Dr Manivannan Selvaraj
MD, DnB, Founder and Managing Director, Kauvery Hospitals
Kauvery Hospitals, one of the leading healthcare centres in Tamil Nadu, had over 95% success rate in the treatment of over 7000 Covid patients who were treated at five of its dedicated branches in 2020. The patients, who were admitted with moderate/severe/critical COVID, included 108 doctors, of whom 98% went home safely.
Besides operating round the clock, Kauvery Fever Clinics and Emergency Centres at all five Kauvery Hospitals provided follow-up services to people who were house-bound during quarantine. Despite all the challenges, every effort was made to ensure that all 5000 health care staff maintained good health. “Looking back, we wondered how we managed that? Our hearts and minds told us how. This was a new disease to which we had no immunity, and no bank of knowledge to draw capital and confidence from. We were extremely vulnerable. So, we opted to hit the ground running; think, and act fast, on our feet,” says Dr Manivannan Selvaraj, Founder and MD, Kauvery Hospitals.
The most valuable lesson learnt from the experience of handling COVID patient right through the crisis was to ‘Keep your health workers safe — at hospital, in the community and at home. “All other resources can be replenished swiftly, but not the health worker,” says Selvaraj.
Evaluating both national and international guidelines which continued to evolve helped. Kauvery put into place what the BMJ and WHO later called “Living Protocols”; they were online and live, 24/7, incorporating emerging, sound and well tested evidence into them. All Kauvery COVID management teams remained “in sync” across the five designated COVID hospitals.
Besides oxygen and anti-coagulation, the only drug for which there was evidence of benefit to the patient with hypoxia was dexamethasone. WHO’s Solidarity Trial, the largest multi-country trial in COVID, eventually showed only weak evidence in favour of remdesivir. The Solidarity Trial also reported no evidence in favour of HCQ and lopinavir-ritonavir in COVID.
ICMR’s PLACID multi-centre trial of convalescent plasma showed no benefit. Trials also provided no empirical evidence in favour of oseltamivir or ivermectin in the management of COVID. There is also no empirical evidence to support use of azithromycin or doxycycline as antivirals. Monoclonal antibodies, single or as cocktails, are not yet in use in India for out-patient treatment of early COVID. Procalcitonin is a useful marker of bacterial infection.
Secondary infection or sepsis in COVID is to be treated only as per hospital’s antibiotic stewardship policy on diagnosis and treatment.
Evidence on use of cytokines in COVID has continued to evolve. Specific cytokine levels and related inflammatory markers have been consistently higher in bacterial sepsis than in “viral sepsis”. The jury is still out whether in COVID we are seeing a “cytokine storm” or a “cytokine breeze”.
Roche’s own research led to withdrawal of tocilizumab as anti-inflammatory agent in COVID in view of related immunosuppression and secondary infections.
The most important lesson learnt from COVID was that risk of a severe and critical disease was more in the presence of uncontrolled “non-communicable diseases” (NCDs) – diabetes mellitus, hypertension, coronary artery disease, heart failure, chronic lung, liver and kidney diseases, significant physical and intellectual disability, hypothyroidism and obesity.
The stark lesson to be learnt is that a “healthy way of life” is our greatest protection against developing severe or critical COVID or any other pandemic in the future.
There are some possibly related puzzles in COVID as stated below which we need to study and unravel. Many patients have presented “de novo” with major organ complications, without a clear history of typical COVID like fever, sore throat, cough, body ache, loss of smell or taste and fatigue.
These presentations involved all major organ systems — cardiac arrest, arrhythmias, heart failure, stroke, acute kidney injury in the background of chronic kidney disease, diabetic ketoacidosis, thrombotic occlusions in circulation, acutely threatening organs and limbs, etc.
Another related phenomenon is multiple organ complications that occur either during hospitalization for COVID or in the post-COVID period. Any pre-existing chronic NCDs can decompensate during or after COVID. Re-stabilization of them is an integral part of responsible and successful COVID management.
The baffling phenomena of “long COVID” may overshadow the life of anyone who was infected, whether it led to an asymptomatic state, or mild/moderate/ severe/ critical COVID. A responsible COVID physician offers continuity of care till the quality of life is restored to the patient.
Pregnancy was a risk factor for those developing severe COVID. Paediatric COVID could threaten a child’s life with multisystem inflammatory syndrome or vascular thrombotic emergencies. At Kauvery hospitals the mother and child were kept safe from the ravages of COVID.
Cancer patients were doubly at threat from COVID as it could leave patients immunocompromised. As such, cancer care often got disrupted during COVID. At Kauvery, the clock did not stop for cancer, the care continued.
All over the world, non-COVID care suffered during COVID, but not at Kauvery. For example, they did not hesitate when COVID patients required surgery. They did not deny patients who needed surgery during COVID times. Life should not wait for disease and death to capture it. Even renal transplantations were successfully offered at Kauvery Hospitals.
COVID taught us some valuable “collateral” lessons. These included:
1. How to mix ethics, humaneness (the quality of compassion or consideration for others, people or animals), technology and planning for creating a successful anti-viral formula.
2. How planning becomes the best vaccine to prevent pandemics.
3. About fostering the organisation — that people are the key and that collaboration, enabling and empowering each other, and intelligent adaptation of technology simplify both problems and solutions.
4. Everyone is equally vulnerable. As such health is wealth, and the family is the best investment in life. The world also witnessed why women leaders excelled at critical times like COVID with their unique perspective, insight, instinct and intelligence in both hospital and health care management.
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