Thread by @anandj_

Had a long conversation with a friend who is practising in one of the large government hospitals in Chennai. He shared some vital information that I would like to share here. (1/40)

I am not a doctor and I am only sharing what he shared with me as an advice. In case any of these information are not right or ambiguous, do let me know, I will correct it. (2/40)

For those who made calls to hospitals in the last 3-4 days will know how difficult it is to get a bed in Chennai. Some pick up and say beds are not available, while some don't pick up calls at all. Some even disconnect the call. (3/40)

You can't blame them either. How would you feel if your phone rings incessantly every 3 minutes? For 20 continuous hours? For 15 straight days? And you have some 100 lives to save on top of that as well? (4/40)

Take any hospital, public or private, a maximum of 40% beds would be oxygen supported beds. And some 5% with Ventilator and ICU. (5/40)

The reason we need oxygen support is that our infected lungs won't be effective in allowing the oxygen from air to pass into our bloodstream. So we need supplemental oxygen while the COVID recovery takes place. (6/40)

If someone walks in with an SpO2 of say 94 or so, and if their spo2 levels don't fall, then the doctors can keep them in normal beds. (7/40)

If the SpO2 deteriorates, then they need external supply of oxygen. But excess oxygen is also bad for the lungs. (He said it causes way more damage) (8/40)

So doctors first determine how much oxygen to administer to the patient. If Spo2 goes down to say 90 or so, slowly they start administering oxygen (some 3-4L/min) through nasal tubes and non-breather masks. (9/40)

If Spo2 goes further down, then pressurized continuous oxygen is provided from machine, having a higher flow rate. If Spo2 goes even further down, then Ventilators are used. (10/40)

So most Covid makeshift hospitals that are being set up in Chennai can only provide nasal oxygen (or non-breather masks). This is why most of them say they can take in only mildly or moderately severe cases. (11/40)

Getting ICU and ventilator beds are becoming very very difficult because obviously they are less in number, and also require full time Anaesthetist in the hospital. So the beds are more or less available in large and moderately large hospitals only.(12/40)

My friend shared that in his hospital, they don't usually accept new admissions for ICU. Everyday, some of the people who have been admitted in oxygen ward get critical and they get moved to the ICU. In other words, it is very difficult to get a direct ICU admission today.(13/40)

Most likely, this might be the same situation in large private hospitals as well. Internal fulfillment happens and that happens in heaps. (In addition, there are also recommendations from internal doctors/nurses working there.)(14/40)

104 works. And 104 works really well. But...(15/40)

Let's understand how the oxygen and normal beds get fulfilled today. (No brainer - direct walk-ins.)(16/40)

In Govt hospitals as much as I was informed, depending upon the capacity, 60-100 patients get discharged everyday from each hospital. So in a 500-bed hospital, some 60 beds are available everyday.(17/40)

And the patients are discharged between 8AM till 10AM.. And my friend said, people start queueing up from morning 6AM itself to get an admission.(18/40)

104 updates are provided by around 10AM. And within the next 30mins or so the entire beds get filled by the patients waiting in line from morning.(19/40)

So 104 works. The updates are provided. But the situation is such that the speed of fulfillment is much much higher.(20/40)

But this rate might not be the same for other small to medium hospitals. So 104 is able to provide support. But those small to medium hospitals might have oxygen bed challenges. Refer point 11. (21/40)

While this is the ground reality, there are some absolutely critical points for us to note: (22/40)

I have heard multiple stories from him on how COVID deteriorates health at such a short time span. So every day counts.(23/40)

If you have even the slightest of fever, rush and do your RT PCR. And don't wait for results. Go do your CT that day itself. (he didn't say X-ray though)(24/40)

Actually, start now. You can avoid panic SOS tweets for CT later. Check your nearby labs and hospitals. Get information about where and how you can do your CT and RT PCR nearby when (if at all) you develop any fever at a later date. Twitter is your friend. (25/40)

Get your oxymeter. This is by far the only tracker we have to assess severity from home.(26/40)

The reason oxygen beds and ICUs are so full is because people reach hospitals late. Not everyone can afford oxymeter either. So things are getting very difficult for less previledged families today.(27/40)

If you can afford, please go and buy an oxymeter. If you can buy one extra, please provide oxymeter to someone who can't afford it. (and teach them how to use it)(28/40)

(I wish Govts do something to bridge this oxymeter inequality today.)(29/40)

If your chest CT is normal (but you still have symptoms), home quarantine yourself. Keep checking your SpO2 level. If it goes below 95, visit the nearby covid centre.(30/40)

If your chest CT shows mild deterioration (score less than 7), even if your RT PCR is negative, get to Covid centre, file for home treatment, get medicines and home quarantine yourself. (31/40)

Monitor your Spo2 level at least 6 times a day. If the Spo2 decreases (it happens gradually in a day) and hits say 94, start your search for hospital beds. (32/40)

Getting a hospital bed when you have SpO2 above 90 is easier, refer point 11. Therefore getting treated gets easier as well.(33/40)

It is at this stage, my friend said, that they would administer Remdesivir. If the Spo2 goes much lower, say 80 or so, then he said the medicine would not be helpful. (34/40)

Because, everyone is rabid-using Remdesivir, the ones who actually need them are not getting them today.(35/40)

He said they have stopped using Tocilizumab and other IL6 inhibitors in Govt hospitals. They used it last year, but seeing no big improvements and because of a lack of any concrete scientific evidence, they have stopped it this year.
It is ridiculously expensive as well.(36/40)

When SpO2 gets lower, the deterioration gets rapid. So he is pleading everyone to get to hospital when SpO2 levels are starting to deteriorate. (37/40)

If someone does not have an oxymeter, the moment they face difficulty in breathing for basic tasks - like walking, speaking etc. is the time to visit the hospital. (38/40)

Even today there are 40 beds vacant in his hospital, but they are normal beds and with no takers, because everyone is coming to the hospital with some serious oxygen requirements only.(39/40)

Hope we all are safe and will be safe. But no harm in being prepared.
Thank you. (40/40)

Update: A lot of people, including doctors, pointed out the section regarding CT scan.
Is it risky? Is it necessary? Why immediately take a CT etc.?
To clarify, I spoke to him again. Here's his explanation. (A/R)

CT scan has radiation risks. True. 300 times more radiation than XRay (as said by AIIMS chief) might be an exaggeration. But multiple studies definitely prove it has atleast 70-100 times more radiation risks than an X-ray. (B/R)

He said he would not have recommended CT scan last year. But he says the virus in second wave is more virulent and as a doctor (and a radiologist) he is recommending his patients to take CT. This is his perspective based on what he is seeing on ground.
His reasons being: (C/R)

This is a pandemic situation where he is seeing some insane amount of people suffering everyday. If someone has a fever now in a city that has 20k cases infections everyday, there is a greater probability that it might be due to COVID than say due to flu or typhoid. (D/R)

As a doctor, it is his responsibility in this Pandemic to consider and be prepared for the worst case scenario, than being optimistic that it is normal fever that would subside after 3 doses of paracetamol. (E/R)

In this second wave, he is seeing a lot of people (especially young patients) having a condition called 'Happy Hypoxia'. (F/R)

Usually, when our SpO2 levels go to 94 or 93, we start experiencing breathing difficulties. But in recent Covid cases, people feel a lot healthy (happy state) with no breathing problems at those SpO2 levels. (G/R)

Only when their Spo2 dips to say 85 or so, they start feeling breathlessness. And by that time, the patient is already critical. If there is no bed availability then, their condition rapidly declines. (H/R)

But he is not denying the radiation risk. He says there are evidences that CT scans might have cancerous risk. There are also a tiny number of cases where people might have contacted COVID at CT centres. (I/R)

But he also adds, by taking one CT scan, people don't need to worry to the levels of cancer and all that. The chances are very very faint. But avoid taking CT again and again so that the radiation risk is minimised. (J/R)

Patients who are Pregnant are anyway advised NOT to take a CT scan. (K/R)

X-rays also help in determining the lung damage. But he says the difference between an x-ray and CT scan is that, the former is two dimensional. You can assess the depth of lung damage only through a CT scan (and therefore get CT score) (L/R)

In the last wave, when fever surges and mildly subsides afterwards, the effect on lungs was not that significant. This time, he says, the lungs are getting badly infected and assessing the extent of damage upfront will help in quicker recovery. (M/R)

Under the following conditions, he has been advicing his patients for CT, being cognizant of the radiation risk: (N/R)

If a patient is over 60, (or with co-morbidities or obese) is experiencing fever over 100 degrees continuously, do an RT PCR *AND* a CT scan. (O/R)

If a patient is young and experiencing mild fever and no breathing problems, do an RT PCR and an X Ray. No CT needed at this time. (P/R)

If a patient is young and starting to experience breathing difficulties, or a drop in SpO2, get admitted at once. (Q/R)

Hope this clarifies some doubts relating to CT scan in my above thread. Thanks. (R/R)