an entirely different PPE and were marked, too. Clinical cues obtained during the routine rounds were a challenge too, especially with double gloves, goggles and face shield that would fog, lack of use of stethoscope etc. The universal housekeeping staff issues and absence of caretakers inside the wards lead to healthcare providers assisting patients with their feeding, helping them with bedside urinals and bedpans- a unique role as a doctor or a nurse, much to the relief of the distressed patient.

The other major challenge was communicating the status of patients to the relatives. Usually done by phone calls from a control room telephone, the updating of data was often few hours old. Teams of healthcare professionals were often employed to collect real time data and pass on to control room at 6-hrly intervals. The information to the families of all patients who were intubated was immediately done from inside the wards by the doctor posted specifically for the administrative duties inside the hangars. Methods of clinical data collection was innovated by using common reporting sheets at end of every shift, employing data entry operators at the control room, who would upload the data twice or thrice a day on a common website, open to relatives who could access it with some basic login information.

The mortality rates were much higher than the last wave, owing largely to the behaviour of the mutant strain. Handling the anguish of the next-of-kin of the patients who passed away was a round-the-clock endeavour of the staff in the administrative role.

The few weeks of full strength of the hospital, the rush of the patients waiting, the physical endurance of the staff and the mental pressure to tide over the crisis was an arduous time. The fortitude and resilience during these trying times strengthened the mind and body. For those in endurance sports like marathon and long-distance cycling, preparation of body and mind goes hand in hand. The few hours during the sport activity requires grit and determination beyond the normal. The demands are heavy and the result is often exhilarating despite the drained mind and stressed body. The preparations involve attention to adequate hydration, nutrition and fuelling during the event. The role of the healthcare provider during this wave was an endurance event, day after day. The importance of rest could not be more emphasized.The end of the shift left the body dehydrated, hungry and the mind tired. However, the support of colleagues and kind words and blessings of the patients who left the hospital on recovery provided the much-needed solace. The future those days appeared very uncertain. The mission at hand very demanding.The role of the healthcare provider redefined, the value of life fortified, the soul searching for calm and succour. The bottom-line was very clear- save as many lives as possible. For, after every storm, the sun always shines, sooner or later. The future is still uncertain, but we shall brave for the storm.


Courtesy - Indian Journal of Medical and Paediatric Oncology (IJMPO)
Editor-in-Chief - Dr. Padmaj Kulkarni
Section Editor - Dr. Sneha Bothra
Editorial Assistant - Devika Joshi