Story of the fight inside COVID ward #Indian express


 

At this time, where  CELEBRITIES and REEL HEROES are fighting the war on Television to prove their real worth in CORONA-TIMES as if they are of some use to society; entertain.  Trying to prove as if the name, fame and wealth  showered on REEL HEROES was not an overhype, INDIAN EXPRESS has been wise enough to publish the real fight in the wards and plight of REAL   HEROES. As the stories of the real plight remains confined to medical groups only.  This article has appeared on 12 April Sunday.  Now the time has come to worship the  REAL HEROES and not use them as sacrificial lambs, otherwise in next pandemic only REEL HEROES will be available for good dialogues, and not the saviors.

      The hazmat suit can get oppressive, the separation from loved ones painful, and fear of the virus paralyzing. The Indian Express recounts 24 hours in the life of four doctors and nurses on the frontlines of the battle against coronavirus in the Capital, armed with a few PPE kits, bottles of sanitizers, and — when the stress gets unbearable — Mohammad Rafi songs

Soaked in sweat after a grueling shift, every night, she returns to the Dental Block of her hospital to sleep.The goggles and mask stretched across her face all day leave bruises; the heat, she says, has set off pimples. Her limbs ache from wearing a PPE suit a size too small. What she craves then is a bath, but dreads it too.

“My room is not a dormitory, it’s a laboratory. There are three toilets, no bathroom… I use the jet spray to take a shower. Then I wash my clothes near the toilet and hang them on a railing where clothes of 17 other nurses — all of them exposed to  COVID 19 patients all day — are also left for drying. That’s the moment I break down every day,” says the 50-year-old nurse who was assigned to the special ward of a dedicated COVID-19 hospital. “Dar lagta hai, rona aata hai (I feel scared, I feel like crying)… But I just take a painkiller and sleep.”

 

In another part of the city, a 25-year-old doctor, who has been working in the COVID-19 ICU of a Delhi government tertiary care hospital since March 26, is relying on a pill to stay safe. “I have been taking a dose of  HCQS,  I went to 15 shops to get it, but it was not available anywhere. I finally had to borrow from a friend.

Its effectiveness in treating COVID-19 has not been proven but it’s recommended. I know it can have serious side effects. I read that a doctor in Guwahati died after consuming it. But I am taking my chances,” he says.
On a continuous 14-day shift in the COVID-19 ward before he gets a break for a fortnight of quarantine, the post-graduate resident doctor from the internal medicine department says he loves his job, but fears putting the lives of his elderly parents in danger. “The ICU is the most infectious zone. I have to insert tubes through the patient’s mouth into his airways, put food tubes, catheter, if needed… I am constantly exposed to their body fluids,” he says, adding, “My parents are very paranoid, and insisted on taking the hydroxychloroquine tablets too. But I didn’t let them.”

As the country remains in lockdown, with people barred from stepping out of their homes, a large army of doctors and nurses have been making their way to COVID wards each day and night, treating patients even as they fight their own fears. With the novel coronavirus cases in India crossing 6,000, the burden of treatment has largely fallen on the country’s creaking government healthcare system and its over-worked staff. In Delhi, with over 20 virus hotspots and 14 deaths, at least six hospitals/blocks have been dedicated to the treatment of nearly 1,000 COVID-19 patients, and thousands of suspected cases.

 

the six floors of my hospital are brimming with people, there’s hardly any social distancing that happens. Ambulances are dropping off family after family, all suspects. I am not in a PPE kit all the time, so when I first come in contact with suspected cases, I usually have only a surgical gown and a three-layered mask for protection. If any of them coughs, I shudder… At times such as these, I simply plug in my headphones, listen to Mohammed Rafi songs for a few minutes, calm down, and return to the job,” says the 50-year-old nurse.

Before the shift

These days, the 25-year-old doctor begins his day with a WhatsApp video call to his parents. Since the Cardiac Care Unit at his hospital was transformed into a COVID-19 ICU, he has moved to a separate floor of his house.

“I tell them to prepare my food and leave it at the door. I was given the option of staying at a hotel, but my family got extremely worried and insisted that I stay at home,” he says. He also makes calls to a few friends, mostly doctors, across the country, to catch up with them. “They have been my support. I have to admit that I have been calling them more than usual,” he says. The post-graduate resident doctor, who is now three years into his job, has been working in three shifts — 9 am to 3 pm, 3 pm to 9 pm, and the night shift every third day, from 9 pm to 9 am, after which he gets a day off.

Given the infectious nature of the disease, separation from family is a reality for many doctors across the country, like for a 40-year-old cardiac surgeon from a Delhi government hospital who has also been staying on a separate floor of his house.

“In the mornings, my daughters, 5 and 8, come out in the balcony and we shout out and talk to each other. They have also invented a game — they have named me corona and pretend like they are out to catch me,” says the doctor, who volunteered for a position in the COVID-19 ward in early March.

 

“The distance was necessary because my father, in his 70s, has both a lung and heart condition… I have worked in tuberculosis wards earlier, so my family is used to me taking precautions. But this time it’s a pandemic and so the stress levels are higher,” he smiles.

For the 50-year-old nurse, a diabetic mother and a 10-year-old son at home made her opt for the hostel facility at her hospital. “I have been in the profession for 22 years. I married late to focus on my career. My shifts have usually been long, but this is the first time that I have been away from home for this long,” says the nurse who hails from Goa

So now she spends her mornings talking to her child and husband, often “hiding my worries”. “They read about the staff at the Delhi State Cancer Institute getting infected, they ask me all kinds of things. I just say everything is fine. I have also told them that I don’t have a phone with me, so don’t call me till 10 pm. But I have one; I just don’t want them to call me when I am busy with the patients or when I am too stressed,” she says. “Since it’s Lent season, I also pray for the safety of my family before leaving for work. I have bought some dry fruits and fruits from outside which I eat to strengthen my immunity,” she says.

 

As she enters the toilet in the Dental Block to freshen up, she says, she cringes at the sight of the bucket, mug and towel. “They were used by the staff here before us. I don’t know if they have been disinfected,” she says.
But she is relieved that she does not have to go back home after the shift. “Two nurses at the hospital have been travelling from Noida every day. Their families are exposed to the virus. Once my 14-day duty ends, I hope they test me before sending me home. The 50 nurses who worked before us were not tested, just sent for 14-day quarantine.”

Inside the ward

As per norms, and accounts by doctors and nurses that The Sunday Express spoke to, the COVID-19 wards in the Capital are “well-ventilated spaces with beds placed at least six feet apart and no extra furniture”. They are disinfected with sodium hypochlorite several times a day. Separate toilets would be ideal, but at most places, at least three to six patients share a facility.

“The rooms cannot have air-conditioners because that would lead to stagnant air, an ideal environment for the virus to thrive. This also means that a doctor or nurse can’t wear a PPE suit for more than two hours, because it gets very uncomfortable in this weather. It is easier in colder countries,” says the 40-year-old doctor, whose first challenge upon arriving at the hospital is ensuring social distancing among the large groups of patients who arrive at the reception every morning. The 450-bed hospital he works in has 200 COVID-19 patients now.

“I take two rounds of the wards in the day. I use the stethoscope for auscultation, I have to come in contact with positive patients and suspected cases,” he says.

Around seven people, including nurses, security and cleaning staff, are present in the hospital’s COVID ward at any given time. When not in the ward — there are six COVID wards at the hospital, including the ICU and Flu Clinic — the doctor works from a ‘COVID-19 office’ that has been set up at the hospital recently.

“Recently, a man who had returned from Thailand and had COVID-19 symptoms kept holding his little son in his arms. I had to counsel him for long before he agreed to let him go,” he says. Patients with fever, cough and sore throat first arrive at the hospital’s Flu Clinic to get tested. At least 50 patients have been testing positive at the hospital every day.

 

“I then move on to take stock of PPE, about 15 of which are used in each shift, and then go through patient files, and finally brief all my staff — nurses, ward boys, cleaners — on how to deal with COVID-19 patients. I can also easily tell when one of them is scared, it’s on their faces. I try to be jovial with them, that helps,” says the doctor.

For the Goa nurse, the “fear” is mostly a sinking feeling as she slips into the pink kurta-pyjama uniform at her hospital every day. “It’s washed with clothes of all other nurses. I rub a lot of sanitiser over it,” she says. Her hospital has 600 active and suspected COVID-19 cases, while her ward has six positive patients.

“We are four nurses on a shift, and only the one who goes into the ward gets a PPE kit. The rest are in surgical gowns and masks. But suspected cases are walking into the hospital all day long,” she says. She is part of a group of 120 nurses working at the hospital in three shifts — 7 am to 2.30 pm, 2.30 pm to 10 pm and 10 pm to 7 am.
For a 32-year-old nurse, who is now at home after completing her 14-day shift, it was the “donning and doffing of the PPE that left me anxious… We didn’t have a separate room for changing, about six of us did it together. I washed my hand after removing each part of the equipment,” says the nurse who hails from Kerala and has been working at a Delhi government hospital for the past six years.

A single parent who lives with her elderly mother and child, she says she stays in a separate room at her house, uses a different toilet, and pours Dettol all over her shoes and clothes every day. “Unlike doctors, nurses are not tested after the 14-day shift ends. There was no thermal screening facility at my hospital either. So I am continuing with the precautions,” she says. However, she says, she is relieved that she doesn’t have to wear gloves until her next 14-day shift. “I am allergic to latex powder that is used while wearing gloves. My hands would remain itchy all day. I would wash them all the time.”

Washing his hands 20-25 times is also among the many precautions that the 25-year-old doctor takes every day as he begins duty. “Even in the 20 minutes that it takes to wear the PPE, I wash my hands five-six times. I then head to the ICU, where I have four patients now,” he says.

His three years in the job have seen him being posted in infectious wards before and he is “not scared of the work anymore”. “I once got pricked by a needle used for a suspected HIV patient. It was 3 am and I rushed to get a test. It took six hours for the results to come. Fortunately, it was negative. Such incidents will happen, you can’t avoid it,” he says. He will be tested for the virus when his 14-day duty ends.

With no family attendants for the patients, doctors and nurses end up doing a lot more work. “Changing diapers of elderly patients, emptying urine bags… all of this carries chances of infection.”

And then there are the “VIP patients”. “Some of these patients are frustrated at not having found a place at private hospitals. Food complaints are a constant,” he says.

 

VIP patients have made the 50-year-old Goa nurse’s “life difficult” too. “They all have mobile phones, and they keep calling the landlines and our mobile phones, asking for chai, juice, their reports. Once, a patient accused me of hiding his reports… They complain about the cleaner, electrician, ward boy, and they blame nurses for everything. Hum kisko bolein (Who do we complain to)?” she says.

She serves food to patients three times a day in disposable plates and glasses. “It comes from the hospital kitchen — roti-sabzi, dal-chawal. If a patient is diabetic or has any other underlying condition, the diet is changed accordingly,” she explains.

The 40-year-old doctor says it’s normal for patients to be frustrated.

“They are away from their family, there is no emotional support. For a significant part of my shift, I double up as a counsellor. Recently, a young patient sat on the window sill, flung his legs out and threatened to jump. I had to pull him in. I later realised he was a drug addict and was experiencing withdrawals,” he says.

As for his own mental health, says the 40-year-old doctor, “Knowing the science behind the spread of the virus, and not relying on ‘WhatsApp and Facebook science’ keeps me sane. I have been following reports from Wuhan and Italy. It’s going to be a long journey. We can’t lose steam this early. My thoughts are similar to that of any soldier.”
To keep his staff healthy, the 40-year-old doctor also ensures that they eat on time.

“I get my food from home,” he says, adding that the staff takes turns to eat, and ensure social distancing.
The 50-year-old nurse says food is one thing they don’t worry about. “We recently got meals from Taj Hotel. It was very tasty,” she says. However, she has been taking care not to drink too much water so as to avoid using the toilet. “We have to remove the entire suit to use the toilet, and then disinfect. Plus, going to the toilet, which the other nurses have also used, only adds to my stress. COVID shift mein physical se zyaada mental stress hai (There’s more mental than physical stress while in COVID shift).”

So what does she do to fight it? “Apart from listening to old Hindi songs, I lean on my friend of 22 years. We started out together as nurses. We share our concerns and motivate each other,” she says. “I like to take care of people and that is why I became a nurse. But we need some care too.”

After the shift

After a long day at the hospital — that can range between six and 14 hours — the 25-year-old doctor begins his “return home routine”. “I first take a shower at the hospital and inform my parents that I am leaving so that they can leave my food outside my room. There is a sanitiser in my bag, in my car, at entrance of my house, at the door of my room and in my bathroom. I use them all. I keep the used plates and my clothes in a polythene bag outside my room. There is a separate bathroom for washing these,” he says. “My parents often ask me if the risk is worth it. I think it is.”

How often does the fear of contracting the virus cross his mind? “I have thought about it many times. If that happens, I will get admitted at Max or Medanta Hospital,” says the 25-year-old.

As for the 50-year-old nurse, when she returned to the Dental Block on Thursday night, she was filled with hope. “There was a protest by off-duty nurses for accommodation. The doctors are being put up at five-star hotels, why not us? Today we were told that some of us will be shifted to a new place, where there will be two nurses per room and an attached toilet,” she says. “I want to take a proper bath.”

Till then, the painkiller and Mohd Rafi melodies will keep her company for another night.

 

Strengthen hands of medical staff

Over 150 healthcare workers, including doctors and nurses, have tested positive for coronavirus so far. On the frontlines of the battle against COVID-19, the country’s health professionals have so far flagged issues such as shortage of personal protective equipment and lack of accommodation, besides being stigmatised as carriers of the virus.

 For the government, this then is the time to acknowledge some of these concerns and strengthen the hands of the medical fraternity. The ordering of 1.7 crore PPEs in the past week is a step in that direction.

 

Inside the COVID ward- Indian Express

Reel Hero vs Real Hero

21 occupational risk to doctor and nurses

“Battle of Corona”-Win or loss in People’s hand: not doctors or Governments


 

This is a disease that people can prevent, but doctors cannot treat.

Prevention is better than cure

In this era with knowledge of modern medicine, we know how to prevent the infection from Coronavirus. This is a completely preventable infection and everyone has enough knowledge about it. Heads of Governments requesting people to follow rules of prevention. Strangely these rules are not difficult. Hon’ble Prime minister Mr. Modi has himself requested people to follow simple precautions. Imagine if just by following simple rules can prevent a catastrophe in countries, world and families,  there should be no reason to not follow them.  If it happens, it shows the sheer carelessness and irresponsible attitude of people.  The success or failure or winning the battle against Coronavirus will not be of doctors, but people themselves.

This is a disease that people can prevent, but doctors cannot treat.

India Ahead News Video

Real failures of Dr Hazida Bawa case: Five issues to ponder-why doctors suffer?


 The case of  Dr Hazida Bawa  is of importance worldwide in many ways, an opportunity  for learning some hard and truthful lessons, as it touched upon various crucial aspects involved in medical treatment, especially in difficult situations. Every one has sympathy for the deceased, but  to blame a human factor, doctors should not be presented as sacrificial lambs.

       The current verdict is nearer to reality and away from a feeling of revenge and harsher penalties. It  gives a hope  that now there will be  acknowledgement of the difficult circumstances and limitations of medical system in health care environment.  To make doctor scapegoat for the  system limitations, poor prognosis or severe disease may be satisfying for some but not sensible. In this case doctors lodged their protest, collected money for lawsuit and the decision was re-looked legally. But every  doctor may not be  lucky enough and may have to suffer  in silence.

 Real failure in this case will be ignoring the factors that actually cause huge suffering for doctors-

  1. Presumptive failure by retrospective analysis: Retrospective analysis of any treatment will always show few things at hindsight that could have been done and would have proved life saving.  One may presume that omission or commission  of certain actions during treatment would have saved the  life,   but one can’t be sure whether these additional presumed treatment would really have benefited the patient.  Therefore a  perception-reality gap is created and with  negative perception towards doctors, it is interpreted as a  failure of doctor merely on presumptive basis and hence declared as negligence.  The doctors who deal with life and death know that it is not correct interpretation, and no one can ever be sure of what the real outcome would be. They just do what they think will be most effective for the patient, and it may not eventually turn out to be the best ever.
  2. Variable interpretation: Same evidence, incidence and circumstances are interpreted and  judged differently by people and  even courts. Some will say it is negligence and other will say it is not. Some will bay for doctor’s blood and other will not. This variation in perception is not only in minds of lay men but also in the learned courts, who  decide  differently.  At the time of death of patient, a constant and  universal last link is only the doctor, that is visible. He is an unfortunate victim, a human factor   and blamed for  the harm done because of variable thought process.

 

  1. Medical knowledge vs wisdom: People who do not treat patients, may be very wise and may acquire medical knowledge by various sources. But medical wisdom comes  only after years of medical practice,  by observing varied situations and spectrum of diseases. An understanding of what can happen in given circumstances comes only by treating such   emergencies.         For non doctors, it is very difficult to  comprehend the medical complexities and real time scenarios. Even doctors, who do not treat regularly emergency patients, can attribute the harm as doctor’s  mistake.

 

  1. Feeling of revenge:  in case of an  adverse event, negative thoughts prevail all over. In present scenario with legal powers with the sufferer and common sentiments against doctors, it is easier to identify and blame some human factors.   Adverse outcome is frequently covered by media to create a sensation among masses.  Real circumstances can only be felt by doctors  but that remains unheard. Harm to patient, media cry and negative sentiments against the service providers creates a sense of revenge in mind of people.

 

  1. Doctor’s negligence vs system inadequacy; This visibility of doctor at the time of  declaration of death  or while treating the patient on his bedside, makes him vulnerable to all kinds of accusations. By application of an average wisdom, all deaths can be easily attributed or linked to fault of the doctor. Subtle presentations of severe disease, rapid deterioration, multi organ complexities, under staffing and sub optimal systems, inadequate equipment and  other innumerable shortcomings of the whole system may not be visible or not given consideration in the  haze, as compared to  publicity and attention  given to only doctor’s faults.

 

Dr Hazida Bawa-Garba case: sacrificial lambs “The doctors” and not health administrators? Dangerous precedence for doctors worldwide


Dr Hazida Bawa case is of importance worldwide in many ways, an (lost)opportunity  for learning some hard and truthful lessons, as it touched upon various crucial aspects involved in treatment, especially in difficult situations , for doctors.  At the time of death of patient, a constant and  universal last link is only the doctor, that is visible. This visibility of doctor at the time of  declaration of death  or while treating the patient on his bedside, makes him vulnerable to all kinds of accusations. By application of an average wisdom,  all deaths can be easily attributed or linked to fault of the doctor. Subtle presentations of severe disease, rapid deterioration, multi organ complexities, under staffing and sub optimal systems, equipment and  other innumerable shortcomings of the whole system may not be visible or not given consideration in the  haze, as compared to  publicity and attention  given to only doctor’s faults. This is specially so when the wisdom is applied retrospectively, with knowledge  of hindsight,  and by the people who have never treated emergencies or have never been in such difficult situations  themselves.

Analogy to  Dr Hazida Bawa case

        Imagine a situation where during a bad sea storm, large number of people are trapped and are in mortal danger. The coast guard on the duty tries his best in the emergency situation with his limited resources and saves a large number of people. There were only a few coast guards present, equipment were inadequate and sub optimal.  However the guards manage to salvage the situation by doing the best possible in the circumstances. There were instances, where they decide, act, communicate and document events simultaneously, in an instant.  Those who could not be saved were exposed to risk of death as resources allocated by authorities were limited.  The near and dear ones of those who died were unhappy and revengeful with the services. Inquiry is done to find out the cause of failure in preventing those deaths. Rather than appreciating the facts that greater proportion of victims were saved in those difficult circumstances, the guards are blamed for those who could not be saved. Guards who are already apologetic for not been able to save the few, are blamed for doing their duty shabbily after careful fault finding analysis of the event. The administrators  who are responsible for allocating the inadequate number of guards and equipment, who actually failed in their duty, also participate in pointing fingers at the guards.

  The saddest part was that courts also were  unwilling to apply wisdom to look beyond the guard faults and  reach beyond the fog in present hazy circumstances. Systems and administrative lapses and inadequacy of number of coast guards was not raised as a concern. The responsibility of the deaths is thus fixed on the persons who struggled to save the lives of many. Every one has great sympathies for the deceased, but there is another angle for doctors in such  difficult situations.

This is an analogy to Dr Hazida Bawa case, but similar unfortunate incidents are happening to medical professionals worldwide, more so in developing countries. The new regulated system of medicine has an aberrant evolution and   chooses to hang their own wounded soldier for not putting up the best fight, rather than accepting the limitations of medical science or errors in the supporting systems.  Was  she an easy scapegoat for some obviously non- admissible reasons prevalent?

Why is it always necessary to punish a doctor, and  conveniently overlook errors of the sub optimal  system in cases of unfavorable prognosis, especially in sick patients. Why a sub optimal system or unsafe working conditions  like  all other registrars were on leave simultaneously, or only one registrar in place of three and that too a trainee. There was no consultant or registrar covering her?   Why is a single doctor stuck in a difficult situation  not  treated as  just another human being in an emergency situation, especially in cases of very sick patients? Why administrators or managers are not punishable for putting doctor and patients at risk and unsafe condition ?

If a doctor is supposed to raise concern (may be at cost of his career), then what is the role of managers, management and administration?  Are they inefficient or incompetent  to anticipate the situation? A new doctor coming on duty can not anticipate the deficiency of system. He will not have time to assess the managerial deficiencies. Therefore raising a concern by doctor on duty is something, which is expected but at the same time not feasible always, in true sense.  This expectation to raise  a concern  may be  used to later implicate the doctor as to why he or she did not raise a concern.  At the same time it takes responsibility off, from the  administrators whose  duty was to raise concerns.

NHS is looked upon in the world as one of the better organized health care organization in terms of uniformity. If such an organization has to sacrifice its working hands in the form of scapegoats to prove its quality, deliberately overlooking its system errors, then it is a sad state for doctors all over the world. This would set a precedence for governments and health administrators, world over to be  fearless in  putting errors of sub optimal system under the carpet by punishing the doctors instead. Since there will always be a doctor in the end who will declare the death, is the last and common link in all deaths. Other circumstantial issues would be overlooked  because of sheer unwillingness to do so.

Irony of the situation is that generally people who have been invested with the power to decide on these issues of medical negligence  may  have  never faced  such situations themselves.  They may be the people in administrative positions who have never treated a single patient, leave aside emergencies.  They do not even  know, what it takes to deal with emergencies of life and death, that too multiple ones, with limited resources. The court takes years to decide on these issues discussed retrospectively with wisdom of hindsight, on issues which the doctor had to decide in a jiffy.  A person who perhaps can only imagine such a situation, or  never handle it himself, even in his wildest dreams is the one who decides what went wrong merely based on how the situation is placed and presented before him.

         If there is unsaid immunity to governments and administrators for providing a suboptimal systems, then the doctor should be the first person to get this immunity. But unfortunately nobody seems  to be willing to find out who is responsible for putting  the doctor  in such  a difficult situation, making everything error prone.

       If in such system a doctor is punished, then the administrator, manager or trust should be an automatic accomplice to the doctor’s punishment. Firstly   for providing an unsafe and  suboptimal system, and secondly for not raising a concern as management . Thirdly for putting it’s doctor in difficult circumstances. If it was an understaffed system, then disaster was bound to  happen sooner or later. This is a perfect example how management lapses contribute to death but doctors are the only ones who are entirely blamed and punished in isolation.

  Another sad part is the unwillingness of judiciary system to look at the larger picture and the fault in the system, which has led to mass demoralization of the doctors. The doctors are denied the true justice in many such cases.  They are being used as sacrificial lambs. Health administrators are obviously at an advantage enjoying the invisible immunity and perks, at the cost of medical professionals.  By crucification of the doctors, vengeance of the society is fulfilled and everyone feels  satisfied  with false sense of justice.  But does this give any advantage to the society? Definitely not. In fact  the society is thus raising a  demoralized force to be their care providers, who under duress, will definitely not perform to their very best.  If this is quality of justice for saviours, this demoralized force may also not be available in future.

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