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Concluding Keynote: From India to Bharat for better handling of future waves and pandemics

Jun 26 | 4:00 PM

The time has come for India's rural areas to be equipped with the best healthcare infrastructure and equipment's, have proper public health systems in these areas, and having the right set of knowledge, skills, protocols and referral systems in place.

uh very warm welcome dr dhruva chaudhry we are very very honored to have you with uh there are lots of publications lots of work in the society [Laughter] without without further let's start so sir you wrote a paper in november in the journal of critical care tidal winter is coming and this was published on 24th november and this was when everybody was giving us the first wave and the small wave afterwards had just gone and we were all celebrating and getting ready to enjoy Diwali you mentioned a note of caution in that article and paper at that time that tougher days are ahead and that these are going to be turbulent times this was one of the few uh notes of compassion coming out at that time where do you think it would have been better but i mean multiple conversations happened around oxygen requirements there were voices from some quarters why then did we get so deep into the second wave was it inevitable was it the sheer course of the disease or further things we would have done before also continuing that point uh what do i think one word has been overconfidence and lack of sight with hand sight you're always wise but at that point of time people thought that we are alarmist covid fatigue was setting in and at the same time uh probably people thought that now the bad days are back now and we can go and enjoy ourselves in fact large number of institutions are dismantled their covid services and and it highlighted when we talked about it people thought that we are allowed and if you see i think the best thing is we should actually look at the way the covid has come up and the way the covid has spread if you see covid never came to us from china in one or two places which started came it came from the western world so what we have been doing in the world of wisdom i am not an epidemiologist but i have learned a couple of things being a part of let's say commission we have mathematical modeling we have other things we had the sense of purpose when this came because we saw what happened in ohio we saw what happened in northern italy we also saw what happened in new york what happened in london so so looking at it if you see the initial cases to us came from the western side being middle east or be it from the europe and that's what we have been saying and by and large if you see in the europe uk usually follows france by a month or so four to six weeks and roughly six to eight weeks on an average extending up to 10 to 12 weeks is the time we are following the uk this is how the circle is going down if you realize it the government of india had stopped flights at that point of time around 22 of december from uk because of the kent variant now known as alpha variant that was an eye-opener which we have done and secondly i think probably the jingoism took over when we allow the vaccination coming up we we did allow vaccination but we thought that probably by alloying means we've injected it and i think a lot of um machoism and jingoism went into it without realizing it and people started writing the arbitrary of the disease before it could have in fact i remember writing to my own institution the vice chancellor of my department of my my institution they didn't reply anything except that end of the january and beginning of february i got a letter that if there we will restart in one week let's go back to the normal there was nothing wrong with going back to the normal because non-covid people were suffering but to dismantling the services completely and then to restart it had become a problem second thing i think what has been taught to us by the flu epidemic which happened in 2009 it gave us a very interesting uh a network of the network which has took the test of the time and uh i think we must remember doctor vishwanka the dgsmr secretary research they started in various medical colleges what you called as a as a media uh vrdl while research development labs which were well sorry viral diagnostic research fact pdrl that was there and they become now the backbone of it and which then this epidemic struck us similarly in this we had the diagnostic we but we didn't follow the principles of molecular epidemiology that probably could have warned us and then we also had signals started coming up from maharashtra if you see the data we looked at it and and you will be surprised i was on one of the program in the month of first week of march when we had the data with us that cases are going down government of india did send its team to maharashtra to look at it all to punjab to other places and you will be surprised that the local has spread at that point of time and if you see and trace again the history from the scientific perspective irrespective of the political parties irrespective of the command it started from maharashtra and then pune came in between and then mumbai earlier it was mumbai followed by pune and then went to nagpur and that point of time when the cases started going up that led to the uh the consortium of labs of icmr and comets if you see it's still pronouncing dvd icmr and csi are labs which have given us so we have not followed molecular epidemiology which i believe now should be part and parcel of of us and we need to expand our labs i think if you will ask me tomorrow what should be the game if we have if we can have a big network of of genomic sequencing labs in the content because earlier it was taken simple because it was part of our research labs but but when you look at it they are multi-dimensionals so you can follow your local patterns of diseases you can have it in cancer can take you from to precision medicine so it has the multiple roles and it should not be specific or bound to let us say to covid as if today it is covid tomorrow it could be something i think that is what was there but probably the surges were in a hurry to operate physicians had certain fatigue i i think probably yeah and when things were coming up probably people thought oh nothing else it's a localized thing i think that is a mistake when you look at the hindsight they should have done and then you had the elections and the elections in maharashtra first UP has been uh localized because of the elections so so it and the other events which have taken place so i i would say that you claim a government and government b coming it people walked across and uh and that led to the spread and that's all it's all about so so it's how it has happened since you mentioned so what are your thoughts on what did bombay do right and even to an extent initially was a lot so what are some of the things that these uh bodies did well and uh therefore in the coming pandemics things for us to dive you see a lot of people the bombay model chaired uh i i was pleasantly surprised when i saw that model i read it and and when what we completed what we had actually planned for haryana in the month of december for home care particularly was similar there was 80 percent similarity so that means there was a thought there wasn't there but remember one thing anything you do in india has a far bigger disability and when we start in terms of the interlines tier 2 tier 3 tier 4 cities they don't look at that projection but at the same time i think what they did right was they able to segmentalize the city into zones which are the municipal zones and then they were able to create critical network the home isolation they were able to use their workforce of minister corporation then they centralized the thing in terms of control and command to which they ended up the all major uh health facilities so they knew real time the number of beds available so so they were able to with that central parent command they were able to see to it that the people were able to reach at the right places i think that was very important and then obviously they did it haryana with the help of d lloyd we did the same sort of stuff at karnal we call it the karnal model on this one here what we found out and we took some help from kerala model and ernakulam they had that major command control kerala has one very good thing it's a very sustainable maintainable primary healthcare sector and then they have a very good reference medical colleges and the teaching training institutions so i think they put that one in place on ground so we took it from there we learned it from there and then we have put it with the help of deloitte within two weeks we were able to launch that model on 24th of may though that that the pandemic was regressing at that time we had 5 000 patients in the home care so what we did what did we do what we did was very simple you had a cycle command we try to strengthen or create field hospitals at the periphery of the villages so that the bharat doesn't stay away from it and attached it with the state medical college which was there medical college at karnal and that district unit was in eight chcs and the blocks so the age block we had amubalence and we for the oxygenation we had oxygen concentrators of 5 to 10 liters that's what we did and in this period of two weeks when it was executed we were able to transport safely 38 people within that fight which roughly turns out to be if you see that is what is expected and rest all were managed there and everyone was given home kits and the home kit contains 15 things but three important things was one was pulse oximeter temperature probes and your uh steamer and once it was patients were cured these were taken back and given somewhere else so so that way the home kits were provided oximeters are provided and we also created another interesting thing which is the channel and also that they contracted with the in the labs so so they were able to give a very simplified cost if i remember correctly what i have been told is around about 80 rupees of 50 rupees that was the one so at haryana we created because now it was the peak time and to go play interline taking samples so what was very important was that at that point of time we we had roughly uh four tests we did it blood sugar CRP and LDH so it gave us a lot of idea without going in and with an oxygenation that's how we went because any model which has to be there has to be cost effective and then we need to see to it whether it is sustainable so with the command center we were able to control everything and that's exactly if you see uh have some prevalence of what mr chandler did and for the cities of the home care we had converted them into wards with warden it has one team and that team be coming to the center responding responding and then going to the uh to the hospitals which are there so they are taken care of around 30 or 40 percent off and later up to three-fourths of the beds of the way wave hospitals i think that's how things have to work in the public sector and and the private sector also all said and done the fundamental difference they find between the first and the second wave was in the first wave hospitals are not there to be seen except you handed the government or to talk and tertiary care hospital rest everything was closed but this time i think the doctors are not as scared and everybody realized that probably uh the last time the number was much more yeah that is true so so they practically have seen surgeons other people all becoming covid specialists opening up but that provided us a huge huge number of beds otherwise it would have been more devastating yeah that's that that's going to happen and the topic that we chose today uh was uh india to bharat so we would i mean i would like to hear your thoughts on this in three different dimensions the first india to bharat which has happened or which is happening is how healthcare is moving healthcare which was concentrated in metro cities and bangalore bombay hyderabad delhi would have the best facilities now we have cath labs uh coming up and BSL labs coming up in smaller towns so that's first that's the geographic movement from india to bharat the second is a renewed interest or respect for public healthcare facilities so earlier that people everybody including people like us everybody favored private setups large corporate hospitals now in covid we saw that people actually [Music] branches of medicine has alternative medicine been one of the bigger gainers out of the whole pandemic so so let's look at this India to bharat transition on these three dimensions you see when you talk in terms of these three dimensions they're all important but remember one thing what is very interesting has happened over a period of time especially if you really ask me the diagnostic services you have talked about shifting it up uh yes you are right uh that the health care in terms of deliverance for the tertiary care and other things was much more in in these metropolitan cities no doubt about it but but remember one thing health is not simply tertiary care that is only one part of it health is much more than that we need to look at primary healthcare secondary healthcare tertiary quarterly healthcare systems are there because it is some this is the tip of the iceberg and with the health care we have associated if you really ask me is a concept of wellness concept of uh looking at it a mental health concept of social health all that part is there unfortunately we have forgotten social health now the good part of endemic is it has brought it back that people are realizing loneliness is killing now they are realizing that there is a much more than what we could even think in terms of isn't it that is one part second is uh when you talk in terms of diagnostic services and all you will also realize something very interesting is that already looking at you look at the larger technical lab groups they all have expanded to tier two tier three tier four city because they realized that when they were there in the in the cities they had a limited number the number is big i'm not saying but when you go up it it's the tip of the iceberg when you go up when the bottom that it's too large too big so so that is how they have been there and thirdly we realized also like you gave a classical example of cath lab then i will come to covid i'll give you an example if you see it in delhi i i i come i'm on the outskirts of delhi in the cardiology there used to be a fight on cath labs in terms of angiographies angioplasties today you will realize that i am certain gujarat is no different is not different UP bigger town cities are not different rajasthan what we found out is they calculated that each and roughly 15 to 1600 cases are referred for and angiographies so people said the whole fight is on it and i was looking at our intensive care unit of coronary care today in my small city of half a million you will be surprised to know we have more than five cath labs working down the clock and some of them are so busy that people after dm are coming for training so things have expanded but they have expanded far more in private sector than public sector right secondly in this epidemic what we realized was because there are phases of this epidemic if you start from the first phase of the preparation and in the preparation the public sector was the active participant in terms of public health infrastructure creation so one was the classical 3Ts we all talked about testing treating and tracing so so practically it was the government sector which participated in it tracing and testing initially for a very long time the government sector so it built up like at my own institution today we have exponentially increased from 250 to nearly 2 500 RT PCR tests in 24 hours that's what is easy if you really ask me from 250 to 10 it may look 10 times but it's a huge thing which has happened so similarly uh uh similarly if you ask me we also uh in the public sector expanded up in my own state now we are doing up to 30 000 uh tests each day then after that the public sector gradually started going down so initially from medical ecology when it came down to the district hospitals then the private sector opened up so they started taking the samples uh am i audible yes sir huh so so so what did we find we we fought so so it gradually went down so the thing which was available in the metropolitan became available in the places where medical schools were there and then from there gradually it went to the district hospital so that way a transition has happened and now you will all be surprised to know that within a 48 hour we had 27 RT PCR machine how because universities are a huge source universities where you find out that departments of biotechnology at their institution we we borrowed it from there from the both government as well as the government of india as well as the government of state government i think that must have happened at other places also now we created the infrastructure in the district hospitals now these district hospitals even if the epidemic goes the strain manpower will stay there the machines will stay there so your diagnostic capability of the whole state whole country has gone up so practically there has been a watch which has taken place from tertiary care now to the secondary level of care and then obviously and the appliance sector also expanding simultaneously when they permit it to do it thirdly rapid antigen testing itself gave enough power you will ask me how there are challenges there are issues no doubt about it you look at it haryana started a very interesting program where we started going into villages and we scrutinized one crore 80 lakh people in our villages which is roughly equivalent to two-thirds of our population and what did we do we simply put up the patients with influenza like illness now what you had is influenza like illness you picked them up you didn't read testing in that we found out certain number of people which were positive there and those who had influenza like illness who turned out to be negative and all RT PCR was done and i am saying this was done twice from within may and the fourth time was 14th of june today from the peak in my institution we had 37 percent positivity obviously for the selective data which was coming up every other percentage was 50 to 18 percent and now it has come down to less than 0.5 i know today uh uh warning of the issue for faridabad in terms of uh delta plus varying so so that is what we found but where we have failed till now is to know the genomic sequencing we are going to IGIB we have got 158 data where we know in the districts the delta variant delta plus uh this like the delta variant is the is the main one but initial phases we found out and alpha variant was the big one so so there has been a gradual shift and change as daily exploded we have it so what i am saying is what affects india affects bharat what affects bharat affects india so you will see that large number of patients were accommodated at a smaller institution smaller cities smaller hospitals so so that way it has helped and dissemination of information same thing is happening in cancer care same thing is happening if you see it because more of the people who are doing their post graduations and they are going and settling down because quality of life in smaller cities seems to be better but but in the covid that is what has happened but with the karnal model which i talk to you it is giving us entirely different thing which says give as a post covid one of the best thing will be to drive these models and create a referral system is through the use of IT it has to be IT enable i think that is very important what does that what does it mean it means now look at it earlier there was a challenge in terms of acceptance of your uh and there was a challenge in terms of acceptance of your uh of people of digital health or online consultations online other things but with the covid the national medical commission now earlier in as per mci gave permissions so it is legally acceptable legally i doubled with IT i doubled with telemedicine earlier we found it to be utter failure except in the remote areas of himachal or where private sector was looking in terms of as part of CSR but it was helping them out so i think that is a major shift which has taken place and today if you will be surprised the karnal model we created in this our medical students final year the one player student was looking at 25 patients and all five patients and five students was one teacher so if there was exponential reach which happen so if now we have to harness this and see to it it is sustainable it stays back and deliver and for me and i realized i saw my own daughter and my uh and would be son-in-law both doctors the way they looked after the home care simple MBBS students i think there was no better learning ground for them on the age across the country i can talk about it so they learned about it how to manage it and if you ask me today the heroes and heroines today are these young doctors these young nurses these young paramedics for sampling who used laboratory people dental people dental student dental post graduates so everybody was utilized in a way so what we learned was a teamwork in healthcare system what we learned was a coordination at certain places private sector people from the help of ima were taking off then we also realized that it is in the benefit of everybody be it government or private to work together and move together and work it out you look at it the oxygen challenge which was come on which was across by whether it was a it was a metropolitan city or it is a small tier city and then it also tells us that the quality of the care can be given that is what i have learned at the level of chc's phc districts or at the private level the only thing is required is the hand holding the institutions we private the public they need to help them enable them empower them i think that is what we have learned and that is how india can help bharat so that people they feel confident to deal with the situations with which they have come up but whatever each centre needs to need their limitations i think that is very important and they should have very clearly defined tried and referral system i'm again want to share with your audience and our audience today is for the first time when we had the limitations of those committee was constituted across all the all the state we were looking at it for for the whole state we have three people and first time as a part of driving objective criteria we picked up as was in the nights we followed that shape which people are talking today about about those citizens were being approved by and by NIH or FDA we followed the same thing of oxygenation plus inflammation and you will be surprised the same was then we we started from rohtak we put it in haryana picked up by the state of delhi rajasthan and other states same thing we tried to do it for the amphotericin same we try to do it for other things so the best practices are not only the domain of metropolitan cities smaller smaller cities can do it and it is an extremely learning experience for both from each other because realities are different criterias are different like the amount of concentration of people let's do people in mumbai delhi it's amazing whole area is 2.8 crores but whole delhi is around two crores so it's the ncr which provided the depth strategy depth to the patients of the delhi so i think it is important the states have to realize and at the same time we need to realize that at certain areas disease will be more certain area of disease will be less so we should be ready with the dynamic model that if it happens besides following the principles of epidemiology in infection we are able to send our forces there to take care of it that's in gujarat tomorrow you have a problem with bhavnagar the next day you may have a problem with saurashtra so or you may have in the kutch or you may have a central gujarat or north gujarat you should have teams which should be able to go so so i think that sort of a dynamic strategic reserve now each state has to keep that is one part now you talk in terms of public health care facility reserve is a private sector uh well again it depends upon the dynamics and the uh ability of the risk taking public sector is violated risk taking a watch private sector is is for it people realized it in the public sector all medicines were available in private sector 8 they have to struggle and secondly the cost of treatment whatever the government may say truth of the matter is that those who have the money they could go there am i right and people are extremely reluctant to come to the government sector because we are providing cure care was a challenge care was a challenging private sector also but it was inherently believed so one of more people that i think the major difference still between the public and the private sector i think one remained war in the severe critically ill patients and one of the major reasons is that these services are far more developed in in corporate tertiary care hospitals than the public sector if you take that thing away and if we can put a some amount of a service component to do to the public sector i think it's a win-win situation we need to learn it that the hospital is hospitality that is where the world has come up and the words that come from the imprisonment so so you realize when you pick the place like same so we need to learn the hospital component hospitality component for the private sector because that provides the care and again i am sharing with you now that the rohtak at least in my intensive care unit with the open consent of the patient attendance or those who had covid in the past we allowed them to stay with the patient and trust me if it reduced the mortality it improved the mental health and that's how we experimented it and that's what i will say that that should be a standard model now where you allow in the sick patients in this scenario when your staff is your staff is stressed that they provide the care you provide the cure combined together and work together for the benefit of the people even again there is another issue between alopathy or ayurveda or alternative medicine i think it's in the stupid argument engagement both are important both of their values both have their philosophy and and i always feel that the modern era two things are most important one is your anesthesia another is your antibiotics both of them have made a huge difference and and infections nobody can clear better than allopathy surgery nowhere it is better than the allopathy and it is because of anesthesia which has come up which is the biggest name of the modern medicine but at the same time a lot of medicines and allopathy have come from plant or they have come from the natural sources to that extent if you see it your majority of antibiotics are also coming up today you must have read about plant are plant and they've been used along with the with the uh genomic sequencing to create new vaccines i simply say you give sincona it is ayurveda you give chloroquine let's say you give quinine it is allopathy alkaline digital is you look at it it came from plant understand so much you look at the people take so much of tea when they have asthma it comes from there your filings have come up from there i think it's it's a it's a it's a stupid excuse engagement which people are going into it tulsi you see if you see it in that in the lab it has an accident and influenza activity similarly other thing and children you look at it the way thing is used so they have chemically active substances which work but what is important is people should respect the place in which they are trained they should practice in that and accelerate that you can always have at the pancreas just sometimes need requirement you can go up and down but but to simply admonish each other i think is neither desirable nor required and probably i think we should have faith in our own medicine we should have faith in our own this thing it will work today we are talking in terms of microbiomes today we are talking about the microbiomes in your respiratory tract which decides which patient will respond or what symptoms will be there you must have read those case histories where people became drunk in u.s and china and they claimed that their tee-to-taller and they found out in one the species of fungus and another they found out species of klebsiella which fermented the carbohydrates so alcohol and these people had one of them actually had cirrhosis and they were looking at a fatty liver and he was not very fed this is where it come up therefore observations are important evidence is important whether it's whether it is your when you see it combined together find out work it out and see what what works so i think after that so show me that excuse and there is nothing that ayurveda has won or the allopathy has won end of the day it is the patient who should win and we should follow the first principle for the hippocrates that no harm should be done it's a misconception among the mind of the people that ayurveda is harmless i think that should go away completely you know it the blood poisons are there you know it people can uh used to use it to kill people alinga toxicity is there other plants are there so so to say that they take it every drug is a poison parcelsus said those makes it poison be it allopathy or be it ayurveda thank you very much sir that is very very clear and uh also makes a lot of sense i think there is just a lot of xenophobia towards how did covid affect you as a critical care specialist you have a long uh and distinguished career uh already but were there some things that you learned as a clinician uh whether it's about history or diagnosis or management anything so are there a few things which you would now do differently i think the first and fourth most important that you need to have an approach like an armed forces you need to stay cool you need to stay calm because these are ambitious that's not this is the last ambition it will keep on coming up i think we need to redefine our safety processes in the intensive care generation so as a leader i think we have to realize that the personal safety of your staff is the number one because if they're around you can do it secondly which is important because if they are safe your patients are safe they are the most highly trained people in the in in modern medicine second is and whether it's a doctor or nurse is a paramedic i'm talking of all of that when i say it that is what i have believed in it that's what i learned it that has been re-emphasized i think it needs to be reinforced to everybody secondly what i have learned is that have faith in your juniors and youngsters they are your uh they are your strength trust them empower them and and help them and another thing which i have learned is that technology is the answer here also because manpower shortage will be there every time it happens you will find it difficult to people to chip in so you need to adopt and adapt both in critical care already it is there and i think in coming times artificial intelligence will play an important role but end of the day it is the bedside which is important what i realized in the critical care was you see i don't know how many of you have gone there inside the ICU setups it's a scary feel it's a scary feeling for one simple reason you have 20 to 30 patient like in an area extremely sick then one is dying another is being intubated or being going up somebody is not able to pass you and not stool they can't go to the loo you need to learn and empathize and understand the agony which going on and look at the mental trauma somebody is dying in front of you however you might try to do it is clear it looks like that you're the next in the back so i think you need to speak to them you need to look at the mental health of your patients give them positivity that is again what i have learned when you see that then becomes what i realize they will look better will be effective communication both with the patient and the families we have the patient inside we couldn't speak to the attendance then care component which is very important we think that the nurses will provide the care already stressed all of them very soon you cannot see them it looks like uh some people from third land has come up and examining you seeing you another thing he told us have they sent it up to adapting the or adopting the car how many of us are hospitating these people within the intensive care because that brings doctor-patient relationship it was not there practically it was it was like that you two people from Unknown land talking to each other i think that is what yeah yeah i will i i will come to that and then probably another important thing is ppes which we had it personal protection equipment etc i think we need to redefine it i would not like to go and i would like to have very clear cut triaging in the triaging not the sickest will go to the ICU that triaging will be in terms of when you see it individual cases yes but what you do it in a disaster in a disaster too sick are not taken reasonably too well are not taken so you need to emphasize on the people on the middle level of illness i would like to go for the moderate and severe rather than two critical people you work hard they don't come out so my emphasis should be and will be on saving large number of people if in that process i can help other person out because their average day time will be 70 to 80 days and finally we need to redefine what we want everybody bring maintain after ventilator yes they need it we need to redefine the protocol of regulation when to take whom to take how quickly to take but i think if you ask me i would like my MBBS my MD my MS students to know the principles of oxygen therapy that is what will save us from this sort of a pattern which we need to redefine re-look at it and finally i think people should realize wisdom should prevail and not the name for it for damage to panic one of the highest degree of quackery we have seen at any point of time was in this epidemic if possible for me i would like to come with a very heavy hand we have created a monster out of it in terms of complications not that it would not have happened otherwise but personally if you see today besides everything and finally uh rohan if you ask me i will go for somewhere a centralized research issues protocols like what recovery has come up the uh NHS has given us the data i think we now need to have a national network on research also during epidemics so that we can so that we can practice and come up with our answers to it rather than uh following uh the half evidences or perceptions or two things so i look at it the way things have happened i think the way NHS goes up it should be a model we have created a model for diagnostics we now need to create a model for the research in epidemic and pandemic that is what i would like to redo it if i have something to do so that we know our answers of our problem finally to your question sudden death we have seen it one of the major reasons what we have found out and early morning we saw a lot of them happening when vagotonia was there in intensive care units you are following the cases or your monitoring is little lesser because staff is tired and secondly what we found out was that there is a we did a study ah not i would say a study as a curiosity those people who continue to have tachycardia we did it in around about i have done around about 10 or 12 uh MRIs and out of them one third were having an evidence of a oedema that means they had an evidence of myocarditis similarly we found out that patients of covid who were given remdesivir steroids or even otherwise had nearly 10 to 15 percent of cases bradycardia therefore this is probably a reflection of a myocarditis a reflection of a that your bundle that is a electrophysiological the bundle of face or other conducting system is not stable so you need to look at it that is how kind of death i remember one case in my ICU one of my colleagues father-in-law we shifted him he was very bad high level of sugar having a very significant encephalopathy recovered stabilize settle sitting and we said we will discharge him and everything fine we went to the walking everything fine document and he collapsed right there within a second of five minutes and when you start looking at it we have found few cases also have pulmonary embolism so so you have myocarditis you can have pulmonary embolism and you also can have a problem associated with conduction system all starting from s a node going out to av node and bundle of his so that they are the few things which we have seen which we have encountered and also again be careful lung is one part heart is not helping out we have seen few cases of us who are having coronary artery disease so acute ischemia going up will be there so any person who does complain to you breathlessness you find that lungs are clear either rule not pulmonary embolism that is also not there it may not be angina equivalent therefore it is very important to be having threshold and finally another important lesson i have learned is no elective surgeries except emergency surgeries not for anything else give you another example senior colleague of ours had a covid lung recovered walking briskly felt discomfort turned out to be coronary evaluated initially we thought in the asthmatic also recovered but he said now i'm feeling comfort they did tmt positive angiography and was advised bypass and uh there was a lot of debate we physician insisted it should be waiting because he had started developing the collaterals an idea was stated that we should look at the surgery after three months didn't agree and for the surgery it would happen to anybody they ended up all sort of problems because tissue healing will take six to eight weeks now data has come up please don't go for surgeries elective surgeries is particular emergency surgeries yes they are needed they are required but for elective surgeries somebody is having hernia why you want to go similarly in the bypass if you are having it we have collaterals well developed data shows clearly that medical management is as good as bypass unless and until there is a same life threatening disease leading on to low effective infection so the point i am saying is stick to the basics of medicine refrain from jumping to uh uh uh on major responses that i think will be more appropriate except the third view will come eventually uh when it will come we don't know the size and shape of the view but can you uh forever uh for all of us for all our benefits just in a very brief uh like a couple of minutes uh recap what is the standard of care today for my mild to moderate disease because a lot of drugs have come and gone a lot of guidelines have come and changed but as of today what is the standard of care in mild disease i think i will not give anything i will just wait and watch look at the risk factors and probably offer now on the cocktail which is available now we have some experience and i don't mind offering it and especially anybody who has a respect for 12 years and above the weight is for cause you see i am fortunate enough in public sector it is free of cost because it was given and became a donation to us for 1000 patients one secondly the cost which kept is around sixty thousand two the only thing is that if the formula in which it is coming up it is twenty twelve hundred twelve hundred milligram i think and you total required six hundred six hundred milligram of eculizumab and adalimumab that combination you need to require so it's also it is need to be given to the two patients we use on one another it should be used within 48 hours because there are no preservatives so i think that is one thing which i will definitely offer to a patient anybody who is more than 12 years of age having weight which is more than 40 kgs and along with it have comorbidities 65 and above anybody so i think that part we need to look at it so high risk group we need to define for me another is high risk group people are what we're talking about is is is the patient in the family who had a severe covid if father had it i will definitely offer to son not to the wife to the mother similarly the genetic pool which coming up lineage vertical i definitely will give it that is very important because we have seen the host responses are the key besides the virulence of the virus so so that is i think is important in the mild one simple paracetamol close watch be careful around 6th and seventh day of illness that is one part now one controversial thing again there is no consensus on it and there is a transatlantic divide also in terms of using other antivirals like remdesivir to be used or not to be used you know it's a weak antiviral but today the data is showing a fair number of it persists for a long point of time at risk factor people at an individual level i definitely will offer antivirals in the first seven to ten days in the patients who have who have and the major one will be now monoclonal antibody and now once that is available probably i may not use remdesivir if person develops second week onwards any fever any shortage of high grade fever if it has not responded or if person starts getting severe fatigue tiredness and have along with it an evidence of inflammation or moderate involvement of lung that is anything both around 14 and above or 12-14 sometime which gives you an impression on seeing it also that is the time even if hypoxia is not there is a one small subset of people where definitely we would like to use corticosteroids i'm saying a very controversial thing people are saying where is the evidence but gradually data has started coming up like this small subset where we are also coming up with the paper in indian journal of critical care so it's a just survey what we are saying here we look for critical parameters we look for inflammatory parameters and we look also for radiological parameters out of them if two clinical one information parameter is together or there is the significant radiology means it is more than 12 10 to 12 then we will use it but remember one thing please first check the children and that is one group of people which will be a research thing to me to look at the role of remdesivir with jac 1, jack 2 to if i don't want to use this is something people have still not used it but that is one thing which we need to look at as a part of research trial protocol not otherwise for the moderate one hypoxemia when it sets in but prior to that before a hypoxemia you should always do six minute walk test any drop of three even if may not be less than 94 for me is important and significant so there again steroids will be coming up early and we'll be using around six to eight milligram dexamethasone or equivalent but when you come to the moderate one where hypoxia is there i put a lot of emphasis on respiratory rate before you develop a hypoxemia respiratory rate is going to go up so if somebody has a basal respiratory rate of 16 or 18 if you see it steps up by 25 percent or so that means by default it will be crossing 20-22 up to 24 that is what is an arbitrary so what we will do and follow is medical emergency working scoring if the data comes up and the points go up by four points definitely for me it's a warning time i would like to look at that point of time information parameters for me hemogram CRP that is what i'm sorry it'll up and down doing it but that end of the one week CRP hemogram LDH and blood sugar these are the four things i will do and if i find that neutrophils are going up lymphos are going down ML ratio going beyond four and at this point of time we have seen platelets can also go down they can either be thrombocytopenia or they can also be talking about immune thrombosis taking place if it is associated with hypoxemia and that is a signal negative sign for me in moderate remdesivir with hypoxemia we talk about less than 10 days yes a routine but now data is enough because then the person is immunosuppressed maybe little later also steroids you will use it now the basic standard dose we talked about the evidence was there but the evidence is coming up in terms of we are also doing a trial now of the methyl prednisolone this room that we look at appear to fio2 ratios and and if it is less than 200 we are going as a part of the trial protocol 250 milligrams of methyl prednisolone on day one day two day three and then we come down to the standard protocol of not a fixed dose but in moderate we go by point five to one mg per kg of uh point zero five to five point five point one kg off dexamethasone or equivalent in point five to one mg of uh methyl prednisolone or equivalent of steroid that's what we do it and and what is important for us is that this is also is the time you don't use the pulse value once that is for the severe cases so here you diagnose you do remdesivir you do steroid and this is also is the place where you can use now NIH is saying Barcitinib with remdesivir but what we are doing is barcitinib or tofacitinib or or your jack 1 jack 2 inhibitors is when we give 48 hours of steroids not responding instead of increasing or decreasing we are adding now that will get to individuals in severe cases as i have already told you higher dose of corticoid double that amount it will become 0.25 to instead of 0.1 to 0.2 and there that will become 1 to 2 mg per kg of methyl prednisolone and if your PHF is less than 200 we are using in these cases pulse therapy or if you have a sudden drop of oxygenation with with that is important keyword CRP more than ten times if it is ten hours seven sorry seven point five eight times if it is ten we go by seventy five if it is five we go by fifty and above that is how we look at it the rule of tocilizumab is there but remember tocilizumab will help you one in 25 and there also if for some reason you have don't have an availability of tocilizumab you may either use methyl prednisolone pulse or that is 250 mg for two to three days or people are talking about dexa or with that i have no experience or i have an experience now with this and then you may think in terms of are you adding up marcitinib or tocilizumab but remember one thing meticulous control of sugar is the key with steroids or otherwise we have used up to 20 units of insulin even in an hour to keep that sugars less than two hundred i think uh insulin has a pluripotent effect not only it has it reduced uh bring down the sugar anabolic effect anti-inflammation properties and it tends to promote healing also i think this is important for us that's how we are going and you know children in particular uh when they're coming up to us when you gradually we are taping steroids over three weeks period when you have a significant lung lesion and information is that we are going up to six to eight weeks also and now the data is again coming up that the people who had a fibrosis here again the only definitive evidence of fibrosis for you is your honeycombing low dose corticoids of 20 to 30 milligrams that this equally is effective i know there is a big setback because of fungus which is there people may come up and say but now the data is evolving things are coming up but what is important is when you try you need to know the complications you need to take patient and confidence and do not unnecessarily try uh other drugs like which have been sanctioned for it they will only should be done in the setting of trials thank you very much sir i think we we have a few more questions but we're really running uh yeah i have no issues with that one or two questions yes also one question which has put on is theoretically has multiple uh effects with anti-inflammatory as well as anti-fibrotic what is their role we still don't know answer is to be honest data is not adequate data is emerging but they have to be add-on not a replacement for corticoids but when you use related be careful with anti-coagulation and liver functions so just uh one line answer on methylene because it's something on which we haven't heard too much i mean there are there are always people who say it works and doesn't work and today incidentally one young lady came from USA her mother is not doing well so she asked you for the methylene blue we have not used too much of it this is a you see repurposing of drugs is going on and between you some people watch for it times of india i am not a big fan of it because it came up with meth-hemoglobin actually now neither you can prove not disprove it but the data and the trials which are there is not very supportive as of today sure sir sir as we as we conclude so in this entire cloud of covid what is the silver lining for india it's also the concluding remark for the conference you want to end with a positive note so what is the silver lining in all of this for us silver lining for us is that first of all i think it is the covid has been a great learner and post covid i think health system will not be the same you will see penetration of digital health you will see a our change i i presume personally in terms of the way health care is being delivered and probably we will be far better ready and i think from from my perspective what will be very important like after swine flu we had viral diagnostic labs probably this is the beginning of a genomic epidemiology which was required and can be extended now to large number of other conditions like tuberculosis i think for one thing which is a public health problem or to other infectious diseases if they come up i think it is going to create that and finally vaccines are one area which probably will give up and i think it is going now to give as a part of other thing and i hope and i presume and it will bring back up the respect it will bring back the importance of healthcare workers but for the healthcare workers i think and as a policy planner if it can bring back the concept of one health i think that will be the key where you will realize it that we are one of the only we are not the only one but we are one of the one of the species which nature has made to stay in the world and we have to learn to stay in harmony with our environment we need to respect environmentalists we need to respect public health people they need to respect zoologists botanists you know that's how together that makes the environment and we do that's how we look at it amazing sir so we started also on on a very similar note we are stressing on the need for more research more uh BSL labs the importance for more zoonotic surveillance and the fact that climate change is important and deoxy glucose again works on warburg effect the person who got for the malignancies i had a detailed discussion with the rdu and that operate these people while they have to do it while with the cdi and people have this people did try it and it has reduced the requirement of as for the data which is there 2.4 or so i think we still need to look at an answer that it's only time will tell with more field trials but nevertheless it looks encouraging but i won't say beyond that it should only be used in the trial settings sure thank you very much uh i i just just give me a second sorry i had to turn off my video yes so uh now i would just like to thank you sir for taking so much time and to all the delegates for attending on all three [Music] days you

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dr. Dhruva Chaudhry

Dr. Dhruva Chaudhry

Senior Professor & Head, Dept of Respiratory Medicine & Critical Care at PGIMS, Rohtak

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dr. Dhruva Chaudhry

Dr. Dhruva Chaudhry

Senior Professor & Head, Dept of Respiratory ...

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