Dr Tasaduk Hussain Itoo,
Dr Tasaduk Sultan Khan
Amid Covid-19 pandemic in the eye of its second wave , India has been witnessing a huge surge in Covid-19 infections. The rise in case numbers has been exponential in the second wave. If we analyse the figures, On 18 June last year, India recorded 11,000 cases and in the next 60 days, it added 35,000 new cases on average every day.
On 10 February 2021, at the start of the second wave, India confirmed 11,000 cases – and in the next 50 days, the daily average was around 22,000 cases. But in the following 10 days, cases rose sharply with the daily average reaching almost 90,000. The number of deaths also increased rapidly since March 2021, rising from less than 700 in the first week to around 1,900 by the fourth week.
The second wave of Covid-19 differs from the first wave in two main aspects. One, its speed, spread and penetration is much more than that of first wave. This time, it has reached rural areas, which have neither the medical infrastructure nor preparedness to handle the pandemic. Two, the patients infected by new variants of the virus need more oxygen and hospitalisation, which are inadequate.
Considering the massive surge in cases and more challenging second wave, which has caused a visible strain on the healthcare system, the strategy to adopt in approaching the patients has to be economical, rational and in bearing with the existing healthcare system.
We should learn to ensure scientific and evidence-based investigative and therapeutic practices if we have to effectively treat Covid patients. Irrational use of some antiviral drugs and even steroids (which otherwise improve the chances of survival if used properly) is counterproductive. As per scientific research, the use of steroids should be avoided in patients who do not require oxygen. The indiscriminate use of otherwise useful drugs may even harm patients.
Another life-saving therapy is to treat hypoxia. The experience from prominent medical institutes and hospitals has shown that optimum oxygenation using masks, high flow nasal cannula, non-invasive ventilation and proning position along with other scientifically researched treatment help most patients recover. Invasive ventilation is to be discouraged, unless all non-invasive measures have been effectively attempted. Resorting too early to invasive ventilation is also counterproductive except in few critical cases. Meticulous adherence to optimal scientific and evidence-based medical guideline practices will go a long way in achieving better treatment outcomes in our patients.
One important investigation which has to be rationally used during this pandemic is the CT chest scan. People are being advised CT scans even without having any symptoms. CT scans are only indicated in cases with worsening hypoxia and chest symptoms. The aim must be to treat the patients based on established scientifically researched and proved clinical guidelines. Unnecessary use of investigative tests and procedures will diminish public confidence in medical and healthcare professionals, as patients with limited means would be constrained to waste precious resources. Experts must help and guide their professional colleagues to follow evidence-based clinical best practices, so as to provide the best possible care to patients.
Moreover, patients with co-morbid conditions must be given quick access to treatment at public healthcare facilities. Optimum and timely treatment of such patients for the underlying diseases would not only ensure better outcomes but would help in reducing mortality among such patients. We need to adopt an outreach approach to identify and help such patients. The mobile clinic service shall help meet this end. More to say, healthcare professionals have to create confidence among the people to avoid any kind of rumours or anxiety.
During an online talk, I reached out to one of the Kashmiri born leading UK-based expert pulmonologist Dr Tasaduk Sultan Khan, Consultant Respiratory and Internal Medicine UHMBT NHS UK, who shared some vital information to adopt by the treating physicians and patients for effective Covid management – that is summarized below in the following points:
* A majority of Covid positive patients would not need to get admitted. These are the ones who have no chest complaints like bad cough or feeling of shortness of breath. They can stay at home and be managed with paracetamol and/ or oral antibiotics. They need to stay in isolation until they have no fever for more than 5 days or 10 days have already elapsed since they first had fever. They don’t need any repeat Covid test.
* Those who test positive and have respiratory symptoms and low saturations need to go to hospital ASAP. Again after they have recovered fully they don’t need repeat Covid test and it is very important to make sure that they have adequate oxygen saturations (more than 94%) on room air and no significant dip in Oxygen saturations on ambulation. If they have low oxygen saturations but have no fever and are ok otherwise they can go home on oxygen to continue till saturations return to normal range at rest and on ambulation.
* Remdesivir is not a life saving drug and has shown no benefits in reducing mortality in severe Covid infection cases. We didn’t use it in the second wave in our trust.
* All admitted patients should be given a double dose of LMWH prophylaxis.
* Injectable dexamethasone needs to be given to all admitted cases who need supplemental oxygen.
* Tocilizumab should be given to admitted cases who need higher levels of supplemental oxygen and have severe ARDS.
* HFNO ( high flow nasal oxygen) is recommended for those whose oxygen demands are very high and not maintained by conventional nasal or mask administration.
* NIV is a step further if HFNO doesn’t work.
* If patient is young and has severe ARDS then early ventilation is the best way to manage such patients.
* For those patients who have tested positive and have only fever, there is no need for CT chest, Interleukin 6 tests. All they can do is a full blood count, CRP and a chest X-ray. Fever can stay for up to 10 days even, so don’t panic as long as there are no chest complaints.
* No role for Vitamin C, Ivermectin and Convalescent plasma. Vit D can be given to those who have checked their levels and found them to be low. Otherwise there is a risk of hyper vitaminosis D.
* If you have symptoms of Covid and rapid test is positive, it confirms Covid. No need for RT-PCR. If you have symptoms of Covid but rapid test is negative then only we need RT-PCR.
* Disease severity markers should be asked for only those patients who need admission and include trends in serum Ferritin, CRP & D-Dimer. IL-6 levels are not a routine test even in hospitals.
* For those Covid patients who present with on going or worsening shortness of breath even after weeks or months after they had Covid infection we need CT-PA and Echocardiography as baseline tests. CT-PA will also give us lung window thereby obviate any need for a CT-CHEST and we essentially need to rule out complications like pulmonary embolism, pulmonary fibrosis and cardiac complications like myocarditis.
* Radiologists should desist from reporting fibrosis for Ground Glass reticulations earlier on as these changes are reversible and can only instil anxiety in our patients.
Lastly, it is better to avoid Covid infection in the first place by masking, social distancing and frequent hand washing.
Vaccination is the only real hope to get over this pandemic. The complication risk from vaccination is much less than the risk of complications from Covid infection. Mind You, even mild Covid infection could give an alarming complication.
(The authors are Director Jammu and Kashmir Innovative Foundation for Transforming Society (JKIFTS) and Consultant Respiratory and Internal Medicine, UHMBT NHS Foundation Trust, UK)
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