“Njan marichu enna vichariche (I thought I had died),” said Nasarullah over the phone in a matter-of-fact way.
On September 11 last year, Nasarullah, a 50-year-old chronic kidney patient settled in Mandya district of Karnataka, was rushed in an ambulance to the Pariyaram Govt Medical College Hospital (MCH) in Kerala’s Kannur district after he was infected with coronavirus. The oxygen level in his blood had plummeted and it was increasingly clear that the virus had started taking hold of his lungs and other organs. His wife, Fathima, also tested positive, but barring a fever, she had no major complications.
“For 17 days, he remained in a critical condition in the ICU. Doctors told me to pray because all his indicators were high. He had pneumonia, high blood pressure, chronic diabetes with his kidneys badly damaged,” said Fathima, who spent the time lodged in a room in the Ayurvedic block of the medical college whose only window opened out to a forest at the back.
“My daughter also had Covid and she was being looked after by a family friend. It was a really testing time for us,” she said.
After three weeks of intensive treatment, Nasarullah’s pneumonia was cured and his blood sugar levels brought back under control. Once he became stable, he was transferred to the ward where he was joined by his wife.
“All that I remember in the ICU is someone brushing my teeth in the morning and feeding me upma. Most of the time, I was unconscious,” he recalled. “If I am alive today, it’s all thanks to medical superintendent Dr K Sudeep and the team of doctors and nurses at the hospital. I got the best treatment I could have ever hoped for,” he said.
And that affection lingers even today. Since their return home, Fathima starts her day by sending a good morning message on WhatsApp to Dr Sudeep, a man she has never even met.
“Dr Sudeep gave us a new life, a re-birth. If we hadn’t come to Kannur, my husband wouldn’t be alive. I’m very sure of that. I will always be grateful to him and all the health staff there. I don’t know their names, but I will always remember them,” added Fathima.
But where there are stories of hope such as this, there are also anecdotes of grief and loss.
June 6, 2020 is a date that Dr Shinas Babu will perhaps never forget in life. That day, the Manjeri Govt Medical College Hospital (MCH), where Dr Babu serves as the Covid-19 nodal officer, recorded its first casualty of the virus: 61-year-old Hamza Koya, a veteran footballer who played for Maharashtra in the Santosh Trophy in the 80s.
In May, Koya, along with his family, had travelled to his hometown in Kerala from Mumbai, contracting the infection in the process. His wife and son were the first to test positive, followed by him, his daughter-in-law and grandchildren. But while they didn’t develop serious symptoms, he was brought into the ICU as his condition deteriorated fast.
“We did everything we could, including plasma therapy. But we lost him,” said Dr Babu.
Before the last rites, Koya’s family, also admitted to the same hospital due to Covid-19, expressed a desire to see his body. But as per protocol, access to the ICU is granted only to seriously-ill patients and healthcare staff.
To honour their wish, Dr Babu had an idea.
“I put on the PPE, inserted my phone in a transparent cover and stepped into the ICU. I went near Koya’s body and I video-called his son Lihas on WhatsApp to show them the body. They asked me if I could hover the phone over his face so that they could blow a kiss. It was very, very traumatic. They were all crying on the phone and somewhere I broke down too because there was nothing else we could do,” recalled Dr Babu, calling it one of the most painful moments of his life.
Across ICUs in the world, the past year and even now, such episodes are playing out, offering a profound view of how healthcare workers are straining to do their jobs and at the same time bridge the gulf between Covid-patients and their loved ones. The ICU, even with all its advanced contraptions to sustain life, has been a very lonely place the past year. For many, it’s these health workers in full-body PPE gear, unidentified by name and unrecognisable by gender, who remain at their side at their most vulnerable — brushing their teeth, feeding them and taking out their waste. And sometimes, if their luck runs out, they are also the last people they see in life.
An ‘unpredictable’ virus
Even as the rest of India, with the possible exception of Maharashtra, have dialled down infections considerably, Kerala, once hailed for its efforts against the virus in the initial stage of the pandemic, continues to report a weekly average of over 6000 cases. That means, hospitals, especially the tertiary care facilities, in the state are still overwhelmed and health workers teetering on the edge. Officials claim the conduct of the local body elections in December and a general decline of alertness among the public are seen to have spiked cases again.
Though the case fatality rate of Kerala (0.4%) is still among the lowest in the country, daily deaths have oscillated between 10 and 30 for the last six months. Nearly 75% of the deceased have been above the age of 60.
The key to saving the life of a seriously-ill Covid patient, said Dr Fathahudheen, Covid-19 nodal officer at the Ernakulam Govt Medical College Hospital (MCH), is to bring them in, early in the disease process. “If you get the patient in the right window period early in the disease process, they really improve and come out well. But if the patient comes in late into the ICU with severe deficiency of oxygen and injury to other organs, whatever you do, there’s no response in the patient,” he said.
“The factor that determines the outcome is the interaction between the virus and the body’s host immune response. If the immune response is balanced and you get early treatment, you may come out of it (illness). Some people’s immune response is highly irritable and when it’s dysregulated, it goes for an overdrive leading to a cytokine storm, and resulting in death.”
When indianexpress.com called Dr Fathahudheen in April last year, he was beaming about the successful recovery of a 57-year-old British tourist from Covid-19 at the hospital. His team at the Ernakulam MCH had successfully used HIV antiretroviral drugs to beat back the virus despite the patient’s serious comorbidities. But since then, as cases soared and the infection slipped into the community, deaths became unavoidable.
Dr Fathahudheen said, “It was heartbreaking to see many, especially young patients, dying before our eyes despite making all possible interventions. It’s when science turns helpless and you become a mute spectator before this highly contagious virus.”
In fact, in several conversations with doctors serving in the Covid ICUs, the ‘unpredictability’ of the virus and its propensity to wreak havoc in the respiratory system at a rapid pace has always stood out. Doctors said they were baffled to see patients, even young ones who look happy and cheerful in the morning well on their road to recovery, suddenly developing a cardiac arrest and dying within the next hour. Or as cases of ‘happy hypoxia’ where blood oxygen levels come down, leading to shortness of breath and shutdown of organs.
For the bystanders and loved ones, such unexpected deaths are incredibly hard to process and sometimes, it’s the health staff bearing the brunt of it.
“It created a sort of medical agony for us to talk to them and convince them that this is how this disease behaves. And so, we always tell families of patients admitted to the ICU that the outcome of this disease is unpredictable. And until and unless, the patient’s oxygen levels become normal and until they are able to breathe normally without oxygen support, we cannot say they are in a safe zone,” said Dr Fathahudheen.
Dr Jacob K Jacob, internal medicine professor at the Ernakulam MCH, said he’s often felt that the public are not able to understand the seriousness of the work that goes on inside the Covid wards and ICUs. That it’s a fierce struggle between life and death, and many times, even the best of experienced doctors cannot predict which way it could tilt.
“We are dealing with a highly misunderstood population. They are looking at it through a consumerist lens. But having said that, it has not deterred us in any way to go back on our duties… some of these deaths leave an imprint on us and we feel a sense of inadequacy. That, even with all our armoury, we feel that ultimately it’s not in our hands,” he added.
In such a context, communication becomes a pivotal aspect of Covid-19 management, both with patients as well as their bystanders. There is an obligation to calm their nerves, and at the same time, inform them of the urgency of the situation.
Dr Shimna Azeez has manned the Covid outpatient department at the Manjeri Govt MCH for nearly ten months, conversing with hundreds of persons who came in with suspected symptoms and their families. She’s also a writer and an influential voice on Facebook, helping to decode complex health issues for the layman.
“Any disease which mandates physical distance between a patient and his family is a tragedy. So, just like my father and mother are important for me, for somebody else, their parents are important too. When it comes to Covid, I have never tried to console people. I have always informed and educated them with facts and pointed out the risk factors. Otherwise, it may backfire because we don’t know when this patient’s condition may deteriorate. Giving false hope is also unethical,” said Dr Azeez.
One of the affirmative initiatives of the Manjeri Govt MCH, early on in the pandemic, was creating a WhatsApp group of persons who recovered from Covid in order to foster a sense of togetherness. Through the group, doctors advised them on post-Covid recovery and dispelled doubts about the virus. It was also used to encourage them to donate plasma for the treatment of those in critical condition. The state’s first plasma bank was also set up at the hospital.
The loneliness of the disease
For many healthcare staff, the past year of the pandemic has taught lessons they could have never learned in medical school. They have seen deaths, and lives being reclaimed, at close quarters. They have heard innumerable stories of suffering and trauma, of feeling isolated and neglected. Families and friends torn apart by a virus. To an extent, that at some level, their work stopped being just a job, but a larger part of a school consciousness.
Dr Jacob said, “One of the things I understood quite clearly in the last one year was the meaning of life, especially when I interact with patients and their families. People are propelled by money and ego in life. But once inside that ICU, there’s no ego or money. Patients bid goodbye to their families and they come with just a bag of clothes.”
He continued, “I have seen many people, in their 70s and 80s, who are such a beloved part of their families. Inside the ICU, they seem so helpless and alone. Sometimes, when we get a feeling that a patient may not last long, I hold their hands to make them at peace. They clasp my hands tightly to their chest. They need that touch and there’s no one else to do it at the time. I have even broken down into tears, talking to them. But since I’m in my PPE, no one can see me crying.”
Similarly, Dr Azeez spoke of receiving a call from a man from UAE one day, complaining of toothache. She contacted her friends there and set up an appointment for him to meet a dentist. “And then, I asked him if he had any food to eat. He just started crying. He said he didn’t have any food and that he was planning to pluck moringa leaves from a neighbouring compound, boil it and eat it. I froze,” she said, adding that she arranged to get him provisions for one month through her network.
“In the last year, the definition of being human was made clear to me. Every patient was a story…”
For Sheena KP, a staff nurse in the infection control team at the Kozhikode Govt Medical College Hospital, the pandemic’s worst effects are not completely new. For she was a critical part of the team at the hospital that fought the Nipah virus in 2018 which claimed the lives of 18 people. And a year later, when Nipah returned to the state through a patient in Ernakulam district, Sheena was at the forefront of training other nurses in infection control.
“In 2018, all of us at Kozhikode had performed duties wearing PPE at a time when no one knew what a PPE was. Our parents had warned us, but we couldn’t stay away… we know the risks of infection, but we still do it because this is our profession. It was a huge learning experience,” she said.
But unlike Nipah, which was short-lived albeit with a high mortality rate, the Covid-19 pandemic is still very much here, a year later, leaving nurses like Sheena exhausted.
“Then and now, health workers are working round-the-clock. We are not going on vacations or shopping for clothes. Everything’s been put on the backburner. Today, our bodies have adjusted to the PPE. Everyone among the nurses here has lost weight. We have skin-care problems and urinary tract infections,” she said.
With that in mind, I asked her if the pandemic and its physical and emotional struggles ever prompted a rethink of her profession.
She paused for a while and then replied, “It’s not that I wanted to be a nurse. I wanted to be a teacher. But my family didn’t have a strong financial standing to put me through a graduate degree and higher education. A family friend, who was a nurse, saw my high marks in school and advised me to become a nurse.”
“I do this job because I like it. The thing about this job is that we are with a person when they are at their most vulnerable. There’s nothing more debilitating than getting an illness.”