Sunday, March 06, 2022

July to December 2021

Its been a while since the blog was updated. Much has happened in the interim. 
 Six months is a long period of time. The waning of the epidemic, local outbreaks, the fear of the havoc wreaked by the DELTA all kept us on our toes.

The lockdowns in some form or the other continued and as usual people adapted, moving on with their lives. Framing, dairy, goat rearing and trade all continued. The tomato crops brought in good money. Above all, the copious rains


Total Patients: 8287

CHILDREN:  170; (M:F :: 94:76)
ELDERLY:   1284; (M:F :: 751:533)
ADULTS:     6883; (M:F :: 3189:3644)

INCOME: < 48000 pa : 8171



Masked Crowds at the Bus Shelter
ASHA Workers being felicitated for the yeoman work

 







New BPL 450 mRad X Ray machine



        
An old patient being loaded onto a make shift ambulance      
    

Retinitis Pigmentosa with T1D



   

Paddy - Transplanting, ripening and harvesting
                                                                                                                                                                                                                                                                     

                                                              GROUND NUT HARVEST                                                                                                
                                                                                                                                                                                                                                                                                                      


                                             BOUNTEOUS RAIN & THE LANDSCAPE CHANGES


A LOVELY TIME FOR THE GOATS & CATTLE

  

Here is wishing everyone a wonderful 2022

Wednesday, November 03, 2021

Learnings from an Epidemic: Looking back and "Forward"

      This post is a collection of my personal thoughts on the COVID pandemic as it unfolded. In previous posts I have written about the impact on the people in our neighbourhood. 
    I am certain that much of what I have written below has been articulated at some time or the other by others. 

PANDEMICS

     The world had forgotten what Pandemics are and the havoc they cause. The 1918 flu pandemic has been largely forgotten, maybe a distant  memory in some. The Asian flu pandemics of the late 50s and 60s, lasted about a year causing between 1 - 4 million deaths worldwide. The lessons from these were consigned to dusty pages of Textbooks on Community Medicine. Most of us doctors, just read these answered questions in an exam and promptly forgot about it!

    Ebola, SARS, Swine Flu all reared their heads but did not sweep the world. Advances in medicine, hygiene, vaccination etc. all probably ensured that these epidemics were controlled. There were possible Virologic factors too which limited the spread of the disease.

    In Dec 2019, the first reports surfaced of a new Virus with high morbidity and mortality emerged from Wuhan in China. Just as the rising sun seeks out and illuminates all in its path,  the CORONA Virus spread through the world seeking out every nook and corner, affecting every part of the world. None were spared the Viruses reach, cutting through swathes of humanity. Panic and mayhem followed in its wake.

    The medical community was scrambling to find answers being demanded by the administrators and people. In a sense, advances in hygiene, medicine, investigations, drugs and technology had kept COMMUNICABLE/INFECTIOUS DISEASE EPIDEMICS at bay. The epidemics of old were consigned to history and possibly only distilled lessons from these epidemics remained in text books. 

    The silent epidemic of NON COMMUNICABLE diseases was the talking point everywhere. Minor outbreaks  of Ebola, H1N1 etc. were quickly contained. Ebola with its high mortality, is scary but it never spread, though the threat of that remains.

    CORONAVIRUS changed all that. The virus spread rapidly throughout the world. The virus did not conform to patterns of behaviour of other Influenza viruses. Winter, Summer, Rain were all the same for the Virus. While in China, Europe and USA the virus ravaged the populace in Winter, In India and Asia it was in Summer. Geographically, every country in the world North South East or West has been affected.  In the midst of all this chaos a pattern emerged:

    Crowded, ill ventilated places seemed to have a higher incidence of Viral infections and associated morbidity and mortality. As such, In India at least, Rural India was less affected than Urban India. Urban includes small towns (so called Tier III towns too).

    So fresh air and ventilation seemed to halt the spread of the Virus. In our rural hinterland almost all the cases were imported, with people coming back from the cities with the infection.

SEARCHING:
    There was a mad rush to find the pathophysiology of the disease. What were the factors that caused the virus to spread so rapidly, why was it causing so many deaths, what could be done to prevent deaths, how to prevent spread and mortality etc.?
    Stories and pictures of hospital wards overflowing, patient lining up for admission, fighting for Oxygen became common place.
    Medical Teams were treating only those who had a chance of survival. Many were given, palliative treatment, the best that could be offered. That brings me to the concept of Triage. Not many medical personnel are familiar with this concept. Primarily used by the Armed Forces and Emergence Medical Services - specialists in Hospitals have really no idea of this concept.

TRIAGE
    In the Armed Forces, during War, where mass casualties are expected - we were trained to spread to our resources to benefit the maximum. Use the resources to Save as Many as possible. Quickly dispose of those less serious so that the load comes down. Axiomatically that meant that some of the seriously injured were stabilised and treated only when possible. 
A more detailed reading: https://en.wikipedia.org/wiki/Triage


COVID PEAKS 
    A similar situation unfolded with the COVID outbreaks too. Hospitals in India and across the world were overwhelmed by the sheer number of sick people that reached them. There was a shortage of everything - Personnel, Beds, Oxygen, Fluids, ambulances - name it and it was short. Medical personnel worked continuously through the months of the epidemic peak. Even in war, one does not see so many casualties all coming in at the same time. All medical personnel, from the Doctors to the ward aids will have stories to tell and memories of harrowing work in the hospitals. It is not easy to deal with a deluge of deaths, patients seeking succor where none exist. 
    As an example: 
    WW II saw about 21 - 25 million military deaths (including 5 million in captivity) - for the period Sep 1939 to Aug 1945 (06 years)
    As of Nov 2021 - COVID 19: Death: 5.1 million from Jan 2020 to Nov 21.
    The number of deaths are comparable on an annual basis. However, do remember that during the war, there were many other factors like, lack of food, access to health services which were also impaired

    Civil society came to the forefront - lending a helping hand in whichever way possible. Stories abound of people opening their resources to those affected. So also for the Great Migration that took place in April May of 2020. I am sure that someone somewhere will chronicle these stories so that people do not forget.

CONFUSION and MISTEPS
    The search for a cure, stemmed from an initial rudimentary understanding of the Virus and the disease process. ACE receptors, Cytokine storm, Multi Inflammatory Syndrome, CORADS score all became household words!! 
    Ever so often there was an article touting this drug or that drug as a miracle - Hydroxychloroquine, Doxycycline, Ivermectin, Remdesivir etc. all were touted and none have lived up to their initial hype.

    There were so many "SCIENTIFIC ARTICLES" each claiming to know it all. For us doctors it became impossible to separate the chaff from the grain. None of us knew what works or what does not. 

Retraction Watchhttps://retractionwatch.com/retracted-coronavirus-covid-19-papers/
Retracted:                                                  149
Retracted due to Journal Error                      12
Retracted and Reinstated                             05
Expression of Concern                                  07

Similarly 06 Papers in high impact journals were retracted within 30 - 45 days of publication: https://pubmed.ncbi.nlm.nih.gov/33989091/

What of the World bodies; WHO, CDC, NHS, ICMR?

    As with the rest of medical community these organisations were also grappling with the unknown. From an initial response in which the Pandemic or rather the seriousness of the disease was played down to finally getting some sort of understanding of the transmission and disease process - the journey was arduous and filled with missteps.
    Advisories sent out, recommendations made and then modified/rescinded. Treatment protocols changed overnight. 
 
PREVENTION
    The recommendations on Masking, Distancing and Personal Hygiene formed the bedrock of prevention. These have been valid since time immemorial. To add to the above came the renewed emphasis on Ventilation.

    Recommendations on the use of PPEs changed over time as the medical community slowly understood Viral behaviour. While masking was mandatory, the space suits were consigned to the ICUs and places where Aerosols were generated. Then came the finding that the Virus was capable of Airborne transmission. So this led to the recommendation of Ventilation.

    At the Rural Health Centre - from April 20 - we shifted to outdoor clinics. We had the space to do so. Of course most patients were treated strictly NO TOUCH TECHNIQUE.  I remember as a student, passing snide comments on one of our Teachers, who never touched a patient. All of us thought very poorly of the professor. None of us knew that 40 years down the line we will be doing exactly the same thing.

GRAPPLING
    Physicians devised their own treatment protocols, most with some rationale behind their use. Most of us stuck to a sort of common sensical approach, approaching it like a Viral fever, but with much more care. Received wisdom (what is taught in medical school and thereafter) was of no use. So also Perceived Wisdom (based on scientific articles, observations, patterns of fever etc.) was also of no use. The virus changed its spots (genetic code) faster than any known virus. I think that the few things which sort of worked were Hydration, rest and fever mitigation. As a primary care physician, I have only a vague second hand understanding of how it was in Critical Care Units and dealing with patients with Hypoxemia.

COOPERATION & SPEED
    What has stayed with me has been the speed of the response and massive amount of material which was available as open source. Technology was leveraged in a way never before, setting a possible template of responses for future epidemics.
    Just look at the speed with which, Viral genetic sequencing was done and data shared world wide.

Global Initiative on Sharing Avian Influenza Data (GISAID): https://www.gisaid.org/

Reproduced below is a graph showing the extent of collaboration: https://www.nature.com/articles/d41586-021-01069-w



    In India the Department of Biotechnology established 
INSACOG (Indian SARS-CoV-2 Consortium on Genomics (https://dbtindia.gov.in/insacog) 
This consortium is able to quickly trace Mutations and helps track the disease spread.

VACCINES
    Thanks to gene sequencing, Vaccines were quickly produced and tested. 
    GAVI - the alliance for Vaccines and Immunisation is a fine example of this collaboration.   https://www.gavi.org/ 

(Gavi, officially Gavi, the Vaccine Alliance (previously the GAVI Alliance, and before that the Global Alliance for Vaccines and Immunization) is a public–private global health partnership with the goal of increasing access to immunization in poor countries. )

 If one looks at the speed with which the vaccines were developed, the chart below gives you an idea. In less than a year there were multiple vaccines available. 

https://ourworldindata.org/vaccination


Another excellent resource on vaccination is: https://www.historyofvaccines.org/

SUPPORT and SHARING

    I have always felt that "tech" has taken over our lives  - Ironically, as I write this on my laptop, the material is being saved in some cloud somewhere and people all over the world can access this piece.
    For all the deriding of the WhatsApp University - this platform became invaluable during the pandemic. Widely used to mobilise support, exchange information on hospital beds, oxygen status etc. it proved invaluable in providing peer support to families struggling with COVID. 
    For doctors it was a platform where information and constantly evolving best practices were shared. This exchange of ideas and thoughts from all corners of the world was and continues to be invaluable.
    Of course one had to be careful and separate the ludicrous from the ridiculous. Nuggets of great importance had to be searched for!

  Anecdote:  I was approached for help in Delhi for a Rishi Valley Alumni. The doctor treating him was an AFMCite, a couple of years my senior. Through the AFMC network was able to trace him and speak to him. The patient pulled through, giving all some very anxious moments in between. 

OPEN SOURCE DATA

    Volunteer driven, crowd sourced effort to track the COVID outbreak in India - https://www.covid19india.org/
This website was a lifeline for us, working in the field. Up to date and informative, this became one of the most trusted data sources for us. Unfortunately the website shutdown on 31 Oct.
The other website https://www.worldometers.info/coronavirus/ 
Patterns and progressions of disease in every country in the world was mapped. 
It was terrible seeing the number of people affected world wide. One could also the numbers exploding as the pandemic reached its peak in the affected parts of the world. 

ARTICLES:

Dr MS Seshadri and Dr T Jacob John have been regularly publishing articles in the print media. For those interested all these are available online.
Dr Shankar Subramaniam from the Armed Forces has a number of very interesting publications, including one on Mathematical Modelling and another the largest study on Vaccine efficacy. All available online

THE FUTURE: 
    It is impossible to foresee the shape of the COVID 19 pandemic. Foresight is 6/60 and hindsight is 6/6 vision!!
However - I am giving it a shot
1. This pandemic will slowly move towards endemicity - with few local outbreaks
2. There will be other Viral pandemics in the years to come. 
3. Human beings will necessarily have to change the way we live - in what way I do not know, but the lockdowns have given us an inkling of shape of life to come. 
4. We will all need to care for the environment in a much more holistic way. At present humanity is at odds with itself and with the environment.
4. However, human ingenuity will continue to seek answers and am sure that humanity will find a way to live at peace with itself and the environment.

STAY SAFE AND HEALTHY
Kartik


Sunday, September 05, 2021

FAREWELL Dr RAMESH

 Dr G Ramesh Babu, joined the RHC in Jan 2008. He turned 65 in April and decided to "hang up" his stethoscope. A paediatrician by training, he took care of all types of patients.

Ramesh with his energy, zeal and commitment to patient care was a real asset to the RHC. Very good with children, he took excellent care of them. He was always available for any emergency or consult anytime of the day or night.

The RHC will miss his presence. 
Some photos from his farewell