As the COVID-19 cases in Mumbai have spiked, the city is facing a shortage of hospital beds, ventilators and oxygen support. BMC Chief Iqbal Singh Chahal, addressing the media had said that the richest municipal corporation in the country, BMC is trying to increase the availability of beds to remedy this, and also streamline procedural delays that citizens are facing because of shortages in ambulances and delays in testing.
Meanwhile, BMC has stated that 99% of the 645 COVID-19 Care ICU beds were occupied, 65% of the 4,292 beds with oxygen support were occupied, while 72% of 373 ventilators were in use as of May 28. But patients and activists have complained that their experience while searching for these facilities are quite different. News agency PTI reports that the Maharashtra Public Health Minister Rajesh Tope announced that they have served show cause notices to four prominent private city hospitals for not following rules with regard to COVID-19 treatment and warned of strict action against hospitals violating norms.
Farah Ingale Senior Consultant, Internal medicine at Hiranandani and Fortis Hospitals comments on the number of cases she sees in intensive care in Mumbai. She says, "75-80% of the case are asymptomatic or mild, 15% are serious and 5% of them only are critical. And then different strains of viruses also, which we are not yet clear about. Initially, there were a high number of serious cases but now the figure has come down. It is at par with any other major city across the world."
Dr Bharat G Jagiasi, Head Critical Care, Reliance Hospital, Navi Mumbai agrees with Dr Ingale. According to him, one of the reasons there is a shortage of ventilators is that COVID-19 patients need to be on ventilators for too long.
He says, "A COVID-19 patient requires ventilation for 14 days, and it can extend up to 25-30 days. which is different from other diseases where patients are free from the ventilator in 5-7 days. And it is occupied for a longer time. The recovery is very slow among COVID patients."
But Dr Bharat G Jagiasi says mortality rate has come down because India was not one of the initial countries to face the disease. "The understanding of the disease is better now, so what we were doing initially we thought it was more of a thrombosis. We have learnt to manage the disease in a different way. The mortality rate has come down, we've understood how to treat the disease. We are learning something new everyday."
Dr Ingale says echoes the same sentiment, "We initially thought it is a respiratory illness but now we know the pathophysiology of the illness. We are looking at what is happening around the world and we are treating people accordingly."
You can read the full transcript of the discussion conducted by BOOM's Govindraj Ethiraj below.
Govindraj Ethiraj: Your takeaways from what you have been seeing in the last couple of weeks and the progression of the disease particularly among COVID 19 patients.
Dr Farah Ingale: Basically, what you said, I completely agree with you. Mumbai is a metropolitan city; the population density is also very high in Mumbai. All the major metropolitan cities, all over the world, have large number of cases. Why Mumbai more so is because—now I can take the classic example of Dharavi, Asia's largest slum, and in the world the most densely populated slum.
Now, here in Dharavi, we have people who are not from Mumbai in particular but have come and settled from outside. See, it is a distance of about 1.25 sqkm, but the population is around 7-9 lakhs, I think. So, you just imagine how they must be accommodating themselves—in a room of maybe 10x10 or 10x12, there are about 12 people staying. So social distance has gone for a toss.
And they do not have attached bathrooms, toilets and washrooms with them, so they use the common ones. This virus gets excreted in the stools also. And it can remain alive for a month, 4-6 weeks. Once the infected patient uses the washroom or toilet, they should flush it out properly and the other person should not use for 1-2 hours, which is not possible. So, I think that is the reason—no social distancing, no personal hygiene that much in the slums, and then these people are into trade. They have leather, textile and pottery; people from good socio-economic status go and visit their shops and that is how it must have got transmitted.
Govindraj Ethiraj: That explains the high number of cases, what explains the high number of cases going into intensive care?
Dr Farah Ingale: As you said 75-80% of the case are asymptomatic or mild. 15% are actually serious and 5% of them only are critical. And then different strains of viruses also, which we are not yet clear about. Like what you said, initially there were high number of serious cases but now the figure has come down. It is at par with any other major city across the world. It is not that...initially it was high...
Govindraj Ethiraj: Dr Jagiasi,how are you seeing patients coming to your hospital—I am talking of COVID 19, of course. Do these numbers that we are seeing from the BMC match with what you are seeing at your hospital?
Dr Bharat G Jagiasi: As of now, what we are seeing is there are around 250-300 cases admitted under my care; around 50-60 are in the ICU and certain number on the ventilator. As Dr Ingale, said, it is right, there are a number of cases—you need to understand the definition. I think there was confusion when we were narrating the figures by the national authority. The intensive care patient and the critical care patient remain the same. The same terminology: I mean the meaning is same, terminology is different.
You cannot say different figures for the intensive care and different figures for the critical care. So, what they must be thinking is—there must be a certain set of patients who require just oxygen, and they do away with it or we can call it hyponasal cannula or non-invasive ventilation. So those are kindly, I would say that they are still severe, they must have said that those are modestly severe and there are certain cases who require full blown ventilators. We have those kind of cases along with us. So, the percentage wise, as Dr Ingale said, somewhere around 10-15% needs intensive care. But severe are the ones who I would rate require the ventilator—those are around 3% or 2.5% of the cases, which require the ventilator.
The problem here is the average ventilation time is pretty long. One of the patients that go on ventilator minimum is 14 days and it could extend to 25-30 days, which really involves a ventilator for a long period of time, which is not like the other sets of disease where the patient is ventilator free in 5-7 days. Here my ventilator is occupied for a longer time, and this is where the acute shortage of ventilator comes in play. So, the figures, what you have been propagating, I think there is some confusion; someone who has projected the figures, these are not the real ones. Maybe I would not say, real one, no one would project those kinds of figures, there is some problem in quoting the numbers or understanding the terminology.
Govindraj Ethiraj: So, let us put the numbers aside. The idea is not to debate the numbers. I am trying to understand from your own experience. So, you said, you had about 250 patients from start or is it in the last....currently?
Dr Bharat G Jagiasi: It is not the numbers at this moment. Total patients admitted under my care 250, and around 170-180 have been discharged out of those and 80-85 have been left under my care, at this moment.
Govindraj Ethiraj: Of these you said only a few are on ventilator right now?
Dr Bharat G Jagiasi: Yes, few are on ventilator. About 2.5% go on the ventilator.
Govindraj Ethiraj: That figure is somewhat accurate...
Dr Bharat G Jagiasi: That is among my institute. I do not know what is happening at the other institute.
Govindraj Ethiraj: Among these patients, you are also saying that most of these patients have been under ventilator for more than 14 days or at least 14 days.
Dr Bharat G Jagiasi: That is the average median time, that is across the globe. The recovery is very slow among these patients and so the average ventilation time if someone recovers is obviously 10-14 days among these patients.
Govindraj Ethiraj: How many ventilators do you have in your hospital?
Dr Bharat G Jagiasi: That would be difficult to quote because those stats are with the hospital, but we have enough I would say.
Govindraj Ethiraj: Dr Ingale, how is it in your hospital or in other hospitals that you know of. The number of patients on ventilators vs the number of patients in the general ward, who are also being treated for COVID 19?
Dr Farah Ingale: As Dr Bharat has rightly said, see the number of patients on ventilators are at par with any statistics, anywhere else. It is not that we have too many...and it varies from person to person as to how many number of days they are on ventilator. But usually it takes 2-3 weeks, once they are on ventilator. Now, ours is a DCHC, so we have mostly mild to moderate patients in our hospital. But you never know, patients just deteriorate fast, in a day also they may deteriorate.
And those patients who require ventilators, inhouse patients, then we put them on ventilator. We do not accept serious patients from outside just because ours is not a COVID hospital. So, like what Dr Bharat said, it is around 2-3% and that figure matches, the figure anywhere else. And it is not like that Mumbai patients are more on ventilators or Mumbai the patients are not recovering. Many of them are recovering, we are following the standard protocol and they are responding as they are anywhere else.
Govindraj Ethiraj: Let us take a step back. Let us look at critical care or intensive care—in intensive care it is not necessary that you are under ventilator
Farah Ingale: Correct
Govindraj Ethiraj: So, how is the percentage or proportion then?
Dr Bharat G Jagiasi: 5% somewhere around
Govindraj Ethiraj: 5% is intensive care, so, what is the periodicity. So, when people go into intensive care unit, we are only talking of COVID 19 patients. How long are they usually there in your experience?
Dr Bharat G Jagiasi: We said recovery takes pretty long. So average stay in ICU is around 10-12 days and if someone gets ventilated, then the stay is prolonged. The percentage of ventilator, though ours is matching with what the society has, but obviously there are different demographics, if I have more of diabetics, more of 65 years and above coming with me, so those are the risk factors associated with the patients going on the ventilators. We have very few patients being young and being on the ventilator. It all depends on the demographics. There have been institutes where there are more patients on the ventilators; the reason being they had more of the older patients, diabetic patients, heart patients along with them.
Govindraj Ethiraj: Let me ask you a slightly different question. Do not give me numbers. But give me percentages if you can. In your hospital, suppose there are 10 beds in the intensive care unit, how many are being occupied by COVID patients, how many are being occupied by non-COVID patients who may have been there much earlier.
Dr Bharat G Jagiasi: Now see, as Maam rightly said, we have been the COVID unit, so we have certain assigned beds for the ventilators, certain assigned beds of the hospital for the COVID patients; so all those beds are occupied by the COVID patients and there is no bed left in that unit for non-COVID patients.
Govindraj Ethiraj: But in the hospital, overall, you do not have any non-COVID patients who is also in the ICU...
Dr Bharat G Jagiasi: We have few patients for the non-COVID patients as well, but the occupancy over there is not.... because in this era, people are not willing to come to the hospital for the other complaint. That is the reason those beds are lying vacant. But whatever number has been allotted for the COVID patients, those have been almost occupied.
Govindraj Ethiraj: Dr Ingale, let me ask the same question to you. The reason I am asking you this is, in normal times hospitals are full in this country—people are in ICU, people are getting ventilated for all kinds of problems. What is that load that you are seeing at this point particularly in critical care units, apart from COVID.
Dr Farah Ingale: As doctor, Bharat said, in this period of lockdown, people are not supposed to move out of their house unnecessarily, except for urgent work. What I have seen is, because we are staying indoors, most of the communicable diseases, the incidences have come down. Of course, there are patients. Like there are not many patients, because of fear they are not coming out and we are not doing elective surgeries. Most of the surgical-ICUs, we have post-op patients.
So elective surgeries we are not doing this season, more concentration is on COVID. That does not mean that we are not accepting non-COVID patients, or we are neglecting them. But the overall reporting from non-COVID patient is comparatively less. It is only the emergencies we are taking. So, we have both the COVID and have started non-COVID work also but everywhere else also the non-COVID work is less, and it is only the emergencies that are coming.
Maybe because of the lockdown, maybe because of social distancing, maybe because we are using the masks, the incidences of infectious diseases, I feel, have come down dramatically. That is why maybe those patients are not that much coming out, they are not reporting to us, because the incidences itself have come down.
Govindraj Ethiraj: That is very interesting. Can you give us an illustration of an infectious disease that someone may not be getting now but may have been getting earlier, because they are adopting all these precautions?
Dr Farah Ingale: All sorts of communicable diseases, basically, which are transmitted through the droplets—that is the respiratory illness—the other because people are not going out, they are having food inside their house, so those problems, the gastrointestinal problems, maybe eating in the restaurants, the hotels, outside that also is less. So gastrointestinal problems, respiratory problems, cough and cold, influenza like illness have come down.
Govindraj Ethiraj: We are talking about critical care; we are not just talking about patients coming into your hospital?
Dr Farah Ingale: Ya, that is true. But those patients also get critical because of the infection. If the infection spreads everywhere—they land in sepsis, multi-organ problems and so on. Not all of them, now the diabetic, they are taking extra care of themselves.
Those patients who become critical are the elderly patients, diabetics, people who have cardio-vascular problem, hypertension—now they are also taking good care of themselves, not exposing themselves, taking the medicines on time, following the consultation with the doctor, they are keeping the problem under control because of the extra fear they have...So they are not getting serious.
Govindraj Ethiraj: That is a good thing to hear. I am assuming that the other kinds of cases of you are not getting much is accidents...
Dr Farah Ingale: Accident also, because nobody is there on the road to drive that much. That many vehicles are not there on the road
Govindraj Ethiraj: Is that your experience also Dr Jagiasi...some categories of
Dr Bharat G Jagiasi: She rightly concluded. Maybe because of lockdown, everyone is sitting at home. So, you have enough time to look after yourself. Everyone is taking medications on time. They are not missing the doses, which would routinely happen when you are busy with work. Outings have gone, outside food has gone, so incidences of food poisoning have gone down.
I would like to add just one more thing—the air is more purified now outside; pollution levels have come down. So, the patients who were coming to the intensive care were the acute patients of asthma, COPD, they were the ones who were taking major bite of the ventilator. So, all those have come down because air is more purified. Patients, neither because of the polluted air, nor because of the infections.
Govindraj Ethiraj: These you are seeing a dramatic difference between January, February, March, April...or April May
Dr Bharat G Jagiasi: It is a very big difference. What we are seeing is the amount of the non-COVID patients have come down significantly. Whatever you take. You take it as pulmonary disease, cardiovascular disease, abdominal disease everything has come down.
Govindraj Ethiraj: This is not because, my own colleagues tell me constantly that, people are trying to get admission into hospitals but are not able to get...You are saying, fundamentally, the disease profile for now has changed...
Dr Bharat G Jagiasi: No, for the normal non-COVID area there are enough beds available everywhere because though the hospital has assigned 20% of the beds in the non-COVID area as per the new regulations of the government, even 20% beds are lying vacant. I do not think to occupy that 20% of the beds is a problem, anywhere in India at least.
Govindraj Ethiraj: Dr Ingale, I was speaking to Dr Srinath Reddy of PHFI, and I was asking him what is the one figure you would look at to understand or to convey, what is our grasp of this situation in terms of fighting back the coronavirus? His point was: the only data point that matters is the death per million, DPM, or essentially how many people are dying. What is your experience on that score Dr Ingale? Are we doing well, are we doing fine?
Dr Farah Ingale: We are doing really fine, I can say because the number of deaths has come down now. See, initially, the mortality was high, in Mumbai, if I talk, it was 7.2 something. It has now come down to 2.9 to 3%. So, we are doing well, we are at par. Now, people have got used, I think there is a sort of, maybe, I cannot say herd immunity, many of them are already infected, maybe they are asymptomatic, they do not come to us.
Those people are not infective to society, but they may be helping indirectly ibn developing immunity in society. And the people are responding, and we are at par as far as the mortality is concerned. I do not think that the problem is going to go away that easily. I think it will stay. We have to continue staying with the problem. It may be like HIV patients, the measles patients, the chickenpox patients, the other viral illness—which comes in crops, seasonal and it may stay.
And the vaccine is also not seen in the near future. It may take 1-1.5 years. So that problem is going to say, but over a period of months, it is nearly six months, since December the problem has started in China and we have experiences from all over the world and we have learnt which medicines are acting better. So, we have come to, in a way better treat the patient now, with experiences from all over the world and we are getting better results also. So, the mortality has definitely come down.
Govindraj Ethiraj: Dr Jagiasi what is your sense of mortality? How are we doing? Also, in the mortality we are seeing are there any more insights about where the incidences are higher, and the demographics?
Dr Bharat G Jagiasi: No, mortality has come down. But my explanation of mortality coming down is different from what Dr Ingale says. I would say we are lucky that we were not the initial ones to have the disease. So, we had the experience of China, Italy, NHS and we are talking to our colleagues across the globe. So, the understanding of the disease, understanding of COVID 19 is better among the critical care specialists.
So, what we are doing initially, what we do for a normal person is kind of a different disease altogether----initially we thought it was more of pneumonia, now everyone has agreed that it is more of thrombosis....... that is happening. So now the treatment is different from what we did initially. Now we have learnt to manage the disease in a different way. So, the mortality has significantly come down, even the survival from the ventilator.......better than the global......we had initially. So,…. unfortunate one to have the crisis earlier on, we did not know exactly what it is, now we have understood it and now we know how to treat it in a particular manner. This is what is helping us.
Govindraj Ethiraj: You are also the joint secretary of the Indian Society of Critical Care Medicine. So, what are the kind of notes that you and your colleagues are exchanging right now?
Dr Bharat G Jagiasi: There are the regular webinars happening and we have involved all our friends from US, Italy, UK. So, understanding of the disease is better. Initially, over two months back we used to ask them what exactly is happening, and they had those post-mortem reports. So, the treatment has varied—initially what they were doing at that moment—and what we are doing now is really a different treatment and we have different approach altogether towards the patient and that is what is helping us. So, this is what the discussion goes on always. Because it is a dynamic field, a new thing, everyday something new comes up and it helps us a lot.
Govindraj Ethiraj: Last question, Dr Ingale. In the mortality records, in the deaths we have seen, any trends, any common factor. I have seen the data on the age profile and so on. Any other insight you have from the mortality we have seen so far
Dr Farah Ingale: See, as Bharat has said, initially we thought it was respiratory illness. But over a period of time, with data coming from all over, we have come to know that it is not completely respiratory illness. There is thromboembolic phenomenon involved. And as he said over a period of 5-6 months, we have evolved and come to know what is the pathophysiology, and we are treating accordingly. So, we have started with a treatment protocol based on all the experiences from all over the world.
And that is why we are getting better results. I completely agree with him. And that is what we are also saying. When we do the scan, we find the typical findings, when we do the lab tests we come know...they have high d-dimers, high fibrinogen levels, FTP level is high, CRP is high, there is a thromboembolic phenomenon—involving the patients all over.
Those are the reasons......and that is also the reason for mortality. Accordingly, we have come to understand the pathophysiology better, that is why we are able to treat better. And we have formed a protocol accordingly and that is why patients are responding better.
Dr Bharat G Jagiasi: Among the risks what you are asking, apart from the normal, what is more important is, what is not very much aware of...is obesity. It is the number one risk factor, more than diabetes and hypertension. Obesity is one of the highest risk factors; this is what we are getting from across the globe.
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