Worried Warriors

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Doctors, paramedics and biotechnology scholars, currently on the frontline in the battle against Covad-19are delivering efficiently. They, however, regret that the system, their management and sometimes even the society at large, is pushing them to limits, reports Saima Bhat

Doctors on duty at Chest disease hospital which has converted into COVID hospital. KL Image: Special Arrangement

April 19, Dr Ahmad, a 40-year-old Senior Registrar (SR) was treating patients in the emergency unit of district hospital Baramulla. Diagnosing the diseases in patients, Ahmad found signs of infection in himself. Panicked, his colleagues were in shock. Immediately his samples were collected and sent to a laboratory in Srinagar for testing.

The following 24 hours were spent in distress. Literally, on toes, his family and colleagues invoked different verses of the Quran. Prayers on lips that test should come negative. But as it was, Ahmad was confirmed positive, the first doctor in Kashmir. Moments later, contact tracing started and at least 12 of his colleagues were put under isolation. When his family was tested, his wife was also confirmed positive.

Surprisingly, Ahmad had not been taking care of Covid-19 patients. The administration has dedicated a different building for Covid-19 cases, separate from the premises of the main hospital.

Initially, Ahmad, a resident of Kanispora in Baramulla was put under isolation along with his wife in a nearby hotel. As the news spread, locals of the area protested his presence. He was shifted to the hospital and put alongside other positive patients.

“He was told that he will be shifted to SKIMS Bemina but he refused, citing the reason for unhygienic conditions there. He preferred to stay in the Covid-19 centre of his own hospital,” said one of his colleagues.

Isolated, Ahmad along with his wife is recovering, “But this case raised questions over the claims that only doctors treating positive cases need protective gear. Aren’t they putting our lives at risk by exposing us to work without PPEs?” questioned Dr Mohammad, Ahmad’s colleague, in the same hospital.

Working alongside Ahmad, Mohammad, a resident of Srinagar says it is a difficult situation, both inside and outside the hospital.

A doctor takes the sample of a women passenger in Srinagar. KL Image by Bilal Bahadur

Since the last month, when Kashmir declared its Covid zero patient, Mohammad finds it difficult to reach the hospital. He says the management has provided them with a bus, where social distancing is not possible. To avoid the contact, he along with his two colleagues has hired a private vehicle. “We have hired a vehicle in which only four people travel including the driver,” he said. “Going into an ambulance is also a problem. You don’t know if that has been used to ferry Covid-19 positive patients,” said Dr Mohammad.

Once they reach the hospital, Dr Mohammad says their anxiety levels are high and they keep on praying that no Covid positive patient should cross their way. “Initially there was a lot of confusion, no protective gears were provided but then a local NGO run by the doctors helped. This gear is not 100 per cent effective, but we manage with it,” he said.

The hospital has constituted different teams for the door to door survey in the district. Provided with only face mask and pair of gloves, the teams visit different areas. “We have seen 80 per cent of the Covid-19 positive patients are asymptomatic and we go to the red zone as well. We are short of N95 masks but still, our supervisors manage to get us surgical masks that we require,” Ali Muhammad, a health worker in the district, said.

A doctor displays a collected sample of a person in a Redzone area of Srinagar on Thursday 30 April 2020. The administration is conducting a health audit of the entire population of Srinagar to contain the spread of coronavirus infection. Kl Image by Bilal Bahadur

The crisis is triggered due to the rotation of the staff in the gynaecological department.  “The gynaecology department is a problem. The SRs have to give their duty in Covid-19 building and then with normal patients as well, which poses a serious risk for doctors as well as the patients. A medico can also be a carrier,” said Dr Mohammad. “The district administration had earlier decided to dedicate Sopore district hospital as Covid-19 dedicated hospital but what happened to that plan nobody knows.”

As on April 30, a total of four professionals have tested positive in north Kashmir including one doctor, one staff nurse, and one paramedic from district Baramulla and one more paramedic from the Kupwara district. Out of these, two were reported to be off the roster so nobody knows how they got the virus. The district has 105 positive cases so far.

Inside the labour room, on April 27, four pregnant ladies from a red zone of Anantnag district, who had all tested negative, were put in a ward where a six-month pregnant lady, a Covid positive, from district Baramulla, was already admitted. With one lady already in labour, the doctors on duty were one SR and PG. When they called a consultant, she suggested delaying surgery until the following morning. The pain did not allow the delay; however, operation theatre was in a shambles.

“The doctors had to decide between life and death. The SR first cried her heart out and then went for the surgery. There was no apparatus available, not even to check the foetal heart rate, and when she called the radiology department for a USG, they came after an hour, when the surgery was already done. Till the delivery was done the doctor did not know if the baby was alive,” said Dr Shazia, her colleague.

Coronavirus: 20 more positive patients recovered, discharged

This is pure injustice, said Dr Shazia. “Before declaring it a Covid-19 exclusive hospital we had asked them to include a negative pressure room for anaesthesia and a positive pressure room for surgery capable of exchanging theatre air 25 times per hour. The air coming out of theatre has to be treated to prevent the dissemination of viruses into the air. Simple exhaust fans are super-spreaders especially if repeated surgeries are conducted under them. Instead, they tell us we have fumigated the hospital but are we fools that we will accept it which is a 24-hour process. They have put our lives at risk. They are helping in increasing the community transmission,” she added.

Done with her duty, when the SR completed her shift, she had to go for quarantine. She reached the designated hotel by 6 am where she was made to wait for four hours. “She cried in desperation,” said Dr Shazia.

The gynaecology department in SKIMS Bemina has six consultants including the head of the department, seven senior residents (SRs), and four postgraduates (PGs), which means the SRs and PGs have to attend their duties thrice a week.

But last week when the department received a Covid-19 patient from Baramulla, it exposed two of the doctors: one SR and one PG, who were sent in quarantine.

Dr Sara, one of the doctors informed Kashmir Life that when she comes for duty, she prays first at home that no Covid-19 patient should come to her department. “And when I have to wear PPE, believe me, I keep on reciting darood sharif and other duas, not to get this virus. If you check our anxiety level while wearing these PPEs it will be 100 per cent.”

“These PPEs are mere a double layer of disposable dining sheets. When you wear them it gets foggy and the person next to you gets blurred, then how is it possible to conduct surgeries in such gears? Last time I started wearing one and its zipper broke and I had to tie it with the pin of my headscarf,” she said.

Meanwhile, a doctor wearing a PPE got his foot stuck and he rolled down four staircases. Somehow a nursing orderly came to his help and saved him.

Kashmiri medical staff walks in a residential area which was declared as a red zone by the authorities in Srinagar, on 9 April 2020. The UT government has declared 45 areas as red zones in Jammu and Kashmir. KL Image: Bilal Bahadur

The problem in the hospital is there is no differentiation. As insiders said, all the positive patients nearing 150 admitted in this hospital are asymptomatic and they keep on roaming around. “If you come to the hospital you will think they are attendants. They don’t sit on their beds. How do you know they have not touched any surface? They use the same washrooms. At least they should have separated the Covid-19 hospital from the routine patient care,” said Dr Shaista. “We are not saying we will not treat positive patients. We are ready to give duty in those wards but please don’t put our lives and patients live’s at risk who come for surgeries.”

Lamenting the system, another doctor, Hajira said: “Delivering a baby means involving a lot of blood. When you are doing surgery, means you have 90 per cent chances of getting infected. When ladies are in labour, it is obvious that they shout. Viruses from fumes of her blood and mouth put treating doctors at risk. And they give you N95 for theatres when we should have respirator masks for surgeries.”

“The doffing area, where we put this PPE and wear masks, you will see a pile of around 5 feet of used PPEs in the labour room alone. The hospital administration doesn’t clean them,” said Dr Hafsa. She added, “It is us juniors, SRs and PGs who have to treat these patients. Consultants just pay a visit once a day and they don’t even touch them.”

Raising their concern, a delegation of doctors went to the office of principal on April 29, and gave in writing that if they are not provided with adequate facilities to conduct surgeries they will go for mass resignation. “We have got exposure with positive patients and then they ask you to give duties even before completing your WHO set quarantine of 14 days. Why should we opt for suicides?” question these protesting doctors.

In 2018, an audit found the doctor to patient ratio in the erstwhile state was one of the lowest in India at 1:3866 when the national average is 1:2000, while the World Health Organization recommends a norm of 1:1,000. The study also found less than 50 per cent of nursing positions had been filled.

At present, there are around 70 SRs at the SKIMS Bemina, out of which three remain available on every night duty. “Dr Asif, a junior doctor was terminated because he asked for standard quality of PPE but instead he was handed over his termination. They can’t threaten us for not speaking for our demands. How can they run a Covid-19 hospital when they have just two ventilators available,” said another protesting doctor.

All these doctors at SKIMS Bemina say they don’t speak to one another but once they are in their quarantine homes, they call to talk and share their anxieties on phone.

At SKIMS Soura, the story is different. Nobody is willing to talk or share anything. The warning has gone around, the suspension would follow. From doctors to support staff, everybody is tight-lipped.

The administration in SKIMS has designated a separate building as Covid exclusive centre and everything is held in secrecy.

But by keeping the Covid-19 hospital inside the Kashmir’s tertiary institute has affected its routine. Sources in the hospital said these days only 10 to 20 per cent of the patients visit this hospital in the OPD and that flow includes mostly cancer patients who have their treatments due.

“In the last one month, we had eight Covid-19 deaths but tell me what will be the number of patients who must have died because of heart attacks, kidney failure, accidents, and other diseases. Was it worth doing this injustice with the routine patients who have their last hope with SKIMS Soura only? They could have kept this service for Covids at some other place,” said Dr Dar.

Other than Covid-19 duty doctors, the rest of the staff who come regularly to their work have been provided with surgical masks only. “Just yesterday when I was coming out of a microbiology lab, I saw three-person in PPEs roaming around with samples. No doubt the samples were packed but what is the guarantee that those three officials had not come in contact with positive patients and is there a guarantee that they had not touched any handle. They are exposing all others. The Covid-19 testing is done on the second floor of the microbiology department and normally it is not traceable. It should have been kept somewhere on the ground floor,” said Rafiq Ahmad, an official in the hospital. Giving numbers he said, “Before this pandemic, the lab used to get 450 samples a day but now there are barely a few. And there is no guarantee that for baseline testing if there is no mixing of samples of Covid positives and negatives.”

One staff nurse of this hospital has tested positive after she returned from Umrah but it could not be verified if she had joined her duties back or not.

In south Kashmir’s Anantnag, a new Covid-19 hotspot so far three paramedics have turned positives. The area recently had controversy when Rukaya, a pregnant lady with twin pregnancy died along with her babies inside the hospital. She was declared positive posthumously.

Earlier, when Rukaya reached district hospital, many passersby helped her while coming out of the ambulance. Later many helped in the hospital and after her body was taken back home.

“When we received her, no microbiologist was available for taking her sample. Her sample was taken by a registrar of the ENT department. It is a failure of administration that proper SOPs were not followed. The doctors who came in contact have gone in quarantine,” said Dr Bhat, a senior consultant.

Another doctor in the hospital suggested that specific ambulances should be kept for red zone areas. “If we have specific ambulances for red zones that will help in identifying the risk and use of the protocol. Otherwise, there will be huge community transmission,” said Dr Nasir.

The Super Speciality Hospital at Shirinbagh In Srinagar.

In Shopian district, where the Hirpora area is turning another breeding ground, one paramedic has tested positive and in Pulwama district where a staff nurse initially developed symptoms after coming in touch with a positive patient has tested negative recently.

The district hospital Pulwama is the only Covid-19 exclusive hospital where the segregation of patients has happened. On March 28, the Deputy Commissioner Pulwama, Dr Raghav Langer while invoking the Disaster Management Act took control of two private hospitals in the area and converted them for treating routine cases. One was designated for gynaecology, obstetrics and paediatrics and another for general surgeries.

“This decision helped us because we have a satisfaction we are separate from Covid-19 positives. We conducted at least 205 delivery cases in Mohmadiya nursing home and treated more than 2600 patients in OPD. In paediatrics, we saw around 1300 patients,” said Dr Shahnaz. She also says the gynaecology department bears the brunt as earlier they did not know who could be positive or suspect.

“We used to take patients from the red zone with high risks because we had no other option. It was a double-edged sword. But now thankfully there is a new guideline where every pregnant lady will be tested in her 34th week. It will help in reducing our anxiety while dealing with such cases,” Dr Shahnaz said.

Her colleague in the surgery department, Dr Rouf said they also conducted around 50 routine emergency surgeries in another private hospital, Zeenat Nursing Home.

At the main district hospital premises, where only positive patients are treated, there are only five physicians on duty. More than one thousand samples were taken at this hospital. Of these, 11 patients tested positive, 8 have been sent back for home quarantine and 3 are still in the hospital. Other than that 200 more patients were put in isolation in another building of the hospital.

“We have been given required PPEs but after performing our duties, when I reach home, I put myself under self-isolation because I have a nuclear family so going home is important and at the same time you cannot put the life of your family at risk,” said a doctor posted at Pulwama.“I have elderly parents so self-isolation is the only option for me.” He also accepts the fact that no doctor got the time to be in necessary quarantine if the doctor got exposed to a positive patient.

Back in Srinagar, at the super speciality hospital in Shireen Bagh, an extension of SMHS hospital, panic gripped when a female patient in the plastic surgery department, admitted for last seven days, tested positive on May 1. Her surgery was not done in time as her test was awaited.

The hospital went into panic mode as the patient was admitted in a normal ward with at least eleven patients, including two who were recently operated upon and had tested negative.

The doctors on duty said that this hospital also lacks negative pressure or scavenging system in the operation theatres. “OTs are the most vulnerable places as a lot of aerosols is generated, which makes it unfit for any kind of surgery in the wake of the pandemic.”

Now the samples have been taken from all the patients and at least 30 health workers including five doctors, nurses and dressers who have been put in quarantine for the time being. “Trust me the whole hospital has been exposed because the doctors on duty that day themselves accepted they were going to other departments as well,” said a doctor privy to the developments.

As on date, one senior doctor from this hospital has tested positive and two more attendants have also tested positive, including Asif Mir, 32, who died on the intervening night of May 6-7 in the SMHS hospital.

The situation has led to the dearth in staff in the hospital and at the same time, officials blame hospital administration for putting their life at risk. “If health workers will get a virus with this pace, then who will be left to treat the patients? All routine surgeries should have been put at halt till this pandemic would have been over. We don’t have any PPEs to operate to treat patients,” said a doctor posted in the hospital.

Dr Khan, working in the SMHS hospital, was on duty two days after this incident. “Trust me I was not feeling like coming to the hospital. When I reached the hospital they provided us with a long raincoat, which they call PPE and gave four surgical masks saying this is my quota for one month. This was the first time I was provided with this stock since March 18. Trust me the face shield with this PPE was of a normal polythene bag. When I asked them how this can suffice me when I have three duties every week, they said I should take them home and get them washed. I was astonished to see their approach. How can I wash a disposable PPE and the masks?”

When Khan was on duty, he sent his pictures to this reporter showing how he was wearing a surgical gown over the given “PPE” and three surgical masks beneath an N95 mask. “I requested my colleague in the surgical department who gave me his extra PPE, eye shield, face shield and N95 mask which he had purchased from the market. I am also thinking of purchasing my sets now. The hospital administration is good for nothing,” he said adding, “We are stressed not of Covid now but of arrangement these PPEs now. We don’t have even doffing and donning areas, we have to change at home. Imagine we are taking all this to our homes.”

While Khan was on duty, they received a patient from Shireen Bagh hospital. “Nobody is daring to go and check the patient. We don’t know if our gears will save us or not.” His colleague added, “Outside India only consultants and HoDs died because of treating Covid patients but here in Kashmir it is all opposite. These patients have been put at the mercy of SRs and JRs.”

The same night panic gripped Kashmir’s lone maternity hospital when the doctors came to know that the lady they received in the middle of the night and helped her to deliver her baby normally, was actually a Covid-19 positive patient. It has compelled at least two doctors and eight other staffers including nurses to go in quarantine, out of them one staff nurse has tested positive. At the time she was admitted in a three bedded labour room, she was placed on a bed where usually one bed is shared by two or three patients. “We have overcrowded labour rooms and then the attendants outside labour room are also in hundreds. We heard her attendants were present in the waiting area, who knows they are not positive?” said an insider.

“At this hospital, on an average a hundred deliveries are done every day, imagine how a Covid positive patient can turn this hospital into catastrophe. Can’t we be civilised in revealing our identity,” said a doctor from LD hospital claiming the patient had hid her details that she was a Covid positive and allegedly she had not revealed the details at Anantnag and SKIMS Bemina hospitals, where her attendants had said she is negative.

=As the rate of testing has increased at the two testing labs at SKIMS and SMHS associated labs, the picture is getting clear of how many Covid-19 positives Kashmir has. Initially, only 150 to 200 tests were done but now around 1000 samples are tested every day. The insiders give credit to the helping hand provided by the Vice-Chancellor of Kashmir University and SKAUST who gave their researchers as volunteers to work in these labs.

“The government had asked for highly specialised equipment such as PCR- or polymerase chain reaction-machines to use them for Covid-19 tests. And then they asked for researchers as well. From Kashmir University alone, we have provided at least 10 researchers who volunteered for this work from three departments: biotechnology, biochemistry, and clinical biochemistry departments,” says Dr Altaf Bhat, assistant professor of biotechnology department and the coordinator of this help.

SMC workers fumigate disinfectants in the area housing the Chest Disease Hospital that was recently converted into a special Covid-19 Hospital. The picture was taken minutes after one patient died on March 26, 2020. KL Image: Bilal Bahadur

“We provided them with equipment such as RT-PCR machines, which can run 96 samples per run. We also provided them with a high-speed refrigerated centrifuge. In addition to that, we provided other small equipment like reagents for testing,” Dr Bhat added.

These researchers are presently working at the SKIMS and CD laboratories where Covid-19 tests are being done. “We cannot do these tests in normal labs, it has to be bio-safety level 3 labs only where the chances of spreading the infection are less,” said Dr Bhat.

The help from these two universities was appreciated by Dr Muhammad Salim Khan, the spokesperson of the GMC hospitals in his tweet. “The faculty and research scholars of The University of Kashmir and (SKUAST) the Sheri Kashmir University of Agriculture Science and Technology have volunteered to be part of Covid-19 labs at the Government Medical College Srinagar and SKIMS (Sheri Kashmir Institute of Medical Sciences). They came forward wholeheartedly while understanding the risk of working with the live virus causing Covid-19. They are the role models,” tweeted Khan.

Other than these researchers, at least 500 lab technicians were trained and sent in all districts of Kashmir for sample collection. “Earlier patients from district hospitals had to reach CD hospital or SKIMS lab for sample collection but now we send the sample collectors in these districts and they send us only sample not patients,” said a doctor privy to the developments in the directorate of health services.

“We usually do not sleep during nights,” one of the SKUAST scholars who volunteered for the exercise said. “Nights are cool and calm and without any intervention. We are doing our best to reduce the load and keep the society safe.”After every two nights, he goes home for a few days rest and returns to the duty.

Meanwhile, a doctor at the police hospital, who had come in contact with a positive patient at Pantha Chowk police lines, was traced and tested for the virus. “He was living on rent. When we traced his contacts and tested him, only one person from the same building tested positive but the doctor himself and his family tested negative,” said a health official.

But the worst case was reported from Jammu where a doctor from microbiology was tested positive while working in the hospital. Later his wife, a dentist, and his father, a retired senior superintendent of police, also tested positive.

The assistant professor of microbiology at Jammu Medical College got the infection while working in his laboratory but there was a “smear” media campaign against the doctor saying that he had links with Tablighi Jamaat.

A Jammu newspaper quoted Dr Shashi Soodan, head of microbiology at the medical college, as saying his infected junior was not part of the Coronavirus testing team. The implication seemed to be that he had got infected somewhere else. But when the same doctor was called by The Telegraph she said that the infected doctor was 100 per cent part of the sample collection team.

“The doctor was never associated with the Tablighi Jamaat. They were just giving it a religious angle, said one of his friends and colleague from the same college. But by then his family had to pay the price as they were not initially tested and then they had to wait for three days to get hospitalised, reported The Telegraph. So far there are six doctors who have tested positive in Jammu.

(All the names of the doctors in Kashmir have been changed on request.)

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