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#LongThread on #COVID19 #ICU Management in #Pakistan:
Spent last 15 days going thru the decaying orders of our healthcare system embattling Covid-19. A close relative was on bag-mask oxygen in emergency unit of a tertiary care. He developed SOB, fever on Eid day.
For days we were confused whether to treat it on Cytokine Release syndrome lines or not. Strong Neutrophilia was suggestive of sepsis as well. So some of my consultant friends cautioned against actemra.&we lost valuable time. Punj. gov criteria for actemra added to the confusion.
They had 3 lab parameters (ferritin, Crp, d-dimer) and all 3 of them had to be raised but they were never increased in unison; were rather increasing in tandem. Both these together meant we didn’t administer actemra until it was v late.
But treatment issues like these are not my biggest concern. Not even close! The dreadful conditions of gov ICU’s that are left at the mercy of novice juniors, heartless staff with critical structural failures is a systemic problem prevalent everywhere.
On 3rd day of hospitalisation, my uncle had to be intubated & mech ventilated in ICU. Things seemed calm at first. But 1 day later, it started. First the ICU was severely understaffed, so nurses would leave it unattended for sometimes 20-30 mins on end, also forget critical meds.
Oneday a nurse decreased the dose of muscle relaxant (med that’s supposed to keep one paralysed) by mistake, &the pat. started removing the ventilator tube(ETT) himself. The tube is a big discomfort & pt’s have to be sedated/paralysed on vent cuz they’d try to remove it otherwise
It was 8:20am(20mins past shift change)& Nobody was inside. Alerted by vent alarm, I peeked inside & informed the doc on duty who rushed inside with just mask on, without any PPE to stop the patient from practically killing himself.
One disaster averted, but an even bigger one loomed the next day. I was home for some rest,was awakened by a seriously panicked call by my cousin who was on night duty with my uncle. There was a rain &ICU had its electricity cutoff for last 30mins +main O2 supply was also down.
Vents have backup battery for ~1hr but how’d it compensate for O2!
3 patients were on vent that fateful night. 2 needed 100% O2. My uncle was on 60%. The other 2 died in first 5-10 mins. My uncle survived cuz he was manually ventilated (ambu bag) for 30mins by 2 doctors.
His clothes in the morning, once the thick sweat (that he exuded out during all that effort) dried, felt as if someone sprayed mutiple layers of starch on them.
It was beyond horrible. I decided to move him on vent ambulance. No pvt setup was taking Covid patients in my city.
So I took him to a somewhat ‘better’ gov hospital with older ICU with more trained staff & less chances of such sys failures. This ICU was not understaffed. Nursing was better. But now the docs on duty were heartless, & callous.
Many of them unwilling to do 1 SINGLE round inside the icu to check on the patients. Their management was way off of newer standards. They would stay inside their office and pass orders on intercoms to nurses all day, & ‘d get mad when nurses suggest they come inside.
I was actively managing my uncle, getting consults from Nephro.& cardio. when he developed Kidney injury etc. 1 day I asked one esp callous doc to change 1 nephrotoxic antibiotic. He,having not set foot inside ICU for all his duty hours, suggested I go inside &do it myself.
Unbeknownst to him, I never hesitated to go inside. So I started donning PPE. Dude looked at me in disbelief. Even after knowing me to be his colleague, he never expected this. I went inside (wasn’t my 1st trip anyway) did what was needed.
Later one day, when I was inside for some other issues related to my uncle, another doc intercommed me to ask me to put a urinary cath in another patient ‘since I was already inside’. This magnitude of fright that these guys were manifesting was severely compromising the care.
And it reached the point of medical negligence the next day, when I told them about a patient who was pulseless & was on vent.The guy needed vent atleast 12hrs ago (sat84% on bag-mask O2). 1st they didn’t put him on vent despite admitting & 1 vent being free[cuz of fear/inaction]
2nd, when finally he was intubated & put on vent, the vent started sounding alarm right away. I was inside, checked the pulse. He was pulseless. They informed their seniors. It still took them 4-5 hours to put him off the machine and inform his attendants of his death.
With this level of care, it is a no brainer that mortality in gov ICU’s all across Punjab is virtually 100%. 3 ICU’s in my city has in total 1/2 patient(s) extubated & that too was non-Covid.
Care is better in HDU’s where one is not paralysed & not at the mercy of hosp staff.
Another big issue is no consult from medicine/pulm. is considered by ICU team, which practically comprise of a bunch of anesthetists. These guys have no idea how to deal with a lot of medical issues in ICU,yet are too stubborn to ask around.
There’re No rounds by med consultant.
It was 1 day before his death, that i went inside the ICU, played his wife and children’s recorded messages on phone in his ear. Recited & played some Quran beside his pillow. Took care of some nursing issues. All the while he was asleep peacefully on narcotics and benzos.
He passed away on 14th day of ventilation,16th day of hospitalisation. It was a long & painful journey. Being doctors, We could never leave him unattended (for even 30 mins) for the risk of malpractice/negligence was huge. But no effort could change what Allah willed.
This was a big lesson in humility for us too. We tried everything in our power, from convalescent plasma to tocilizumab(actemra), without any luck. We practically saw him slipping from our hands slowly, and couldn’t do a thing despite all resources in our hands.
He was a v healthy 57-year old, with no comorbidities. Left 3 children & My aunt, a doctor herself. May Allah elevate his rank in Jannah, grant us patience to deal with this. And help us understand this disease so that we can rid our world off it!
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