"I was admitted to a government hospital where infection control may not have been that great. Luckily, I didn’t catch sepsis or any infection" - Sachin H.R. Bhat, who underwent seven orthopaedic surgeries following an accident
"Serious medical conditions like severe infections, respiratory, cardiac or multi-organ failure, surgery, accidents and neurological problems require ICU care" - Dr Rajesh Chawla, senior consultant, respiratory and critical care at Indraprastha Apollo Hospitals in Delhi
"ICU care is expensive because of the need for more nurses (1:1 to 1:3 ratio) and doctors per patient (1:8-10) in order to provide optimal care" - Dr Shivakumar Iyer, president, Indian Society of Critical Care Medicine and professor and head of department of critical care medicine at Bharati Vidyapeeth University Medical College in Pune
Two months ago, Mariyamma, 62, was rushed to Sparsh Hospital at Yeshwanthpur in Bengaluru with a heart attack. Her husband, Anjanappa H., had found her lying face down on the kitchen floor. He was shocked; Mariyamma had served him tea only an hour ago when he had returned from his farm in Madure.
She was rushed to the emergency room. The echocardiogram revealed a far more serious and uncommon problem, says Dr Rajesh T.R., consultant cardiovascular and thoracic surgeon at Sparsh Hospital. “There was a rupture at the site in the heart where the attack had happened. Blood, under high pressure, was leaking from the heart and collecting in the sac outside,” says Rajesh. A coronary angiogram was quickly done, which revealed blocks in two blood vessels, one of them 100 per cent. “The part of the heart which got blood through this vessel suffered the attack, making it nonfunctional and weak,” says Rajesh.
Mariyamma underwent a surgery during which Rajesh, along with Dr Chiranbabu, another cardiovascular and thoracic surgeon at Sparsh Hospital, repaired the ruptured area in her heart while it was still beating. Then they created a bypass for the blocked vessel, restoring its blood supply.
Four hours after the surgery, Mariyamma was sitting on an ICU bed, fully awake and sipping water as if she had just woken up from a nightmare.
For many, ICUs are the corridors of death. They often get panicky when someone they care for is admitted to an ICU. Patients, too, might have unpleasant memories of an intensive care unit where there are more machines than human beings. Some studies indicate that two of three ICU patients develop delirium—a state of confusion where your thinking becomes foggy and you may even see and hear things which do not exist.
Why should a patient be taken away from his near and dear ones and sent to this sad place when they are critically ill? “Such patients who are physiologically unstable require continuous close monitoring so that immediate treatment can be given,’’ says Dr Rajesh Chawla, senior consultant, respiratory and critical care at Indraprastha Apollo Hospitals in Delhi and chancellor of Indian College of Critical Care Medicine. “Serious medical conditions like severe infections, respiratory, cardiac or multi-organ failure, surgery, accidents and neurological problems require ICU care. ICUs are equipped with diagnostic and monitoring tools and treatment devices to take appropriate and immediate action.”
Critical care medicine has evolved as a speciality in India only recently. What used to be a clinical-based speciality has now become more advanced and technology-driven. Nevertheless, there are still challenges to overcome. “There are around 60,000 ICUs in the country. But we have less than 2,500 intensive care specialists,’’ says Dr Pradip Kumar Bhattacharya, director, emergency and critical care services, Chirayu Medical College and Hospital at Bhopal in Madhya Pradesh.
New training modules are being made to fill the gaps in manpower. The Indian Institute of Science in Bengaluru has come up with mannequins with advanced features to help medical students learn the various procedures in a critical care unit. The mannequin has human-like manifestations like blood vessels, a palpable pulse, chest rise and stomach distension. It comes with a simulator platform which consists of a central processing unit and interfaces normally present in a critical care ward.
The protocols for controlling infections are some of the key elements of these training programmes. There are guidelines on how to wash one’s hands and how to prevent cross-contamination.
One of the biggest challenges in intensive care is infection control. Poor hospital hygiene is considered to be a major reason for the high incidence of sepsis in India. Studies say that sepsis is a bigger killer in India than cancer and AIDS put together. Every hour, 36 Indians die because of sepsis. One of four ICU patients catch sepsis from the hospital’s emergency unit itself, according to The Indian Intensive Care Case Mix and Practice Patterns, a study launched and sponsored by the Indian Society of Critical Care Medicine. Conducted on 4,209 patients in 124 ICUs across India, the study found that even those who get admitted in ICUs for non-surgical treatment are at a great risk of developing sepsis. The study also indicated that half of the patients with sepsis succumb to the infection. Unfortunately, there is very little awareness about it.
When there is an infection, the body releases certain chemicals into the bloodstream to combat it. Sepsis occurs when these chemicals cause inflammatory responses in the body. Severe sepsis, caused by a variety of micro-organisms, can result in multi-organ failure and high mortality. “Early diagnosis and treatment, however, could improve the patient's chances of survival,’’ says Chawla. “With new tests like MALDI/TOF, which is currently available at Postgraduate Institute of Medical Education and Research in Chandigarh and Apollo Hospitals, we are able to diagnose the type of micro organisms within a few minutes. It helps in starting the treatment immediately. It is important to start the first dose of antibiotics as early as possible, ideally within one hour of the development of sepsis.’’
Jharna Narang, one of the survivors of the 26/11 terror attacks in Mumbai, is also a sepsis survivor. The 41-year-old who was having dinner with her parents, brother and sister-in-law at The Taj Hotel when she was hit by four bullets. She developed sepsis and it took Narang several months to recover from the potentially fatal condition.
It was a septic shock that resulted in the death of Savita Halappanavar, an Indian dentist, who was admitted to the University Hospital Galway in Ireland in 2012 with severe back pain when she was 17 weeks pregnant. Though her condition was critical, Halappanavar was denied abortion citing Ireland’s anti-abortion law. Following her death, Ireland formulated new guidelines for the treatment of people with sepsis.
The medical fraternity now has a better understanding of sepsis. “Recent research has given us more insights into the role of nutrition and sugar control in the treatment and management of sepsis,’’ says Chawla. One needs to have expertise supported by infrastructure and best practices to deal with a condition like sepsis.
Sachin H.R. Bhat of Banashankari in Karnataka considers himself lucky. He underwent seven orthopaedic surgeries after he met with an accident on Mysore Road in 1999. "I was admitted to a government hospital where infection control may not have been that great. Luckily, I didn’t catch sepsis or any infection," says Bhat, 37.
Bhat, who was unconscious for nearly three weeks, didn’t have a say in where he was taken for the surgeries. Had he been conscious, he says, he would have anytime preferred a government hospital. "The surgeries, intensive care and medicines cost me just Rs.2.25 lakh. Had I been admitted in some private hospital, the cost of ICU care itself would have been more than that," he says.
Anushree Chakraborty of Gangtok would agree. Recently, her mother, Purabi, was admitted to a private hospital in Kolkata. “She suffers from coronary artery disease and had to undergo an angiogram,” says Chakraborty. “She was then admitted in the ICU and then moved to the CCU. The CCU and ICU charges alone was Rs.9,100 a day. For three days, the bill was more than Rs.70,000.”
Since her mother's condition was quite serious, Chakraborty couldn't lose time trying to move her to a government hospital. “I requested the doctor to move her to the ward since we cannot afford the cost,’’ she says.
While cost is a major factor when it comes to critical care, the fact is that it is still inaccessible to a vast majority of Indians. “The public sector is practically nonexistent. Even where it is available, patients have to usually buy medications and disposables,’’ says Dr Shivakumar Iyer, president, Indian Society of Critical Care Medicine and professor and head of department of critical care medicine at Bharati Vidyapeeth University Medical College in Pune.
ICU care is expensive because of the need for more nurses (1:1 to 1:3 ratio) and doctors per patient (1:8-10) in order to provide optimal care, says Iyer. "Similarly, the cost of equipment, expensive disposables, medicines and the need for repeated investigations to keep a close track of the patient's condition push the costs up. Input is also required from multiple specialists to provide appropriate care," he says.
An intensivist with several years of experience, Iyer has a suggestion to bring down costs. "The best way to reduce costs is to provide ICU care only to those who need it. If it is seen to be non-beneficial then such care should be discontinued as soon as possible after honest and accurate communication with the family,’’ he says.
Emerging and pre-emerging infections like H1N1 are another major challenge faced by the critical care community in India. "Some of the friendly organisms in animals could be pathogenic to human beings and vice versa. When humans come into contact with animals, there is a crossover of these organisms and hybrid bacteria and viruses are formed. They are highly dangerous for human beings and cause infections which could potentially be fatal," says Bhattacharya. These newer infections have significantly added to the burden of critical illnesses in India.
Despite the challenges, critical care units in India have been able to save many lives. Mariyamma often tells her daughter about her journey to the brink and back. When the memories become too harrowing, she tries to lose herself in the afternoon serials.
Critical care units in rural areas leave much to be desired. Some of them are not equipped to handle even snake bites or poisoning cases. Specialists often refuse to work in hospitals in small towns which hardly have any equipment. Things are not different in places like Jammu and Kashmir where neonates die owing to lack of enough ventilators.
Dr Srinivas Samavedam, director, critical care, Century Super Speciality Hospital, Hyderabad, is set to bring about a positive change. “The tele-ICU unit in the hospital will reach out to the peripheries and deliver quality critical care,” he says. “It is truly gratifying to deliver the service to places where it really matters.”
CRITICAL CARE PRACTICES
LESS IS MORE Many changes in medical beliefs and practices in the recent times have resulted in better patient outcomes. Less seems to be the emerging mantra in ICU care. Intensivists now prescribe low dosages of steroids and diuretics and less amount of blood for transfusion. The monitoring has also become less invasive. Low volume ventilation is another remarkable change. It gives a better outcome. “Earlier, the concept was liberal use of IV fluids. Now, we give only an optimal amount,” says Dr Pradip Kumar Bhattacharya, director, emergency and critical care services, Chirayu Medical College and Hospital in Bhopal, Madhya Pradesh. “Patients in the ICU now receive low doses of morphine and relaxants, and less amount of oxygen. We try to reduce their exposure to radiation, too.’’