Scared patients, overflowing hospitals and overworked doctors​: It's time Tamil Nadu govt got its act together in Chennai

It's 8 pm. The streets of Chennai are dead. The checkpoints have multiplied for this 12-day lockdown, so have the cops on the street. Every vehicle is being stopped, scanned, questioned.

Near the Rajiv Gandhi Government General Hospital (RGGGH), one of the four main facilitates which is treating COVID-19 patients in Chennai, this reporter saw an MTC bus leaving with a few healthcare workers. All of them looked like they were about to pass out. As we parked next to the canteen, this reporter spotted a doctor in blue scrubs and a green mask, walking with her head bowed down. In 2017, this reporter had interviewed a bunch of newly-christened ‘doctors’ at this very spot. Three of them had animatedly spoken about throwing themselves headlong into the profession, in spite of the various drawbacks.

Opposite the parkin, a board read: new PG Hostel. Wonder how many of the 42 PG doctors from Madras Medical College, who had tested positive for COVID-19 almost two weeks ago, stayed there.

Meanwhile, the reporter's friend’s cousin got out of the car and was waiting to catch a glimpse of her husband, who had tested positive a few days ago. He had almost recovered from fever when he experienced a bout of breathlessness and had to be rushed back to the facility. Since he has been at the COVID facility inside the RGGGH campus. She was bringing him a change of clothes, some medicines and was seeing him for the first time since he was admitted at the facility. They exchanged a few nervous words, as my friend and I tried to look away.

The COVID Outpatient Block is two towers away from where we stood in Tower 1. These towers have a raised entrance, which makes the reception visible from the road, as well. As we started driving past the campus, I looked at the bright lights coming from the tower. Nothing poetic came to my mind but the dead silence, which is unusual to the hospital because usually it is bustling owing to Chennai Central Railway Station which is located right across the road. The jarring lights coming from the COVID Outpatient Blocks, only added to the general uneasiness that one had started to feel in Chennai.

Rajiv Gandhi Government General Hospital in Chennai

The COVID-19 Outpatients Block at the RGGG Hospital is built like a wedding hall. It has huge steps leading up to a hall-like reception. On either side are ramps. Ambulances stop at the right corner, from where patients can be wheeled in. Before you enter, there is an assistance kiosk outside labelled ‘May I Help You’.

Those entering were made to sanitise their hands at the kiosk. The healthcare workers, manning the kiosk, also answer questions if you are confused. This kiosk though is not manned at all times. While we were there, a few people had to look around for help. Diagonally opposite the kiosk is a space to wash hands. Inside the hall, there are rows of chairs, all placed at a distance of 4-5 feet, facing a reception area. Patients have to wait their turn to make their entry at the reception, following which doctors on duty will assess the patients. Some have attendees helping them, while most of them are there by themselves.

There are huge windows on either side of the entrance. This is where the family and friends of those who’ve gone inside are waiting.

Pushpa, a resident of Thideer Nagar in Besant Nagar, was here with her husband K*, who was diagnosed with blood cancer in September 2019. He was just about to commence radiation therapy at Cancer Institute in Adyar when another patient at the institute was tested positive for COVID-19. Since April, as many as seven patients and three healthcare workers from the institute had tested positive.

All the patients from that ward were told to test themselves for COVID 19 before seeking further therapy. K’s first test was negative but a second test confirmed their worst fears. After this, K was advised to seek help from RGGGH.

"Now, they have said even though he is not showing any symptoms, he will be taken to an isolation ward for 14 days as he is a cancer patient," said his brother Suresh. Pushpa is worried that postponing radiation therapy will adversely impact K. "We already pushed it by three months. Now I am not sure when we can actually get to it," she said. As Pushpa continues to tell her story while waiting for the ambulance which would take K to the isolation facility, a doctor in a blue PPE darts out, a nurse in a green PPE at her heels, signalling for a stretcher.

"Why isn’t it here yet, it's been half an hour," the doctor asked the nurse. “No ma’am, I’ll get it, just a moment," the nurse said before signalling furiously to a group of healthcare workers standing 100 meters away, next to a few stretchers. Two of them, with a face mask and no PPE, hauled it across the ramp, while the doctor looked around, clicking her feet. While waiting for the stretcher, the doctor glanced over to this reporter, and almost as if reading the reporter's mind she quickly looked away before there was a question. It was almost a telepathic no.

Close to a month of tailing healthcare workers on COVID duty across the state will teach you to steer clear of them when they were working. Interrupting the nurses or the doctors on duty inside the OP was out of the question.

"You need to understand that everybody is in a lot of tension. There is a lot of work. Just during my eight-hour shift, more than 600 people trickle in," said Palanisamy*, a contract worker from Korukpet, who was overseeing security arrangements outside the OP. "It wasn’t so much in the beginning, but now it is 24/7. This place doesn’t sleep anymore,” he added, explaining that asymptomatic patients from RGGGH were sent to facilities outside, whereas those with moderate to severe symptoms were housed within the hospital. "People are scared. Look at his face, can’t you see panic in it," he remarked, pointing at a middle-aged man who walked past us.

“There is no reason to panic, we are very much in control. The uncertainty is going to be there because we don’t know how this pandemic will turn out but that doesn’t mean one should panic,” Dr K Narayansamy, Director of the Hepatology Department at MMC, said. He was recently appointed the Dean of MMC and Rajiv Gandhi Government General Hospital after the former Dean Dr R Jayanthi went on leave until further notice.

MMC and RGGGH have been through choppy waters in the past few months, with many doctors, PGs, nurses and healthcare workers testing positive for COVID-19. It seemed a little ironic to be sitting inside a building with a possibly high viral load but being told that RGGGH is dealing with the pandemic head-on, minus the panic.

Asking about F's experience, a COVID-19 positive patient who had told this reporter that he was turned away from RGGGH when he had shown up there with his results. F had said that he was denied admission due to lack of beds in the hospital. Dr Narayanswamy says that it must have been a misunderstanding. "We’ve close to 1,000 beds, half of them equipped with oxygen supply. We are constantly upping our capacity, there is no way anybody would have said there are no beds," Narayanswamy said, explaining that doctors make an assessment of patients in the OP block. If a person shows moderate to severe symptoms, they are admitted to the COVID care unit. If they don’t, they are sent to isolation wards outside RGGGH for observation. "This is how we ensure that facilities are available to those who are in actual need, without burning it all out," added Narayanswamy.

Eventually, F was admitted to RGGGH and is at the moment, stable. F said he is happy with the facilities now and feels that he is well taken care of.

Whether or not his problem was a wrong assessment of the patient’s symptoms or if the patient had misunderstood the doctor, what was told to him doesn’t seem easy to figure out. This problem though has been mentioned by many doctors on duty. Some of them, across several districts in Tamil Nadu, said that they assess ILI (Influenza-Like Illness) symptoms in patients and to ensure that the system isn’t overburdened, admit those who absolutely need hospital care. If not, they are told to rest and recover at home. A few patients are also not very forthcoming which hinders the process further. But since the decision largely rests on discretion, as there are no guidelines set in stone, there is room for error.

***

Kilpauk Medical College Hospital, Chennai

The waiting area outside the COVID OP Block in Kilpauk Medical College Hospital (KMCH) was an open space, like a sit out in a park. It had an enclosure on top but was open otherwise. Ambulances were lining up right in front of the waiting area, from where patients were being taken into the OP.

The ones waiting their turn had worry written all over their faces. Approaching a young woman seated alone, the reporter asked her in Tamil, "Neenga positive patient ah (Have you been tested positive)?" She first shook her head and then nodded. She introduced herself as C* from Nepal. The reporter switched to Hindi and asked her if she wanted to speak to her. She said yes, and pulled out a piece of paper from her bag. She pointed to the section which said ‘POSITIVE’. "I don’t know where they are going to take me," she said.

C has been living with her son in Chennai for more than a year now. The lockdown had been a drag as she was out of work. But she had managed until she developed a fever a few days prior. Though her fever subsided, she tested positive for COVID-19. So, she packed up, told her son to stay home and set out for Kilpauk Medical Hospital.

“What will they do now, how long will I have to wait here?” she asked. She had two young teens to keep her company. Their uncle, who was on dialysis, had tested positive for COVID-19. "He is in there, getting it done. They usually do it on the arm, but this time they are going through his neck,” one of them said explaining the process of dialysis. Two rows away, an individual who was waiting his turn, spat onto his side. Everybody looked, a few hissed.

Twenty-four hours later, C had been allotted a room at a COVID isolation facility in Pulianthope. She was first lodged at a facility within KMCH, and then the next day transferred. It has been three days and she seems okay.

The problem that patients seem to face at government facilities is only at the beginning. Stricken by panic in the beginning, most patients are confused and need reassuring. Healthcare workers, however, seem overworked and not in a position to do so.

***

Government Order 174 issued by the former health secretary Beela Rajesh, dated April 3 of 2020 reads:

“1. In the G.O. read above, the Government has notified the list of designated Government Hospitals for treatment of COVID-19 patients. Further, treatment for COVID-19 is being offered in all Government Medical College Hospitals, District Head Quarters Hospitals and Key Sub-District Hospitals completely free of cost.

2. It has been brought to the notice of the Government that certain patients/public desire to have treatment for COVID-19 in Private Hospitals also.

3. Considering the spread of CoronaVirus Disease (COVID-19) in the State, the Government have decided to include the Private Hospitals in the State for treatment to COVID-19 patients to prevent the spread of this communicable disease.

4. Accordingly, the willing patients are hereby informed that they may approach the Private Hospitals listed in the Annexure to this order to receive treatment for COVID-19, at their own cost. The hospitals are directed to follow the treatment protocol prescribed by the Government of India from time to time.”

Of the 22 hospitals listed on this Government Order, the number of private players catering to COVID-19 patients in and around Chennai has increased to 45 in a period of two months. Yet, there is uncertainty regarding the functioning of these hospitals.

First, a few videos emerged saying that these hospitals are charging exorbitant and unaffordable rates. This was followed by another government order, which capped the price for private hospitals. For non-critical cases, the cost was to be capped at Rs 5,000 per day. For critical cases, the cost was fixed at Rs 10,000 to Rs 15,000 depending on whether the patient required ICU and ventilator facility.

Another video by a news anchor and television actor S Varadharajen went viral, where he claimed that a friend of his, who had severe breathing problems and fever, was unable to secure a bed for himself at either a government or a private hospital. Health Minister Vijay Bhasker immediately got into a damage control mode and announced his team was making all efforts to ensure that facilities are adequate. "There are 75,000 beds in Tamil Nadu and 5,000 in Chennai alone," he announced a day after the video went viral. Provisions of IPC, the Epidemic Diseases Act and the Disaster Management Act were invoked against Varadharajen for the offence of ‘falsifying information to create panic.’

Two weeks since and all the damage control later, the feeling of panic in Chennai is far from gone. A flurry of transfers, including that of the health secretary hasn’t helped matters. '‘Mismanagement' is the word on the street and the rumour mills have become difficult to track. It's mostly hearsay as very few "go on record" to say anything. The fear among doctors and bureaucrats keeps them from speaking out aloud. But statements by those leading the state are hard to miss. For instance, chief minister E Palaniswami’s transition from "our positive cases will be zero in a few days" to "God alone knows when this will end."

"Strong leadership and a clear line of command is crucial to managing any public health emergency. When people are clueless as to who to turn to for a decision, you know there is a problem," said Dr Aiswarya Rao, public health consultant and former joint director of Tamil Nadu State Aids Control Society (TANSACS).

In April, there were multiple teams comprising bureaucrats who were put in charge of managing the situation. Then came the appointment of another committee. There was also the health secretary who was issuing directions on one side, while the ministers did their own thing. This is pretty much how April and May went by for Chennai. Even after the appointment of Dr J Radhakrishnan, who has managed to control multiple crises in Tamil Nadu, this crisis seemed all over the place. His reinstatement as health secretary seems to have given many within the department hope.

What about frontline workers in Chennai?

The basic fear, reiterated both private and government healthcare workers, doctors, nurses and technicians, is the fear of exposure. April witnessed many protests by government doctors and nurses in Chennai, demanding basic preventive protective equipment and post-duty quarantine facilities, after a bunch of them tested positive at RGGGH.

In a few weeks, healthcare workers at Government Stanley Medical Hospital tested positive. While government doctors have to work irrespective of fear of exposure, the same isn’t the case with private practitioners. Many private establishments have sought help from the government stating that they are not able to take on the costs required to operate a COVID-19 facility. Sanitary workers organised a strike this week after one of them died following exposure to COVID-19 positive patients.

While the government has been saying that it is meeting these demands, how the government hopes to sustain meeting these demands remain unknown. So does the expenditure over COVID-19 so far.

During his interaction with Prime Minister Narendra Modi, Palaniswami sought a grant of Rs 9,000 crore and a sanction of Rs 3,000 crore for medical equipment during a pandemic. An official statement by the chief minister also said that 2.75 crore triple-layer face masks, 38.85 lakh N-95 masks, 21 lakh PPE kits and 15.45 lakh RT-PCR testing kits have been ordered by the Tamil Nadu government. There is no official figure on how much the government has spent on personal protective equipment.

The biggest challenge for the government continues to be how it will bring about some level of accountability from private hospitals in the middle of this pandemic, which doesn’t seem like will abate any time soon.

Many non-COVID patients have spoken out about how cumbersome it has become to get private hospitals to cater to them, even under serious circumstances like deliveries. The norm at every private hospital since April has been that almost all procedures only after a COVID 19 clearance. Two months since the lockdown, yet private hospitals have not figured their way out, and that's worrisome.

Many seem to be treading the safer path by staying away. But senior doctors say that media trying to put the entire blame on private hospitals is unfair. "The costs are high, the usual patient load less. We are doing what we can to keep the hospitals running with the bare minimum," said a private practitioner, "When will the government step in and help out?"

Real situation at private hospitals listed as COVID-19 designated centres

Firstpost looked at the Tamil Nadu live dashboard and spoke to all the 45 hospitals (four from Chengalpattu and Kanchipuram districts) listed under Chennai district.

Of these 45, many of the hospitals are already operating at full capacity. Doctors at some of these hospitals said "that isn’t the case but don’t want to say anything further." In the case of some hospitals, authorities said there were no beds available anymore. Even though in some cases the live dashboard says the opposite. Some of them tailor their answers after asking a routine set of questions, which are common to all:

How old is the patient?
Are they obese?
Do they have any existing conditions or co-morbidities?
Do they’ve breathlessness?

A positive answer to the fourth question brings forth this answer: “We are out of ventilators” or “Where are you at the moment?
Okay, then go to the closest government facility, that would be the safest for you.”

Here is a brief of what Firstpost found

The Live Dashboard says these hospitals are running at full capacity: Apollo Hospital, Be Well Hospital, Bharathiraja Hospital, CSI Kalyani General Hospital, Dr Kamakshi Memorial Hospital, Dr Mehta’s Hospital, Fortis Malar Hospital, Kauvery Hospital, Lifeline Hospitals, Maya Nursing Home, Venkateshwara Hospital, Noble Hospital, Panimalar Hospital, Prashanth Hospital, MIOT Hospital, Medway Hospital.

For other hospitals, the dashboard, as on 22 June (some updated on 21 June) say has 1,865 beds, 89 ICU beds and 71 ventilators. Here are the responses of the hospitals, when contacted regarding beds:

1. Apollo Hospitals: No beds
2. Sri Ramachandra Medical College Hospital, Porur: Dashboard says 184 beds are available, hospital authorities said there are no beds.
3. Bharath Medical College: Dashboard shows as having 60 + 2 ICU beds. Authorities said that they aren’t admitting any patients as they don’t have the staff or the resources to handle the situation.
4. Be Well Kilpauk: Asked if the patient has insurance. Then said beds are available, will quote fees only after consultation with the doctor.
5. Chettinad Hospital: Dashboard says 161 empty beds at the hospital whereas the hospital authorities say that there are no beds available.
6. Kanchi Kamakoti Child Trust Hospital: Facility available for children.
7. Aysha Hospital: Will assess the patients and admit according to need. If oxygen is stable, patients can home quarantine and recover.
8. Gleneagles Global Health City: Authorities said patient can come for a check up, cannot confirm if there is a bed.
9. Mint Hospital: Said beds available at the cost of Rs 35,000 per day.
10. Vijaya Hospital: No beds, if there is a discharge and a slot opens, can contact. Cost Rs 30,000 to 40,000 a day. With ventilator will cost Rs 70,000 a day.
11. Tagore Medical College: Beds are available, costs are Rs 12000/day for asymptomatic patients, Rs 14000 with oxygen support, Rs 21000 if ventilator is used.
12. Sundaram Medical College: Full, there are patients waiting in the ER.
13. St Thomas Hospital: There are beds but they will decide after it's communicated how serious the patient is.
14. SRM Medical College: Dashboard says 103 beds + 3 ICU beds is incorrect, they are running at full capacity.
15. Sathya Sai Medical College: Not a super speciality, can only admit mild cases as they don’t have resources to take care of severe cases. Will cost Rs 15,000 to 20,000 a day.
16. Balaji Hospital: Can only admit mild cases as ICU beds are full.
17. SIMS hospital: Full, can’t admit.
18. National Hospital: Overflowing, government hasn’t updated dashboard.
19. Muthu Hospital: Beds are available, cost will be communicated after assessing the patient.
20. Meenakshi Medical College: Not admitting private patients at the moment, only admitting patients from government hospitals.
21. Karpaga Vinayaga Medical Science & Research Facility: Beds available; Rs 5,000/ day is the base amount, exclusive of oxygen support or investigation/scan charges.
22. Melmaruvathur Aadhiparasakthi Medical College: Is a Trust Hospital, all charges will come up to Rs 10,000/day
23. GLB Hospital: Beds available, will cost Rs 35,000/day
24. Appasamy Hospital: 1 bed available, will cost Rs 23,000/day.

***

J Radhakrishnan IAS, the newly reinstated health secretary says that the health department is pushing its limits to ensure that facilities are coping with the increase in numbers. “We are increasing beds in government hospitals for people who depend on us. Many non-COVID beds are lying vacant, as most aren’t coming for routine procedures, so we are constantly in the process of switching that dormant lot to our COVID bed strength. We’ve added 25 percent of those beds into COVID care,” he told Firstpost.

The health department is also trying to create a call centre for access to private facilities, in addition to 104 services, so that they can cross monitor, Radhakrishnan explains.

“We held an open meeting with private hospitals, and the estimate of beds with them is 5000. We are attempting to provide dynamic data of these beds, in order to facilitate a smoother process for COVID patients”, he adds. When I inform him that many of the hospitals aren’t admitting patients even if they have beds, he says, “Close to 170 hospitals are registered with us for treating patients. If they are not admitting COVID patients or even non-COVID cases, we will take action against them under the Clinical Establishments (Registration and Regulation) Act of 2010.”

*Names withheld to protect the identities of COVID-19 patients

from Firstpost India Latest News https://ift.tt/2Ys6vBk