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Covid-19 basic care at home

a year ago

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As the Covid-19 saga unfolds, many are now allowed to quarantine at home if they test positive. With a seven-day average of 190 deaths per day, Sri Lanka is currently gripped by the fourth wave of Covid-19 with newer variants of the virus. Against this, the numbers keep rising, overwhelming the health sector in Sri Lanka as well as globally.  With the increase in demand for specialised care, the Ministry of Health has initiated a triage system for the admission of Covid-19 patients. The management of asymptomatic or mildly symptomatic patients is being handled by the newly introduced Integrated Home-Based Care Management System. The Ministry of Health, the Sri Lanka Medical Association (SLMA), the CGPSL, and other primary care professionals have commenced the practice of telemedicine. Allowing those who are asymptomatic or mildly symptomatic to quarantine at home has helped to reduce the burden on the healthcare system. [caption id="attachment_160447" align="alignleft" width="251"] CGPSL Honorary Secretary Dr. Dumindu Wijewardana[/caption] In this light, we spoke to CGPSL Honorary Secretary Dr. Dumindu Wijewardana and CGPSL Editor Dr. Kalpanie Wijewardana to update us on the current homecare recommendations, if we or our loved ones test positive for Covid-19. The GP as a team player In this setting, the role that could be played by the general practitioner (GP) in educating the community on how this infection could be prevented and controlled needs to be highlighted. The GP would be able to counsel the individuals in the community to cope up with various problems that may arise due to isolation, quarantine procedures, and contracting the disease itself, according to the relevant health guidelines provided by the Ministry of Health. Moreover, the GP could continue to prevent and control non-communicable diseases (NCDs) that exist in the community, such as cardiovascular diseases, diabetes mellitus, chronic lung diseases, and chronic kidney diseases, without delay, thus reducing the burden of the health sector in this time of need, stated Dr. Wijewardana.   Basic care at home [caption id="attachment_160448" align="alignright" width="273"] CGPSL Editor Dr. Kalpanie Wijewardana[/caption] In the case of treating the Covid-19-suspected or confirmed patients in their homes, the chance of transmitting the virus to other family members at home should be looked into. According to the recommendations of the guidelines laid down by the Ministry of Health, the following categories of patients are eligible for home-based care:
  • Patients aged above two years and under 65 years
  • Patients having facilities to isolate in a well-ventilated separate room with adequate washroom facilities
  • Patients with adequate self-care or caregiver at home
  • Patients having proper communication facilities (either patient or caregiver being able to communicate)
  • Patients without uncontrolled co-morbidities (diabetes, hypertension, chronic lung/heart/renal/liver/diseases, or morbid obesity BMI>30) and on regular treatment
  • Those not suffering from an immune-compromised situation (organ transplanted, cancer, HIV/AIDS) or not on any long-term immunosuppressants
  • Patients who are pregnant and in the gestation period less than 24 weeks (six months)
Responsibilities of the patient and the family while at home:
  • Limit the number of household members coming in contact with the patient
  • Minimise contact while using the washroom/toilets if only one is available
  • Avoid sharing personal items
  • Adhere to strict hand hygiene
  • Maintain distance and wear a facemask while coming in contact with the patient
  • Make arrangements for proper waste disposal
On the other hand, the infected person should be able to keep communicating throughout the quarantine period with their family doctor/GP or other relevant healthcare personnel assigned to them by the Ministry of Health. Instructions an infected person is expected to adhere to during the quarantine period:
  • Ensure strict bed rest
  • If suffering from diabetes or any other diseases, make sure the conditions are under tight control
  • Be sure to take the prescribed medications
  • Avoid any physical exertion such as running, climbing stairs, dancing, or any recreational physical activity and manual work at least for two weeks. Do not try to test exercise tolerance at home
  • Sleep on your abdomen to reduce shortness of breath
  • Avoid smoking and alcohol consumption
  • Ensure adequate hydration – consume at least 1.5-2 litres per day
  • Check your daily oxygen saturation with a reliable pulse oximeter and do the modified exertional desaturation test (MEDS), when and where feasible
  • Seek immediate medical advice if shortness of breath or MEDS <96% is experienced 
Detecting silent hypoxia/happy hypoxia and how to perform MEDS:
    • Observe oxygen saturation (SpO2) at rest for 60 seconds to ensure stable SpO2 of >96%
  • Those who have saturation >96% may perform the modified exertional desaturation test daily (monitor baseline SpO2 ? after standing and sitting 8-10 times within 30 seconds)? rest for 90 seconds and monitor Spo2 again? record the lowest level of Spo2)
  • Do not perform the test if the patient is too ill or saturation is <95% at rest and seek immediate medical advice
  What should the patient/caregiver monitor and communicate to the assigned doctor (GP/family doctor) on a daily basis?
  • Body temperature – fever (>380C or >1000F) checked using a thermometer
  • If there is breathing difficulty at rest/on mild exertion, discolouration of lips (blue), or shortness of breath, oxygen levels 
  • If diabetic, check test sugar levels (FBS/RBS/PPBS) where possible and as advised by the doctor
  • If there are any symptoms such as feeling unwell, tightening or heaviness of chest, reduced urine output, thirst, and newly developed skin rashes
Common clinical characteristics of Covid-19 These include cough, temperature of >38°C, fatigue, excessive sputum production, shortness of breath, muscle aches, sore throat, headache, chills, nasal congestion, nausea and vomiting, diarrhea, and any other co-morbidities. Identifying red flags The GP or the family doctor assigned to a Covid-19 patient managed in the home setting should lay out a proper monitoring schedule and a management plan which consists of symptomatic treatment, adequate nutritional management, and hydration. Clinical concerns:
  • Temperature >380C
  • Respiratory rate >30 breaths per minutes
  • Heart rate >100b/min with newly developed confusion
  • Oxygen saturation <96% after minimal excretion or drops at any time
  • Low blood pressure <90/60mmHg
Identification of any red flag symptoms through an urgent assessment – either in person or by a good video call, depending on the clinical situation – requires urgent hospital admission for further care. Red flags:
  • Severe shortness of breath at rest (being unable to complete a sentence at rest)
  • Difficulty in breathing (wheeze, needing to lean forward and support themselves to breathe)
  • Blue lips or face
  • Coughing up blood/haemoptysis
  • Pain/pressure or tightening sensation of chest
  • Cold, clammy, or mottled skin
  • Newly developed confusion/altered conscious level
  • Loss of consciousness
  • Difficulty sleeping
  • Severe headache
  • Neck stiffness
  • Little or no urine output
  • Non-blanching rash
Long Covid syndrome Long Covid or post-Covid-19 syndrome is a term used to describe a diverse set of symptoms that persist after a minimum of four weeks from the onset of a diagnosed Covid-19 infection. This is when signs and symptoms that develop during or after an infection which are consistent with Covid-19 continue for more than 12 weeks and are not explained by an alternative diagnosis. The ongoing symptomatic Covid-19, on the other hand, is defined as signs and symptoms that persist between four and 12 weeks from the onset of the infection. Therefore, the term “long Covid” includes both ongoing symptomatic Covid-19 (4-12 weeks) and post-Covid-19 syndrome (>12 weeks). The recovery from long Covid syndrome differs from person to person. While many people will come out from long Covid after 12 weeks (three months), it might take a bit longer for some others, depending on how one’s body and immune system react to the virus. Even those who had mild Covid symptoms may still experience long Covid symptoms. Common long Covid symptoms include fatigue (extreme tiredness), shortness of breath or breathlessness, and cough. Other symptoms that may be experienced by the patients are chest pain or chest tightness, cognitive and neurological defects (memory fog including difficulties in concentrating and memory loss), insomnia or difficulty sleeping, heart palpitation, dizziness, a pins-and-needles feeling, multiple joint pain, muscle pain, tinnitus, earache, gastro-intestinal dysfunction (loss of appetite, stomachache, loose motions/diarrhoea), skin rashes, high body temperature, headache, throat discomfort or sore throat, mostly dry cough, changes of taste and/or smell, and psychological instability (anxiety, depression). What causes long Covid is still not clear. But there are certain theories coming up. One such theory is that the infection makes one’s immunity go into overdrive. The syndrome may lead to more severe complications such as damage to the blood vessels, causing cardiovascular and lung or brain disabilities. A point to note here is that long Covid syndrome is not contagious, and its symptoms appear due to the body’s response to the virus beyond the initial acute phase. It is currently a “diagnosis of exclusion”, where doctors first rule out other possible causes and treat it symptomatically, stated Dr. Wijewardana. When to seek immediate medical advice in long Covid syndrome:
  • Sudden onset of shortness of breath or progressive shortness of breath
  • Chest pain that is sudden or severe and doesn’t go away
  • Sudden chest pain that is accompanied by vomiting, nausea, sweating, or shortness of breath
  • Sudden chest pain that is accompanied by a loss of consciousness
Older people, women, and those who had five or more symptoms in the first week of becoming ill with Covid-19 were more likely to develop long Covid syndrome. Increase in persistent symptoms was seen with every decade of life and was more likely to affect women. Long Covid is more prevalent among people who are overweight or obese, smoke, live in deprived areas, or had severe Covid illness and needed to be admitted to hospital. Tips to overcome long Covid symptoms:
  • Pace oneself – plan the things to be done and avoid overexertion
  • Try to break tasks down into smaller chunks, and alternate easier and harder activities
  • Consider the best time of the day to do certain activities based on energy levels
  • Frequent short rests are better than a few longer ones; so rest before you get exhausted
  • Try to gradually increase the amount of exercise. Try going for short walks or doing simple strength exercises and build up from there
  • If using a walking stick or a frame, lean forward on it when feeling breathless
  • Connecting with other people can help make you feel happier; make sure to keep in touch with family and friends
  • Having a daily routine can be good for your mood and sense of stability
  • Stay active – continuing to move will help release endorphins and improve the mood
  • Make notes – this helps you remember things, whether it’s in work meetings or medical appointments
  • Take care of your mental wellbeing
  • Always best to check with the assigned family doctor/GP before starting a new exercise regime

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