While most citizens continue to remain indoors owing to lockdown restrictions, we have been witnessing an increase in outdoor movements; family members running grocery errands, movement of delivery personnel, etc. is commonly seen. For the senior citizens, who form one of the most susceptible groups of individuals who could easily contract the infection, being homebound is the only option. Family members or neighbors carefully take precaution on their behalf; however, there is a great risk if they come in contact with these senior adults.

These patients usually have a delayed diagnosis and admission. The recovery may then be complicated due to – late admission, advanced age (Usually above 70 years or above) and comorbidities that are common at that age.

As older adults have a weakened immune system primarily due to other conditions such as Hypertension, Diabetes, Heart, Lung or Kidney disease and other complications, they are automatically vulnerable to infectious diseases, along with the concept of ‘being frail’ which refers to age related psychological, physical and social problems. These two factors jointly contribute to the body’s inability to combat the overall stress to the immune system.

Safeguarding older people through COVID-19

• It is imperative to understand that the elderly is equally at risk at home; so the other family members need to be extra vigilant about hygiene practices and importantly, take notice of symptoms of the elderly as a possible COVID- 19, as they may have caught COVID even at home
• It is important that even while being homebound, if a family member ventures outside, once returned, the practice of social distancing is implemented.
• Refrain from coming in contact with visitors unless absolutely necessary. It is preferable that only healthy people are met with. 
• Avoid close interaction with children or younger adults as they can be asymptomatic carriers
• Hand and respiratory hygiene are of great significance.
• Seniors are generally anxious in nature – as they do not consume media as much as the younger adults and are often oblivious to the ramifications of the situation. It is important to relieve them of any stress, panic or anxiety by addressing the situation preventing any triggers.
• It is important to watch out for signs of respiratory symptoms so that timely medical aid is sought
• Avoid over the counter or curative measures; opt for tele-consultation with your doctor and discussion your issues in detail so you can begin on guided medication.

For elders above the age of 60yrs, the ‘3Minute Walk Test’ (3MWT) is recommended; i.e. a do-at-home test to look for Cardio-Pulmonary exercise tolerance. It should be performed by the individual from the 5th – 12th day of the onset of symptoms. This will give a clearer picture about the Oxygen levels of the individual. This test will help the homebound, who are worried about getting infected; the results of the 3MWT can be discussed with the physician over tele-consultation to understand the next steps.

Here’s how it is done:

• Advice your older adult to walk in the confinement of his/ her room for 3mins non-stop, without any Oxygen support
• Once the walk is completed, using a Pulse Oximeter measure if the Oxygen saturation of the individual has dropped below 93%, or if there is an absolute drop of more than 3%. A fall in oxygen below 90% should be considered as an emergency and the patient must hospitalized immediately.

Since the beginning of pandemic, it has been noted that men tend to be more susceptible to infection, and the severity of their disease is much more. Though many recent studies have shown that women are infected as frequently as men, but it is the severity of disease in men which is perplexing. 

It is commonly known that men have a higher incidence of co-morbidities like Hypertension, Diabetes and Heart disease. Also, there is an increase trend towards smoking, also, possibly, men seek medical attention much later as compared to women. While these common observations do help in understanding the incidence of infection, it does not explain the severity. The data from India also shows that there is almost 65%:35% ratio (Male: Female) death rate disparity due to COVID-19. 

Medically there are various theories which have been discussed to be the reason for this gender bias; the three top theories being (1) Angiotensin Converting Enzyme-2 (ACE-2) receptor, (2) Oestrogen &Testosterone which affects the immune system and (3) genetic predisposition. Let’s understand these better:

– ATTACHMENT TO ACE-2 RECEPTORS:  

It is now clearly understood that the ‘spike protein’ on the corona viruses like COVID, SARS (Severe Acute Respiratory Syndrome), MERS (Middle East Respiratory Syndrome) have an affinity for the ACE-2 receptors; it is almost like the ACE-2 receptor is the gateway for these viruses. The concentration of ACE-2 receptors is present in abundance in males as compared to females. They are found in high concentration in the Lungs, Heart, Intestine and Gonads.

– UNDERSTANDING THE OESTROGEN AND TESTOSTERONE CONNECTION:

Female is a stronger sex with respect to immune response and resilience. The female hormone Oestrogen stimulates the immune response rapidly and also supresses COVID-19 virus replication. Whereas the male hormone Testosterone inhibits the body’s own immune response, hence making males more prone to severe infection. This quality of Oestrogen is not only seen in COVID -19 cases, but also in other viral illnesses like Influenza.

– THE GENETIC PREDISPOSITION:

The possible third reason for this phenomenon is that the genes which are responsible for identifying a pathogen in body and mount a response to them, are present on the X chromosome. Since females have 2 X chromosomes, they are more likely to have a rapid immune response to a pathogen and offer better protection. On the other hand, because of Oestrogen and rapid response to immune system, women tend to have more auto immune problems as compared to men!

 

In a recent Sero survey conducted in city of Mumbai, it was found that more women had developed antibodies to COVID-19, which affirms the fact that women probably had a very minor illness which went un-noticed as compared to men, hence while more men went on to develop symptoms, women probably remained largely protected due to their immune response.

The effect of the ongoing pandemic has rippled through the whole healthcare ecosystem; and healthcare workers continue to battle on the frontlines to treat as many patients as possible. May patients with COVID19 needed intensive care, and with great support and impeccable clinical acumen, patients have emerged victorious. However, those who have been critically ill, and those who were treated for prolonged periods in intensive care units may need a few more months to recover fully, despite completing treatment for COVID19. 

There is significant evidence that some people with relatively mild symptoms, who were treated at home, may also have a prolonged sickness, even after beating the infection. It is observed that the virus not only affects the Lungs but also has an impact on one’s Heart, Brain, the digestive system, and Kidneys amongst other organs. This new phenomenon that has emerged is termed as the ‘Post COVID-19 syndrome’.

HOW SOON, AND WHY DO THESE SYMPTOMS SHOW UP?

The symptoms, especially fatigue, may be a continuation of the recovery process and some symptoms may be only noticed after the patient is discharged. In almost 80% of patients, fatigue post illness stays for several weeks and gradually resolves. Poor exercise tolerance, disturbance in sleep wake cycles are noticed usually when the patient returns to confines of his home. The most difficult are the neuropsychiatric and depressive symptoms; it needs specialized training like that of a Clinical Psychologist to diagnose it.

HOW SOON CAN A PERSON START SEEKING POST COVID CARE?

It is important to seek post COVID19 care right from the 1st follow up post discharge, or usually around 2 weeks post discharge. Then as per requirements, clinical support, physical rehabilitation and psychological support can be offered.

REHABILITATION PROGRAM TO TACKLE POST COVID SYNDROME:

The post-COVID19 Syndrome must be tackled through clinical assessment, psychological intervention and comprehensive rehabilitative care. An expert panel of doctors, at a dedicated post COVID19 OPD must help clinically assess the patient. This is the first step towards helping the patient tackle the residual impact of the infection. Physical rehabilitation will play a crucial role in assessing the impact on mobility, decreased/ increased exercise tolerance and muscle weakness. Also, psychological evaluation plays a big role in addressing Post Traumatic Stress Disorder (PTSD) amongst those who have battled severe COVID19 and had a prolonged stay in the hospital. These areas of focus will help diagnose and treat the long and short term complications amongst COVID19 survivors. 

HAVE PRE-EXISTING CONDITIONS? HERE’S HOW COVID IMPACTS YOU:

Those with pre-existing conditions such as Diabetes, Hypertension, Obesity, etc. must be evaluated to gauge the seriousness of the disease before, and after contracting COVID-19. It is noticed that due to the impact on ACE 2 receptors during COVID-19, the blood glucose levels are usually high. This is compounded by steroids, which patient receives. Especially in diabetics, patients may need a short course of Insulin before returning to tablets; dosage may also need alterations. Similarly, Hypertensive patients may need altering of their medication regime, post COVID-19 Tachycardia (a condition that makes your heart beat more than 100 times per minute) may need betablockers to be added to the routine medication. Similarly, patients with Chronic Lung Disease or Asthmatics may need additional evaluation of the Pulmonary Function Test.

With the winter approaching, self-medication becomes a major concern for doctors. Often it is the friendly chemist, friend or patient themselves who suggest self-medicating based on the common symptoms. Needless to say it is completely inappropriate to take medications without a proper medical consultation.

For one, most of the winter illness are mild illness, caused by viruses and are self-limiting. The treatment required would often be just symptomatic care, but often antibiotics are dispensed for the same and this promotes the development of resistant organism. Secondly, what looks like a mild illness would be actually a serious problem, requiring appropriate diagnosis, tests and treatment. If precious time is wasted in self-medicating, the consequences are dire, often leading to hospital and intensive care admission or in some cases, threat to life.

The more common symptoms like cough and cold, may actually be symptoms of Pneumonia, if not treated appropriately, the consequences are serious. It is important that the patients understand, that chemists are not allowed to dispense medications like antibiotics, pain relief medications, anxiolytics etc. without a doctor’s prescription. The reason being that Chemists may have an understanding of the drug and its actions, but lack the clinical skills, lack understanding of effects of a particular drug on physiological variables and certainly are not able to correlate with different system and drug interactions. The paucity of this knowledge may be deleterious to patient, causing harm than good.

Chemists mostly tend to dispense paracetamol with an antihistamine combination, followed by Non-steroidal anti-inflammatory drugs and antibiotics. Sometimes, these are not required as they are unaware of the person’s clinical history and findings. Most of the time the most concerning self-medication is for fever; fever could be a symptom for a lot of other factors. Self-medication hampers the possibility of being treated for the right reasons. Doctors do not advise taking an Aspirin as home intervention before reaching a hospital for treatment in regards to cough, cold, fever or headaches. Taking a mild paracetamol prior to doctor consultation or a remedial steam inhalation is preferable. 

Introduction

Brain Death is defined as the irreversible loss of all functions of the brain, including the brainstem. The three essential findings in Brain Death are Coma, absence of Brainstem Reflexes, and Apnoea. An evaluation for Brain Death should be considered in patients who have suffered a massive, irreversible brain injury of identifiable cause. A patient determined to be Brain Dead is legally and clinically dead. There is a clear difference between severe brain damage and Brain Death; Brain Death is the principal prerequisite for the donation of organs for transplantation. The 1994 Transplantation of Human Organ Act defines brain stem death in India, as opposed to the whole brain dead in many countries like United States.

Evolution of Brain Stem Death

Historically, death was defined by the presence of putrefaction or decapitation, failure to respond to painful stimuli, or the apparent loss of observable cardio respiratory action. The widespread use of mechanical ventilators that prevent respiratory arrest has transformed the course of terminal neurologic disorders. Vital functions can now be maintained artificially after the brain has ceased to function. In 1968, an ad-hoc committee at Harvard Medical School reexamined the definition of Brain Death and defined irreversible coma, or brain death, as unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified.

Brain Death Certification

Prerequisites: 

(1) Identification of history or physical examination findings that provide a clear etiology of brain dysfunction.

The determination of Brain Death requires the identification of the proximate cause and irreversibility of Coma. Severe head injury, Hypertensive Intracerebral Hemorrhage, Aneurysmal Subarachnoid Hemorrhage and Hypoxic-ischemic Brain Insults are potential causes of irreversible loss of brain stem function.

The evaluation of a potentially irreversible coma should include, as may be appropriate to the particular case; clinical or neuro-imaging evidence of an acute CNS catastrophe that is compatible with the clinical diagnosis of brain death.

(2) Exclusion of any condition that might confound the subsequent examination of cortical or brain stem function. 

• Shock or Hypotension
• Hypothermia  with temperature < 32°C
• Drugs known to alter Neurologic, Neuromuscular function and Electroencephalographic testing, like Anaesthetic agents, Neuroparalytic drugs, Methaqualone, Barbiturates, Benzodiazepines, high dose Bretylium, Amitryptiline, Meprobamate, Trichloroethylene, alcohols.
• Brain stem encephalitis
• Guillain- Barre syndrome
• Encephlopathy associated with Hepatic Failure, Uraemia and Hyperosmolar Coma
• Severe Hypophosphatemia

Brain Death Examination

Test all the three components of coma, loss of brain stem reflexes and Apnoea.

Before starting ensure the following

• Pre Oxygenation with 100% Oxygen for 15 min. 
• Core temperature ≥ 36.5°C or 97.7°F
• Euvolemia-  positive fluid balance in the previous 6 hours
• Normal PCO2 – arterial PCO2 ≥ 40 mm Hg
• Normal PO2 – pre-oxygenation to arterial PO2 ≥ 200 mm Hg

Demonstration of Coma

• Absence of movement/ grimace to central deep painful stimuli in cranial nerve distribution Supraorbital Ridge, Temporo – Mandibular Joint (afferent V and efferent VII) or Trapezes Muscle squeeze (afferent and efferent spinal accessory nerve)
• Painful stimuli in spinal dermatome distribution will not test response to central pain
• Patient may have spinal reflexes present in brain stem death

Absence of Brain Stem Reflexes

• Pupils- no response to bright light Size: mid-position (4 mm) to dilated (9 mm) (absent light reflex – cranial nerve II and III)
• Ocular movement- cranial nerve VIII, III and VI
• No Oculocephalic Reflex (testing only when no fracture or instability of the cervical spine or skull base is apparent)
• No deviation of the eyes to irrigation in each ear with 50 ml of cold water (tympanic membranes intact; allow 1 minute after injection and at least 5 minutes between testing on each side)
• Facial sensation and facial motor response
• No corneal reflex (cranial nerve V and VII)
• No jaw reflex (Cranial Nerve IX)
• Pharyngeal and tracheal reflexes (cranial nerve IX and X)
• No response after stimulation of the posterior pharynx
• No cough response to Tracheo-bronchial suctioning

Demonstration of Apnoea.

• Complete monitoring and disconnect the ventilator
• Deliver 100% O2, 6 l/min, into the trachea. Option: place a cannula at the level of the carina.
• Look closely for any respiratory movements (abdominal or chest excursions that produce adequate tidal volumes).
• Measure arterial PO2, PCO2, and pH after approximately 8 minutes and reconnect the ventilator
• If respiratory movements are absent and arterial PCO2 is ≥ 60 mm Hg (option: in carbon di oxide retainers  20 mm Hg increase in PCO2 over a baseline PCO2 ), the apnoea test result is positive (i.e. it supports the diagnosis of brain death)
• If respiratory movements are observed, the apnoea test result is negative (i.e. it does not support the clinical diagnosis of brain death)
• Connect the ventilator, if during testing
  • The systolic blood pressure becomes < 90 mm Hg (or below age appropriate thresholds in children less than 18 years of age)
  • or the pulse oximeter indicates significant oxygen desaturation,
  • or cardiac arrhythmias develop;

• Immediately draw an arterial blood sample and analyze arterial blood gas.
• If PCO2 is ≥ 60 mm Hg or PCO2 increase is ≥ 20 mm Hg over baseline normal PCO2, the apnoea test result is positive (it supports the clinical diagnosis of brain death).
• If PCO2 is < 60 mm Hg and PCO2 increase is < 20 mm Hg over baseline normal PCO2, the result is indeterminate and a confirmatory test can be considered. (not allowed in |Indian law)

When two doctors either Neurologist, Intensivist, Anesthesiologist or Physician who are nominated by appropriate authority, perform the test independently at least 6 hours apart, and if both tests are positive for brain death, the patient is declared as Brain Dead. The complete process is also observed by primary admitting doctor of the patient and the hospital head, who along with the two doctors complete the Form 10 and certify death. The time of death is end of second apnoea test.

Once death is declared the next of kin of patent are informed and counseling for organ donation should be done.

Healthcare services in India are undergoing a paradigm shift. The infrastructure, healthcare workers, national and public health policies are seeing an important trend towards improving outcomes. Infrastructure is being created in such a way that it will help patients recover early, and also provide good working environment for doctors and healthcare workers. While health may not be everything, however everything else is nothing without health!

It is an expectation of the population that the government provides them with uniform healthcare at an affordable price. The success of this has been far from reality in rural areas, where perhaps primary healthcare centres have been successful, but speciality care is still a dream come true for rural India. Even in the urban areas, the vast diversity of population in socio-economic sense, makes it difficult for the public sector to fulfil the demand. This has led to private healthcare lending a hand by filling in the gap, to slowly establishing themselves as centre of excellence in delivery of healthcare along with improved outcomes. However, quality comes at a reasonable cost, which for a country like India, not many can afford to avail. The insurance sector while growing rapidly has not been able to bridge the divide and often the patient or his family have to pay from their own pockets or savings.

Infrastructure development has occurred at a phenomenal pace; right from the development of hospitals, safer for patients, efficient workplace to improve manpower output and to increase operational efficiency of healthcare space, infrastructure has been the core of it. Hiring efficient and trained doctors, nurses and other healthcare professionals has been a simultaneous process. There has been a shortage of skilled manpower across the board, but there is significant improvement as compared to what it was several years ago.

One agenda to all of this development is centred on a common destination which is ‘improved patient outcome’. So the destination is common for all – good outcome, but how we reach the destination could be modified. The best analogy which one can give is our Indian Railways. Surprised!! The Indian Railways put in a lot of infrastructure and effort in safety of rail travel, however, actually to the traveller it offers different class of comfort. From an unreserved compartment, to the reserved sleeper coach, to the luxurious air-conditioned compartment offering sleeper to a private cabin. Thus all travellers are travelling towards a common destination, but their journey experience is different.

Indian private health care has evolved on the similar principles. The doctors, nurses and other staff who treat patients do not differentiate between what type of service patient is availing from the hospital, e.g. is a he a general ward or a private suite patient. The same doctor delivers top quality health care uniformly to all patients; common destination – good patient outcome. Similarly, the infrastructure and technology needed to provide this care is also the same e.g. operation rooms, CT scan machines, laboratory test etc., are used for all patents. So the only difference is in the perceived comfort factor which patient opts for and chooses to avail in the hospital. This form of system has integrated service and hospitality industry within the healthcare industry.  The synergy is so strong that patients often relate their good or poor hospital experience to the service and hospitality part rather than the actual healthcare delivery aspect. 

The fear is, have we created an illusion for ourselves that we provide good service and hospitality, and then the actual health care part just follows? The answer is no, we still have to keep the destination in sight that is good patient outcome, and then rally all other things around it. In the day and age where luxurious hospitals are becoming the norm, big infrastructure is looked as quality; I think we should not forget the destination. Quality healthcare can be delivered even in a small infrastructure, like a small hospital, as long as quality is the centre of attention. It is our duty as healthcare providers to make people understand the difference between quality service and quality healthcare.

The sacrosanct relationship between the doctor and the patient perhaps is at a tipping point. The paternalistic medicine has ceased to exist. Doctors playing the role of a medical advisor and guiding on what must be done, is slowly becoming a thing of past. Trust in doctors may not be completely eroding but is certainly grinding down. Patients are now immensely educated through the internet, however its use (misuse) via Social Media platforms is dangerous and often the reason for trust deficit; patients and doctors must evolve to this fact. Often poor communication and unrealistic expectations form the basis of deteriorating trust and thus it is time to redefine the doctor patient relationship in India.  

You wouldn’t want someone you don’t trust handling small, everyday matters for you, much less diagnosing a health condition or performing a complex surgery. Trust is the foundation of any relationship, and a doctor-patient relationship is no exception. With this background let’s look at some key aspects to build trust in the 21st century.

Open Two-Way Communication

The single most important aspect is open communication. A doctor is expected to listen to patient’s problems, symptoms and ask relevant questions in order to arrive at a diagnosis. Gentle manners, undivided attention and compassionate communication form the hallmark of good doctor communication. Similarly, patients are expected to convey all information, symptoms and events leading to the problem. However embarrassing or subtle the point may be, the information must be shared with the doctor for him to arrive at a correct diagnosis.  Patients and their families must remember that doctors are trained professionals and only humans, rude or aggressive behavior towards doctor or other healthcare professionals is not only distracting and stressful for these caregivers, and it can also lead to error of judgement. Patients must understand that NO doctor ever wishes any harm to the patient. While it is expected for patients to ask for queries and questions regarding their problems and disease, an irrational interrogation of medical decisions or doubting the ethics will only add to delayed diagnosis and inadequate care.

A doctor should offer a patient and their family with options, and decisions should be mutually shared. Yes, we can tell them what we think is the best option; however, ultimately, the patient and their family are making the decision. Doctors must also act like educators, point patients towards right resources on the internet for reference and protect them from wrong information which is available there. This will help in confidence building. Often an open communication on other opinions helps build a lot of trust.

Cost of healthcare delivery

In a country where majority of healthcare is privately driven, the cost of healthcare is rising daily. Though insurance and some government policies have bridged the gap, it still remains out of reach for a large section of the population. While most doctors and healthcare facilities are sensitive to this issue and do their bit, it remains a challenge. In India we provide quality healthcare at an very economical rate compared to the world and healthcare professional’s remuneration is only a small part of the total cost. But to deliver quality care, one needs infrastructure, equipment, quality checks and standardization, this is where the cost escalates. Our patients need quality healthcare and therefore the cost will have to be shared. Government, insurance, tax exemptions on equipment and infrastructure etc. are some of the key elements to reduce cost burden to patient. While healthcare is now being considered an industry, it is rather unfortunate that some see it as a client and provider relationship. While it is important to bring accountability in healthcare, it cannot be at the cost of disintegration of trust. As I often feel that patients and doctors are one team in caregiving, with a single goal of making patients better. There should not be any ambiguity in understanding this.

Practicing medicine is becoming more difficult than ever before. There is an evolvement of technology and innovation from all corners. Data has become more quantified and we are regulated to follow new guidelines. Our time is being constricted, while more and more is expected from healthcare providers. On these lines, patients have time constrains as well, because they are going through a similar turmoil at their work place, financial burdens and emotional stress. But there are only so many hours in a day and both sides need to balance and redefine how they will interact with each other to optimize care.

Globally, healthcare ecosystems have majorly shifted focus to primarily combating and focusing on the management of COVID19. Citizens all over the world are in pertinent fear of being infected by the unseen threat and continue to take precautionary steps to avoid infection, as guided by administrative protocols. Clinicians in the field have been working with newer diagnostic and treatment delivery tools to ensure better clinical care, along with the continuation of screening measures to adapt to any uneventful situation for those in need of advanced care. 

The 6-minute walk test (6MWT) was established as a clinical test to look for Cardio-Pulmonary exercise tolerance, is now commonly being used as a screening tool for patients with COVID19 who don’t have Hypoxia (low Oxygen Saturation <94%) at rest, or those at a high risk, including patients with comorbidities like existing Heart disease. It is proposed to be performed by the individual from the 5th – 12th day of the onset of symptoms. This will enable a clearer understanding on probability status of Oxygen level decreasing, and will be a huge bonus for those who have been homebound worrying about the infection, especially the elderly. The 6min Walk Test (6MWT) will help measure your Heart rate and blood oxygen levels; which are bound to fluctuate upon exertion. The test is entirely self-paced and you have to do as many laps during the 6mins as you can manage, at a comfortable walking pace within the confines of your room/ home. The test can be administered by a family member using a finger Pulse Oximeter, and does not mandate a doctor, nurse or paramedical to be present.

Here’s how it is to be done: 

1. The patient must wear a simple cloth or surgical mask
2. The pretest baseline Oxygen Saturation should be > 94%, the individual must not short of breath, be at rest and should be able to walk unsupported
3. The individual must walk in the confinement of his/ her room for 6mins non-stop, without any oxygen support
4. After the walk is complete, use a Pulse Oximeter to measure if the oxygen saturation of the individual has dropped below 93%, or if there is an absolute drop of more than 3%

It is important to note if the person is feeling unwell i.e. light headed or short of breath while performing the test, these significant findings need to be noted. This is called ‘unmasking hypoxia’, these patients may progress to be Hypoxic (absence of enough oxygen supply into the body), and hence early intervention in the form of admission to a hospital, or shifting to ICU with Oxygen support +/- steroids as per the admitting doctor. Oxygen concentration in the blood should stay between 94%-100%, a drop below 90% should be considered as an emergency and the patient must immediately be hospitalized. It is important to note that the 6min walk test may be cut short for 3mins in patients above 60yrs of age.

If the person is able to walk unsupported, and is not needing Oxygen to maintain base Line saturation of >94%, there is no need to rush the person to the hospital. You may connect with your doctor over a tele-consultation to share your 6MWT findings, and concern if any.