A doctor's journey in treating COVID patients at ICU JNIMS

Dr Seni Potsangbam *

Jawaharlal Nehru Institute of Medical Sciences, (JNIMS) Porompat, during Covid-19 pandemic in May 2021 :: Pix - Shankar Khangembam

As we all know, COVID-19 surprised us and brought the world to a screeching halt. My home State, Manipur was no exception and lockdowns throughout the country ensued. Medical care though in the State is lacking in terms of facilities and delivery, we managed with the best of our abilities to overcome this pandemic in the best way we could.

Here's my Covid second wave experience of my journey as Consultant in COVID ICU, JNIMS (Jawaharlal Nehru Institute of Medical Sciences).

With limited knowledge and not enough specialized equipment, the fears and anxieties were palpable in Covid 1st wave. The wave set in a little late than mainland India. 3rd wave has already begun. 2nd wave of COVID-19 arrived in the middle week of April 2021 in Manipur. Those with severe disease requiring ICU admissions brought the anaesthesiologists to the limelight. We have always worked behind the curtains just like the musicians and our surgeons, the singers.

One of our chief tasks is the intubation (i.e. putting a tube into patient's wind pipe to make the patient breathe and increase the oxygen levels) of a patient who needs to go on ventilator. This is a highly infectious, aerosol generating procedure.

Our team has been managing patients on ventilator at Surgical ICU, JNIMS We were assigned duties to take charge of Covid ICU, Covid infected to non-Covid surgical patients, plus emergency calls from ward, casualty, medical ICU and post-Covid ICU. As Assistant Professor, we were posted every 4th day in the ICU which later extended to a week time duty. In a nutshell, we were overburdened with work while carrying out such an arduous task.

I commenced my duty from May 2021 at the dedicated Covid 3 block with 10 'PM Cares' ventilators. It wasn't an ideal ICU as we would expect. We had a red zone, where patients were housed and a green zone where we worked. As a departure from an ideal ICU, one attendant for each patient was allowed in our ICU. But often there were more than one attendant inside.

It was difficult to control the relatives. Government sent additional ventilators, PPE (Personal Protective Equipment), medicines, point of care testing kits, ABG, X-Ray, ECG, USG machines, etc. I am very thankful for what the Govt. did and due to such response many lives were saved.

There were inputs from all over the world, in terms of knowledge, donations, ventilators, BIPAPS, Oxygen concentrators, eatables etc. Here at JNIMS, doctors donated a handsome amount to our Health Care Workers' Welfare Committee. This fund was utilized for providing food to Covid infected health care workers, buying them medications, supplying energy drinks to Covid stations, etc.

After about one and half months we were given charge of 20 bedded ICU which later increased to 30 bedded ICU at Covid 2 block. There was a dearth of health care workers compared to the number of patients, but our team made sure that the doctors, nurses and attendants were available round the clock, not to forget that our operation theatre technicians and doctors from other departments were just a call away.

Even filing work, consuming much time was a tedious job. Just outside the ICU entrance, there was a narrow corridor where the distressed relatives huddled. The passage was overcrowded and hence, risk of infection was higher. Once I wrote a list of investigations to one of our patients.

He had been there in our Covid 3 block for over a month before I was assigned duty. The patient's father expressed his inability to send any blood investigations to private laboratories as it was not available in JNIMS.

Following this, frantic efforts were made to make those investigations available inside JNIMS. Timely response from our Director made it possible for the investigations to be available inside JNIMS and added help from our laboratory team made the test reports available on the same day.

Many of our health workers got infected. It was this early part of 2nd Covid wave that our dear colleague, Dr. Richard lost his battle to COVID-19. This reminds me of the regular updates our worried JNIMS family were following regarding his progress. I met him regularly in our operation theatre. It was sad to see such light-hearted and modest person undergo the trauma of COVID-19.

Every individual is different and the response to the loss of their loved ones is also different. Some incidents like breaking ventilators, monitors, doctors being shoved by the angry relatives were condemnable acts.

Communication gap was the reason surely, though alternatives were available at hand. What struck me was that Covid patients were dying because of the scarcity of ventilators and violence by the patient parties led to even more less number of ventilators.

I wish people were a little more thoughtful. Similarly, relatives yelled at the doctors and nurses on duty. But at the end, we were hardly left with any energy to see other patients. Contrasting this, was the benevolence of the relatives of other patients where they had accompanied a devastated 23-year old daughter who had lost her father, brother and her mother being admitted in a critical condition. Humanity still existed at this time of crisis.

She was clearly in a state of shock but held back her tears, pacifying her mother. The daughter didn't have the wherewithal to pay for the medical expenses. Our Director backed her up. Her mother had a comorbid condition and despite our sincere efforts we lost her mother. An elderly, male patient, aged 77 years who had taken double vaccine dose was admitted. He was like 'See doctor, I am double vaccinated, still I got Covid'.

Usually, those double vaccinated patients got away with mild symptoms. This patient had an associated comorbid condition. He stayed for over a month in our ICU and was not keeping well. His relatives were cooperative but he was fed up of staying in ICU, wearing a big NIV mask on his face. He had kind of given up. He said, he wanted to see his grandchildren and his relatives requested us to discharge him.

I had held his hand tight during rounds before discharging him knowing that it was his last day. On the other hand, there were family members who wouldn't give up. The quavering voice of a distraught father to save his young son still rings my ears. In contrast, there were patients in our ICU without any attendants inside and outside ICU. What kept me going was the patient and patient party's trust, their sigh of relief on recovery and a little compliment from them.

I had seen a maximum of 7 deaths on a single day. I can recall the panic-stricken patient before putting him on invasive ventilator (his breathing completely controlled by ventilator). He was 70 plus, had lost consciousness on and off and was having a severe infection(sepsis). The patient had regained consciousness and was trembling in fear.

He wanted to see his son again assuming that he wouldn't survive. I was traumatized and couldn't sleep for nights. He expired after a few days. Most of the relatives accepted the fate of losing their loved ones.

Some of them sobbed silently and some held back their tears and took the patient's body home if they had a Covid negative report. Those with positive report, at times wanted to take the body home and conduct the final rites but this wasn't acceptable by the locality.

Some of them requested us for a negative report. I can't imagine the misery they endured. Then, there was a time when our ICU got infected with resistant bugs and we had to upgrade the antibiotics. Some of them refused to buy the antibiotics, the prices being exorbitant. This triggered to strictly vacate the crowd in the corridor and to impose rule of one patient –one relative inside ICU.

Covid second wave saw many young patients losing the battle too. Quite a few number of patients denied Ryle's tube (nose feeding tube) insertion while on ventilator. Feeding them kitchen- cooked food made us difficult to calculate whether they were receiving adequate energy to fight infections. Also there was a chance of infection and loss of lung recruitment pressure ( i.e. losing the pressure support).

I also want to mention here that many patients were transferred to JNIMS ICU due to the financial crunch. Many of them passed away on their way to our hospital. So, please remember that if the patient is on ventilator support please transport them with a ventilator support. Make sure that the ambulance is equipped with a ventilator.

Twice I felt the heat of wearing PPE. Both times I felt nauseated, headache and with a sense of impending collapse, rushed out of the ICU to catch a gush of fresh air. Apart from these, there was pain at the bridge of nose, fogging of goggles/face-shield and we sweated profusely inside PPE. Some resident doctors fainted while on duty. The stress of work took a toll on our mental health as well.

Our family members were constantly worried about our safety and vice versa. Few of our lady doctors are yet to recover the hair lost due to stress. One of our female Postgraduate students chopped off her hair completely as she was tired of washing her hair daily after duty. There was an adrenaline surge every time the oxygen pressure alarm beeped , warning us from shortage in oxygen supply.

Survival of patients like Ranjana, 50 years and Rebecca, 54yrs was a miracle. They were there in our ICU for almost 2 months fighting infections up and down. Their families stood like a rock. I met them in our post –Covid ICU. Both of them were off the ventilator. There was a look of ecstasy on them and the faces of their family members.

It was a formidable task and Covid brought the anaesthesiologists from behind the curtains to the forefront.