ICU Mismanagement At A Lahore Hospital Claimed Coronavirus Patient's Life

The healthcare system in Pakistan has been collapsing with the rapid increase in coronavirus cases and several deaths every day. An account of a similar casualty was recently doing the rounds on social media where a coronavirus patient in his late fifties lost his life.

A doctor, Hassan Chaudhry tweeted a thread of how his relative was treated after having tested positive for coronavirus and getting into a critical stage. "Spent last 15 days going through the decaying orders of our healthcare system embattling Covid-19. A close relative was on bag-mask oxygen in an emergency unit of tertiary care. He developed SOB, fever on Eid day."

"For days we were confused whether to treat it on Cytokine Release syndrome lines or not. Strong Neutrophilia was suggestive of sepsis as well. So some of my consultant friends cautioned against actemra and we lost valuable time. Punjab govt criteria for actemra added to the confusion.

They had three lab parameters (ferritin, Crp, d-dimer) and all three of them had to be raised but they were never increased in unison, were rather increasing in tandem. Both these together meant we didn’t administer actemra until it was very late."

But treatment issues like these are not the biggest concern. The dreadful conditions of government Intensive Care Units that are left at the mercy of novice juniors, heartless staff with critical structural failures is a systemic problem prevalent in all of Pakistan.

He said that on the third day of hospitalization, his uncle had to be intubated and mech ventilated in ICU. Things seemed calm at first. But one day later, it started. First, the ICU was severely understaffed, so nurses would leave it unattended for sometimes 20-30 mins on end, also forget critical meds.

One day a nurse decreased the dose of a muscle relaxant by mistake and the patient started removing the ventilator tube (ETT) himself. The tube is a big discomfort and the patients have to be sedated/paralysed on ventilator because they would push to remove it otherwise

"It was 8:20 in the morning (20mins past shift change) and nobody was inside. Alerted by vent alarm, I peeked inside and informed the doctor on duty who rushed inside with just mask on, without any PPE to stop the patient from practically killing himself. The next day. I was home for some rest, awakened by a seriously panicked call by my cousin who was on night duty with my uncle. There was rainfall in the city and the ICU had its electricity cut off for the last 30 mins and the main O2 supply was also down."

Vents have a backup battery for about an hour but how’d it compensate for O2? He said that three patients were on vent that unfortunate night. Two of them needed 100% O2. "My uncle was 60%. The other 2 died in the first 5-10 mins. My uncle survived because he was manually ventilated for 30mins by two doctors."

"His clothes in the morning, once the thick sweat (that he exuded out during all that effort) dried, felt as if someone sprayed multiple layers of starch on them. It was beyond horrible. I decided to move him on a vent ambulance but no private hospital was taking Covid-19 patients in my city."

So I took him to a somewhat ‘better’ government hospital with an older and more trained ICU staff and less chances of such system failures. This ICU was not understaffed. Nursing was better. But now the doctors on duty were heartless, and callous.

Chaudhry said that many of the doctors there were unwilling to do a single round inside the ICU to check on the patients. Their management was way off of newer standards. They would stay inside their office and pass orders on intercoms to nurses all day and get mad when nurses suggest they come inside.

"I was actively managing my uncle, getting consults from Nephro. and cardio when he developed a kidney injury. One day, I asked one callous doctor to change a nephrotoxic antibiotic. He, having not set foot inside ICU for all his duty hours, suggested I go inside and do it myself," tweeted Chaudhry.

"Unbeknownst to him, I never hesitated to go inside. So I started donning PPE. Dude looked at me in disbelief. Even after knowing me to be his colleague, he never expected this. I went inside (wasn’t my 1st trip anyway) did what was needed."

Later one day, when I was inside for some other issues related to my uncle, another doc intercom-ed me to ask me to put a urinary cath in another patient ‘since I was already inside’. This magnitude of fright that these guys were manifesting was severely compromising the care. And it reached the point of medical negligence the next day, when I told them about a patient who was pulseless and was on the vent. The guy needed vent at least 12hrs ago (sat 84% on bag-mask O2). First, they didn’t put him on vent despite admitting and leaving one vent free because of fear/inaction.

Second, when finally he was intubated and put on vent, the vent started the alarm right away. I was inside, checked the pulse. He was pulseless. They informed their seniors. It still took them 4-5 hours to put him off the machine and inform his attendants of his death.

With this level of care, it is a no brainer that mortality in government ICU’s all across Punjab is virtually 100%. Three ICU’s in my city have in total half the patient(s) extubated and that too was non-COVID. Care is better in HDU’s where one is not paralyzed and not at the mercy of hospital staff, he believes.

"It was one day before his death, that I went inside the ICU, played his wife and children’s recorded messages on the phone in his ear. Recited and played some Quran beside his pillow. Took care of some nursing issues. All the while he was asleep peacefully on narcotics and benzos."

The patient passed away on the 14th day of ventilation and the 16th day of hospitalisation. It was a long & painful journey. Being doctors, We could never leave him unattended (for even 30 mins) for the risk of malpractice/negligence was huge. But no effort could change what Allah willed.

"This was a big lesson in humility for us too. We tried everything in our power, from convalescent plasma to tocilizumab(actemra), without any luck. We practically saw him slipping from our hands slowly, and couldn’t do a thing despite all resources in our hands.

He was a v healthy 57-year old, with no comorbidities. He left three children & my aunt, a doctor herself. May Allah elevate his rank in Jannah, grant us patience to deal with this. And help us understand this disease so that we can rid our world off it!"

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