This Article is From Mar 24, 2020

Indian Doctors On How Hospitals Should Handle Covid-19

A little under three months since the first case of the novel Coronavirus (COVID-19) was first reported from Wuhan, China, we now have over 300,000 positive cases detected worldwide with 15,000 deaths at the time of writing this article. India as of 23 March 2020 has reported 415 cases. The rapid spread of the infection has blindsided many countries, and led to spiralling pressure on health systems, pushing them close to collapse in countries like Italy. 

The rising number of cases in India over the past couple of weeks, including those cases where the source of infection has not been still traceable indicates we are probably already in stage 3 where community spread is occurring.

Indian health system: a reality check

Data has never kind to the Indian healthcare system and reflects a story of chronic neglect. As revealed by the Union Health Ministry, we have one isolation bed for every 84,000 and one doctor for every 11,600 Indians. There is an obvious shortage of beds, ventilators and equipment. The rising number of COVID-19 cases would be akin to a natural disaster and requires us to respond in the same way in our preparation and response.

This will require us to work at two levels: the first would be designing and innovating on the infrastructure front. Allocation of spaces within hospitals and health centres for isolation wards, halting elective procedures and discharging patients who are stable to create more space is the need of the hour. Specific buildings, vacated for the purpose, should be used as makeshift centres for isolation of patients. Ventilators need to be judiciously used across the public and private sector: these can be sterilized and reused to maximize the use of limited equipment for patients, while new ventilators are being procured. Personal Protective Equipment (PPE) needs to be aggressively procured, given its importance in ensuring a safe workplace for healthcare facility staff.

However, what we equally need to worry about as the second element is the trained human resources element of our response: the paucity of doctors who have training in critical care management of patients with serious respiratory ailments, and relevant nursing and support staff. Shortage in this area could handicap the Indian healthcare system if this exceptional battle does - as many experts warn - go on for months.

India's harrowing statistic of 9.26 lakh doctors for an entire nation of 1.3 billion turns into an absolute nightmare when you layer on the fact that less than 20,000 of these 9 lakh doctors are trained in anaesthesiology and critical care, pulmonology and emergency medicine - the three key departments who will attend to the worst patients that get transferred to the hospital requiring active life-saving intervention.

Of the four key areas the WHO Director General focused on in his media address in the second week of March, the first was to prepare and be ready for what's coming. Having viewed how health professionals across different affected countries struggled, it is important that we heed their warnings to try and avoid a similar situation. Within our hospitals, we must prepare for the worst and hope for the best in the weeks to come. Towards this end, it's important that medical professionals convene in their hospitals and focus on a key tough question: how do we optimize efficiency of our critical care teams, and what happens once the teams running the ICUs are potentially incapacitated themselves, either by COVID-19 or pure fatigue?

Exceptional scenarios, such as the ongoing pandemic with high transmission rates, require exceptional solutions.

It is time to involve all other specialities - both from the clinical and non-clinical side - in this battle against COVID-19 and not stick to just the critical care fields. Present critical care teams should be divided with some members placed on leave who would serve as the next squad should the primary team get infected. Back-up teams of healthcare professionals should be prepared and provided training via crash courses by intensivists and other professionals in skills directly related to COVID-19 management, starting from preventing the spread of infection to managing the worst patients in intensive care units.

Both extremes of the 'doctor life-cycle' - the undergraduate and the retired - need to be counselled that at some point in the near future, they may have to take active participation in this unique situation, and prepped/trained towards this. Their potential exact roles can be delineated.

Specialists in other domains such as ENT and other surgeons who can deal with airway management should be drawn in. Everyone has a role to play and needs to serve as a backup key functionary in a hospital level response.

Medical professional associations such as the IMA and regulatory bodies such as state medical councils and MCI/NMC need to work cohesively to support the process during these unprecedented times for hospital administrations and doctors.

All this needs to be done now while there is still (limited) time rather than procrastinating in the hope that additional services will not be needed and speculating that the virus might succumb to the heat of the Indian summer, even as WHO has discounted a weather correlation. If early preparation is not done, large hospitals which would be the tertiary centres at the heart of the COVID-19 clinical response run the risk of reaching a state where they might have potentially hundreds of doctors with amazing skillsets and hard-earned degrees at their disposal, none of whom know how to intubate a critically ill patient, or manage a ventilator in an overcrowded ICU filled with gasping patients.

Considering what we have witnessed globally and knowing how we could see future such novel viral spreads and other health threats, creating, training and maintaining a ready-to-deploy fully trained reserve medical teams (plural) could be a global requirement. For now, it is the need of the hour in India.

It's probably not what many medical professionals in India envisioned when they completed their degrees in their chosen fields. It is also frightening to consider being on the frontline against a foe we know so little about, armed with such limited equipment to both defend ourselves and fight back. Nonetheless, this is an important discussion hospitals need to have right now.

If the ongoing situation is going to last months, as speculated, it will need truly innovative measures and sacrifices of the medical fraternity, with many having to don new masks - not just physically but also professionally and metaphorically - to save their fellow countrymen.

Because, in the end, where COVID-19 is concerned, they are the only ones who can.

(Dr Roshan Radhakrishnan is a consultant anaesthesiologist and award-winning short story writer. Dr Anant Bhan is a researcher in global health, bioethics and health policy.)

Disclaimer: The opinions expressed within this article are the personal opinions of the author. The facts and opinions appearing in the article do not reflect the views of NDTV and NDTV does not assume any responsibility or liability for the same.