Covid19 was declared a pandemic in the first quarter of 2020. Everyone’s lives changed. We, the doctors who were looked down upon by the public, suddenly found ourselves in the midst of a revolution wherein we began to take the role of leading the healthcare battlefields from the frontlines. We knew our limitations and scarily enough, the implications of jumping into the fray without the protective gear (PPE).
Being doctors ourselves, both my wife and I knew that it was dangerous to venture outside the safety of our home. We had been taking precautions from the time that lockdown was declared. We were also taking HCQ prophylaxis, however being a gynaecologist, my wife had to attend to a few emergency surgeries and that was when the inevitable happened. The following is the set of events that will showcase the tough battle that she faced against her invisible tormentor – COVID-19.
• On day 1: She had a fever up to 100 F with a feeling of malaise.
• Till day 3: A spike of fever up to 100 F continued. Since she was feeling better on taking Paracetamol, we felt it was a case of a simple viral infection.
• On day 4: A fever spike went up to 101.7 F. She also complained of total anosmia along with severe fatigue which led us to suspect the silent killer – COVID 19. We decided to self quarantine her. While being in self-quarantine, she took HCQ 200 mg BD (to complete 5 days course) and Tab Ivermectin 12 mg BD (2 days course) along with 1000 mg Vitamin C and 100 mg Zinc.
• On day 6: Fever spike went up to 103 F. We decided to get her tested by RT PCR. Since the fever was increasing and being in the high-risk category (age factor, though no comorbidities), our friend and Infectious Diseases Specialist – Dr Tanu Singhal – advised us to admit her. We followed the same and got her admitted at Fortis Mulund (COVID Ward). Her CBC was having leukopenia TC 3400 with lymphocyte 37%, CRP 15 ( normal less than 10 ) LDH and d Dimer slightly raised, so she was put on intravenous Methyl Prednisolone and low dose injection of Clexane. Her CT scan on admission showed minimal changes in the lung.
• On day 6 to 10: Fever disappeared from the time she got admitted and she was generally feeling much better. Her repeat CBC remained the same and CRP came down to 8 and so discharge was planned on the next day.
• On day 11: They repeated CRP before planning to discharge but it had increased to 16 and so was advised to be there for one more day.
• On day 12: Repeat CRP test indicated that it had increased to 81 even though clinically she was feeling fine. So repeat CT done was done, which showed moderate changes and ground glassing. In the late afternoon, the SaO2 on 3 min walking went down to 90. She was immediately put on O2 – 2 to 3 lits – by nasal prongs and was advised proning. At night She was also shifted to ICU to start injection Remdesivir (the pros of which outweighed the con – which was a slight effect on the liver which was easily reversible). There was also a strong suspicion of the start of a cytokine storm thereby contemplating to put her on injection Tocilizumab (which can suppress immunity leading to increase in viral replication and also increase the chance of secondary bacterial infection by 20%). To avoid all of these, she was put on injection Remdesivir and injection Meropenem.
• On day 13: CRP shot up to 222 and though other reports like IL6, d Dimer were awaited, because she was desaturating without wasting much time injection Tocilizumab 600 mg (@ 8 mg per kg) was administered at once. After some time, the IL6 report came – which was, as suspected, high. All throughout this, injection Methylprednisolone and injection Clexane along with HFMO (high flow O2 @ 60 lit per min. fiO2 of 0.6%) and proning continued. (HFMO is better because of less dead spacing compared to intubation and mechanical ventilation.) In the meantime, it was noticed that the sugar levels had also shot up to 250. To counter this, injection insulin was added. After all these, it was noted that P/F ratio was remaining at 100 (which otherwise is expected to be 150 or more) and She was finding it difficult to remain in a prone position for a longer duration, and so intubation was contemplated. Having a fear of intubation, she somehow managed to remain in a prone position for longer durations and P/F ratio started improving after 24 hrs of injection Tocilizumab and High flow O2 with proning.
Totally after 10 days of admission which included five days of injection Remdesivir, 3 days after a single dose of injection Tocilizumab, 5 days of high flow O2, 10 days of injection methylprednisolone and injection Clexane, she showed improvement in oxygen saturation levels and also improved clinically and radiologically. She was shifted to one of the wards for 3 days under observation wherein the external O2 and injectables were stopped. Ultimately she was discharged after spending 15 days in the hospital with the advice of proning, respiratory exercises with spirometer and rest.
I am forever grateful to Dr Rahul Pandit, Dr Anita Mathews, Dr Kirti Sabnis and all the frontline health workers of Fortis Mulund.
My Observations
All is well that ends well. Great efforts paid well at the end. Some lessons learnt. Monitoring sats at rest and on some exercise is the key to detect complications and take timely steps. Don’t shy of using steroids in moderate cases and Tocilizumab in severe cases as we are racing against time once cytokine storm sets in.
Remdesivir seems to be working but getting it is not easy and now with Indian companies officially marketing it should make it a bit easy.
A key point to be noted that though we all harp on clinical clinical clinical (which is true in 99% of cases), it tells us the importance of labs especially in a confusing disease as these.
As Pediatricians, we may have discarded the CRP rose from 8 to 16 on day 11 (remember she was clinically fine.. don’t know what the sats on walking etc were on that day) ..but paying attention to that and advising to stay back proved life saving.
A good and timely decision, judicious use of appropriate medicines and a strong medical facility besides blessing of all good wishes makes you win the battle!
We are much better off now then say at the beginning of the outbreak as we now have a better understanding of the disease, better drugs, better facilities and most important better experience and confidence in treatment protocols to conquer COVID.