(Dr Devi Shetty is an Indian cardiac surgeon and chairman, Narayana Health. In an opinion piece authored by him and published in The Times of India, he suggests measures for India’s various stakeholders to better fight the COVID-19 pandemic. The following is a rejoinder to his piece by Dr Mathew Varghese, a veteran orthopaedic surgeon who’s known for his contribution in eradicating polio and for running the country’s last polio ward at St Stephen’s Hospital, Delhi.)
1. Dr Shetty: Every major city should dedicate two major 1000 bed government hospitals and convert them into COVID-19 Hospitals with piped oxygen, suction and compressed air supply to run 1000 ventilators.
Dr Varghese: How many 1000 plus bedded hospitals are there in the country? Does every city have them? Where are the ventilators? They do not exist and cannot be created overnight like wards and beds. Piped oxygen supply and suction are all good long term solutions but short term they are a pipe dream!
2. Dr Shetty: The entire COVID-19 hospital needs central piped oxygen. In western Europe, a patient died because oxygen supply got exhausted.
Dr Varghese: Piped oxygen supply for more than 20 or 30 beds does not exist in most hospitals. Oxygen cylinders are a limiting factor. Has anyone done a stock checking on how much oxygen supply is available? Piped oxygen for larger areas will need liquid oxygen supplies which would need more time to set up.
3. Dr Shetty: Health ministry should create two teams of doctors one for screening and triage, and another ICU team to manage critical care service.
Dr Varghese: You do not need doctors for triage. This can be done by allied health professionals who are not part of mainstream intensive care or laboratory work. Doctors and nurses should be trained for intensive care and ventilator care. Only four questions are required: Have you travelled to an area reported to have patients of COVID-19? Do you have a fever? Do you have persistent/dry cough? Do you have breathlessness?
4. Dr Shetty: Patients who may not require advanced critical care support should be treated at the COVID-19 hospital. Critically ill patients with respiratory failure should be sent to private hospitals with a modern ICU, highly skilled staff, and equipment like ECMO.
Dr Varghese: Why should critically ill patients go to only private facilities? These should be created at government tertiary care centres. The lockdown time should be used to upgrade all tertiary care ICUs with equipment, piped oxygen and other essential drugs.
Use the lockdown period to train all theatre, ICU staff, anaesthesia and surgical staff for intensive care and ventilator management. Operating room technicians and physiotherapists could also be trained for this. Three levels of backups should be created so that when one fails, there is a next level available. Plan A, Plan B and Plan C should have staff available and trained for all aspects of ICU care. All anesthesiologists should not be together, but should instead be staggered to lead each plan A, B and C.
ECMO is a waste of resource because for the cost and effort of one ECMO, we can have 10 ventilators. The outcomes with ECMO are poor anyway as they are used in end-stage ventilatory failure. These will not be available to buy now. They will only be available in institutions doing tertiary care cardiac surgery and interventional cardiology.
5. Dr Shetty: Fever clinics with online consultation across the city with guidelines on viral screening and follow up.
Dr Varghese: You do not need fever-only clinics as the ‘four questions’ are a no brainer for triage. Most patients who are worried about having the disease will panic and would only be happy with physical verification of their symptoms and/or testing for COVID-19.
Even in a major tertiary care hospital, there was a panic reaction among post-graduate doctors who were insisting that they should be tested, and that all patients coming should be tested!! Irrational demands out of panic. Has anyone considered counselling for caregivers as something as important as for patients in these situations?
6. Dr Shetty: For 2000 ICU beds, a six-hour shift needs 700 nurses, 200 resident doctors and 100 anesthesiologist intensivists. For 24-hour coverage 2800 nurses, 800 resident doctors, and 400 anaesthetists. We need at least 200 senior intensivists or anaesthetists to cover2000 beds remotely through WhatsApp.
Dr Varghese: It will be impossible to create 2000 ICU beds at one place, that many piped oxygen outlets will need a liquid oxygen supply and supportive monitors. Pulse oxymeters will need time to be created perhaps in a stadium or convention centre or warehouse. The staffing numbers will need 30% (some areas 45%) additional for leaves also. This is assuming that many reserve staffs and specialists are available and patients do not have day-to-day emergencies of strokes, MIs ( heart attacks), Caesarian sections, and other emergencies requiring ventilators and anaesthesia during this period. There is anyway an acute shortage of Intensivists and anaesthesiologists nationally.
2000 regular COVID-19 beds and even high dependency wards are possible within a week as was shown in Wuhan.
7. Dr Shetty: COVID-19 ICU simulation should be set up at large hospitals to teach staff on safe practices. Safety of health workers should be of utmost priority.
Dr Varghese: Where are the simulators and the trainers? We need to use the Lockdown period and staff available from routine surgery and anaesthesia care to be available to scale up training. I am not sure if we have Training modules for brainstorming or three-day crash courses for this.
8. Dr Shetty: India is acutely short of ventilators. No other country is allowing the export of ventilators. The government must support local companies to manufacture ventilators on a war footing.
Dr Varghese: Ventilators are high tech equipment and most of the ones made in India are also made from knocked-down kits imported from abroad. No country will allow export of these now. There may be one (or perhaps two) companies that do 100% Indian manufacture, and even they, I am told, have no supplies off the shelf. They will take months to meet the demand. ‘War footing’ will also take time.
9. Dr Shetty: PG students must be given the option to work in COVID-19 ICUs as part of their training programme. PG students, interns and final year students should be posted in the ICUs to familiarize with ventilated patients.
Dr Varghese: All final year students have been sent on leave. Many of them have gone home as even hostels are closed and they cannot travel back as there are no trains/flights. Many PGs are already being trained in medical colleges and these could be scaled up during the lockdown period
10. Dr Shetty: National Medical Council (NMC) should allow young doctors trained in recognised overseas medical colleges a temporary license to work under senior doctors. In the end, it is the nurses and the doctors who are going to save lives.
Dr Varghese: Why have these temporary recognitions for students from abroad? Most of them are anyway poorly trained. The local students from government medical colleges are far better and far easier to train. Why give back door entry for these doctors?
11. Dr Shetty: Medical Council of India should permit online consultation and e-prescriptions to manage COVID-19 patient data from here and maintain medical records. INC should allow final year nursing students to take care of stable ICU patients.
Dr Varghese: Online consultations and e-prescriptions can only be for review of patients who have already been physically examined and for whom treatment has already been started. Otherwise this will get into the grey zone of half-baked treatments.
All nursing students have been sent on leave and are not available.