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Goa doctor tries ‘power of proximity’ to heal disease that isolates

In the 33 days between March 18, when the state’s first patient was admitted, to April 19, when the seventh and last was discharged, a peculiar protocol has played out on the fourth floor of the hospital.

Written by Smita Nair | Goa, Margao |
Updated: April 26, 2020 4:39:47 pm
Goa coronavirus, covid-19. covid-19 goa, goa doctor Dr Gomes heads the team at Goa’s COVID hospital. (Express photo by Smita Nair)

THURSDAY, April 23, was a busy day for Goa. It counted 300 hospital beds in preparation for a possible second wave of cases from among stranded sailors coming home, installed testing kiosks at the state’s borders and ports, and revised its SOPs. It was also when Edwin Gomes, the doctor leading the team at ESIS Hospital, Goa’s designated COVID facility, had a visitor.

Edgar Julian Remedios, one of the first COVID-19 patients to test positive, had returned to the hospital. “He came to give a hug,” says Gomes.

This week, Goa, which had sealed its borders from March 22, will allow the first convoy of buses from Mumbai with over a hundred Goan seafarers who had been stranded at sea when the country went into lockdown on March 25. The state, which had recorded seven COVID positives, now has no active cases.

In the 33 days between March 18, when the state’s first patient was admitted, to April 19, when the seventh and last was discharged, a peculiar protocol has played out on the fourth floor of the hospital.

As scientists and experts race against time to study the virus and its behaviour, Gomes has been probing a different science: “The power of human proximity in fighting an epidemic.”

Across the globe, positive patients have been taken away by staff in PPEs and sent to isolation wards, without the comfort of family and without any of the colour from flowers or words in get-well cards – with just the cold, sterile hospital architecture for company.

With the coronavirus novel, so are the fears. As Gomes and his team of four resident doctors ( Nidhi Prabhu, Geetali Velip, Masood Mujawar, Harshal Mamlekar) and nursing staff responded to questions from patients – mostly related to “nature of death” — they made it a point to repeat “you will be alright” at intervals.

Dr Gomes (centre) with his team of doctors.

As the patients started to come, the systems too evolved. “We decided we will not allow any patient to feel alone. We divided ourselves and would take turns to go to each person thrice — for a good morning round, a good afternoon round, and a good evening round – and asked a set of questions normally reserved for geriatric care. We would talk to them about hours, their homes, their families. If they dreamt something, how did they sleep, the memory they wanted to discuss,” says Gomes, Professor and Head of Department, Medicine, at Goa Medical College Hospital.

“The questions would change depending on the time of the day. So in the afternoons, we would stress on cool water and keep them distracted since we do not have an AC facility and it tends to get uncomfortable. Evenings are mostly spent understanding their dilemmas in life. We did this every single day, after which we doctors exchanged notes,” he adds.

Globally, hospitals are having these “conversations” through telemedicine services, often with the practitioners and patients on opposite sides of the door.

Gomes, who has handled the H1NI epidemic in the state, is a believer of herd immunity, but asks not be mistaken — he wants a vaccine developed soon. But he feels “equal importance” needs to be given to studying the other intervention: “effects of proximity and personal engagement while nursing infected patients, directly connecting the medical attitude of the caregivers in slowing or shifting the trajectory of the novel coronavirus SARS-CoV-2 or any such fast replicating virus”.

“The patients are fighting it alone and that loneliness can have a drastic impact,” says Gomes. “We are trying to understand if it impacts their treatment course.”

The doctor has now trained his team on the manner of treatment and is preparing to use all the experience from the seven full recoveries to treat the next batch of seafarers. With additional nursing staff being deployed, Gomes says protocols are now in place to handle between 80 and 100 patients at any given time, with the state having requisitioned up to 300 ventilators.

In the initial days, Gomes and his team divided the state’s seven COVID positive patients – who came on seven different dates between March 18 and April 4 – as per ICMR classification: one asymptomatic, two symptomatic with fever and cough, and four requiring extreme care due to pneumonia.

While the ICMR-prescribed anti-malarial prescription worked on the symptomatic patients, in the case of the four patients with pneumonia, a decision was made to give a combination of Cephalosporins and Amikacin antibiotics. “We were bold enough to give it in the correct dose. No one does sputum culture now because it’s COVID so we do not examine the sputum. We went by our knowledge and gut feeling. We have never given this antibiotic before, let’s just say we don’t play with this much,” recalls Gomes.

Since February, the team has been researching, reading and reassessing research papers from Italy, China and Seattle on various aspects of treatment.

“While we take extreme caution, and wear PPEs, the five of us also unofficially decided to wear the head gear that we use for treating HIV virus. The face is fully visible in that. In such cases, when they are confined, they need to see a doctor smile, and be able to identify us and connect with us. We ensure we are at a one-metre distance when we are talking but make sure they can see us and also respond with expressions,” he says.

Nursing staff at ESIS revising Protocol for next wave of covid-19 patients.

The nurses who were praying — during Lent — decided to pray loudly to ensure the patients heard. Once, Dr Gomes himself popped an anxiety pill along with a patient. “I told him this pill is not to put you to sleep but to make you feel good. I popped it myself the first time so that he would be reassured.”

Gomes says for patients rendered lonely by the virus, the physical examination by the medical staff was often the only point of human contact. “I would wait for that moment as that meant some kind of proximity… It was calming,” says one of the recovered patients.

The staff’s ward duties also included having to constantly check on the patient’s phone battery. “Initially, since patients were scared and also new to the hospital, they would only make voice calls. We encouraged them to make video calls to family, friends or anyone who can comfort them,” says Gomes.

“It’s a constant learning — dealing with an epidemic. In that sense, everything matters. How to talk to patients. How to remove their fears. The treatment protocols. What is that extra that made it better, what helped? We need to answer these questions. We are looking to study all this,” he says.

As he silently documents the impact of “engagement”, “conversations” and “touch” on his patients, Gomes agrees his study is an anomaly for a disease whose cure is still elusive and which has created fear and stigma.

“In the West, the four COVID cases we had with pneumonia would have been intubated, put on ventilator. In fact, now we are reading research papers where people are unnecessarily ventilating,” he says.

On the fifth day of a patient’s admission, a requisition was initially made by Goa Medical College Hospital for a video conference call with a psychiatrist. Doctors and nurses agreed that it would not have the desired impact. “It was heavy anxiety. The fear had gripped We had to work fast. We went to him, kept distance, and started talking talking face to face. Things started to improve from there,” recalls Gomes.

Then there was the 19-year-old patient who had to be coaxed to take cold showers through the night till 6 in the morning, with a gap of two hours after “every stupid medicine failed to work”. With cold sponges impossible due to him being a Covid-19 patient, it came upon the resident doctors to engage with the boy, coax him, convince him. “We just needed one more day for the antibiotics to work and the fever which was at 104 had to come down for that. We kept talking and coaxing him every time we had to send him back to the shower. We asked him not to wipe dry and let the clothes remain wet,” Gomes recalls.

This week the team celebrated the news when another patient texted he had become a father.

Head nurse Niloufer recalls the fear among nurses when a patient checked in at 1 am on March 25. “Those were early days and we didn’t know how to handle. Now we will not leave anyone alone. Things have improved drastically,” she recalls.

Gomes says he and his team are looking at June 15 as a crucial date. “Till June 15, if we can keep a control, then we would have learnt enough from the disease. We will have to take precautions and observe till then. We are learning everyday…and we hope to do our best. Our only request is to reach us sooner.”

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