Challenges Doctors face during COVID-19
This is an interview with Dr. Raghunath S. Krishnappa.
Dr. Raghunath S.K. is a Uro-Oncologist who has conducted over 3000 uro-oncological surgeries. Dr Raghunath is the first uro-oncologist to establish a dedicated uro-oncology department in South India at HCG. He is the 1st uro-oncologist in South India to perform robotic radical cystectomy and total intracorporeal ileal neobladder surgery for bladder cancer and robotic perineal radical prostatectomy for prostate cancer. He has served as the secretary (2013) and president (2018) of Bangalore Urological Society. He is currently serving as the secretary for Society of Genitourinary Oncologists (SOGO) of India.
For more details about Dr. Raghunath S.K. visit https://www.hcgoncology.com/doctor-details/206
Interviewer: How has COVID-19 impacted the number of patients you see in a day?
Doctor: My specialty is a quaternary care specialty; it is a subspecialty-based practice after my urology super specialization. Before COVID, I used to see an average of 15–20 patients daily. During COVID, on an average, I see about 10 patients a day. So, there has been a 50% reduction of outpatients in the COVID period.
Interviewer: Due to COVID, what additional measures had to be taken for the safety of doctors and other hospital staff?
Doctor: We screen all the people who enter the hospital. Those who have fever or cough will not be allowed to enter the hospital. That is, at the primary entrance itself, we screen patients to prevent anyone with COVID symptoms from coming inside. Many patients could be asymptomatic carriers; it is a challenge to identify them. We expect every single person who enters the hospital to wear at least a simple mask: not an N95 mask, at least a simple mask. Some elderly people come to the hospital with head gears or visors. We recommend this at least for people who are at risk of getting COVID. Once the patients or the patients’ attendants come inside the hospital, they will be required to maintain social distancing. Sanitizers are provided everywhere, including within the elevators. Whenever they touch either the staircase rails or the doors or switches of the elevator, they can sanitize their hands.
In the OutPatient Department (OPD), when the patients come to meet the doctors, the chairs are arranged such that social distancing of at least 2 meters is maintained. When it comes to doctors, whenever we go to the OPD, we always wear PPEs (not full PPE). We use respirators, facials, and gloves and wear gowns while examining the patient. We also maintain social distancing within the consultation chamber. We allow only one patient and one attendant into the consultation chamber. They should sit at a distance of at least one and half to two metres. It is very challenging after wearing PPEs and respirators or masks to communicate properly with the patient, so we sometimes may have to raise our voice to communicate well. We don’t entertain any patients for more than 5 minutes. Before COVID, when new patients came for complex surgeries, we sometimes counselled them for one hour because it is very important to counsel any patient for surgery or any treatment for that matter. In this COVID period we have reduced that to five or maximum ten minutes. If they stay in the consultation room for more time and if they are COVID positive, asymptomatic carriers, the risk to the hospital staff would be relatively more.
When we go to the ward (either patients awaiting surgery or post-surgery patients will be there), we wear gloves, masks, visors and facials and maintain social distancing. Either patients have to get their own mask or the hospital will provide a mask and they have to wear it all the time.
When it comes to the OT, patients are wheeled in with a mask after thorough checkups and confirming COVID negative. Patients are not entertained to enter the OT complex without a COVID negative report. Our anesthetists and cardiologists will not see the patient unless they are COVID negative. If any further suspicion is there, we go for COVID antibody test; we quarantine them for some time. Only after they test negative, we take them for surgery. Within the theatre at the time of induction, the manpower within the room is very limited. One anesthetist will be inducing, one nurse will be preparing and one assistant will be there to help them. All of them will be wearing gowns, full PPEs, gloves and facials. After 5–10 minutes of intubation surgeons go inside and do the surgery wearing full PPE. We have to protect ourselves and we have to protect the patient. The man power within the operation theatre should be restricted to maybe three or a maximum of four people even for major complex surgeries. Once the patients are wheeled out of the theatre and into ICU, we also follow the same guidelines.
Interviewer: Wow! There are a lot of precautions that have to be taken. What are the challenges you face while following these guidelines?
Doctor: Sometimes it would be very difficult and uncomfortable for us to operate major cases for 4–6 hours wearing these PPEs. We build up lots of carbon dioxide inside our bodies because the mask will not allow adequate exchange of oxygen. Sometimes we do get headaches. So for a long surgery of more than 2 hours, I would say at least 50 percent of anesthetists and surgeons, if they work continuously, would get headaches. On some occasions, due to carbon dioxide overload, at the end of the surgery we take pure oxygen inhalation. We wear sterilized oxygen masks and take pure oxygen for 10–15 minutes to bring out the carbon dioxide that is there in the body. It is a tough situation for all healthcare workers, especially surgeons who are doing complex and major surgeries because they have to be in complete PPEs for 4–6 hours. This is a challenging situation.
Interviewer: What would you do for cancer patients who are COVID positive? Would you perform surgeries for them in some cases?
Doctor: There are two possible scenarios: elective surgeries and emergency surgeries. If it is possible to wait for fifteen days or one month or one and half months without compromising the outcome, then we postpone the surgery. In the meantime we take some measures to prevent progression of the disease. I am a uro oncologist. I treat a lot of prostate cancer patients. To prevent the progression of prostate cancer there are some hormone therapies like some drugs or tablets. By giving these, we can avoid progression of the cancer. Whereas kidney cancers are usually slow growing tumors, so generally we wait for fifteen days or one month to allow the patients to take treatment for COVID. Once they are COVID negative we again check their antibody levels: IGG and IGM levels. If the antibody levels are suitable, only then we take them for surgery. This is for elective surgery where there is a provision for postponing the surgery.
In emergencies, for example, a person coming with bleeding or when the risk of progression of cancer is very high, even if the patient is COVID positive we have to act. Sometimes bleeding can be there from the gut or from the urine, we can’t postpone the surgery as otherwise they can sometimes bleed to death. But we take all the precautions. We convince the patients that the outcomes would be suboptimal if we operate. They have to accept that risk. Sometimes they can develop more complications from surgery because of COVID. After explaining the suboptimal outcomes, we take them for surgery.
Interviewer: What are the different ways in which you have made yourself more approachable during COVID, for example, do you consult over the phone?
Doctor: Yes, I do. Lot of patients don’t prefer to come to the hospitals, particularly elderly individuals. They take an appointment and we give online video consultation: we see the patient and understand though we cannot examine them physically. To understand the disease status in a better way, we suggest some investigations. We get all the reports through WhatsApp or e-mail. We go through those and consult them. It’s a face to face, one to one interaction. If it is a semi emergency or emergency situation and physical examination is mandatory to decide the right treatment, then after all these investigations we call them to the hospital. If it is an elective situation we don’t call them for surgery immediately and they can take the decision to come to the hospital after some time.
Interviewer: Thank you so much for explaining all the measures taken in the hospital. Thank you for continuing your service to society during this difficult period. All of us are indebted to you and all the health workers in the world. Do you have any general advice for all of us?
Doctor: We have to protect ourselves and the message to the public is that they are neglecting the situation. They don’t wear masks; they don’t maintain social distancing. The mortality or the death rates from COVID in India is around 1–2% which is a little less compared to the USA. But life is only one; it is precious; we have to take care of ourselves; so stay safe: use sanitizers and masks to protect yourself and to protect others.
Interviewer: Thank you for enlightening us. Thank you so much for your time.
