All Hands On Deck - The Checkup

With a sharp uptick in the number of COVID-19 cases in the country (more than 4000 positive cases and over 100 deaths as of 5^th April 2020), the burning question is not so much how widespread the disease will be but on how equipped our healthcare system is to manage the upcoming onslaught of cases. Considering the worst-case scenario, in the absence of mitigation procedures, it is presumed that 30 – 50% of India’s population will ultimately be infected with the coronavirus. Data from other affected countries have revealed that about 80% of infected patients have a milder form of the disease while ~20% require hospitalization, of which ~5% have severe disease requiring ICU care and mechanical ventilation.

This translates into over 100 million requiring hospital beds and 30 million ICU beds over the next few months. Although current measures such as social distancing and an extended lockdown, combined with cluster containment and rapid antibody testing may help ‘flatten the curve’ for a few weeks, it is inevitable that the existing hospital bed capacity is likely to be overwhelmed soon. By the most optimistic estimates, it is expected that at least 1 million hospital beds will be required in India over the next few months to deal with the surge of COVID-19 cases.

As of 2019, there were less than 10 lakh allopathic physicians to cater to a population of 1.3 billion people, resulting in a less than desirable doctor-patient ratio of 1:1445 Indians, compared to the minimum WHO standard of 1:1000. This doesn’t paint even half the picture of the disparity in medical services between urban & rural areas since most of the medical workforce is concentrated in metropolitan cities and urban areas. Hospital bed capacity in India shows even more dismal figures. As per the World Bank, India has only 0.7 beds/1000 population compared to 4-13/1000 population in developed countries like Italy, USA & S. Korea.

What does this mean for the healthcare system and healthcare workers?

As hospitals & ICUs get over-run with patients during the community transmission phase, the first casualties will be medical personnel on the frontlines of healthcare. This includes medical intensivists, critical care physicians & nurses, pulmonology specialists etc. In countries like Italy, Spain, USA & China about 8 – 14% of all infected patients comprised of healthcare workers.

Lack of personal protection equipment (PPE), long working hours causing fatigue & stress, and physical exhaustion from overburdened capacity will gradually deplete the healthcare force on the frontlines of care. The Indian Society for Critical Care Medicine (ISCCM), a 12,000-strong body of critical care specialists including doctors, nurses and respiratory care therapists have constituted a special task force to develop guidelines on treatment strategies & allocation of limited resources to deal with the expected surge of patients. However, there are a finite number of specialists with expertise in advanced critical care and there is a clear & present danger that these experts will be stretched thin in an overburdened healthcare system.

What steps can be taken to protect our warriors in the frontline of healthcare?

Just as no army sends in its soldiers to war without adequate ammunition, the government must take urgent steps to provide all necessary PPE to healthcare workers. Hospital beds can be rapidly expanded, production of essential equipment can be ramped up, but healthcare experts cannot be adequately replaced. There must be a ‘call to action’ right now to ensure that our healthcare workers are properly protected, as they step up to do what they are trained to do best.

With elective cases & routine hospital admissions suspended to free up hospital beds, a large pool of non-critical care physicians are available for redeployment. Realizing the shortage of medical intensivists, countries such as Italy, Spain & USA have sent out a call to all physicians to step forward and get reassigned to critical care duties.

Several inducements such as free travel, food & stay and threats such as loss of pay have been used to ensure that healthcare workers are available to replace a rapidly depleting force. General physicians, surgeons and specialists such as gynaecologists, orthopaedists, dermatologists, etc., have been re-assigned to ICU duty. With a large medical workforce, this is certainly a feasible option for India, provided certain conditions are met :

- Many of these physicians have not dealt with critical patients since years and cannot be expected to re-tool themselves in a flash. The government and critical care associations must provide refresher training in various aspects of critical care to such physicians as per their skills & comfort level. There is an urgent need to initiate training of redeployed physicians now and not after hospitals & ICUs start getting overwhelmed with patients. This is to ensure that all physicians abide by the overarching motto of ‘primum non-nocere’ or ‘first do no harm’
- There must be an adequate and ongoing supply of PPEs to ensure that these 2^nd level specialists are protected in the line of duty. Training webinars need to be conducted on proper donning & doffing of PPE to prevent inadvertent contamination.
- The government & private healthcare systems must provide additional benefits such as on-site lodging, free meals & healthcare insurance to ensure compliance. Physicians must be indemnified during the course of the pandemic to prevent vexatious medicolegal cases resulting from unavoidable complications & death.
- Medical personnel must be triaged depending upon their skillset & confidence level in critical care management. Redeployed physicians must not be expected to make critical decisions regarding patient management or expected to carry out complex procedures such as ventilator management. They must receive training in simple procedures such as vascular access, easy intubations, proning manoeuvres, fluid management etc., in uncomplicated patients in order to take off some of the pressure from ICU staff.

As the focus shifts from containment efforts to disease mitigation, the healthcare community must step up as one to lend its expertise as never before. These are exceptional times that call for exceptional measures. Our patients need us to move out of our comfort zones and heed the clarion call for ‘all hands on deck’ in order to defeat this newest contagion that threatens all of humanity.