Introduction

It was a pleasant afternoon on March 12, 2020. I had traveled from Bhopal to Mumbai to attend the graduation ceremony of the final year batch (my son being one of them) of the Lokmanya Tilak Municipal Medical College. This was when I first came to know that COVID-19 was spreading fast in some countries and had been declared a pandemic by the World Health Organization (WHO) just a few hours back. By that time, only 73 patients had been diagnosed with COVID-19 in India. As this information was sinking in, I began to visualize its impact. I had read about such pandemics but had never faced one.

As I looked around, before me was a batch of ecstatic smiling faces of young people who had just passed their M.B.B.S. and were about to be awarded their hard-earned degrees. The faces of their parents shone with pride. No one, including me, could ever imagine that in less than a month, these smiles would be hidden behind masks and face shields. And the pride in the parents’ eyes would be replaced by concern and fear for their children.

Early days

Coronavirus is not a single virus. It is a part of larger family of viruses that have existed for a long time. Several known coronaviruses circulating in animals have not yet infected humans. Of the various categories of coronavirus, the beta coronaviruses are known to cause severe disease in humans like Severe Acute Respiratory Syndrome (SARS) in 2002–03, the Middle East Respiratory Syndrome (MERS) in 2012, and now, COVID-19. Coronavirus is the name of a family of viruses. The specific virus in the present case is Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), and the specific disease is named coronavirus disease-2019 (COVID-19).

Soon after the first lockdown was announced, people all over India tried to stock whatever they could as coming times were unpredictable. Doctors and other healthcare workers (HCWs), however, did not know ‘what to stock’ in the hospitals and clinics. The medical fraternity suddenly found itself on the frontlines of a battle with an unseen enemy, with no weapons in hand. As I look back, when the first few COVID-19 patients came into our hospital, I realized that the system to deal with them was still in a very nascent phase. The primary focus of top-level teams who were working day and night to develop protocols for handling COVID-19 patients was not only to treat them, but to prevent other patients and HCWs from getting infected. The disease was found to be highly infectious with a Ro (reproduction number) representing transmissibility of 2.5, which is significant. Patients suffering from a variety of infectious diseases attend out-patient departments (OPDs) in India. But such high and rapid transmission has not been seen before by my generation of doctors. Personal protective equipment (PPE) was a foreign word for most doctors. We had only seen it in Hollywood movies. A sense of helplessness in dealing with sick COVID-19 patients, combined with the fear of getting infected, was visible on the faces of all doctors.

The Incipient Phase: Addressing the Unknown

The day when I was informed about the first few patients of COVID-19 in our hospital, before leaving for work, I took off all my jewelry, tied my long hair in a high bun (which I had never done before), and searched for a dress which was easily washable and compatible with PPE. Fancy footwear was replaced by all cover boots. Gone was my favorite leather purse. It was replaced by a washable plastic bag that was filled with masks, sanitizers, eye tight goggles, throwaway pens, and a face shield. At that time, like everyone else, I thought that these adjustments would be necessary for only a month or so.

I now laugh looking back at the apprehension I had while encountering my first COVID patient. My first COVID-19 positive patient had to wait for fifteen minutes as I struggled to get myself into my first PPE kit. It was like doing my first surgery—the nervousness and anxiety, and the fear of failure. Those were the days of many ‘firsts’ for doctors the world over, as the disease and its management were new. But one thing that was not a ‘first’ for them was a strong will to deal with whatever they were faced with.

Since that day in March, my mobile phone has not been switched off at night lest my team needs me for an emergency. I wonder how I managed to remain alert all night. It was very similar to a new mother’s experience. The mother is aware of her limited knowledge and experience and the unpredictability of her baby. She knows that the only thing that stands between her baby and a catastrophe is her alertness. Armed with the basic knowledge of dealing with infectious diseases and having read some literature on COVID-19, my staff and I began to treat patients with all grades of severity as they started coming in large numbers into our hospital. We gradually started to rein in the disease by our determination. We also started to understand the disease better.

Clinical Presentation

‘When I had a mild fever and a running nose, a few hours after my evening walk, I attributed it to not covering myself properly as it was a cool evening. But I soon started having chills and felt feverish. I could have easily overlooked the problem had there not been severe body aches that night. Knowing that I had been a little careless recently, I went for a COVID test the next day— with fingers crossed. But unfortunately, my report was positive. It has been a month now but I still continue to have joint pains and fatigue, and I suffer from a lack of concentration. My advice – it is a bad disease. Be vigilant. Avoid getting it’.

Ashutosh, a mild COVID-19 recovered patient.

Patients with COVID-19 were present with a very wide variety of symptoms including fever (90%), dry cough (75%), shortness of breath (50%), extreme tiredness, body ache, generalized or localized pain in the back or limbs, throat irritation, nasal congestion, and loose motions. Loss of smell and taste are also commonly seen symptoms, usually found in the early phase of the disease. The transmission of the disease from person to person commences in the incubation period (the period between infection and the first symptom), two to three days prior to the onset of symptoms, which on average lasts for fourteen days. Some less common presentations include signs of heart or kidney disease, skin rashes, vomiting, acute chest pain, and paralysis. Symptoms of late presentation, seen mostly in older people, are acute breathlessness, disorientation, and drowsiness due to hypoxia (low oxygen levels in blood) and at times, acute pain in the limbs due to blood clots. ‘Happy hypoxia’ is an interesting term. However, there is nothing happy about it. This situation is commonly seen in COVID-19 patients in whom the virus works its way down the throat and into the lungs. The oxygen saturation of the body starts to decline, but the patient does not have any symptoms of breathlessness and keeps doing his routine work. It is only when saturation drops significantly that symptoms of breathlessness and giddiness appear, and this may be too late. To counter this situation, it is important to check SpO2 levels (oxygen saturation) in older people with a pulse oximeter at regular intervals.

It is a common dictum in medicine: ‘Your patient is your best teacher. Keep learning by his side.’ Never had I given this dictum its due credit until COVID-19 taught me to do so. I learnt more about the disease as the footfall of COVID-19 patients increased in the hospital. Amazing hard work by research teams, clinicians, pathologists, scientists as well as government support machinery has, within a period of ten months, resulted in us having considerably more knowledge for managing COVID-19 patients than we had in April 2020.

The Problem of Late Presentation

Late presentation is most commonly seen in older patients because of medical and social reasons. They have co-morbidities (associated pre-existing diseases) and a compromised immune response which masks symptoms like fever. Many a times, vague symptoms such as body ache, fatigue, and loss of appetite are attributed to old age and, therefore, ignored. Such patients reach the hospital when they already have moderate to severe lung involvement. Treatment is, therefore, delayed, and as a result, complications set in. Some of these patients are in need of ventilators as soon as they arrive. Therefore, this group of the geriatric population needs extra attention at home. Their temperature, pulse rate, and oxygenation should be routinely checked.

Another high-risk group presenting late is healthcare workers, especially doctors and paramedical staff. They have a higher case fatality rate (17%) as compared to the general population (2.5%). Young, dynamic resident doctors work day and night on the frontlines treating COVID-19 patients in the wards and in the intensive care units (ICUs). Many doctors have lost their lives because they presented late which itself is quite ironical.

To really understand this irony, you have to spend a day with a resident doctor in a government hospital, as no words can describe a classic vignette of a resident doctor’s life, his hectic schedules, and his superhuman efforts. During their training, it is engraved in their minds that as the disease does not differentiate between day and night, young and old, white, and black, and caste and creed, they too cannot discriminate. For these resident doctors, there is no ‘start of the day.’ It could be 2 o’clock in morning or 11 at night. They barely remember when they got six hours sleep or when they were able to take a bath. The demanding hours of work and exhaustive training of these doctors are exceptional.

Though not every medical student before entering this profession has such focused dedication, the journey of learning the art of healing and the sense of responsibility evoked in young minds while attending to an ailing child or a dying human being play an immense role in inculcating self-discipline and commitment. This makes them work night and day without stopping to realize what their tired bodies are trying to convey. Pre-COVID, this was still doable. But in the COVID era, these doctors themselves fall in the vulnerable group. When infected, they often attribute their symptoms of fatigue, body ache, mild fever, and cough to the lack of rest, sleep, and nutrition. This neglect has taken its toll. We have lost many young doctors due to COVID-19.

Like any other disease, a COVID-19 patient with mild disease may progress to a moderate or severe phase. COVID-19 maintains its mystique by virtue of its unpredictability. While most patients steer safely through the 14–21 days of the disease, others deteriorate suddenly. Medical science still does not have definite markers to predict which patient will worsen suddenly. The silver lining, however, is that in India only 5% patients turn critical, 14% fall into the severe category, while 81% suffer a mild disease. The mortality rate continues to be below 2.5% in India.

As we navigate through the pandemic with more resources in our hands now as compared to earlier months, the availability of personal protective equipment (PPE) has become inversely proportional to the personal protective awareness and attitude (PPA). With passing months, people have become less fearful and more careless about following simple methods of protection. A new term, ‘COVID fatigue,’ has been coined to justify people’s attitudes. Public places are getting crowded with unmasked youngsters. What they need to know as responsible citizens and family members is that they themselves might come out of the disease with minimal damage, but they can transmit it to elders at home costing them their lives.

Streamlining the System

After the Indian Council of Medical Research (ICMR) and the Ministry of Health and Family Welfare (MoHFW) developed guidelines for hospitals, specific areas were earmarked for COVID-19 emergencies. COVID wards and COVID intensive care units (COVID ICUs) were set up, and doctors were deployed in each of these facilities. Efforts were made to provide the latest treatment for patients and protective gear for HCWs. However, there were many teething problems. Because of the sudden influx of large numbers of COVID-19 patients demanding attention and resources, non-COVID patients suffered. All specialists were engaged in COVID care and could not attend patients with other diseases. Despite all efforts, mixing of COVID and non-COVID patients could not be completely prevented in some areas like emergencies, pharmacies, and to some extent, in medical out-patient departments. As the transmission modes were still under study and it was not very clear whether COVID-19 is airborne or spread by droplets, staff deployed in the COVID units were fearful about their own safety.

As doctors, we have faced many emergencies before this pandemic—accidents, riots, the infamous gas tragedy of Bhopal, and many more. In those times, when I returned home from the hospital, the pride in the eyes of my loved ones took away all my pain and fatigue. But now, returning home is very different. I can see anxiety and fear in their eyes. As I step out of my car, I am worried about carrying home infection from the hospital. I keep wandering if I washed myself sufficiently or ‘Did I touch something while entering home?’ I worry about where I should put my bag or my keys. I wonder if I could let my sons hug me as before. I wonder whether I should sleep in the corner of the bed or in the sofa in the living room. But despite this dilemma, next morning I wake up determined to deal with the challenge of COVID-19.

As time went on, systems started getting streamlined. Today, hospitals are much better organized and equipped for COVID-19. As is mandatory ‘fever clinics’ have been set up in all hospitals for suspected COVID-19 patients. Right at the entrance, after preliminary checking of symptoms—temperature and SPO2 (oxygen saturation in the blood)—suspected COVID-19 patients are directed to the fever clinic. Thus, non-COVID patients who have other medical conditions are able to consult their specialists. It is good to see that even the smallest of the private clinics are following this system, thus avoiding mixing of patients. Emergency units in hospitals are now implementing a new concept of triage and holding areas. In some hospitals, suspected COVID-19 patients as well as all incoming patients are tested for COVID-19. They wait for the test report to come in. They are then segregated into COVID and non-COVID areas. COVID patients are sent to wards or intensive care units (ICUs). Healthcare workers in the hospitals form COVID teams comprising doctors and paramedical staff including nurses and various technicians (ECG, X-ray). A roster is worked up for rotation of teams in the COVID area, thus ensuring justified use of their services. In most of the hospitals, all planned surgeries are done after testing for COVID-19 with required precautions for doctors and patients. Hospitals that treat COVID-19 patients fall into three categories as shown in Table 4.1.

Table 4.1 Type of facility admitting cases with different severity
Full size table

In order to break the chain of transmission of the disease, the government has earmarked quarantine centers to isolate COVID-19 positive patients without symptoms. Schools, stadiums, lodges, hotels, and even grounds have been converted into quarantine centers. This differentiation had eased the burden on the health system.

As disease prevalence soared and India went into the phase of community transmission, this black and white differentiation began to fade, partly because the availability of beds shrank in several hospitals, especially in the dedicated COVID hospitals (DCH). Currently, hospitals staff are managing both moderate and severe cases. This is because with increasing prevalence, more patients have started falling into a gray zone with the moderate and severe categories oscillating on either side during the course of the disease. Despite all efforts by state governments, a major practical problem being encountered in class B and C cities is the shifting back and forth of various categories of patients because of the scarcity of COVID-dedicated ambulances and basic life support (BLS) ambulances in the COVID pool. Regular ambulances cannot be used for COVID patients because of the risk of infection. Also, a rapid deterioration in the condition of COVID patients makes the shifting process risky. State governments have provided contact points to ensure bed availability in the hospitals, but once again, a large numbers of patients and work overload have hindered these measures. It is difficult to keep up with the pace of the spread of the disease. Many private hospitals have converted 20% of their beds into COVID beds according to the government’s instructions and are admitting all categories of COVID-19 patients. Because of these reasons, differentiation in many hospitals into different categories of patients is not possible. And many hospitals in the country are now catering to all patients by setting up COVID wards and COVID ICUs.

Managing the Unmanageable

In the past ten months, a new virus with no known treatment took the human race by surprise. Developing countries like India faced unprecedented challenges. With more than nine million reported coronavirus cases according to the MoHFW, India is among the worst affected countries in the world. But if we analyze the prevalence of the disease in the light of India’s population size, resources, diverse geography, and last but not least the sab chalta hai (everything goes) attitude of the general public, the disease may not have caused as much damage as expected.

A major cornerstone in India’s strategic approach to the pandemic has been extensive testing. From only one laboratory—the National Institute of Virology in Pune—that tested for COVID-19 in January 2020, today the number of laboratories is more than 2000 all over India. From about 100 tests per day in March 2020, India crossed the landmark of 100,000 tests in a day on May 18, 2020. As of November 25, 2020, the total number of tests done was above 135 million. The importance of testing cannot be stressed enough, because only timely detection can trigger the cascade of measures that follow including isolation, followed by treatment and management. With extensive testing and mass screening, cities in India have prevented the infection from exploding uncontrollably. A notable example is the large Dharavi slum in Mumbai.

Commonly used tests to detect coronavirus are reverse transcription-polymerase chain reaction (RT-PCR) with 70% sensitivity and rapid antigen testing (RAT) with 50–60% sensitivity. Other tests are COVID-19 enzyme-linked immunosorbent assay (ELISA) and chemiluminescence enzyme immunoassays antibody (CLIA) kits to detect antibodies against coronavirus indicating recent infection. Others are True Nat testing for COVID-19, cartridge-based nucleic acid amplification testing (CB-NAAT) and clustered regularly interspaced short palindromic repeats (CRISPR) technology base SARS-CoV-2 test. Molecular diagnosis or testing in real-time reverse transcription-polymerase chain reaction (rRT-PCR) test and reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) assays are other diagnostics. Another important diagnostic and prognostic tool is computed tomography scan (CT scan) of the chest and to some extent X-ray chest. Many a times, a false RT-PCR negative case is diagnosed and treated successfully on the basis of the CT scan findings. There is also a battery of blood tests which are supportive of diagnosis and have significant prognostic values.

Medical science is an imperfect science, which means that two plus two is not always equal to four. An important part of the diagnosis and management of any disease is the clinical assessment of the patient. The treating doctor’s interpretation, based on his/her knowledge and experience, is most important. Because of the limited sensitivity of the commonly used tests (RAT and RT-PCR) or at times, defective collection methods, many false negative reports are generated. A highly suspicious case, even if she/he has a negative RAT or RT-PCR report, should be managed as a COVID patient on clinical grounds. It is wise to go with the judgment of the treating doctor about the management of the patient, as many are detected positive later on. Another conflicting feature is that many patients are found to be persistently COVID positive due to the shedding of the dead virus but are usually non-infective beyond 12–14 days.

As the months pass by with no signs of relief from the pandemic, the biggest challenge in hospitals now is how to adequately staff the various COVID areas with doctors, nurses, technicians, pathology and radiology staff, class-IV workers, and administrators. As COVID-19 is predominantly a respiratory disease, its treatment strategy and planning fall into the purview of chest physicians, general physicians, intensivists, and anesthetists who form the core team for fighting COVID-19. COVID-19 has further reduced the already low doctor patient ratio in India. The physician to patient ratio is 0.7:1000 in India as compared to 51:1000 in Sweden.

Despite the patient overload, the medical fraternity stood up to the occasion and doctors from all specialties like ophthalmology, surgery, and psychiatry offered their services for the fight against the pandemic. This fact is little recognized by the general public who have a tendency to take doctors for granted. Doctors work beyond the call of duty as they keep updating their knowledge on COVID-19 without creating any fuss. This deserves recognition and applause. Orthopedicians, ophthalmologists, gynecologists, and surgeons, who had never entered the medical ICU, have taken a crash training course on ventilators and COVID patient care. The core COVID teams have carried out their duties willingly. While people are treating COVID patients as untouchables, nursing staff are handling these patients with benevolent compassion, recapturing the memories of Florence Nightingale.

Drug Management

There has been a rapid change in the pharmacological or drug management of COVID-19 over these past months. Hydroxychloroquine emerged as the most promising drug in the initial months. However, in June 2020, the Food and Drug Administration (FDA) revoked its emergency use authorization. Many other antiviral drugs came up of which Remdesivir was one of the more promising drugs approved by FDA. However, on November 20, 2020, WHO recommended that it should not be used. Oral antiviral Favipiravir was recognized in some countries including in India, but there are still limited studies on this drug. Ivermectin, an anti-parasitic drug, that has been used for a long time, is currently under trial at the All India Institute of Medical Sciences (AIIMS) in Bhubaneshwar where it has shown positive results for the prevention and treatment of COVID-19. As this viral infection evokes an inflammatory reaction especially in the lungs leading to complications, anti-inflammatory drugs like steroids and many inflammation marker tests have found a role in the management of COVID-19. ‘Cytokine Storm,’ a high mortality prognostic condition with a high risk of death, brought forward drugs like Tocilizumab. But again, this drug has its own potent side effects which are restricting its use. It has been found that COVID-19 induces the formation of blood clots in blood vessels leading to complications such as heart attack, paralysis (stroke), thrombosis in the veins of legs or kidneys as well as ischemia (lack of blood supply). The addition of anticoagulant drugs to counter this has brought a landmark change in the management of the disease. Convalescent plasma therapy with antibody-rich plasma from infected and recovered patients was used initially. But on November 17, 2020, it was invalidated by ICMR. Supportive treatment with vitamins C and D has also a found place in the treatment of COVID-19, but this is still under study. Vaccines to prevent COVID-19 that are being rolled out show a light at the end of the tunnel.

‘Society cannot be left alone at a time when it needs us the most. Someone has to come forward and take charge. God gave me an opportunity to do this—to be with those suffering and to treat them. I have tried to give my best and this was possible because of the dedicated staff of 850 healthcare workers of Chirayu Medical College who worked fearlessly. The pandemic provided me an opportunity to use my clinical skills to help mankind which has given me real satisfaction’.

Dr. Ajay Goenka, Director, Chirayu Medical College, Bhopal, a pioneer in COVID care.

India is a land with age-old Ayurveda, homeopathy, and other indigenous systems of medicine. Several indigenous treatment strategies have emerged for the cure of COVID-19. The role of black pepper, ginger, cloves, honey, lemon, and turmeric milk is well known in Ayurveda, yoga and naturopathy, Unani, Siddha, and homeopathy (AYUSH). A variety of ‘kadhas’ (potions) are finding their place in management of COVID-19. To the best of my knowledge, none has proven to be fully effective. Meanwhile, exploring the world of indigenous treatments offered in our country is an interesting research-worthy subject. Traditional healing systems in remote areas of India offer nature-based lifestyles and treatment to combat the disease. Natural diets include organic fruits with high vitamins C and E and antioxidant content to strengthen the immune system to keep the virus at bay. Flowers of ‘Mahua’ tree are being used by some in Odisha State to make antiseptic solutions. Some villages in Chhattisgarh State make natural sanitizers. In some villages in Odisha, a local herbaceous plant called Bhui Neem or King of Bitters is used to make a concentrate to fight the virus. Ashwagandha or Indian ginseng, Giloy branches, and many other medicinal plants are used by Indian tribes to ward off the virus.

The age-old practice of yoga with its various pranayams (breathing techniques) is gaining importance by virtue of its effect on the lungs. It can make those areas of lungs active which, in a non-practicing person, lie dormant. Based on the same principles, the Awake Proning or Coronary Artery Revascularization Prophylaxis (CARP) method is recommended in the West. ‘Jal Neti’ and ‘Sudarshan Kriya’ can also be added to the list of methods used for improving respiratory hygiene of the lungs.

The Hospital Scenario in COVID-19 Pandemic

During the lockdown and for subsequent months, the world came to a grinding halt. Roads became empty, and people remained indoors for safety. But the rules were different for doctors. Their leave was canceled. Their duty hours were increased. And their mental as well as physical pressures grew exponentially. Doctors are quite similar to soldiers in this war. But while a soldier functions better by suppressing his humane aspect, a doctor brings out his best by revealing his humane face. However, doctors fear that they and their families may get infected while they are trying to be dutiful and fearless. But then they push back all their worries and start each day with a new hope and strength. Armored with knowledge about the disease, which they gained during the previous night by attending seminars on COVID-19 and by reading recent protocol updates, doctors boldly enter the COVID areas of the hospital for their day’s work. The ritual of meticulously donning PPE gear is tedious because they have to stay in this gear for the next 6–8 h when they cannot get any food, drink, or a bio break which can be difficult.

The practice of taking rounds and prescribing treatment is the technical aspect or ‘the science of medicine.’ COVID-19 has incapacitated the doctor–patient relationship—‘the art of medicine.’ What does a patient look forward to when a doctor comes for his rounds? Is it the intravenous fluids planned for him or his intake–output chart or incomprehensible names of medicines? No, certainly not. The patient is searching for some assuring words, a hopeful smile, or a comforting hand to hold. The PPE gear has suddenly taken away this assurance from him. It is the same for a doctor who hides behind his impermeable veil, compromising ‘the art of healing.’ He can only reveal his identity to the patient through his voice, which is also muffled behind layers of the protective mask.

For a patient who is conscious, the atmosphere inside a COVID intensive care unit (ICU) can be scary. Within a closed room, he is inside a small cubicle full of gadgets—constantly beeping machines and monitors with flashing graphs and numbers. Within his visual range, there are some more serious patients and a few faceless and expressionless figures of healthcare workers wearing PPEs. There is a constant wheeling in of sick patients suffering from the same disease as him; some of whom are dying before his eyes. Intubations are going on, sounds of running ventilators are frighteningly monotonous, and healthcare workers appear like white robots moving around. The only other event that happens during the day is a brief interaction on video with his family, which incidentally is also the only activity connecting him to the passage of time because days and nights are otherwise indistinguishable in the ICU. Once in the ICU, the average time for a patient to be fit enough to be wheeled out is seven days. During these nerve-wracking days, the patient feels that he would give anything to see a normal smiling face or meet his dear ones.

For a doctor on duty in the COVID ICU, life is very different from the pre-COVID days. Over the years, protocols have been developed for all other medical emergencies, and doctors are confident that they can get positive results. The course of events in most of the diseases is predictable. But COVID-19 is still unpredictable. The case fatality rate in ICUs all over the world is around 50% which is much higher than in India. In some cases, the fatality rate is more than 90%. Even with the latest information and drugs in his bag, when complications set in, a doctor struggles in a maze of contemplation as she/he is unable to determine whether the problem is a complication of COVID-19, a drug reaction, or something else which is, as yet, not understood.

Wearing PPE is arduous for the doctor. There is physical restriction as well as heat and sweat due to lack of air circulation especially in the ICU where, by COVID protocols, air conditioners cannot be run. PPE hampers communications with patients as well as with fellow doctors and nurses and so work slows down. Emergency handling of patients, intubations, and intravenous catheterizations, which were routine earlier, are now painfully tedious. The doctor finds himself unable to connect with the patient in the traditionally taught ways. The suffocative feeling of multiple layers of the mask distracts him from the much-needed focus and mental alertness required while working in the ICU. He is in command of and responsible for the multiple machines that are pumping life into moribund patients. Any mental clouding can be disastrous. But beyond his own fears and discomfort, he knows that if anything stands between the patients and death, it is him. This keeps him fueled for action. Once out of the ICU, he has to go through the risky ritual of taking off the PPE. This is risky because improper removal of PPE is a common cause of acquiring the infection. Another patience-testing activity is dealing with hyper-anxious family members of the patients. COVID-19 is known to cause psychological disturbances because of isolation. This is called ICU-induced psychosis. It can make patients say or do things which frighten their family members who watch them on video calls for a few minutes that are allowed in some hospitals. This precipitates anxiety and restlessness in the family which also has to be dealt with by the treating doctor. The reassurance given to the family has to be in guarded words as COVID-19 is known to take unpredictable turns.

For senior consultants in hospitals and in private practice, the day is spent managing COVID areas, attending to non-COVID patients, taking administrative decisions for streamlining and revising COVID care, and supervising the execution of extensive paperwork needed as per government policies. These pressing schedules that have continued for many months have resulted in mental and physical pressure and are taking a toll on the medical fraternity who is exhausted and in dire need of rest.

‘My lungs were 90% involved and I was on a non-invasive ventilator for five days and then on high-flow oxygen for five days, all inside the ICU. I was unable to move my body because of extreme weakness. I was also disoriented and sleepy most of the time. A young nurse who looked after my needs also took care of the man in my neighboring bed. I heard him promising to get her married to his son because she looked after him so well. But the next morning when I woke up his bed was empty. The reason was obvious. I saw more people dying than my sick mind and body could take.

I would wait for my doctor whom I recognized, despite his PPE, because he was the only one who called all the patients by their names, otherwise we were just bed numbers. The big wall clock did not seem to move at all. It was very difficult to keep sane.

When I was moved to a ward, my neighbor was a lady whose husband was in the ICU. Her son was in the USA and was expected to come in three days. Her husband died that night and was cremated without any family members around. She was probably not told about his death.

I did not know when I will recover from post-COVID weakness physically, but I know that I can never be the same person emotionally’.

A 74-year-old severe COVID recovered female patient.

Healthcare workers also need the community’s compassion and support. Thinking of one’s own interest can be acceptable, but thinking only of one’s own interest cannot be justified. Those who are facing the pandemic head on, deserve respect and encouragement. This is the only expectation of the frontline workers—which is really nothing in return for what they are doing for society.

‘I have personally experienced very disturbing behavior on the part of my neighbors. They would greet me from afar during my walk in the common park. They would change their path when they saw me approaching them. My cook was urged by many to quit her job lest she gets the infection. I have read news about doctors being shunned in their neighborhoods and not being allowed to enter their own flats. Such estranged behavior and response by society for whom, we are risking our lives, working day and night, is extremely discouraging and pathetic’.

A female doctor in Bhopal.

The Diary of a Patient

Since March 2020, everyone in the world has lived under the constant fear of getting the infection. Over the past ten months, the response to the prescribed precautions of sanitizing, masking, and social distancing (S-M-S) has been erratic. Financial and work pressures and the setting in of ‘COVID fatigue’ in society have made many careless. But even those following the rules to the best of their capacity have been infected. Immediately after being tested positive for COVID-19, the person is isolated. Before the situation sinks in, she/he is directed to an isolation room by government officials and/or by family members. The patient cannot even choose his/her clothes to pack. Basic essentials are kept outside the room to be picked up when no one is close by. The person suddenly realizes that no one wants to come close to him/her. If admitted to a hospital, she/he sees only PPE covered bodies of healthcare workers and misses the reassuring smile of the doctor, the comforting touch of the nurse, or a chitchat with the ward boy. Solitude is definitely the worst experience of an asymptomatic or mildly diseased patient. Solitude plays strange games with the psyche; 90% of patient detest this experience.

In the initial months of the pandemic when someone tested positive, all his/her family members were sent to different hospitals based on the category of their disease. Indian patients are not used to remaining alone in the hospital without the care and presence of their family members and friends. And if quarantined at home, the poster declaring COVID-19, the barricades around the house, and the stigma of the disease can cause terrible embarrassment.

‘I suffered from COVID-19 in the initial months probably because I reside in a densely populated area of Bhopal. At that time, isolation policies in Bhopal were very strict. I was sent to a medical college hospital. Next day, I came to know that my wife and my older daughter had also tested positive. They were taken to another hospital because their disease category was different. My 16-year-old daughter who tested negative, was left all alone at home. As we are a nuclear family, there was no one to take care of our basic needs. All four of us had to manage on our own without any family support. Fortunately, by the grace of Allah, we came out unharmed. But the social stigma, the pain of isolation, the fear for your loved ones, and the anxiety and uncertainty are just not worth it’.

A 56-year-old male resident of Bhopal.

No matter how impatient and agonized you feel on not being by the side of your sick mother, wife, or child, you cannot see them. You cannot hold their hands. You just get a message, once or twice in a day about their worsening condition, and you can do nothing about it. If unfortunately the patient dies, she/he dies all alone without the family by his/her side. The body is wrapped in an impermeable double body bag by trained workers. No relatives are allowed to handle it. Depending upon the local administration, relatives may be allowed to see but not touch the body for one last time before it is taken away by the Nagar Nigam authorities for cremation. This scene is perplexing and upsetting. A dead body can be wrapped and closed in an impermeable bag, but human emotions and memories of a lifetime cannot. Emotions are high and spill over, turning into wrath against medical personnel, who are already terribly stretched in their fight against the disease.

A Doctor’s Perspective

How many of us have visited a hospital, especially a government hospital, in the past ten months? The striking difference is that now it is almost impossible to recognize your treating doctor. All of them look the same as they are dressed in operation theater (OT) scrubs. Scrub caps on the head (gone are all hairstyles), double masks, gloves and if, you catch them off guard with their masks down, you will see a classical skin abrasion mark on the nose bridge which is because of their constantly wearing tight masks.

During their COVID duties, doctors do not go home for as many as fifteen days, lest they carry infection to their loved ones. Young mothers leave behind their toddlers to take care of COVID patients. Life in PPE kits, continuously for eight to ten hours, without food, water, or urination, is inconceivable. In the initial months, the policy was to assign COVID duties for 15 days followed by a week of quarantine to ensure that the doctor was COVID-free before the next duty rotation. In this way, doctors could snatch some rest during the quarantine week. But with the spread of the disease, even quarantine breaks were denied to them. It is not that the doctors are not afraid, like all others when they enter COVID ICUs or handle emergencies. But one thought that keeps them going is ‘Who will do it, if not me?’. Yes, it is understandable that this is a war situation, and a soldier’s foremost duty is to fight. But unfortunately, in this war, the enemy is unknown, the weapons are crude, and training is hurried and insufficient. Doctors know that every day when they go home, they carry a risk of exposing their family members to the disease. Lately, contrary to the general perception, the footfall of sick patients in hospitals has shown an unexpected rise. This poses a serious challenge to the healthcare workers who are already very fatigued.

‘People are becoming casual about COVID now. When the numbers were not so high, people were extremely cautious. Now when the numbers have increased, only a few will get very sick. But nobody knows who will be among those few. We see critical patients daily and so feel scared. I wish everyone was scared enough to take appropriate precautions. Hopefully, COVID will go away soon and we will fly into a COVID-free life. Until then, however, do not loosen your seat belts. Keep on a good mask and be safe’.

Dr. Ashwini Mahlotra, Chest Physician, Bhopal—an active COVID warrior.

The irony is that at times COVID duties are safer than non-COVID duties because in the former case you know that all the patients are positive and so you take adequate precautions. But in the latter case, any emergency patient you handle could later turn out to be positive.

Doctors from different steams of specialization are missing their original work for almost a year now. Refining of specific skills and knowledge in their own fields has nearly come to a standstill.

Despite their undaunted determination and superhuman efforts to confront this deadly disease, the number of cases of violence against doctors has increased. As the country is opening-up, the plight of doctors, due to an unmanageable number of COVID-19 patients, is worsening. The number of healthcare workers getting infected by the disease is increasing. Fatigue has set in in the remaining fighters due to inhuman working schedules. But the sense of responsibility and the will to serve are still clearly evident.

In many areas, doctors are now practicing holding hands, i.e., being in touch with home quarantined patients through tele-consultations and tele-medicine, to guide them safely through the crisis. The only wish of healthcare workers is that people become more responsible and understanding and have compassion for those trying to help them for it as they who stand between them and the deadly disease.

Salient Takeaways

  1. 1.

    Until such time when there is a definitive cure for COVID-19, prevention is the best solution.

  2. 2.

    Do not take the disease or its symptoms lightly. To underestimate the severity of COVID-19 is a big mistake. The unpredictability of the disease, its high rate of transmission, and its variable course in different individuals are major challenges.

  3. 3.

    Early detection and consequently early treatment are the best choice for full recovery. Do not hesitate to get tested at the earliest, even if your cough and fever were mild and lasted for only two days.

  4. 4.

    A negative test report is no guarantee for a disease-free state. Reasons for false negative reports are multi-fold like low test sensitivity (60%-85%), improper sample collection, defective viral transfer medium, or a break in the cold chain.

  5. 5.

    If in home isolation, follow the instructions for treatment that your doctor has given through tele-consultation as the disease is known to take ugly turns anytime during its course. Trust your doctor who advised investigations as they are necessary. Have a positive frame of mind and a strong will to fight the disease.

  6. 6.

    People who start working immediately after recovery are likely to suffer post-COVID syndrome. In this case, there can be persistent breathlessness, cardiovascular problems, stroke, and continuing fatigue. It is, therefore, advisable to take rest following COVID-19.

  7. 7.

    Do not let down your guard after the recovery period. The immunity status has been found to be variable both in strength and duration. Reinfection or a new infection with other viruses or bacteria can occur due to low immunity.

  8. 8.

    If you are COVID positive, do not hide your status. Do not be the one to transmit the disease. Stay indoors and away from everyone.

  9. 9.

    Learn to wear your mask properly. Change it frequently as soiled masks are not protective. Follow social distancing and sanitizing protocols available on government websites.

  10. 10.

    Multiple disciplines and agencies are working resolutely to save lives. They are working fearlessly day and night. Healthcare workers, the police department, government officials, social workers, and many others are on the forefront of the pandemic. Be patient and show them gratitude and respect.

  11. 11.

    The world is talking of a ‘new normal.’ During the Spanish Flu in 1920, same precautions and steps were proposed to contain the pandemic. We did not then prepare for social, environmental, and behavioral change to manage the ecological balance. Understanding this and adapting to the real ‘new normal’ are important for preventing future pandemics in this era of globalization.

  12. 12.

    Keep yourself updated with new guidelines and instructions issued for the public on various government Web sites and keep away from rumors.

‘Hum naa marab, marihe sansaara,’ a well-known Hindi saying by Sant (Saint) Kabir states that things can go wrong only with people around him, but never with himself. COVID-19 has shattered this belief. Starting from Wuhan and reaching our homes in just a few months, this disease has left an imprint on the ever-growing selfishness of human beings. If you want to be safe, care about others and create a safe environment for all.

‘Ubuntu’ is an African tribal word which means ‘I exist because we exist.’ It is impossible for you to be happy when everybody else around you is sad. So, let us join hands to bring about a change for everyone together… for a better tomorrow.