God has been very kind to Indians in showing the trailer of a movie on COVID-19 in China and Italy and waiting patiently for us to act. We have just 20 days to act, sorry, with today gone it is 19 days.
We suggested an action plan for Karnataka. Lombardy, in Italy, has a population of 10 million and Karnataka’s population is 64 million. Lombardy has 13,272 positive patients, out of whom 15 per cent needed hospitalisation and 12 per cent needed ICU care.
Comparatively, Karnataka will have around 80,000 COVID-19 positive patients, 12,000 need hospitalisation and 9600 will need ICU care with 4,800 needing respiratory support with ventilators.
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For simplicity, as an example, let us plan the COVID-19 care for the city of Bangalore, which should have about 16,000 positive patients, 2,400 will need hospitalisation and 2,000 will need ICU care which requires 1,000 ventilators.
1. Let us follow what the UK government did by closing a few big government hospitals and converting them into dedicated COVID-19 facilities. The Karnataka government should close two busy 1,000-bed government hospitals in Bangalore. Convert 2,000 beds as critical care beds with piped oxygen, suction, and compressed air supply to run 1000 ventilators. This should happen today (Sunday) since this work takes at least 2 weeks after placing the order with the contractor.
2. Never take the oxygen supply for granted. Even in western Europe, COVID-19 patients died because the oxygen supply was exhausted.
3. Switch off all air conditioners in hospitals treating COVID-19 patients unless you are 100 per cent certain about the quality of air. Please don’t bother about isolation rooms, the whole hospital should be an isolation hospital, soon you may be forced to put patients in the corridors of the hospital.
4. Ministry of Health should create 2 teams.
4a. A Medical team of general physicians, pulmonologists and infectious disease experts headed by a senior physician from the government hospital with members from both government and private hospitals
4b.ICU team of anesthesiologists and intensivists headed by a physician from the government hospital with members from both government and private hospitals.
5. The first point of contact for the suspected COVID-19 patients should be the government hospital.
6. Patients who may not require advanced critical care support should be treated at the government hospital. Critically ill patients should be sent to large private hospitals after the initial treatment at the government hospital for the benefit of modern ICU with highly skilled staff.
7. Launch fever clinics with online consultation across the city with guidelines on viral screening and follow-up.
8. COVID-19 positive patients, at the discretion of doctors, can opt for monitored self-quarantine at home. It is equivalent to a house arrest. The monitoring team should call the patient at regular intervals to check on the progress. COVID-19 is a mild disease for the majority of healthy people. We don’t have enough beds and the people to take care of all the positive patients.
9. ICU team’s priority is to take stock of the infrastructure in government and private hospitals, Number of anesthesiologists, intensivists, pulmonologists, ICU-trained nurses, junior doctors with basic knowledge of ICU care, nephrologists, radiologists, gastroenterologists, neurologists and cardiologists.
10. The number of ICU beds, ventilators, cardiac monitors, syringe pumps, portable X-Ray machines for Chest X-Ray, beds with oxygen, compressed air and central suction lines, blood gas machines, N 95 masks, protective eyeglasses and Personal Protection Equipment (PPE), disposables like endotracheal tubes, suction tubes, PPE would be required for the workforce for two months.
11. For 2,000 ICU beds, a 6-hour shift needs 700 nurses, 200 resident doctors and 100 anesthetists/intensivists. For 24-hour coverage, 2,800 nurses, 800 resident doctors and 400 anesthetists.
12. At least 200 senior intensivists/anaesthesiologists would be needed to cover 2,000 beds remotely through WhatsApp.
13. The requirement would be to double the number of these medical experts to cover for leave and fatigue.
14. Identified doctors, nurses and technicians should be given a pair of PPE to wear at home for practice. COVID-19 ICU simulation should be set up at large hospitals to teach staff on safe practices to protect themselves.
15. The safety of health workers should be the utmost priority.
16. Additional cardiac monitors, ventilators and syringe pumps should be procured locally or imported. This should be done by the government for bulk purchase urgently. Soon, they will be out of stock. Ventilators are key to preventing coronavirus deaths.
17. PG students working in any specialty, clinical and non-clinical should be given the option by the university to serve the COVID-19 ICUs as part of their training programme. This will provide a large number of young skilled workforce. Karnataka alone has more than 6,200 bright young doctors who specialise in vital medical specialties.
18. PG students, interns and final year medical students should be posted in the respective hospitals’ ICUs to familiarise themselves with ventilated patients. Doctors and nurses will not be able to work for more than a week at a stretch in COVID-19 ICUs. A large pool of doctors and nurses can cover the requirements on a rotational basis.
19. Junior doctors should be trained to work with PPE in non-covid-19 ICUs for 2 weeks under supervision before entering the COVID-19 ICU.
20. The Health Ministry should ask for special permission from the Indian Medical Council to allow young doctors trained in recognised overseas medical colleges for temporary licence to work under senior doctors. In the end, it is the junior doctors and nurses who are going to win the battle to save humanity.
21. Every health worker should have a data-enabled mobile phone.
22. Each Senior intensivist/anesthetist can manage at least 50 patients remotely through apps like WhatsApp. Apart from licensing foreign-trained Indian doctors, MCI should temporarily allow WhatsApp to create patient groups by the doctors and manage them remotely. In fact, nurses in the ICUs wearing PPE will not be able to maintain the progress notes of each patient. It can be only maintained by the senior intensivists/anesthetists from home remotely on WhatsApp or any chat-based app on cloud.
23. The Medical Council of India should permit online consultation and prescription
24. About 12,000 specialist doctors just finished their final year theory paper of specialty exam in anaesthesia, medicine, pulmonology, cardiology, etc under National Board of Examination (DNB). Nearly 38,000 medical specialists finish training in vital specialties under MCI annually. As in the USA, they can be given the degree as “BOARD ELIGIBLE SPECIALIST” and when they pass the final exam, they can be called “BOARD CERTIFIED SPECIALIST.” They can be absorbed by the Ministry of Health to fill in the vacant positions in hospitals.
25. Indian Nursing Council should permit final year nursing students to take care of stable ICU patients.
Every suggestion we have made has precedence in some of the developed countries. All we should do is to identify their best practices and learn from their mistakes. China lost the battle initially because of an unprecedented surge in the numbers. We still have some time and all we need to do is execute.
A British study predicts 22 lakh deaths in the USA and 5 lakh deaths in the UK due to COVID-19. Despite the prediction, India can conquer COVID-19 and set an example for the rest of the world to follow because we have the largest number of young skilled doctors, nurses and technicians, thanks to our government’s progressive policies. We must liberate the true potential of what they can do by empowering them legally and providing them with the necessary tools.
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(The author is chairman, Narayana Health.)