Such a time .....

This young man is in hospital. Now he needs to go home because he lost his mother to the virus and there is no one else to perform the rites. Yesterday a husband, himself not keeping very well, had to take leave from hospital to cremate his wife.Last month an entire family was hospitalized. The 90yr old patriarch passed away. His 70 year old son was heartbroken..he had cared for his father till now. But now for the final journey he couldn't be with him.Mothers weep or simply become quiet and thoughtful, when we talk of children. Their children are at home, far from them. On TV I see an old age home with a plastic curtain that has sleeves. Its meant for children visiting their parents to hug them, the plastic acting as a protective barrier. 

Some of these are patients. But all of these have happened to doctors. Of living away from home. Of missing children. Of being unable to hug their parents. 

This is such a time

How long the pandemic woes?

Just read about the recurrence of cases in Spain. Looks like covid is going to be with us for a very long time. This brings to the fore a number of questions, which need to be thought about. (Only pertaining to healthcare)

Covid treatment facilities 

Presently the treatment is being done at public hospitals, private hospitals and dedicated covid hospitals. Public hospitals are overwhelmed by numbers because they didnt have much capacity to begin with. Private hospitals are going bust because of increased costs on one hand and capping of charges on the other. And covid hospitals are not working to capacity yet.

Treatment of other disorders 

Other obviously important diseases like monsoon fevers, medical emergencies and surgeries have become difficult to manage because the hospitals are occupied by covid patients. Medical issues like knee replacement,  plastic surgeries, dental problems are prone to be seen as 'luxuries' and completely sidelined. In reality, delay in treatment of these will cause lots of suffering, worsening of the problem and complications. Space needs to be urgently created to start proper interventions for these issues.

Work and livelihood 

In Mumbai at least, the age distribution of medical professionals is very peculiar. Most of the healthcare system in private hospitals is managed by doctors above 50yrs. Public hospitals have younger doctors. But they are all into covid duties. Older doctors in public healthcare have been forbidden to work due to risk of coronavirus infection. Older folks in private practice have been forced to work for their livelihood and government compulsion due to which many have died and there is much fear. Largely medical professionals have not been paid their salaries on time. 

So fear, financial problems,  lack of work, overwork are the avoidable problems being faced by doctors. Plus most private hospitals are facing a financial crisis and may close down in the near future.

What is possible? 

We need to compartmentalize the pandemic and deal with it and that according to me is the only solution. For this to work, following needs to be done

1. Strengthen the covid hospital 

Presently the hospital is mostly empty. Patients need to be directed here instead of occupying private hospital beds. In any case the care is about the same and patients will be saved a great deal of money.

There is severe shortage of healthcare professionals in the field hospitals. Generosity from private sector, expanding telehealth services and creating part time positions is urgently needed.

2. Release private hospitals 

Private hospitals should be released from the compulsion to treat covid patients. They can go back to treating non covid issues. Patients will be served by getting all necessary treatments and private hospitals can be saved from financial collapse.

3. Public hospitals 

Senior doctors in public hospitals should start teleconsultation.  Non affording patients stuck in lockdown at different places can avail of their help.Midcareer specialists should take over the respective departments and start treatment of patients with comorbid covid. For example conducting emergency surgery of covid patients or deliveries etc. This way risk to patient is minimized and the academic program can resume. 

PS

Every medical professional in Mumbai must recognize the covid field hospital as a blessing as it is the only exit strategy available to us. All of us must contribute as much as possible to its setting up and smooth running, with or without payment. Otherwise we are all going to remain in infinite deadlock treating covid which is totally draining our resources and will be unable to return to our usual work. If all of us work by rotation, contributing few weeks time, it can be managed.  It  is quite feasible to take leave from practice for short duration. For now we are also in a position to gain respect because we can contribute voluntarily as per our choice and convenience. However there will come a time when doctors will be publicly shamed for not coming forward and forced to work on unfavorable terms. 

Salute the young...

 a strapping 6footer and just finished his graduate medical studies.  He works at the field hospital for covid patients.  Due to his young age and provisions of the 'Epidemic diseases Act' Govt has posted him to do the most difficult job of actually implementing the treatments for patients.Between duties he lives near the hospital. Though the facilities are above average, I wonder how it must feel for a young fellow to be away from friends, family and food of choice for such a long time...and not out of choice.

He brings along his studies on an Ipad and reads when he is not with patients.  Like the typical doctor, studying and preparing for an exam or simply to understand what is happening to his patient.  He shows great concern for his patients and reports to work enthusiastically. We sent him off to the ward duties..6 hrs is the maximum.  I see him after 6 hours...this erstwhile picture of youth and vitality is soaked to the skin in sweat, face is flushed, pupils dilated and he somehow staggers to the couch. Wearing ppe and working in the hot Mumbai weather has reduced our young Rambo to a tottering wilted rag from heat exhaustion. After he takes rest and fluids and in an hour's time he is asking if he should go back in the wards. For now, I tell him its not needed. So he settles on a chair with his ipad..back to studying.

And there is Dr S. She had a bout of food poisoning this morning. Her mother sent her some homemade food and she saved it to eat over few days. By afternoon she is back in hospital,  ready to don her ppe and dive right in. I am scared, this wispy young doctor...will she be ok? She belies my worries does a wonderful job of it. Dr R wants to check each and every of the 100 patients under her care personally and we are trying to teach her to take it easy...its teamwork and some patients are to be checked by the staff nurse and reported to her. Dr K has a misleading soft voice and demeanor and does great work.

Dr D has a medical condition which requires surgery on Sunday. So he works till Saturday evening.  Dr S has a gynec hormone issue and is going through painful period pain..but she pops a pill and dons her ppe. Only upon seeing her rather pale and drained out after half time, we are able to prise out of her what she is going through.  And then too she insists on staying for duty and has to be practically evicted to go and get some rest.

Dr D is a trainee in Psychiatry. For the last 4 months she has been on covid duty, far from her studies and patients. Neither she nor her colleagues are complaining though. They try to catch up on studies through zoom sessions with their faculty professors. Dr A, the resident from the ENT department is trying to practice her examination skills on the covid patients who complain of throat aches. Are they not worried about the time going? About their education? Marriage? Must be worried, but they are all taking it philosophically as an opportunity to learn and grow as people. 

Dr M is an exam going Resident dr of a superspecialty branch. Without the pandemic disruption, he would have been fully qualified and minting money in private hospitals now. He completely and peacefully immersed in work and doesn't show a hint of disappointment.  He has been lent out to the covid hospital on a resident dr's salary. He treats patients, makes protocols, coordinates with families and set up every system here. Young and married..such are many drs living here and going about the work with absolute dedication. 

And so on. All the drs here have the traits mentioned. These drs are young and yet demonstrate oodles of sincerity,  stoicism, wisdom, confidence,  sense of responsibility and competence in their work.  Our response to the covid pandemic is entirely riding on these young shoulders. The qualities they have cannot be taught and I can clearly see...some people are meant to be drs and it shows from young age.

I am so proud of them and honoured to work with them

Thinking of the Earth

Before the coronavirus pandemic started, there was a lot of concern about being environmentally friendly.  As countries went into lockdown,  the air became cleaner and wildlife experienced more freedom. 

In my neighborhood, we had started some waste management practices like segregation and composting. Unfortunately they stopped during lockdown and dont seem to have resumed.  People are using larger quantities of water with soda bicarb. So thats leading to water wastage and probably changed composition of sewage. 

Medical facilities are using non biodegradable materials for ppe and created a huge amount of waste.  Due to fear of infection people prefer to eat in disposable single use dishes using plastic cutlery. And everyone prefers bottled water to refillable RO.

The pandemic has taken a toll on the economy so that now environmental concerns are not going to be given due importance in planning businesses and development..all possible resources will be put at service of recovery and development. 

In the best of times people find it jarring to hear about environmental issues.  When safety from infection and recovery from poverty are of such concern, there is going to be little opportunity for the environmentalists to have their say. Environmental degradation and climate change have caused this series of misfortunes. But will we learn? And is there a way to be environment friendly in this pandemic? 

Day one

Finally I acted on my desire to contribute my bit and started my 'covid duty' in Mumbai.  My workplace is a temporary field hospital. I visited this location for exhibitions earlier...but now it is a fully equipped hospital. The general mood here is optimistic and calm.This reminds me of NIMHANS. And I feel at home immediately. 

After my orientation and induction, I am still wondering how will I be of help here? 

But in a while I witness a lengthy phone conversation of Dr S. A family member has phoned him to report concerns which include behavioral problems.  Dr S quite confidently reassures him of a solution 'because now we have an experienced Psychiatrist with us'. Both Dr and family member are happy that patients problem will be addressed. 

For ppe, there is no shortage, it fits well and it doesn't feel hot at all. Though I know after several hours in ppe...it will get bad. The ward is huge and disorienting. Patients are in nightclothes and carers in ppe. The whole feel is like walking among clouds due to fogging of face shield with rainbow halos around each lightbulb.

As I finish my evaluation my throat gets strained due to louder than usual speaking. I was quite anxious about doffing. And rightly so because the space allotted was small and much of taken over by discarded ppe. Duties were changing, so a large crowd doffing simultaneously undoing the safety efforts of previous hours.

The administration has suddenly decided to change the accommodation of Drs causing disquiet. So it takes us several hours more to sort it and head to base camp.

Starting Covid Duty

I am a mid career Psychiatrist and have joined covid duty at bkc.

I had been already told good things...but the people who told me are very gentle non complaining types. So I wasn't so sure.

Now that I am here I can clearly see that very good work is happening here. Its very safe. People get along well. Arrangements for stay are outstanding. And patients are improving nicely. 

They train you for the work. And because of clear protocols and helpful nature of experts on team...one gets to make a contribution irrespective of subject of specialization. 

I am happy to have decided to join. I will recommend this to other drs like me.

For all the nice things...there is a real shortage of drs and the salaries are not coming on time. The first issue is to be solved by more of us stepping in. And I think it is best to keep salary as lowest on reasons to join..if you can afford to do so.

Hospitality. ...no thanks

In May my friend told me..."my Drs changed a lot. Today I phoned him for an appointment and he answered with a detailed mssg about services and payment for same...all to be done in advance. I have been with him for 10yrs and this seemed jarring."  I think some of my patients are feeling the same. But there is a reason for this change. 

The whole of April I had been very understanding taking patient calls advising them and sending prescription on phone;on occasion even going in search of a postoffice to mail prescription.  For all my troubles and understanding..a shocking number of patients thought they didn't need to pay. A lot of them did not even qualify my reminders with a reply. And those who did felt consultation fee was not warranted for few minutes conversation. 

I dont buy all these arguments. My clinic is open and I am willing to do consultation there. I am even available for emergency consultation at my hospital. But it is patients who choose to prefer teleconsultation. It requires more effort on my part...in terms of concentration and data use to download the reams of test reports that patients forward. Plus I have bills to pay and salaries of 3 employees. 

I decided I am done with the haggling. If any patient wants my advice they must pay me in advance. I am done with pursuing them for fee and then haggling over the amount. Through this I have been giving concessions to those stating economic constraints...but there will be no discount on account of 'i dont think so and i am patient so you are my servant ' philosophy. 

It was notable that illiterate folks with poor economic status paid up immediately after an honest communication about their issues. It was the highly educated iit iim phd and richie rich class of folks who defaulted on payment and haggled on the amounts. Plus they still keep demanding facilities...now i am to download every payment app that they have...send prescription only through the app they have and do facetime through whatever apps they have....schedule consultation when  they are not working from home...list is endless.  

As Salman Rushdie commented...we folks focus too much on the wedding and neglect the marriage. 

So do our patients who focus too much on hospitality from the doctor and neglect treatment. 

I can only wish such folks 'All the Best' and hope that they go to another Psychiatrist.

Its such a joy to help someone in need. My patients always appreciate my help and we dont talk much about money ever. But teleconsultation has shown me that the talk about money can turn ugly. I am not enjoying it.