A peek inside Covid war room: Tales from the ER

As the Sars-cov-2 virus swept its way across India over the past four months, doctors were on the frontlines to treat and save a growing flood of patients. In conversations with two doctors at Delhi’s LNJP Hospital, the Capital’s biggest Covid facility, H

When the pandemic began to grip Delhi in early April, the Lok Nayak Jai Prakash Narayan (LNJP) hospital was the first in the city to be declared a dedicated Covid-19 facility. So far, LNJP has successfully treated 3600 patients. Even as Delhi now has seven dedicated Covid-19 government hospitals, LNJP remains the biggest facility in the city, housing 522 patients at the moment.

LNJP is also a teaching hospital that houses the prestigious Maulana Azad Medical College (MAMC), and in the fight against the pandemic, the service of around 450 postgraduate students of the college — resident doctors — has been invaluable. They form the backbone of the medical force on the ground, taking care of the wards in 14-day shifts, of varying hours, at a time. The “senior residents”, or doctors in their final year of postgraduation, were to have appeared for exams in April, received their degrees, and got jobs by now.

But the pandemic put a halt to that, and they were pressed into service. This is the story of the experiences of two senior residents, Dr Saurav Kumar, 26, doing his MS in general surgery, and Dr Richa Narang, 29, doing hers in anesthesiology, as recounted by them over multiple phone calls.

The conversations highlight the Covid-19 journey from the viewpoint of health care professionals on the front line – their anxieties and challenges, and the emotional and physical load it has taken on them. It also highlights the shortcomings in the medical infrastructure and system — many of which, particularly at LNJP, have been addressed, improved and strengthened over the past three months, which these accounts also reflect.

Dr Richa Narang: During my first posting, I was very scared. This was in April. The hospital was unprepared. We had an ICU [intensive care unit] on the fourth floor with 15 beds, already occupied with patients, and then suddenly, Covid-19 patients started coming and we had to make another ICU. We scrambled to turn some disused rooms into ICUS.

The isolation was not proper at all and we were very scared. Our counter was right in the patient’s room. The PPE [personal protective equipment] kits were faulty. In those initial days, we did not have enough ventilators, oxygen masks, cannulas. It was chaos. We did not know who was doing what or going where, whom to admit, whom not to admit... then things got better.

Dr Saurav Kumar: The day we had to shift from the surgical block in the first week of April was very hard. Some of our friends who were working at the casualty called and said, ‘Today we will get around 150 Covid patients’. I said, ‘Boss that must be a rumour, we can’t possibly get that many patients in one go’… then they started to come, and we got a message that we will have to clear out the surgical ward. That’s 36 beds. I had been working in that ward for three years and I knew it like the back of my hand. In one hour, we were completely uprooted.

When the order came, the first thing we did was go around and ask patients who could be discharged if they wanted to be discharged and sent to another hospital since LNJP would become a Covid hospital. Some of them agreed. But we also had eight patients with open wounds or in post-surgical care whom we had to shift out. There was one diabetic patient whose foot and leg had become gangrenous and had to be amputated from below the knee. His wound was open and required dressing every day, his immunity was low, electrolytes were all over the chart, he needed close monitoring, lots of care. Shifting someone like him was so hard, but we managed, and he was safe.

But now (in the new ward) we did not know where the duty room was, where the nurse’s station was, where the toilets were.

Narang: The day before my first posting, I got a message saying I was to be on Covid duty from the following day. In the morning, I attended a seminar at 11am on safety, basically how to don and take of the PPE. My first thought was, ‘When will I get to see my parents?’ We had our final exams scheduled for April, so I was busy preparing for it and had not gone home since February. Then the pandemic started, and all plans went out of the window, and now here I was, heading into a Covid ICU. I did not tell my parents about my posting.

Kumar: We took the place, which used to be our OPD [out-patient department] block in non-covid days, to create a donning area. It is not connected to any Covid wards, so no cross-infection would happen. You change there, and then you go to whichever ward you are posted in. Four doctors are posted together on a floor with two wards (each floor has 72 beds), and we reach the donning area together and help each other. First we do our handwashing, then we wear the first layer of gloves, then the shoe covers, then the coverall, then an N95 mask and a surgical mask on top of that, then the cap, then a second layer of gloves, then goggles or face shield.

Narang: PPE suits are heavy and depressing. I felt suffocated; the headgear, the mask, the goggles, everything has to fit tightly. After a few hours, the goggles start to fog up and there is no way to wipe it, so you have to work with poor visibility. It is so hard to do anything. Imagine intubating a patient while wearing all of that, and sweating in that heat.

Communication was such a problem.

No one could hear me unless I screamed. When you are handling critical patients, every word is important. So we put in place a system of hand gestures between the doctors and the nursing staff. Also, you can’t go to the bathroom after wearing your PPE, or drink water, or eat. ICU shifts were of six hours, so we had to endure that for the entire duration. There were times when I would be terribly thirsty, desperate to go the washroom, drenched in sweat and finding it difficult to see through the fogged goggles — all at the same time.

Kumar: May 13 was the first time I worked in the Covid ward. I worked for the next 14 days. That’s the first time I wore PPE. Within 15 minutes, I was drenched in sweat. It was like someone had poured a bucket of water on me. It’s supposed to be impervious to water, so it has a laminated layer of plastic. In May, with the heatwave on, it was terrible. After half an hour, sweat was dripping like a waterfall from my forehead. The donning area is on the fourth floor — we stopped using lifts, and we blocked off the walkways so that people don’t walk between the wards. So I wore my PPE, walked down four floors, out of the OPD building, walked 200 metres, and then climbed up four floors again to my Covid ward. As I was walking down the stairs, my first thoughts were: ‘Is this thing open from somewhere? Is there a gap I missed? Did I wear it correctly?’

When I reached the ward, the first thing I did was to ask the nursing staff to recheck everything. Then I was telling myself, there is nothing to fear, you have been here for three years, it’s the same hospital, there is nothing to worry about. I was reminding myself, that I am the kind of person who wants to volunteer, who wants to be challenged... But before I started my shift, I had spoken to a colleague who had already finished his. First thing I asked was: ‘How scared should I be?’

I was posted at the Covid ward in the surgical block, where the stable patients are housed. The conditions of patients at the Covid ICU and Covid medical block is worse; this is where they are shifted when they need oxygen support. My colleague told me, ‘These patients are stable, but they all have surgical elements, fractures, abscesses, some need dialysis, so treat the patient as a whole, don’t only think Covid, Covid, Covid’. He said, ‘Before you change into your PPE, you should know what you are supposed to do, step by step, when you enter the ward. Don’t plan after you put on your kit. The main work in the morning shift is to do the patient round, and to take samples that are listed for testing. Also, you have to be very cautious with Covid patient because they can deteriorate very quickly.’

Narang: Covid is known to create Silent Hypoxia — oxygen levels decrease, but the patient is not symptomatic till the level falls to a critical value. Normally the oxygen saturation in our blood is 99-100%. If it falls to a level below 92%, you need oxygen support to prevent possible damage to your organs.

Normally, when the saturation falls below 92%, there are symptoms like difficulty breathing, restlessness, drowsiness. But in

Covid patients, the saturation can fall to 80% without the patient showing any symptoms. That’s Silent Hypoxia, that’s what makes this disease so dangerous. So one of our main jobs is to constantly monitor saturation levels.

Kumar: On my first day, one patient, a 58-year-old male, was not in a good condition. He was the only one on oxygen support at my ward. He was not able to maintain saturation, it kept dropping. After two days, I had him transferred to the ICU. On the second-last day of my shift, a 70-year-old woman was not maintaining oxygen saturation. We did an X-ray. It did not look too bad, but she was deteriorating. I spoke to another doctor, and then we decided that she needed to be given oxygen and monitored for 24 hours. After this conservative approach, her condition did not improve, and I had to transfer her to the ICU. She was also hypertensive and she had diabetes.

Narang: Patients suddenly develop critical symptoms when the saturation drops below 80%. We call this “air hunger”. Normally, we would intubate a patient whose oxygen saturation is so low without thinking twice. With Covid, we learnt that we need to keep a higher threshold, because we saw that once a patient is on a ventilator, there is not much more you can do, and very few came back from that stage. So we adopted an unconventional approach. First, supply oxygen through a non-rebreather mask. If that didn’t work well, then we use a technique called “awake proning” — put the patient on the stomach while continuing oxygen therapy. This opens up the lungs more. This is a technique used for ARDS (acute respiratory distress syndrome) patients, which is a critical illness of the lungs, a seizure form of pneumonia, and Covid symptoms closely resemble ARDS. I have had great success with putting patients in the prone position. I had a 64-year-old hypertensive patient, admitted with great respiratory distress. His saturation was 80% when he came in. We put him on a non-rebreathing mask and the oxygen saturation began to improve... 80 to 86, then 90, then 94. Two days later, his condition deteriorated again; this time I applied high-flow nasal oxygen — it provides oxygen at 60-65 litres per minute, compared to non-rebreathing mask which provides 10-15 litres. His condition stabilised for another 2-3 days but again began to deteriorate. At this point I started doing proning. The very first night, he felt so relieved that he fell asleep in the position; his saturation was at 97%. After 18 days, the patient was discharged.

Kumar: The first order of the day at my ward was always to take samples. The night shift keeps everything ready — swabs, vials, ziploc covers, pens, micropore, cotton and a chart with the details of who has to be tested. The samples need to be collected and ready before noon, because after 1pm, the lab will not receive new samples.

The way it’s done is an art. We had seen videos and demonstrations, but nothing compares to actually inserting a swab into a patient’s nose or oropharynx.