Often, the doctors are called upon to treat critically ill patients without being aware of the exact disease or certain major parameters. What is the best approach under such circumstances?
As doctors, we formulate a treatment plan based on probable diagnoses while simultaneously initiating all relevant tests. Although this approach may seem like guesswork, it is not. We search the literature for similar cases, draw on our own experience and, not least of all, consult our colleagues.
This approach has a few elements that have a critical impact on the outcome. The first concern being, alert to possible side effects of the treatment and withdrawing responsible therapy. Next, we have to be open to the possibility that we were initially wrong and make the necessary corrections based on new data. Thirdly, we need to be clear about what we expect the treatment to achieve. This plays a vital role in deciding the limits of aggressive therapy.
The most important element though, and we cannot emphasise it enough, is clear and constant communication with the stakeholders – the patient and their families. We discuss with them the treatment options and settle on a course of action based on shared decision making. We regularly update them about the patient’s condition and seek their input at every point. At least, this is how the treatment is supposed to happen.
No such things as the 'Perfect Parallel' exist. However, there are certain similarities between our clinical scenario and the pandemic.
The virus is new. We had little information regarding its infectivity, mode of spread, or fatality in January when we had our first COVID case. But we had enough information to know that the virus and the disease it caused could not be taken lightly. There was an urgent need to mitigate the impact of COVID19 on patients as well as its spread amongst the people.
It is from this perspective that we would like to take a look at the lockdown. Ours is a homegrown perspective, as it should be. Comparing our response to that of Germany, for instance, will not do, as we don’t have their level of resources. More significantly, we have an inadequate and inefficient public health system which has suffered as a result of decades of neglect by successive governments (current one included).
It struggles at the best of times to address the healthcare needs of the people and is in danger of being overwhelmed by the added burden of the pandemic.
Where the Lockdown Faltered
The fact that this hasn’t happened as yet implies that the government may have done some things right and the rest may be demographics and geography. On the other hand, we have a daily tally of more than 5000 cases (after nearly two months of lockdown) indicates that certain things have gone wrong.
Within the initial days of our first case being diagnosed on January 30, the Government banned the entry of people coming from China, signalling that they had taken serious note of the COVID epidemic. By early March, flights from Italy, Iran, South Korea, and Japan were suspended, though at that point we only had a handful of COVID cases.
On 23rd March, with hardly five hundred odd patients in the country, a nationwide Lockdown was announced giving just four hours of notice to the people. The Lockdown was to give the Government the time to bolster the healthcare infrastructure and step up testing. Steps were taken to increase the availability of quarantine facilities, hospital and ICU beds, and ventilators. Testing was stepped up, though not sufficient for a country of our size. Some of these were steps in the right direction.
At the same time, there were a few vital omissions. The most glaring omission was that of not anticipating side effects – the migrant workers’ hardship. It could have been foreseen. In times of uncertainty, it is only natural that people would want to go home.
Transporting them in an organised humane manner, before declaring the lockdown, particularly when we had less than five hundred cases would have been far less risky than doing so now when we have more than a lakh cases.
Millions of migrant workers are suffering because of this failure by the Government. The human tragedy caused by this failure cannot be illustrated more vividly than by the plight of Jeeta, the twelve-year-old girl from Chhattisgarh – overcome by thirst and hunger, struggling on in the scorching heat with the sole hope of reaching her sanctuary, her home. She died!
The second error was in not ‘initiating all the necessary tests.’
This has left us ‘flying blind’ as we try to come out of the lockdown. We do not know where the virus has spread or where our health resources need to be focused. In this situation, the Government is caught between the devil and the deep sea – extending the Lockdown indefinitely or re-imposing it when the curve peaks.
Thirdly, we did not have clear expectations regarding what our treatment, the lockdown, would achieve. A much-touted idea by a section of the media and certain government representatives was that, not only were we going to flatten the curve but, probably stamp out the spread completely. But that has not happened.
Last, but not the least, all stakeholders – such as state governments and experts (even those not from the ruling party) – should have been consulted, with emphasis on shared decision making. We could have looked at the Kerala model, which has been tried and tested both in the Nipah virus and the present outbreak.
Trusted public figures could have constantly and repeatedly communicated with people regarding the necessary precautions to be taken and what to expect in the next year or so. This would have had much more impact in sensitising people to the requisite preventive steps, and in reducing the manifest anxiety amongst them.
The response, or rather the reaction, of the government to this unprecedented catastrophe appears to consist of a series of arbitrary measures. Though there may be method in their measures, we – like millions of migrant Indians – are not privy to their rationale. In going into the Lockdown with scant thought and little planning, we feel that they have truly seized the tiger by the tail.
A “bold” move, no doubt, but common-sense dictates that, should you choose to pursue such a course of action, you should have at least an inkling of what the tiger would do when you let go.
(Dr Sumit Ray is a Senior Consultant, Critical Care Medicine, in Delhi. Dr Himadri Barthakur is a Senior Consultant, Internal Medicine, in Guwahati.)
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