Doctors without borders. Covid-19 frontline warriors in need of the healing touch

* As India’s health workers fight Covid-19’s second wave that has officially left over 2.8 lakh people dead and hundreds of thousands infected, a helpless medical task force is quietly burning out — physically and emotionally

* The Indian Medical Association states that 1,080 doctors have died due to complications related to Covid-19 since the pandemic hit India last year

* “Who will bear the cost of their treatments? Will they be assured a bed in their own hospital if they fall ill? Will their incomes be regularised? Without the assurance that they will be looked after, how can we expect them to dedicate their full intent?” asks Ravi Wankhedkar

***

Dr Dipshikha Ghosh has seen sorrow from close quarters, but nothing prepared her for this one moment. Towards the end of her ICU shift last week at Kolkata’s Apollo Gleneagles Hospital, the 32-year-old resident doctor got on a video call with her patient’s family.

Brand new day: Dr Dipshikha Ghosh (right) and her colleague gear up for their shift in the Covid-19 ICU at Kolkata Apollo Gleneagles

Sanghamitra Chatterjee, a Covid-19 positive 48-year-old, was critical and unconscious on ventilator support despite the best medical efforts. Through the hospital’s daily updates her family had known that she was sinking and that in a few hours she would breathe her last. After enquiring about her vitals, her son Soham asked if he could just look at his mother. Then, as Ghosh held the camera close to his mother, he broke into a song.

It was the popular Kishore Kumar song Tera mujhsehai pehle ka naata koi . The song translates to: We probably knew each other before this life... Whether you are aware of it or not, whether you believe it or not, don’t get lost, don’t get separated from me.

The nursing staff and doctors within earshot stopped what they were doing and stood in silence, listening to a son bid his mother a poignant farewell.

“We shook our heads, our eyes moist... This song is changed for us... This song will always be theirs,” Ghosh wrote on Twitter that day.

The instance also offered Ghosh a few moments of quiet reflection.

“The family had done everything right by getting the patient admitted on time and yet everything failed. The guilt and despair get to you,” she says on the phone to BL ink after wrapping up another eight-hour Covid-19-ICU shift.

For yet another day in over a year, she dons a PPE suit, hides her expressions behind a double mask and controls her thirst, appetite and bladder for most of her shift so that her patients are not left unattended. Unable to switch off even after her shift, Ghosh texts the colleagues she handed over her patients to, with instructions or asking for updates. During her remaining waking hours she responds to direct messages on Twitter, giving pro bono medical consultations to countless anxious patients. “The workload is so much that there’s no time to complain. I’ve not had time to seek any professional therapy,” she says.

As India’s health workers firefight Covid-19’s second wave that has officially left over 2.8 lakh people dead and hundreds of thousands infected, a helpless medical task force is quietly burning out — physically and emotionally. According to the Indian Medical Association’s records this week, 1,080 doctors have died of complications related to Covid-19 since the pandemic hit India last year. Three have died in the last 24 hours. Many are critically ill.

Sense of warmth: Healthcare workers are helping Covid-19 patients both medically and emotionally

Over a third were victims of the virulent second wave of Covid-19. Not all were fully vaccinated. There are no official death records for nurses, ASHA workers and other paramedical staff who are in more difficult situations, many in small towns or rural areas. As India looks at a stretched out second wave that is anticipated to go into August and an impending third wave likely to hit later this year, healthcare workers are pushed to the edge. And the government or the administration seems uncaring.

Hot buttons

Sister Stella* likes to say that this was the moment she had prepared for all her life — to be in the crossfires of a raging pandemic, to assist doctors and provide comfort to patients under her care. But what the 33-year-old Malayali nurse wasn’t prepared for was the indignity meted out to healthcare workers.

After graduating from a nursing college in Delhi in 2010, Stella worked at some of the Capital’s biggest public hospitals. She joined New Delhi’s Safdarjung hospital in 2016 on a six-month contract in the hope that one day she’d be regularised as a permanent Central government employee. While the contract kept getting irregularly renewed, the hospital, along with three other hospitals under the Centre, recently decided that they would do away with 2,000 nurses like Stella and outsource nursing staff.

“We’re being downgraded. This is a hand-to-mouth existence,” she says, the tension evident in her voice.

Last month when Stella contracted Covid-19, although she had all the symptoms including a whacking cough, fever and fatigue, she was asked to work her full shift until she tested positive.

“It was only three days later when my report arrived that I was given leave. I had to buy my own medicines and pay for a doctor’s consultation,” she says, knowing well that getting a bed in her own hospital would be impossible.

According to former IMA chief Dr Ravi Wankhedkar who is also treasurer at World Medical Association (an international confederation of professional medical associations representing physicians), one of the first steps of easing stress and burnout is taking care of the survival needs of healthcare workers.

Frontline workers are exposed to more viral load than others. And yet hospitals are slacking when it comes to offering them prompt vaccination, high quality PPE kits and, most importantly, job security.

“Who will bear the cost of their treatments? Will they be assured a bed in their own hospital if they fall ill? Will their incomes be regularised? Without the assurance that they will be looked after, how can we expect them to dedicate their full intent?” Wankhedkar asks, speaking to BL ink from Dhule, Maharashtra.

Even in the case of the 1,080 doctors who lost their lives to Covid-19, less than a third received the ₹50 lakh insurance scheme announced by the Centre in the event of the death of a healthcare worker, he says.

“If I could summarise the burnout we’re seeing today, it’s helplessness, leading to dejection and anger, because these are factors beyond our control,” Wankhedkar says.

Miles away in Uttar Pradesh’s Banda Medical College, situated at the remote Bundelkhand region, principal Dr Mukesh Yadav has never spent more time and energy trying to arrange for medical resources.

“My blood pressure shoots up each time the trucks of oxygen cylinders are late to arrive,” he says.

While the hospital has a 400-bed capacity, what patients need is oxygen support. They mostly arrive from villages in critical condition with significant lung damage requiring large volumes of oxygen. A severe shortage in manpower implies only 10 out of 26 senior resident doctors are on duty. And they aren’t able to save enough lives. Yadav says his hospital’s mortality was less than 1 per cent earlier. It has increased 10 times in this wave.

Dr Phalguna Kommareddy, who works 12-hour shifts at the emergency department of one of South Delhi’s premier private hospitals, says what really troubles him is having to refuse beds or resources to patients, knowing well that they have most likely exhausted all options and have nowhere else to go, and that another refusal can kill them.

Bhaskar Singh from one of the Max hospitals in New Delhi, says that it is traumatic to see general wards filled with critical cases that should ideally be in the ICU. The lack of comprehensive monitoring impacts their progress adversely, given that their parameters are changing by the hour. “It’s happening in every hospital because we simply can’t keep up with the demand,” he says.

The medics agree that what usually eases the stress is the self-belief that the doctors did their best, irrespective of the outcome. But that assurance is shaken, giving rise to unconfronted guilt.

A senior pulmonologist at a super-speciality hospital in Delhi NCR says that for the first time, she can’t look her patient’s family in the eye when they come asking for updates, because the guilt is crushing. “Given our scanty resources of oxygen supply, ventilators, BiPAP machines and medicines, our quality of care is worse than what a roadside quack would offer and every single staff member knows this truth,” says the doctor, speaking on the condition of anonymity.

To ease her mind, she offers free tele-consultations to her wide circle of friends and family and their friends and family, typing off prescriptions at lightning speed on her phone.

Emotional drain

Because much of the staff members are Covid-19 positive this time around, almost all hospitals are functioning at one-third of their capacity. Being short staffed implies working overtime. Major hospitals such as CMC Vellore have roped in doctors and surgeons from ENT, orthopaedics, cardiology and even psychiatrists who pitch in to handle frontline Covid-19 duty. At other public and private hospitals, doctors from oncology, radiology, nephrology and other departments have been given detailed briefs and added as temporary members of the Covid-19 workforce. Many of these duties are what the medics never signed up for. Apart from medical treatment, it includes providing emotional support to patients and their families.

Vanita Mathew*, a general doctor at CMC Vellore who spends her work week alternating between eight-hour Covid-19 shifts and 12-hour non-Covid-19 shifts, says that the most stressful part of her job is reaching out to families of patients with the news of a patient’s rapid decline and often sudden death.

“We are so crunched for time and yet we cannot be curt while passing on the news,” she says. The emotional support extends to patients too. Matthew recently treated a patient in her 60s who had spent her life serving as a doctor in government set ups. “During her last moments I left my other work to stand next to her bed and hold her hand. I didn’t want someone from my fraternity to die without having anyone to hold their hand,” she says in an interview to BL ink over sporadic WhatsApp messages during her hectic shift.

Mathew says that the pandemic has taught her to see her loved ones in everybody. When her hospital was out of beds it was difficult for her to make quick decisions about giving beds to those who showed the most promising chances of recovery. Some of the critical older patients she had to reject were her parents’ age. “My parents, both diabetic, fall under the category of patients who are likely to get rejected for a bed. I think about that a lot. It’s an ethical dilemma,” she says.

Other sources of emotional drain for doctors include battling “a misinformation pandemic” as one Delhi-based radiologist calls it, answering questions about vaccine safety, Covid-19 recovery, hospital beds, contacts for oxygen suppliers, diet, isolation and often responding to several very basic questions through the day as if each one was “a free 24x7 public helpline”.

Therapy

Not everybody can bear the load. Earlier this month, Dr Vivek Rai, an MBBS doctor at New Delhi’s Max Saket, was found hanging from his ceiling fan at his residence in South Delhi. He had been posted to the hospital’s Covid-19 ICU for a month. Rai’s colleague, who spoke on the condition of anonymity, says, “What got to him was the helplessness of seeing so many people dying while not being able to intubate enough people and do a CPR on time given the limited resources of the hospital.”

But the incident came as a wake-up call for hospital authorities, who have jumped into action and set up counselling services to address the mental health of their healthcare workers. Hiba Siddiqui, a trained psychologist and a senior psycho-oncologist at Max Healthcare, is helming the efforts to set up a support group which currently has psychiatrists, psychologists and doctors from various departments.

Come together: The sense of doom is a shared journey and a support group helps doctors realise that they aren’t alone, says Hiba Siddiqui

“All of us are feeling this sense of doom. This is a shared journey. The point of this support group is to make people realise that they’re not alone,” Siddiqui says.

Many have never done this kind of counselling before. Siddiqui provides a helpful document and a briefing session that guides the doctors on how to open or moderate a session, how to listen with empathy and understanding and how to sidestep their identities as doctors for a while and just be there as fellow humans.

But given that the healers are all overworked, do they really have the mind space to engage with another’s anxieties when they can barely cope with their own? Siddiqui stresses that healing lies in being there for another person. “The act of helping another person cope is something that builds our own resilience,” she says.

While many hospitals have started counselling sessions for healthcare workers, its effects are yet to be known.

Mathew frequently uses the free app-based counselling started by the psychiatry department of CMC Vellore. “But I feel currently processing the trauma while going through it isn’t good for functioning. I have buried it as deep as it would go and will probably deal with it once and if the pandemic settles,” she says.

Doctors and nurses are also the last ones to seek help, busy as they are shouldering medical responsibilities, convinced that they aren’t on the brink yet and can endure more.

“We became doctors for this exact purpose. When the world is in a crisis, we need to rise up to the occasion,” Mathew says.

Looking ahead

If therapy isn’t helping enough then what is?

Strangely, despite the indignity and guilt, healthcare workers such as Stella find solace in staying true to their line of duty. She talks about the oath she took when she entered nursing.

“I will serve mankind with love and compassion,” she had echoed along with hundreds of others. “Nursing isn’t just a job. It’s a service,” she points out.

And even now, what brings her fulfilment is comforting her patients so that they do not feel they are alone. Isolation is as much of a killer as the virus, she explains. A simple conversation with a patient can improve their vitals. Those who survive thank her before leaving and that lights up her day.

Kommareddy too says when the big picture is out of control he concentrates on the little things such as bringing a patient a blanket or some water or making them feel cared for in some small tangible way.

But Wankhedkar knows where the buck has to stop. “It’s bad science, bad politics and bad governance,” he says, referring to the misgovernance by the Central government that led to gross unpreparedness. “It is murder. Doctors and patients are dying due to a lack of facilities and doctors are made to feel the guilt,” he says.

Wankhedkar believes that health has to be enshrined into the Constitution and made a fundamental right for every citizen. Unless it becomes an election issue, until 10 per cent of the GDP is funnelled into public health and unless private hospitals are more strictly regulated to prevent them from exploiting a pandemic, India will always be vulnerable to falling apart in a pandemic like it has, he says.

The Covid-19 warriors couldn’t agree more.

* Some names were changed to protect identities

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