My Corona
Chapter one
It was a
cool pleasant morning in November 2020. As I was striding across the
gravel-studded foot-way leading to the hospital, I had a strange feeling of
newness; everything around me was as if new, the big porch leading to the hospital
entrance, the temple on my right, the scantily parked cars in vicinity and even
the resident doctor who was accompanying me. Everything was as if new. It was
quite natural, I felt, after all, it was after a long break of seven months I
was joining back on my work in the hospital. Full seven months away from the
hospital. Though busy with my private outpatients, a hospital round was always
the cream of my activity. I was forced to keep away from it. The reason:
Corona-phobia. I was 65. Hospital management had advised me to keep away from
the hospital in good faith. I could see the well-meaning logic behind this. I
belonged to a high-risk group for corona disease, given my age; and the
hospital did not feel like taking the risk. Walking back, I explained to my
resident doctor the logic behind this advice and also my prompt and
whole-hearted compliance in the matter. “After all, even if one of the senior
consultants were to suffer seriously due to covid, the negative impact on the
staff would be incalculable, it is prudent for the hospital to advise me that
way” Little did I know then, it was to be my own future after next few months,
a patient of severe covid pneumonitis, rapidly worsening from oxygen therapy to
full-blown ventilation therapy in a matter of two days. This happened five
months after. It was when the so-called second wave of corona pandemic gripped
the entire city in an unexpected ferocity. In a way my keeping away from the
hospital during those seven months, my use of masks for legal satisfaction was
all proven useless. Corona did catch me as per its will and whim.
In the wee
hours of the morning, on the auspicious day of Gudhi Padwa, when there were
plans for a family celebration, it all started. A few days of sore throat, some
fever, many loose motions, and my oxygen saturation plummeted to 90 and below.
A grave sign. Suchita, my wife collected the necessary utilities and I was
rushed to Deenanath Hospital. The memory of the events that followed is patchy.
I remember being emotional at times. Our minds are badly inclined to
negativity. There was a sense of impending death that engulfed my existence. I
went too far, felt sorry to be destined to have so little longevity in our
family. I was so careful about my health otherwise. No indulgence. Good time
management. Extremely regular lifestyle, comfortable sleep pattern. Even as a
resident doctor in my younger age, I would sleep for good four hours in the
evening before I would join my night duty, it was an attempt to prevent sleep
deprivation. I had even refused a role in a drama in my college days, for the
sole reason that it demanded smoking! Looking back after so many years, it
looks so much juvenile, puritan. I have been taking regular exercise to my
capacity. Though not a health freak in the current sense, I was careful enough
not to damage my health in any known way. My primary contention has always been
that body and health are the greatest gifts that nature has endowed us with and
we have to preserve them since they are our only means to enjoying our lives.
Even though I am a physician, dealing with medicines, my own consumption of
medicines has been miniscule. No unnecessary medicines. Maybe that, I had some
extra pride in my health management, an arrogance perhaps; which took a massive
beating as my condition worsened. I took a faint look at Suchita, remembered my
daughters, granddaughters, all my family members as I was wheeled rapidly in
ICU. Things happen so fast that you hardly get any time to express yourself
when you depart. I was grieved, felt annoyed at the course of events.
While in the
ICU the true story began unfolding. The oxygen saturation would not respond
to nasal prong oxygenation, mask breathing, or even high flow nasal
oxygenation. I could see the worry and anxiety written large on the faces of my
colleagues. Outwardly they were encouraging me, trying to keep my morale
intact. Even in that state, I could sense that the optimism they were showering
on me was more out of their love than the reality. Later on, a kind of physical
and mental dumbness started pervading. I became totally negative to the
prospect of any management. I felt like leaving all this and going back home. I
was never a part of management in any serious covid patient so far. I was on a
self-proclaimed leave. But I had my own reservations about many aspects of
covid management plan all over. I had a feeling that steroids should be used
for a very limited time if at all, that Remdesivir need not be used as much as
is possible on account of its poor efficacy, the only point in its favour being
that it was generally nontoxic. I was strongly against using immunosuppressants
for covid. The idea behind this was relatively simple. Whenever a pathogenic
organism enters the human body, it is identified antigenically in as short a
time as is possible. Pending this identification, multiple antibodies are
produced in an attempt to contain it. This is called an Anamnestic Reaction,
and it happens through the activation of so-called memory cells in the blood
which are supposed to carry the memory of the entire lifetime exposure to
various antigens. Since the current virus is a novel one, many of us may not
have any memory of a similar virus in our memory cells. This leads to a massive
outpouring of various non-specific antibodies, complements, cytokines in the
blood, leading to what we call as Cytokine Storm. Maybe that the storm itself
causes harm (the current treatment uses this hypothesis), but it is also
possible that the same mechanism is the way to develop antibodies. In the
latter situation, we could be harming by suppressing the natural immunological
process in the body. All this logic in the background and with that the
prospect of having to consume all these medicines in due course must be at the
back of my resistance. Coupled with all this, statistics were showing very high
mortality in ventilated patients. I am sure our doctors must have found a tough
customer to buy in me! All this flashed for few seconds in my mind and then
followed a complete silence.
I do not
have any memory of what followed. It seems they had intubated me and put me on
ventilation which continued for ten days or so. For me, it was all silence and
dreams. The dreams were all bizarre, irrelevant, and irritating.
In one of my
dreams, I remember lying flat on the floor listening to some vague music of all
sorts. The room that I occupied was decorated with many odd shapes, so was the
floor. The colour of everything was dull blue-grey. Many patients were lying in
all directions across the floor listening to the same repetitive music. I
cannot say whether I should call it music at all and it lasted for eternity.
The instructor came from nowhere finally to stop it all and asked me how did I
find it. I was already feeling lulled into silence, too fatigued with boredom,
had no strength to answer the question. However, there arose a distinct
question in my mind even then in that state - How will this cure my covid?
The daily
sponging with warm wipes must have created a deep impact on me. I felt filthy,
desperate, dependent, helpless against it. There were many dream sequences
involving sponging. They gave me sponging at all places, in the room, in a
tunnel, on an open road, in the evening twilight, early dark hours of the
morning. They were never tired of it, though I felt loathe to have it. I felt
shy of getting nursed, their unending sympathy drove me mad.
There were
hallucinations of various sorts. The ICU itself must be having a lot many
alerts, alarms. Superadded to that I used to hear low-tune music mingled with
that. The music continued all through. Occasionally in the midnight everything
as if would get angry, its pitch rose. the tempo of the music got accelerated,
the rhythm became fast and with that my bed, my room joined in the chorus.
Everything in the room started oscillating to the tune of music. This would
last for minutes.
I could
smell some faint sweetish smell all around, could see tiny creatures akin to
spiders descending in groups along the walls. They shone brightly at night,
dangling on loose threads right from the roof to the middle of the room in
blues, violets, and reds.
The combined
effect of all this made me paranoid. I lost my faith in the people who were
nursing me so well. I doubted their intentions, had a feeling that I was getting
drugged, mesmerized. I would repeatedly request someone unknown to rid me of
this situation but to no avail.
Superadded
to all this there was the phenomenon of what we call 'deja vu'. I had a
constant feeling of having had similar experiences before. This disturbed me
further. The question that why am I being subjected to this agony again and
again became a matter of desperation to me.
Sometime
during this phase, my sedation must have been decreased or stopped, ventilatory
support removed, I was probably put on only an endotracheal tube with oxygen.
Medically these were signs of recovery. But now a different set of problems
emerged. Oblivious of all that had happened in between, but conscious of the
current surroundings only in a vague way, I could not explain my current
plight. My medical knowledge as if had already deserted me. I could not
comprehend the endotracheal tube going down my mouth, was surprised at my
inability to talk or even phonate. This was an expected disability due to the
tube inserted in my windpipe. I found that both my hands were heavily tied.
Further, there was so much weakness, I could not even move my head sidewise.
The tongue was so dry, the entire oral mucosa was dry, thick like a parchment.
There were severe restrictions on my water intake. It was difficult to bear
those with my mouth dry as parchment. Unable to vocalize, to register any
dissent through limbs since they too were tied, I was left with no option but
to lie helpless and philosophize. When you are completely helpless, philosophy
is the need of time. In the good old days, I remember, I had seen an old lady
in a similar plight. Admitted sometime during the night for rowdy behaviour,
she was tied to her bed by night sisters. This was to restrain her from
damaging herself. An act done in good faith. But at present when seen by me it
seemed the lady was fully conscious, no longer needing those restraints. I
found it funny, funny just because it was not me who was restrained. In a
lighter tone, I asked, “Aaji, what did you do in the night so that they
had to tie you?” Her philosophical reply was touching. “It must have been
something that I did some time in the past or may even be in my past life.
Otherwise, why would these girls (meaning sisters) treat me that way? It has to
be my Karma. “I felt amused. I ordered the removal of
restraints immediately and made her comfortable. It was a kind of funny justice
to find myself in a similar position years later. Though it was not
unjustified, the agony of restraint was just as the same for me!
For the next
few days, it was the phase of hallucinations. I had hallucinations of all
sorts. They were auditory, consisting of popular cinema music of the old
generation. This music gave me a constant accompaniment all through. The ICU
staff had given me special permission to play music on my device as per my
choice. After an initial phase of recreation, it became a matter of
hallucinations to me, the music just won’t stop. The songs would continue
unabated one after one in an interminable way. Even whatever dialogue the
sisters would have among themselves became music to my ears. I would see some
unknown paintings the moment I closed my eyes. Wall hangings showing old mugal badshahs,
their darbars. I could see some computer screens, tried to perform
financial transactions on these imaginary screens. It became so repetitive that
I got bored of those. The sleep mainly consisted of vertiginous hallucinations,
the entire surrounding around me vibrating rhythmically, rotating, lifting me
to unknown heights. There was a confusion of thought, I could hear some
religious chants. I could see the books which I had read in the past, all
mutilated, their pages lying apart. All this together gave me a feeling of
extreme depression and negativity which was wordless.
After a
duration of four to five days, these issues were resolved. I started getting
reasonable sleep, increasing periods of wakefulness. But all the same, it was
not the end of the matter. Now weakness took its toll. It was a kind of
weakness never experienced before. There was extreme inertia to activity. I
could see the call bell dangling just by the side of the bed, I felt the need
to call for assistance, but there would be no drive to lift the hand and press
the bell to call for help. Scores of minutes to half an hour could easily be
spent in an indecisive state whether to press the call bell on not. Most of the
activities had to be supported, even turning to one side called for a great
effort. The mattresses in ICU and room were indeed great, they supported the
body very well. Their feel was good, just hard enough to support. They were
easy to clean. But somehow they prohibited me from doing any movement on my
own. Turning in bed, shifting in bed, sitting in bed- every time I had to call
for assistance. This reduced my stamina further adding greatly to the need for
physiotherapy. The beds were electrically operated. Convenient though, they
completely drove away my initiative to move on my own.
There must
have been some problem with my visual cognition, I found it difficult to
recognise and identify faces. Few of my friends, colleagues were regular
visitors for me. With a mask on their face, they had to introduce themselves
every time they met me, and even after that occasionally I had doubts about
their genuineness. My paranoid ideation doubted everything. Both the eyes would
be running constantly, tears trickling down over cheeks. It would give an
impression that I was crying incessantly. I had no specs with me. Looking at
the objects with watery eyes, with no specs- I felt like a fool at times. I
found it difficult to read the wall clock, had to keep on looking at it in a
vain way trying to decide what time of day or night it could be! I must have
irritated the sisters attending me, due to my repetitive inquiries about
timing. Initially, they responded sympathetically but as the query became too
repetitive, they started bluffing it, adding to more confusion. At any time, my
mind had to fight with three timings, one was my mental clock, the actual
timing as shown in the wall clock, and the timing as bluffed by sisters. In
painful situations such as these, our mental clock probably runs faster than
the actual one. There must be a desire to run through the calamity at a faster
pace so that it ends sooner.
Once off the
ventilator and after the endotracheal tube was removed, reasonably stable in
what could be called 'consciousness', my sole aim was to go home. I wanted the
I/V line and the arterial line to be removed, the urinary catheter had to go.
It must have been a matter of great puzzle for all my treating colleagues
listening to my repeated frenzied requests to be sent home. Did I fail to
understand the gravity of the situation that I was in? Yes, I did.
I had
already started dreaming about running away from the hospital. It would be
easy, just sneak out of the room, reach the ground floor, call an auto and
reach home. I could always ring up the hospital after reaching home, discharge
process, bill payment could be managed online. I felt it was so easy. I knew,
my colleagues loved me, had done their best in treating me; but in their
affection for me they had gone blind to the recovery I had made, they were
overdoing their job by prolonging my stay, I felt. My daughters one of whom had
travelled all the way from the UK with her husband and my granddaughter just to
meet me were waiting somewhere at home. I had to reach home at the earliest. I
pressed the bell, the sister attending me reached the side of my bed. I
requested her to remove my catheter.
“I
plan to go home today”, I declared. She must have been aghast. Knowing my
position, my seniority in the hospital, she could not counter my funniest
demand.
“Sir, it’s
three o’clock in the morning; I shall remove it after 6 in the morning, Ok?”
She placated me somehow, but I implored her not to forget this, “I have to meet
my daughters, I don’t have much time with me. My daughter from the UK cannot
wait for long,” I said.
Chapter two
During my
clinical practice of the last four decades, I have always considered myself to
be an academically efficient, compassionate doctor. I claim to have a lot of
empathy for my patients, but in my younger days, working as a resident doctor
it was not so; I used to read a lot of textbooks, discuss a lot with my teachers,
colleagues which gave me a lot of confidence in my academics and also inflated
my ego, but there was no training for the humane aspect of clinical medicine.
During my tenure as a houseman, I had a young patient in his twenties admitted
directly from the casualty, with a casualty doctor’s note saying that he was
deep comatose. With whatever limited expertise I had then, I could see that it
was not so. He was not unconscious; He was drugged, had probably consumed Charas.
Few younger undergraduate lady students were observing all this. The lad under
consideration must have been some religious trainee, scantily clad with a bhagavi dhoti.
I wanted to make the event dramatic and prove my clinical prowess to the girls
around me. In a swift motion, I pulled at the dhoti that he wore. Stunned at
the activity and seeing so many girls around, our patient took a clue, jumped
off the bed, rescued himself running across the ward in a half-naked state,
holding onto his dhoti awkwardly. It was such a hilarious event for us all, a
claimed unconscious person running out of ward on his own in a few minutes,
quite impressionable. Looking back after so many years I can see the cruelty in
my act. There could be a few more such obvious instances to quote from my
practice. But I feel I have matured and changed over the years. But is this
change sufficient enough? I can see my irritation when a patient asks me the
same questions repetitively despite being adequately explained by me. I do get
annoyed when he rejects my scientific advice. My pride still hurts a bit when
he takes an independent second opinion from a doctor. Not only that, I feel
insulted even if a patient gets a few more tests done than I have advised him
to do. There are so many tiny instances where my ego about my compassion stands
as a hindrance in understanding my patient’s viewpoint. If as an experienced
doctor, my reaction to my illness could plummet to levels as I described above,
I must learn to grant many more concessions to my patients.
Amongst my
friends, colleagues, and my students I am generally known to have different
views about medicine than the common perspective held by the fraternity e.g.,
my perspective about common diseases like hypertension, diabetes, ischaemic
heart disease, chronic kidney disease is often different than most of the
others’. The recent corona pandemic was no exception to this. Right from the
beginning, I had doubts about the way this disease was interpreted, about the
way its control measures were suggested, and how it was medically managed. I
had my reservations about vaccination as well. Though I never promoted my views
amongst my patients, never encouraged them to violate the government regulations
from time to time, I had always voiced my different opinions in various groups.
I was fairly aware that fighting against corona was like fighting a war and all
of us were like warriors in the war. A warrior is supposed only to obey, not to
think independently. That was exactly what I was doing and advising my
patients. But there were occasions when I would discuss the different views
that I held with some of them and it had a soothing effect on most of them.
The masks
theoretically may reduce the throw of respiratory droplets thereby reducing
their transmission, however for this they must have defined filtering
characteristics. A situation similar to this was seen in the influenza pandemic
due to the H1N1 virus some ten years ago. It had apparently a similar mode of
transmission. However, it was soon found that any ordinary mask lesser than the
advanced N95 one, was ineffective for prevention of transmission, and hence,
the insistence on using masks was reduced, eventually so much so that no one
even talked of using masks in social surroundings then. However, when the Covid
19 virus emerged 10 years later, the recommendation for masks emerged so
strongly, that not wearing them was treated as defiance of law and was
punishable legally. I am not aware of any research strongly proving the utility
of masks in such a great way, having been conducted anywhere in the last
decade. The additional issue with masks is the way they are used. Wearing a
mask by a surgeon during surgery is an altogether different issue since it is
used for a relatively shorter period by a surgeon who understands the significance
of this activity too well. The situation changes dramatically when it is
advised universally for one and all, regardless of their educational and
understanding ability, and that too when it is advised for 24 hours daily all
through for an undefined period. It simply becomes a plaything for most. They
touch their masks inside out, fold and keep them where ever they like, be it in
their pockets, purses; take them down exactly when they want to talk, cough or
sneeze. There are no ways to check if they are changing those after every use,
it is also a matter of dispute whether it is correct to wash and reuse those.
The legal insistence on using the masks has turned into something like a
religious ritual, the utility of which has to go unchallenged and if you do so,
you are likely to be treated as antisocial.
It is also
possible that a mask made from the wrong material and handled in the wrong way
could actually help the transmission of the corona. Electrostatic forces might
in fact attract the droplet nuclei on it and help to transmit those to the
user’s nose. A mask over the nose is a definite source of irritation, leading
to handling, readjusting of the mask and thus, leading to enhanced
transmission.
Even as on
today, 18 months after the pandemic, we are not sure how the coronavirus is
actually transmitted, whether by droplet nuclei for which masks maybe
partially deterrent; whether it is through surface transmission in which case
masks could be useless to detrimental or whether through airborne transmission
as aerosols in which case one would need only N95 masks. In this situation, a
vehement approach towards mask use seems unjustified.
Another
disadvantage of a mask is that it has become a marker for corona phobia all
over the world. None of the authorities knows enough to advise when to do away
with it. Use it if you are normal, continue using it even if you suffer from
covid infection and get cured of it, use it even after vaccination, use it even
if you test negative or positive for the virus. At the time of writing this, it
seems masks are being considered redundant in part of Europe, the USA,
Australia. But with a theoretical risk of more waves of Coronavirus still in
the air, it is difficult to predict how long this contention would prevail.
Universal
social distancing and quarantine of cases is a similar trap. Theoretically, if
the society completely closes itself with no interpersonal interaction of any
sort; the pandemic would abate instantly, but the golden question is for how
long can we do so successfully. There is no proof that the virus will exterminate
itself after a defined period, so that social distancing during that phase
would stop the viral spread forever, in fact, as history reveals such viruses
remain in the society forever, causing sporadic infection. Social distancing in
this context, will not ‘Break the Chain’, as is the motto of the government,
but will only prolong the chain as it has already done. The so-called second
wave seen all over is actually not a second wave but a prolonged first wave as
a result of effective social distancing last year. The more effective the
social distancing, the more are the chances of recurrence of newer waves.
Additionally, in a country as populous as India, it is impossible even to dream
of effective social distancing for prolonged times.
Additionally,
social distancing leads to a significant economic loss. There is no way to
compare economic loss to that due to the loss of life and to decide which one
of the two was more grievous, loss of life would always score over the economic
one given the emotional overlay attached to it. But now at the end of the 18
months of recurrent lockdown somewhere, most of the governments have started
feeling the gravity of economic losses, they are getting wary of prolonging the
lockdowns further & further. Even there are increasing social outbursts
against such unplanned and protracted lockdown in the society at large.
The
emotional and social losses encountered due to lockdowns and quarantine are
also no less. The educational losses of children and students, lack of hands-on
training of the students, lack of social exposure, family relationship-related
discords too are a part of the great devastation caused by lockdown therapy.
The entire generation of small young children and teenagers has suffered
incalculable harm in lockdowns.
What hurts
more, when one comes to think of the fact that, at no stage, it has been proven
that lockdowns reduce the total mortality due to the pandemic and still they
continue to be promoted so strongly. In the absence of any curative treatment
for corona, a lockdown will only lead to a spread of mortality over a longer
duration, patients who have an intrinsic inability to mount effective immunity
against the disease are destined to succumb to it at some time or other. But
this matter is very difficult to prove. If we look at the scenario in India, at
the end of 18 months of the pandemic with varying levels of lockdowns, we are
actually worse off in all the parameters of the pandemic, the number of cases
going up, deaths still continuing at a high rate, economic breakdown at its
worst, fear complex related to the disease at an all-time high. Still, we
continue to praise ourselves for our achievement through our efforts. Nobody
wants to look back and evaluate the outcomes. In the absence of such objective
evaluation, the masks, and social distancing continue to be considered as the
only sure means to prevent the spread of disease and remain as the ultimate
truth. The objectivity is lost so much that even the failure of these means is
not seen as the failure of our approach but as a failure of people in
implementing it. We blamed ourselves for this failure. This is an unprovable
blame game that all of us are playing. If our efforts during the last 18 months
were really in the proper direction, we should have seen the end of the
pandemic long back and should have been free and happy by now but the case is
exactly the opposite of it, we are in fact far too worse, going through a
so-called second wave of far too worse magnitude and apprehensive of a third
wave of the disease! We are trying to make our own lives more and more
difficult through our preventive efforts!
Amongst all
the modes of prevention, vaccination appears to be the most logical step. Any
pandemic would finally get controlled only after herd immunity is developed.
The way to the development of herd immunity is through natural infection (which
is very fast in a pandemic but fraught with the risk of disease and death) or
through immunisation. There have been certain major technological achievements
during the vaccine development for covid. The new mRNA technology for vaccine
development can be mentioned as the most prominent amongst those. It has paved
way for the rapid development of vaccines for the future. Also, the overall
speed at which all the other vaccines were developed is commendable. At the
back of my mind, there were two tiny doubts regarding these vaccines. These
were the first vaccines developed and deployed on such a universal large scale.
They were also developed in a hurry, were pushed in the market using the
emergency use authorisation. In such situations, the possible long-term side
effects are likely to be underrepresented. Certain degenerative, inflammatory
neurological complications could develop even two months after vaccination.
Given the massive global immunisation drive for the corona vaccine, even a rare
complication could lead to unacceptable morbidity in society since we aim to
immunise the entire humanity at one go in a short time, an experiment such as
this was never undertaken so far.
One more
caveat regarding vaccine has scarcely been thought over. The mortality due to
covid is of 3 types. One; due to covid itself, the so-called mortality directly
related to the infection, two; that due to severe comorbidities, where corona
may have only contributed remotely, and three; that due to the treatment of
corona. This is mortality due to immune suppression leading to superinfection,
blood clotting disorder, etc. As of now, there is no definite curative
treatment for corona infection. Thus, the true mortality due to corona in a way
is not modifiable. This mortality is probably due to some problem in the
immunological system of that individual, who is unable to build up the required
immunological response against the virus. If you extrapolate this to
immunisation, it is highly doubtful that these persons would develop any strong
protective immunity even after vaccination. Thus, it is possible that the true
mortality due to coronavirus would still continue to occur despite vaccination.
What would probably reduce is that mortality where the role of the corona is
merely contributory. It would also reduce the mortality due to
treatment-related complications since it would help to prevent such cases from
complicating thereby reducing the unnecessary treatment load.
Personally,
I wanted to wait for a while and check for its safety before getting vaccinated
myself. And as the luck would have it, I got infected before I took the
decision either way. A few of my personal friends must have seen this as my
whim in not taking the vaccine. It was never the case. In fact, to all my
patients who sought my advice in the matter, I had suggested that they go ahead
and get vaccinated. ’The vaccine is reasonably effective and reasonably safe. One
should go ahead and have it', was my standard advice to all of them. There were
a few who themselves had a different opinion in the matter and did not want to
take it. They would insist on having my opinion regarding this view. I would
reassure them by saying that even if they do not get it upfront, they would
eventually be getting the benefit of vaccination when most of the society get
vaccinated and/or infected. This protection would indirectly be related to herd
immunity and not individual specific.
I was also
of the opinion that the overall efficacy in building up herd immunity through
vaccination is going to be poor. The natural spread and the speed of this
spread were likely to be so great that even with the best resources in western
countries, it would be very difficult to achieve significant immunisation
before the natural course of the infection had run its course in the society.
Considered in this way, I felt that the entire effort and research in the
development and administration of vaccines were partly redundant. Despite this,
I felt that the vaccination was still one of the better ways of preventing the
infection, especially when compared to masks and social distancing.
Chapter 3
They were
all sitting around me, our chief intensivist, all his competent colleagues,
residents, anaesthetists, chest physicians. Some of the residents were my
students. It was some time after I was shifted to ICU for a drop in oxygen
saturation. I was put on high-flow nasal oxygen, but the saturation would not
come up. Mad with anxiety and afraid that I was to receive the same treatment
which I despised so thoroughly, I remember myself making aggressive irrational
comments.
With oxygen
saturation plummeting I could see that I was heading for ventilatory support.
It was known to me to be an unavoidable devil. Despite all the heavy mortality
that went with it, it had to be offered to a class of patients who had no other
means of survival otherwise. I could see that I was one of those.
“Don’t start
me on steroids, immunosuppressants. No ventilatory support. Don’t resuscitate
me if my heart arrests”, my demands became too radical for anyone amongst them
to digest. They must have been stunned into disbelief. The ambiance in the ICU
was actually not that bad. It was exactly the other way round. There were
beautiful pictures painted all over the wall, and ceiling of the ICU. It was
our paediatric ICU. As a treating physician, I had visited this ICU many times
and had praised the interior of the ICU so often. It must be so pleasing for
the children, I felt. But today all of it was dark to me. I was totally
oblivious of their beauty. They looked so irrational, meaningless. Nobody
listened to me. Before I could resist further, I must have been sedated and
intubated.
“What kind
of prescription is this? An antibiotic like azithromycin, steroids, a tablet of
Ivermectin, HCQS, an antacid, a tablet of vitamin C, D, B complex, an
antifibrotic agent, colchicine, some probiotic. All this for a minor covid?
Some 20 tablets in a row, of which none has a specific purpose?” I was almost
shouting.
This
dialogue must have happened a few weeks ago when I read a prescription given by
someone to a minor covid patient. My resident doctor had to take my outburst
with equanimity. It was nothing unusual for him. That is how the covid practice
was going on everywhere.
When I was
studying gynaecology, one of our senior consultants had taught us the concept
of ‘Careful negligence and watchful expectancy’ while managing many obstetric
complications. It meant that an obstetrician must learn to be patient, nature
most often would do things correctly to the patient’s advantage without any
intervention. Four decades down the line, I still remember his words. As human
beings, we must learn to have patience. Sitting apparently idle, doing nothing,
and expecting that something better would happen is a difficult proposition. As
doctors, we feel that we must act; not only that, our patients too expect us to
act. If the doctor does not act, then even patients themselves can act. There
are so many advisers around them. Friends, colleagues, WhatsApp, Google, TV
channels. Knowledge is so handy nowadays! In many cases of mild to moderate
covid close monitoring of oxygen saturation is all that is needed. Many other
parameters such as IL 6 levels, D Dimer assays, CT thorax, CRP, etc. do not add
to any change in the line of management of a mild corona infection. A single
batch of laboratory tests for assessment of covid infection could as well cost
to the tune of 5000 to 10000 rupees. Such test batteries are often repeated
periodically, adding only to the cost of management with no great value
addition. The treatment logic too is just as gun-shot, trying to cover
everything from bacterial infection to inflammation, from fungal infection to
immunity booster, from nutritional supplements to antiviral agents. A
multi-drug approach such as this can lead to drug interactions, drug-related
adverse events, immunity suppression, superinfection with other organisms complicating
the clinical scenario. It can be difficult to separate covid related
complications from drug-related side effects.
"My
dear, do you know what are the ways how a patient can recover from his
illness?” I continued with my aggressive encounter with my resident. He knew
the best way for him was to keep silent on such occasions. He just continued
looking at me as if nonchalantly. “They can recover due to treatment; they can
recover independently of our treatment and to our great luck they can do so despite
our misdirected treatment. Our aim should be to see that we treat them in a way
that we give them only the exact curative treatment and nothing more. This is a
difficult objective oftentimes, but we should at least try to be neutral to
their natural recovery, seeing that we do not cause impediment in their process
of natural recovery, neither do we add to the already existent problem through
our management. Gun-shot management like that can lead to a situation that the
patients have to recover despite our treatment. In case of such a recovery, we
may erroneously claim a victory, since what matters for the patient is only his
recovery, he is not interested in the mechanism, but the real skill of a doctor
lies in finding the difference in these patterns of recovery and monitor his
performance as a doctor accordingly. Will you be good enough to be able to do
that?” I had said.
Back in the
ICU, nobody was in a mood to listen to my arguments; they knew they had to take
their decisions independently without considering my jargon. They must have
chosen to sedate me. I was thrown into the abyss of deep unconsciousness; the
course of management did follow the protocol defined by the hospital. Ten long
days later, apparently, my condition improved and I opened my eyes to reality.
It seemed as if I had survived It all.
Chapter 4
Covid has
proven itself to be a great challenge to humanity. This was a challenge not
only restricted to human immunity, in fact, the immunological challenge could
be the least of the lot, it was a challenge to human psychology, economy,
philosophy, morality. Along with these, our social systems, social values too
were put to test. It tested our scientific capabilities. It exposed so many
vulnerable points in all of us. Immunologically speaking, covid mortality is
considered to be the result of immunological hyperreactivity in an individual.
Simply put, the corona itself may not be as lethal as is the unwarranted
immunological reaction to it. Whether this is an ultimate truth in its pathogenesis
is a matter that could be debated. But when we consider its effects on all the
non-medical aspects of humanity, we certainly can see our overreaction to
corona causing more damage than the virus itself. If we consider the pathology
of many such diseases as autoimmune, thereby meaning that it is our immunity
working against our interest, this logic is equally applicable to other fields
in human life. There has been overreaction everywhere. It can be called
autoimmunity of a different nature.
We as humans
consider ourselves to be a special species. We take pride in our so-called
intelligence. We want to analyse life around us. We want to anticipate
problems. We feel that it is our sole responsibility to solve those problems.
With the advancement of technology, human arrogance has grown even further. We
have started looking at technology as the only thing to be sought after in
life. Technology is intelligence for us, it has replaced philosophy, it has
been the source of all our material happiness. We have reached a level of
arrogance, where we feel we can destroy nature, we can win the natural
processes, and also, we can ‘save’ nature. How bold to think
that it is within our means and also our prerogative to save nature! Nature has
as if become subsidiary to human intentions. There has been a long-cherished
myth that in the process of evolution human beings are the last step in the
ladder, most evolved amongst the rest of the species. I remember a very
poignant statement by someone. ‘The only proof that the human beings are the
best amongst all the species is that none of them have challenged it so far!’,
he said. The real answer behind this contention going unchallenged so far could
be that none of these species are aware that such competition for superiority
could exist and also are not interested in it. The famous Marathi author, G A
Kulkarni has made a remarkable observation in one of his parables. Someone in
one of his stories claimed that human beings are the most evolved because they
can discuss philosophy, which no other species can. He had a ready answer to
this, this is only because all the rest of the species have found their
philosophy, which humans have yet to, he said!
If we want
to study how corona has exposed us, we have to see how we have destroyed
ourselves under the threat of corona. It was systematic destruction under the
garb of self-protection. All our efforts can be seen as an overreaction, a kind
of autoimmune reaction. We killed ourselves economically, by overreacting to
the threat of the disease, putting social distancing, quarantine as the only
means to prevent the spread of the disease, and caused such irreparable damage
to all our economy, that it would take us very long to raise ourselves out of
it. Deaths due to covid are easier to calculate, the deaths due to economic
losses may not be so easy to determine. There are also situations in life where
the economic factors could be so damaging that death would be the preferred
mode of exit! There are no means to calculate this.
The fear of
death due to corona and promotion of social distancing as the sole effective
means to keep away from it, lead to altered behaviour of everyone around us. It
would be wrong to say that people became inhuman, started despising each other,
no it was not so, they were as caring as before but their relationships were
overpowered by fear of imminent death; there was a certain element of aloofness
that pervaded their relationships. It became a common practice to avoid even
eye-to-eye contact with a suspected covid, doors would be closed on the face of
a covid patient with fear that corona may enter through the open door. There is
a complex of apartheid sitting in the mind of all of us. It shows itself as
colour discrimination in some societies, as caste discrimination in some
societies. Even gender discrimination too is a part of it. After years of
fight, we have tried to eliminate it from our minds with only partial success.
Corona opened a new way to the same apartheid. Those who tested positive were considered
different and to be avoided. I call this a 'Corona religion'. Just as some
various religious customs and rituals go on in a religion without any rational
justification, corona rituals were varying from home to home, from communities
to communities, and from nations to nations. In Indian cities, the poor
housemaids were the first victims of this. They were prevented altogether from
entering houses in the initial phases of the pandemic, forced to wear masks,
gowns when finally, they were allowed inside the house. Some were allowed to
enter only through specific doors in the house, allowed entries only in limited
rooms in the house. In some families, the gowns and masks worn by them were
stored separately to be washed by the lady of the house after disinfection. The
maids were disallowed to use lifts. One of my patients got a fever suggestive
of the corona. When I advised him to get tested, he came out with a very prompt
response. “It just can’t be corona, Doc, ever since the last few months I have
been taking bath thrice daily, with all my clothes on my body.” That sounded
like a very fresh idea to me. Taking bath thrice a day with your full suit on
as prevention for corona! Many took to wearing hand gloves even during
day-to-day activities. Social distancing also had many variations. It was
advised even amongst spouses when one of them tested positive. The phase of
transmission starts much earlier than the symptomatic disease, and hence, the
spouse of a case who has been staying together with him/her has already had a
transmission. Thus, both of them should be regarded as infected and treated
accordingly. This is the custom followed in the UK, but not approved in India.
Here we talk of wearing masks even at home! The public gardens were opened with
a lot of reluctance for limited hours in the day, implying that in a limited
period corona transmission would be lesser. Masks were mandatory while walking
in gardens or open spaces implying erroneously that the coronavirus could jump
across individuals even during walking. Curfews were enforced, restrictions
imposed on the number of persons gathering together again implying that the
virus transmission would not occur if persons gathered in numbers below a
specified number. This number too varied from place to place from time to time
and from occasion to occasion. Shops were allowed to open only in a limited
number of hours. This encouraged crowding in shops. There would be numerous
such instances if one wants to enumerate.
There is one
more aspect that may have some important contribution to the spread and
pathogenesis of the disease. If as proposed earlier, the social distancing and
masking do lead to a mere prolongation of the pandemic, there is a likely fall
out of this prolongation and it would be far more dangerous. A prolongation of
the pandemic would mean that the virus would stay for a longer period in the
society, a longer duration would imply a longer time to multiply and mutate.
Thus, these so-called preventive measures may in the long run promote the
development of a greater number of mutants occasionally adding to the virulence
of the organism. Is it possible that the numerous variants of coronavirus seen
in the last few months are the result of the prolongation of the epidemic due
to our control measures?
Finally, I
would like to add a word about science and research about corona. The
contribution made by science in the analysis of corona has been commendable.
The rapidity with which the virus was identified, its structure defined, the
antigenic spike protein was located, the rapidity with which the vaccines were
developed, all this is mammoth progress by science. But along with this, has it
helped the spread of the disease until now? Has it alleyed the fear complex in
the minds of people? Rapid analytical progress in science along with the strong
media has been more efficient in the spread of fear. The newer mutants of
viruses are identified rapidly, and the information about these is spread far
and wide over the globe in no time. The net result is fear of yet another wave.
The blood testing for corona antibodies was developed rapidly, leading to
repeated analysis of antibodies in the corona patients. But alas, it was seen
that the antibodies do not last for long, they tend to diminish in few weeks. The
net result: Fear that the immunity due to disease may not last long! This
coupled with newer resistant mutants would mean more sinister waves. Everyone
was in a hurry to draw negative conclusions, with no time to wait and observe
the events. As is expected, our current research is well organised, but there
is absolutely no need that all this scientific progress to be made public
immediately. I remember a time when I had to wait while my car was being
serviced. Many engineers were looking after it. I could see so many errors in
their judgment, so many times they were trying and failing in their attempt to
fix the problem, I felt disappointed, started doubting their ability in
handling the issue. Finally, they did it all successfully, but the online
undeterred information was far from encouraging to me. Later I knew those car
problems are always fixed only in this way, but all this happens in our
absence, we only get to see the final result. If information flows to common
people too rapidly, it can overwhelm the abilities of the common man to handle
it, leading to phobia. Even as scientists they failed in showing maturity in
interpreting various findings. Conclusions were drawn too fast and they were
often negative in nature. This also generated fear in the minds of scientists
themselves. The development of science without intellectual and emotional
maturity to handle it leads to fear psychosis. Corona did it for us. After sex,
fear is the most dominant emotion in human beings. It was fear that dictated
our behaviour all the way.
I am also
sure many amongst us may not agree with these observations of mine, would
continue to follow these preventive practices undeterred. They would likely
blame me for holding such views & blame my infection with such rebellious thoughts
of mine. Thoughts such as these imply a kind of careless behaviour for them and
this would amount to an invitation for infection! There was a strong forward on
social media suggesting that if you do not wear a mask in life, you will
finally wear it after death. I had a strong objection to this since I had a
feeling that forwards such as these spread fear amongst the population and
glorify masks beyond their utility. There is no such direct relationship
between mask usage and prevention of corona mortality with that absolute
certainty. Most of the sufferers of covid have been reasonable in following
these protocols and still they have had it. Forwards such as this only show the
irrationally strong views held by many in this matter. I do not agree with the
absolute finality that is implied in these views. Though I disagree with these,
neither do I have an absolute answer to corona and its pathology. The views
proposed here are mere alternative possibilities based on logic, but there
could be genuine reasons to doubt their veracity. We have seen on many
occasions in the past, how nature can betray logic. It may so happen in this
case too. But unless, such contrarian views are considered, discussed openly
one cannot expect to reach the truth, if there is any.
I have been
through such a serious illness due to covid, an experience that was so close to
death. I know, I have to answer many questions though they may not be asked
directly to me. People generally are sympathetic; they do not want to confront
you with straightforward questions and hurt you. The question that is going to
haunt me for quite some time now is whether I repent my thoughts after all this
calamity? Would I like to change my views in any way? I used to have a lot of
discussions about covid with my patients. It used to be a kind of stress
reliever for them because I was not so dogmatic in my views, they used to feel
less cramped with fear after listening to me. Some of them would go so far as
to comment that it was ok for me to be complacent and fearless (as they would
feel that I was,) since I was a doctor myself who knew better than most and
also had a better immunity than the rest. That sounded funny. I made it a point
to explain to them that it was not so at all. As an ordinary human being, I
shared the same weaknesses as the rest of them. I was just the same worried
about catching infection myself. Some soreness of throat, a sneeze or two here
and there, some sense of feverishness would send the same alarms ringing in my
mind all through the previous year as it would happen with all of them. I felt
in fact so sorry when I realised that I had not internalised my thoughts in a
way I expected myself to do. I was aware that unless one overcomes the fear of
death, life cannot be enjoyed. But this was only a theory, had I overcome it
myself? Most often our philosophy remains a matter to be enjoyed as a theory by
a select few at select times. Not many of us are even inclined philosophically,
some of them could even have an aversion to it. Those who are so inclined,
consider themselves a special gifted lot, place themselves somewhere above
others but their internal self is most often the same as that of the rest of
us; fragile, timid, and mean. Most of the patients used to be in a denial mode,
declining the fear of covid altogether. They used to hide behind arguments such
as; “It is not my health that worries me, but I have my parents, grandchildren
staying with me. I am worried chiefly for those.” The argument such as this
gives an impression that, but for their relatives, they were altogether
indifferent to their death! One of my patients said, he does not want to die of
disease as horrid as covid, any other disease would do! Again, a kind of
denial. The basic curse to human beings is a denial of a problem when it
exists. Having a problem and further accepting it looks demeaning to them. That
is exactly where I differed from the rest, I accepted that I had a problem and
tried to resolve it rationally. The basic expected norm of behaviour was to be afraid
beyond limits all right but deny it externally and try to resolve the anxiety
through irrational activities. I differed from most of the rest in that I
refused to hide my anxiety and also refused to be dominated by acts that I felt
were irrational. Even that was too much for most!
Even if we
accept that my suffering from a serious covid infection was a failure of some
sort, it was an individual failure in my immune response. It was never a
failure of the theory that I proposed, which said that some of the patients
suffering from covid die because there is an immunological problem in them that
prevented them from building up the requisite immunity. The variable clinical
picture of covid was a reflection of the variable
immunological
competence of individuals against the infection. This is especially so since
there is no effective curative treatment to alter the natural course of the
illness. This theory still persists. My suffering does not negate it.
There is one
more question that I may have to answer myself. I have discussed enough of
theory, many times antagonising the current views. Do I have to offer any
alternative way of handling the pandemic? Would I suggest some different
guidelines for handling a pandemic such as that?
I hope we
are nearing the end of the corona pandemic in the city. There is an
apprehension of the third wave around, but hopefully, it may not materialize.
It could be time for us to draw some conclusions based on the pandemic as I see
it.
The
significance of testing for covid was overemphasized and wrongly emphasized in
the minds of people. Testing is important for epidemiological purposes; it has
little bearing on the management. With this idea clear in mind, the testing
could have been done, but there was no need to make the statistics public and
project it to common people. In the setting of a pandemic daily rise in the
count of cases helps only to generate fright reaction in the minds of people.
Patience is
the key in management. A doctor who is panicked in treating the disease is
likely to overreact, overtreat leading to a different set of complications.
Panic is pardonable in a patient but the same when seen in a doctor, amounts to
professional incompetence. There is an attempt to reach conclusions especially
the negative ones a bit too soon. You find some marginal benefit for one of the
medicines, there is an immediate attempt to use those. You find a fast loss of
antibody titre in cured patients, there is an immediate conclusion that the
immunity is very short-lasting. We do not have the patience to see if the
infections are really recurring. The moment a new virus strain is located, we
send a panic reaction in anticipation of a new wave, more lethal, more
infectious. In a rapidly evolving pandemic, many drugs are pushed in clinical
management protocol through emergency use authorisation. This can prove to be a
dangerous shortcut for their use. This facility should be used with extreme
diligence only for such drugs which are found to have some extraordinary
therapeutic benefit. The drugs that have shown only marginal utility are not
the candidates for this. The potential for the adverse reaction is likely to be
underestimated in such situations. The problems of profound immunosuppression,
coagulopathies were the possible side effects of over usage of certain
medicines. The financial impact due to the usage of such medicines too is
devastating.
The research
has to be undertaken, but the findings of such research must not be shared with
the general population so soon, not even with the doctors working at ground
level. The research would continue at its pace in the background and the
results of such studies should be disclosed only after reaching a certain
maturity. Early release of such findings adds to the panic and overreaction.
The researchers themselves need to show extra restraint and need not feel
forced to draw rapid conclusions in the face of calamity.
Oxygen
therapy is the only game-changer treatment for covid. It has saved many lives.
The entire focus on the management should have been on oxygen therapy at home.
Rather than running after hospital beds, we could have arranged for home oxygen
therapy for even moderately sick persons. A supply of oximeters at home along
with a mobile app to document the oxygen saturation which could be monitored
centrally would have helped us to avoid a mad rush for hospital beds and the
hospital treatment could be offered only to serious unresponsive hypoxic
patients. It would have avoided congestion in hospitals. Only those with a need
for ventilators would have gone to hospitals.
Even for
vaccination, we could have opted for single-dose immunisation for all. This
would have reduced the administrative burden, would have given reasonable
immunity to control the epidemic. We could have immunised twice as many
persons. The need for a booster dose could have been proven and undertaken at a
later date in select populations.
Chapter 5
After almost
three weeks in ICU and my treating doctors developed confidence and decided to
shift me out to an ordinary room. That was a great decision. I felt many of my
problems would settle favourably just by shifting to an ordinary room.
But the life
outside the ICU was also not simple, it was all studded with problems. Problems
of sleep, bowel movement, urination, weakness, giddiness, loss of taste. The
dependence on others for all these activities was very disturbing. The loss of
strength and weakness were so profound, I was taken aback to see my own thinned
limbs. The daily chorus of physiotherapy, was like an unpleasant examination
for me, showing my failure in all activities. I felt I was locked in my spastic
muscles. Eating, mastication was a problem, the jaw would go in a spasm after
taking the very first bite. I lost my enthusiasm for eating. Now my thought
processes were more in line with the reality and as it did happen, my
enthusiasm to go home waned. I started doubting my abilities to survive alone
at home without the help of the support staff that was so helpful and so
needed. On top of it there was a daunting worry of superinfection.
In the
silence of an ordinary room with Suchita around me, slowly did I realise what a
great impact I had created in minds of people who were connected to me. They
were all my relatives, my friends, my patients. Some of them were only casual
contacts and well-wishers. There was such a flurry of telephonic calls and
questions regarding my health condition that my daughter had to keep busy the
whole day answering them. Most of them prayed for me, prayed from their heart.
My corona showed me how people silently love you. So many prayers were offered.
For many, I was an atheist, a thorough non-believer. Praying for me in my
difficult times seemed paradoxical to them, but they continued in their all-out
efforts to try and save me. Personally, I am not an atheist, I am an agnostic.
I fully believe in the limitations of human beings; I am aware that life around
us is not only unknown but also unknowable. It is this unknowable that is God
for them. I respect this God. Though I may not visualise God as most of them
do, may not believe in their prayers as they do, but I do believe in the faith
that forms the basis of their belief, I believe in the love that is in their
hearts. My stay in the room gave me some time for introspection.
“Great, Sir!
So, you have won the battle, the battle against corona. I knew it right
through, was telling everyone around, Our Sir is a great warrior. He won’t take
anything lying down. He has to win ultimately. You have such amazing strength,
determination, ….” Somebody was praising me. I could see how sincere he was
when he said so. But also, could see, how false he was. I have never considered
myself a warrior against nature. There never was any question of winning
anything in nature including nature itself. I have always seen myself as an
inseparable part of nature, in a complete unification with it. The fact that I
suffered from corona infection, that too such a severe one & that I came
out of it was all nature’s choice. I had no choice in it. I cannot have any
discredit for my sufferance nor can I call my recovery to be a victory for me.
I have always been a firm believer of the fact that there never is any choice
for anyone anytime in life. It may sound so brutal, we so much like to have a choice
in life, so much do we feel that we have one. It is on this great pretence that
life is built. Seeing the truth through this pretence is a great jolt, but as
and if we understand it, life would be so simple, just happy floating with
nature. The days when I was sedated heavily, the days when I was being
ventilated supine and prone; are all gone out of my memory now. I am completely
oblivious of those. What kind of life did I live then? Can we call it a life
when there is no consciousness? It was an unconscious life without flaws like
ego, pain, happiness, ambition, etc. Can there be a flawless consciousness even
otherwise in a normal individual?
The time for
my discharge was to arrive in some days. With difficulty, I had to ready myself
to take a dive in the real world, known so well to me until my admission and
now the same world that looked so unfriendly and challenging. Sitting in a
wheelchair I bid my final adieu to the sisters and the ward boys around me.
They were happy to see me go home. I was too grateful to all of them, all the
doctors, sisters, ward boys. I could see that the entire hospital staff was as
if united in their objective to rescue me out of the situation and had done it
so well. A mere look of gratitude, how-so-ever genuine and sincere it may be,
was not enough to convey all that went on inside my mind. I was overwhelmed.
Being
wheeled on a wheelchair in your hospital, where you have always been seen as
the saviour of sorts is an experience in itself. I had enough of it during my
hospital stay. It had cleansed my ego reasonably. The threat that somebody may
recognise me may sympathise with me for my plight had diminished substantially.
I had learned to see myself as an ordinary patient, that too a corona patient.
I had made a truce with my corona. A disease as severe as this has a taming
effect on you. Knowing that life is uncertain is far different than seeing and
experiencing this uncertainty all by yourself. My corona helped me do that. It
was a first-hand experience of hospital and disease for me from the patient’s
viewpoint.
I sat in my
car waiting to be driven back home. The sun was so bright that it dazzled me
and I felt there was so much of a rush in the hospital and on the road. It was
as if a new baffling experience. Everything looked so new, bewildering to me.
Life had as if started all afresh for me. I was about to enter the same old
world as a new man!
