News
Doctors who see the horror of this disease day in and day out at COVID HDUs
- Their plea to the public– reduce our burden, the virus doesn’t travel by itself
- Warn of the unpredictability of the new wave; those who seem to be recovering can suddenly take a turn for the worse and even die, while someone who arrives in terrible condition can get better
COVID-19 is escalating in Sri Lanka. And doctors are forced each day to make difficult decisions: Who is well enough to unhook from oxygen supply so another can take that place?
The work never stops in a COVID high dependency unit (HDU) and the suffering of patients is intense. A doctor who covers shifts in one such section described the pain they endured when their conditions deteriorated.
The case of a 40-year-old village official–who had also been on COVID frontline duty–sticks starkly in his mind. The oxygen saturation in his blood was just 46 percent when it should have been between 98 and 100 percent. Despite having stayed on a different floor of his house to protect his wife and children, the family also contracted COVID.
Medical staff attend to a patient in a COVID high dependency unit
This patient was administered a high flow nasal cannula which delivers oxygen at 60 litres per minute. “Fifty percent or more of our patients need high flow nasal oxygen,” the doctor said. “If they get worse, we hook them up to the CPAP (continuous positive airway pressure) or ventilator.”
“But both the high flow nasal cannula and the CPAP are very difficult to bear,” he said. “They are fixed tightly to the face. Patients suffer intensely. They can be on these machines for six to seven days. They can’t eat properly. They can’t use the toilet. Their lips and throat dry up.”
“On top of that, they have to bear the symptoms of their illness,” he described. “They can’t draw air into their lungs. There are needles and monitors. If the machines are taken off, saturation drops. As time passes, some of them suffer severe depression.”
They saw the village official experience this. He became confused. He worried constantly about his children and their condition (they have recovered). He said repeatedly that he wanted to die. And he pulled off the high flow nasal cannula. It was only by sedating him that they were able to continue treating him. He, too, got better and was discharged.
Another older male patient experienced similar sentiments and tried to pull his CPAP off owing to suicidal feelings. He also spoke about the past and events at home. “It becomes more difficult for us to manage such patients,” the doctor said. “They don’t want to stay. They don’t want to suffer anymore. And when they pull the machines off, we have to unpack yet another new PPE and go back in to hook them back up.”
But such feelings are expected. “They are mentally down,” he observed. “Nobody can visit them. They have to stay in one place for a long period of time. Yet they are awake, unlike other ICU patients who might lose consciousness. They cannot entertain themselves, not even read a book. Even if we switch a TV on, we can’t turn them towards it. They are completely bedridden.”
None of the medical personnel interviewed for this article will be named. Neither will their hospitals be identified as a result of a circular issued by the Health Ministry Secretary barring staff from communicating with media. But the insights they shared can only come from frontline workers dealing with this nightmare every day. Their objective in speaking was to bridge the gap in knowledge between what they see of this disease and what the public know.
One doctor who spends her time now between hospital and her quarters said when she breaks that routine for a day and “you see everyone gallivanting around as if nothing is happening, it’s really, really, really sad.”
The first and second waves of the pandemic didn’t produce too many serious patients, the HDU doctor said. The symptoms were mild and it was rare to find someone deteriorating to COVID pneumonia. There weren’t even enough to fill their small HDU.
Things changed dramatically with the third wave. “It started after the Tamil and Sinhala New Year,” the doctor recalled. “From the time it started, more than fifty percent of COVID-positive patients we receive are oxygen-dependent. Their condition usually sees them in severe distress. And it is across age groups.”
During previous incarnations of the virus, the symptoms would appear within a few days of contracting it, a PCR would be done and then admission would take place. “This time, the symptoms take time to appear,” the doctor said. “There are also instances of the first PCR returning negative but the second returning positive.”
The social stigma surrounding COVID-19 prevents many from seeking treatment. So they don’t push further when they test negative. “They are afraid they can’t go to work or that their plans will be disrupted and their children affected,” he pointed out. “This is particularly pronounced at village level where a ‘COVID-positive’ house is a much-feared thing. Even if a positive result is returned, therefore, they try to treat themselves.”
By the time some of these patients come to hospital, they have gone straight to COVID pneumonia. And they are oxygen-dependent. Doctors at several other medical institutions said they are forced to keep increasing COVID wards because of the sheer numbers of positive cases.
“If we get ten patients, five to six are oxygen-dependent,” the doctor estimated. Category one and two patients–as they are grouped–are asymptomatic or have minor symptoms. But category three and four develop pneumonia and need HDU treatment for at least 14 days. The dire cases can go up to 21 days in hospital. This means, available resources are blocked for a single patient for a protracted period of time.
Doctors talked about how unpredictable the disease was. “With many other sicknesses, we have indicators that tell us how a patient is doing so we know where the case is heading,” said another doctor. “With COVID, someone who seems to be recovering can suddenly take a turn for the worse and even die, while someone who arrives in terrible condition can get better.”
Resources were also an issue. A drug called Tocilizumab is effective in COVID patients, doctors said. But it is hard to obtain. Before administering it, a person must also undergo four tests. Most Government hospitals don’t have that facility. For a patient to send someone to a private institution to get these done is a challenge when his family is quarantined. And the cost of carrying out those investigations is prohibitive for most. The village official was one patient who was given the medication.
“This disease is hard for people also because of its unpredictability,” another doctor said. “People see a patient walking away to hospital. Next thing they know is this person has died and they can’t even see his or her face one last time. The body is sealed immediately.”
Another HDU doctor said COVID wards are heavy work. “The work doesn’t end,” he said. “It is a lot of stress. Apart from patient management, there are ‘bookings’ where HDU beds are requested and we have to decide who is stable enough to release to a ward so that another patient can come in. There is documentation to complete. There are referrals and recalls.”
“The most difficult feeling is not of sadness but of hopelessness and helplessness,” he continued. “That can cut much deeper. Physical tiredness apart, mental tiredness is tough for both doctors and nurses. Some patients ventilated and intubated, yet their saturation is dropping right in front of our eyes. We can see it drop but can do nothing. And now the young deaths are emerging.”
“One patient in his 80s was in the unit for nearly 17 days and was getting better when he suddenly arrested,” he said. “We couldn’t think why. There had been no indication. He died. COVID is unpredictable.”
“But we do save a lot of people,” he smiled. “There is great satisfaction from that. Still, particularly nursing staff go through a lot–at home and in the workplace–to keep this show running. The main thing is for the public to reduce our burden. The virus doesn’t travel by itself.”