COVID-19 Crisis : Deaths, Doctors & Dilemma.
“The Critical Covid Management Dilemma encountered by doctors during COVID-19 second wave crisis in India,”
Here is how it started:
For the first 5-6 days people tested themselves at their comfort and got reports at the laboratory’s disposal. Home isolation with SPO2 measurement by the end-user using a pulse oximeter with the uncertain quality check of the equipment.
Amidst the debates, patients received various cocktails of medications, such as Favipiravir, Doxycycline, Azithromycin, Ivermectin, antipyretics, antihistaminics, antitussives, minerals, and vitamins, supervised, unsupervised, some even self-medicated.
While the debate continued on media and medical platforms about their role of the concoction above for COVID-19 management. Patients consumed Ayurvedic, Homeopathic, and even homemade cocktails with herbs, spices, and whatnot as urged on all media platforms by the self-proclaimed unqualified authorities.
By now the week is over, the fever surges & the cough becomes vigorous. Pulse Oximeter may detect hypoxia but false negatives gave false satisfaction, and the hypoxia got missed. The deteriorated health leads to an HRCT Chest only to find Covid-19 Pneumonia with a score above 13.
The panic phase of the Covid-19 management cycle begins with procuring hospital beds for admission and having oxygen available for the impending Hypoxia. Increased demand and the limited supply are the recipes for chaos. And this was the race against time. With most patients who lost the golden 10 days period for recovery, only a few options remained in hands of doctors for further management in the severely ill Covid-19 patients.
Now we know, the ill impact of the Covid-19 second wave was “Fast & Furious”
With unclear guidelines of medical management other than steroids and anticoagulants WHO, local Health authorities and noted medical publications calling other medicines either equivocal or not effective or can only help if used within a specific time frame. For example, Remdesivir alone didn’t offer mortality reduction and only expected to work if given within the first 7-10 days. Baricitinib plus Remdesivir promised results but only if Remdesivir was included in the first 7-10 days.
Not having any comparative scientific studies for Steroid plus Remdesivir Vs Baricitinib plus Remdesivir, every medical professional was just at a crossroads. Baricitinib emerged as a second choice (only when opportunistic infections were under consideration) but couldn’t rule out the risk of opportunistic infections. This fueled the spread of mucormycosis in patients receiving Steroids or Tocilizumab or any immunomodulator/immunosuppressant.
Even the immunomodulators (Baricitinib or Tocilizumab) did not help the patients on mechanical ventilation. With the hits & trials, the claims of plasma effectiveness couldn’t stand the test of time, and demand to ban plasma therapy emerged. Does the cytokine storm exist?. This Emerges as another topic to debate.
During the first wave of COVID-19 in India, the media, the medical platforms, and the public domain highlighted the benefits of steroids. People considered steroids as a sure shot cure of COVID-19 ignoring the risks. Their pressure was enough to compel the primary care and family physicians to prescribe steroids even in the first week while ignoring the “Timing phenomenon” which recommends avoiding steroids in the first week and absence of hypoxia.
According to basic physiology, under normal circumstances in the first week, the Body’s immunity fights the intruder virus. The second week balances the exaggerated immune response to control the damage. From the third or fourth week “Body’s immunity” had to come back strongly in the game. Wish this was all as easy as it sounds.
There are many other factors a health care professional has to deal with in this management of critical patients in the Intensive care units. Balance the immune response, prevent the deterioration, prevent opportunistic infection, give rest to lungs, maintain the respiratory rate, prevent sepsis, prevent shock, prevent multiorgan system dysfunction, manage ARDS, prevent pneumothorax, prevent pneumomediastinum, prevent sudden cardiac arrest, and above all deal with the panic and anxiety of patient’s kins. God bless our critical care medicine experts, the real COVID Warriors.
Sometimes it feels like nothing much was in our hands and nature has been rampant. But it also gives rise to a thought: did destiny play a bigger role in COVID-19 recovery?
Here are some real scenarios. Two brothers (less than 45 years) with no comorbidity got admitted to the hospital. The elder one came back and the younger one lost life. In another case, the Father, Mother, and son (36 years) got admitted. Father came back but Mother and son lost their lives. Unfortunately, there are many incidents like this around us. Is this the cruel face of natural selection using a criterion other than the fittest that we are not aware of? Only time will tell.
The panic created by the scarcity of medical oxygen during the second wave is something to discuss on another day. Right now the government’s stance and denial to accept the correlation between the shortage of oxygen supply and the deaths that occurred in the second wave have opened up Pandora’s box.
God bless humanity!
Dr. Deepak Chaturvedi MD Medicine