[Based on a conversation with Dr P V Karthik]
In the fight against the current COVID tsunami that’s engulfing us, we, along with a group of amazing volunteers (most of them being young college students and young working professionals), have been trying to respond to SOS tweets and alerts coming in from various parts of the country. With the number of SOS cases increasing from Chennai, we assembled a dedicated team of volunteers to cater to region-specific requests.
Those who made calls to hospitals in the last 3-4 days will know how difficult it is to get a bed in Chennai. On Sunday, I spent six hours calling multiple hospitals to check for an ICU bed with no results. Some pick up and say beds are not available, while some don’t pick up calls at all. Some even disconnect the call. And yes, you can’t blame them either. How would we feel if our phone rings incessantly every three minutes? For 20 continuous hours? For 15 straight days? And we have some 100 lives to save on top of that as well?
Though we are able to empathize with the healthcare fraternity, it is undeniably a terrible feeling when we follow up on a day or a two-day old request to see whether the patient has secured a bed through any means, and hear that the patient is no more. Somehow there is a sense of guilt assailing us, the volunteers, when we are not able to secure a bed for someone who is critically ailing. Things have only exacerbated every passing day.
Since calling hospitals have not been of much help, I got into a conversation with a friend of mine, PV Karthik, who is practising in one of the larger government hospitals in Chennai. My objective was to understand what is happening on the ground and how to prepare ourselves to navigate the situation we are in presently. He shared some vital information that I would like to share with you through this article.
Before I proceed further, a word of caution: I am not a doctor and I am only sharing what he shared with me as advice.
Understanding hospital infrastructure
Take any hospital, public or private, a maximum of 40% beds would be oxygen-supported beds. And some 5% would be Ventilator and ICU beds. The reason one needs oxygen support is that the COVID-infected lungs do not allow the oxygen from air to pass into the person’s bloodstream. So the person needs supplemental oxygen as they try to recover from COVID.
If someone walks in with an SpO2 of say 94, and if their SpO2 levels don’t fall, then the doctors can keep them in normal beds. If the SpO2 deteriorates, then they need external supply of oxygen. But excessive oxygen is also bad for the lungs. (The doctor says it causes way more damage). So doctors have to first first determine how much oxygen to administer to the patient.
If SpO2 goes down to say 90 or so, slowly they start administering oxygen (some 3-4L/min) through nasal tubes and non-breather masks. If SpO2 goes further down, then pressurized continuous oxygen is provided from the machine, having a higher flow rate. If SpO2 goes even further down, then ventilators are used.
Now, most COVID makeshift hospitals that are being set up in Chennai can only provide basic nasal oxygen (or non-breather masks). This is why most of them say they can take in only mildly or moderately severe COVID patients. Getting ICU and ventilator beds is becoming very difficult because obviously they are less in number, and they also require a full time anaesthetist in the hospital. So these types of beds are more or less available in large and moderately large hospitals only.
Karthik shared that in his hospital, they don’t usually accept new admissions for ICU. Every day, some of the people who have been admitted to the oxygen ward get critical and they get moved to the ICU. In other words, it is very difficult to get a direct ICU admission today.
This is most likely to be the situation in large private hospitals as well. Internal fulfillment happens and that happens a lot. In addition, the beds there get filled, thanks to the recommendations from internal doctors/nurses working there. Networking works. Privilege works.
Do helplines work?
104, the state medical helpline works. And it works really well. But to understand why it is really difficult for 104 to fulfill requirements as well, we need to understand how the beds are getting fulfilled today. (No brainer: direct walk-ins.)
In government hospitals, inasmuch as I was informed, depending upon the capacity, 60-100 patients get discharged every day from each hospital. So in a 500-bed hospital, some 60 beds are available every day. The patients from there are discharged between 8 am and 10 am.
Karthik said that people start queuing up from 6 am in the morning itself to get an admission there. If you have seen the images of ambulances line in front of hospitals, you would agree and nod here.
Now, the hospital provides updates to 104 only by around 10 am. So the patients (say 60 people) would have been discharged by then. And the count of vacant beds goes up by 60 in the database. However, there is already a huge queue in front of the hospital. So within the next 30 mins or so, all the vacant beds get filled by the patients waiting in line from morning.
In short,104 works. The updates are provided. They are literally doing their best. But the situation is such that the speed of fulfillment is much, much higher.
This rate, however, might not be the same for other small to medium hospitals. So 104 is able to provide support there. But then, those small to medium hospitals might have challenges with respect to oxygen beds. (Refer point made about nasal oxygen beds above).
A few important things to be aware of
While this is the ground reality, there are some absolutely critical points for us to note.
I have heard multiple stories from doctors on how COVID patients can have a drastic deterioration of their health condition within a very short time span. So every day counts. Please be aware of every COVID symptom. If you have even the slightest of fever/other symptoms, rush and get your RT PCR done.
If a patient is over 60, (or with co-morbidities or obese) is experiencing fever over 100 degrees continuously, do an RT PCR *AND* a CT scan. Don’t wait for the results of the RT PCR. If a patient is young and experiencing mild fever and no breathing problems, do an RT PCR and an X Ray. No CT needed at this time.
It is true that a CT scan exposes you to radiation risks. 300 times more radiation than X-ray, as highlighted by the AIIMS chief, might be an exaggeration. But multiple studies definitely prove it poses at least 70-100 times more radiation risk than an X-ray. Dr Karthik said he would not have recommended a CT scan last year, but the virus in the second wave is more virulent; therefore, as a doctor (and a radiologist) he is recommending his patients to take CT, based on what he is seeing on the ground.
One CT scan should not make one worry about causing cancer; the chances are very faint. But of course, repeated scans are to be avoided so that the radiation risk is minimized. Patients who are pregnant are anyway advised NOT to take a CT scan.
X-rays also help in determining the lung damage. But the difference between an X-ray and a CT scan is that the former is two dimensional. You can assess the depth of lung damage only through a CT scan (and therefore get a CT score). In the earlier wave, even as the fever surged and mildly subsided afterwards, the effect on the lungs was less severe. This time, he says, the lungs are getting badly infected and assessing the extent of damage upfront through a CT would help in quicker treatment and recovery.
He further explains that this is a pandemic situation where he has seen an insane amount of people suffering everyday. If someone has a fever now in a city that has 20K cases of infections every day, there is a greater probability that it might be due to COVID, than say due to flu or typhoid. As a doctor, it is his responsibility therefore to consider and be prepared for the worst case scenario, than being optimistic that it is normal fever which would subside after three doses of paracetamol.
In this second wave, there are also a significant number of people (especially young patients) experiencing a condition called ‘Happy Hypoxia’. Usually, when our SpO2 levels go down to 94 or 93, we have difficulty breathing. But in recent COVID cases, people continue to feel healthy (happy state) with no breathing problems at those SpO2 levels. Only when their SpO2 dips to say 85 or so, they start feeling breathlessness. But by that time, the patient is already critical. If there is no bed availability then, their condition rapidly declines.
It is absolutely critical to get a pulse oximeter. This is by far the only tracker we have to assess severity of the disease at home. The reason oxygen beds and ICUs are so full is because people are reaching hospitals late.
It is a fact that not everyone can afford an oximeter. So things are getting very difficult for less privileged families today. But if you can afford one, please go and buy it. If you can buy one extra, please provide an oximeter to someone who can’t afford it. (and teach them how to use it).
If your chest CT is normal (but you still have symptoms), home quarantine yourself. Keep checking your SpO2 level. If it goes below 95, visit the nearby COVID centre.
If your chest CT shows mild deterioration (score less than 7), even if your RT PCR is negative, get to a COVID centre, file for home treatment, get medicines and home quarantine yourself.
Monitor your SpO2 level at least 6 times a day. If the Spo2 decreases (it happens gradually in a day) and hits say 94, start your search for hospital beds.
Getting a hospital bed when you have SpO2 above 90 is easier, refer to points about nasal oxygen beds made before. Therefore treatment is faster and easier as well. It is at this stage, my friend said, that they often administer Remdesivir. If the SpO2 goes lower than that, say to 80 or so, then the medicine would not be helpful.
Because, everyone is indiscriminately using Remdesivir, the ones who actually need them are not getting them today. He also said they have stopped using Tocilizumab and other IL6 inhibitors in government hospitals in the city. They used it last year, but seeing no big improvements and because of a lack of any concrete scientific evidence, they have stopped it this year. It is also exorbitant and beyond the reach of most.
If someone does not have an oximeter, they must go to the hospital as soon as they face the slightest difficulty in breathing for basic tasks like walking, speaking etc. Even today there are 40 beds vacant in Dr Karthik’s hospital, but they are normal beds and with no takers, because everyone is coming to the hospital only with serious oxygen requirement.
Hope we all stay safe, but it’s always best to be prepared. And authentic information is key to effective preparation.