Candles in the Wind
The life of Sri Lanka’s healthcare workers in this pandemic
By Dr. Dilshan Anthony Fernando
Dedicated to the memory of Dr.Neville Fernando and Dr.Gayan Danthanarayana, who laid down their lives in service of patients and succumbed to Covid-19.
As Sir Elton John sang in tribute to Marilyn Monroe, the Hollywood superstar, and then later as a tribute to Diana, Princess of Wales, The Candle in the Wind comes to mind when I think of the lives of healthcare workers battling through a raging pandemic.
“And it seems to me you lived your life, like a candle in the wind, never fading with the sunset, when the rain set in…”
The melodious words of Sir Elton echo, as we see the heroic frontliners of healthcare shine as a beacon of hope and light during darkness and through these stormy days.
We are in a battle against a foe so powerful, so destructive and virulent, that the entire world has been turned upside down and churned in a turbulent current, leaving in its wake a path of destruction and sorrow. And amidst all this chaos, the onus falls on doctors, nurses, and other healthcare staff to turn up, day in and day out, to combat a virus so powerful, sacrificing much more than can be seen or felt by anyone.
As the first death among healthcare workers was reported on 01 February when Dr.Gayan Danthanarayana succumbed to Covid-19, it is timely to look at what challenges and ordeals the very talented and dedicated healthcare workers in Srilanka have had to face. To look at the emotions, and not the facts and figures.
The first wave
The first wave of Covid-19 started in Sri Lanka in February 2020, and took our health sector by storm, as we were ill-prepared to face a pandemic of such magnitude, and neither the proper practices, protocols nor resources were in place. Healthcare workers were caught like a deer in the headlights. KN95 masks were a rare find during the first few days, surgical masks were scarce. Cloth masks were made in the hospitals itself by the hospital seamstresses. PCR tests for Covid-19 were also less, thus the diagnosis of a Covid-19 patient took around two days for the PCR reports to arrive. Due to scarcity of personal protective equipment (PPE), doctors were on pins and needles when a patient they examined without PPE turned out to be a suspected Covid-19 case, and would isolate themselves till the PCR reports came back.
My memory runs back to the initial lockdown of Sri Lanka in March 2020, where many house officers who were resident in hospitals had to face scarcity of food due to shops being closed; they survived merely due to the goodness of their senior consultants and local villagers supplying food.
Later on, the hospitals started providing meals to resident doctors and other healthcare personnel. Ward meetings, unit meetings, and hospital meetings were common, as policymakers struggled to formulate protocols to combat the virus with scarce knowledge and resources. However, due to timely action by the Government, the first wave was stemmed in the bud without much damage.
Every day, we wake up with a sense of apprehension. Walking into the hospital, we cannot help but feel a fear that is not uncalled for, a fear of whether this would be the day that I get exposed to the virus. Each patient we see poses a potential threat; each bystander, each visitor, a potential carrier; each ward round we conduct donned in PPE, a potential to be infected.
In my personal experience as a doctor working in paediatrics, the psychological dilemma and turmoil are higher due to dealing with delicate lives that have sometimes seen only a few sunrises and sunsets. The decisions we make affect not only the lives of patients, but also their families. But decisions have to be made, bad news has to be communicated. The clinical decisions themselves are tough sometimes, and it is made a hundredfold tougher due to Covid-19. Therefore, stress levels go through the roof among medical personnel.
When the shift is done, relief pours down like a drizzle during a drought. We gratefully remove the PPE, wash off the sweat, and rub the sores caused by prolonged wear of masks, gloves, and face shields.
Driving back home is a dazed affair after the tiring day. There is a short-lived sense of relief as we step into our homes and see our loved ones coming forward to welcome us – but that hug of welcome is elusive, because of the fear of infecting people at home. A daily ritual of discarding clothing, sanitising, and bathing is practiced by many doctors before they even say a word to people at home. Many doctors chose to reside in and around hospitals due to the fear of being the carrier that infects their loved ones at home.
Thus stress, anxiety, and even depression are emotions commonly felt by healthcare workers.
Working with PPE
PPE is commonly available now in healthcare institutions. To the layperson it may even seem reassuring. Even though it is fully understood by each healthcare worker that PPE is for our own protection, working with the PPE is never an easy task. Just donning a mask and running around attending to duties in a hospital is hard, and wearing full PPE and working is almost impossible – but required.
A full set of PPE includes goggles, a head cover, an isolation gown, protective cover all, waterproof boots, boot covers, impermeable apron, face mask, and face shield. Wearing these layers and layers of clothing and functioning as a medical officer is a difficult task – firstly it is very warm inside and you start sweating profusely, your field of vision is narrowed by the goggles and face shield, breathing is laboured due to the mask, and the face shield gets misted when breathing.
Wearing these, examining a patient and making clinical decisions is no easy task. Personally, I started my year of 2021 wearing the full PPE, taking PCR tests of suspected Covid-19 patients on 1 January, which I hope doesn’t define my entire year. After wearing full PPE for a few hours, mild dehydration from the profuse sweating, a headache from laboured breathing, and a mild dizziness set in. Even after removing the PPE, one doesn’t fully recover for the rest of the day.
Clinical decisions during Covid-19
Any clinical decision is never taken lightly, since it involves a patient’s life and health, but many decisions during the pandemic have been tougher than usual. Many hospitals in Sri Lanka have a separate respiratory/fever ward to admit suspected Covid-19 patients until confirmatory PCR results are available to diagnose or exclude Covid-19.
Working in paediatrics, one of the tough decisions I’ve had to make was to decide whether the babies that present with fever are to be admitted to this fever ward, or the normal pediatric ward. A call comes in through the preliminary care unit, and they say there’s a patient with fever, the parents work in a apparel company in the free trade zone where a Covid-19 cluster was reported, and thus the patient is kept in isolation with the mother.
I rush to the PCU, take a quick history from behind a screen, don the PPE and examine the patient. After history and examination, most of the time we face the dilemma over whether it’s a normal viral fever or Covid-related. The patient has to be admitted, but do we admit them to the normal wards with no Covid-19, and risk those patients too, or do we admit them to the fever ward with Covid-exposed patients, and risk exposing this baby who might not have Covid-19 to a potential carrier in the respiratory/fever ward? Rapid antigen tests are done, but it is still not confirmatory.
We decide based on the risk-benefit balance, and pray our decision is right for the patient’s sake. A baby presents to the emergency unit with laboured breathing, the baby is wheezing, struggling to breathe; the mother gives a history of fever as well, and the baby is in distress. The sense of patient care kicks in immediately, and we rush to examine the baby and support with nebulisation or oxygen.
But then we stop in mid-stride like being kicked in the gut, and remember that we first have to go through the time-consuming process of donning our PPE and inquiring about possible exposure to Covid-19 – while the baby lays there short of breath. Is it a normal asthma or is it due to Covid-related respiratory distress? Do we nebulise and keep the baby with other patients, or do we admit them to the respiratory ward?
In another instance, a mother rushes her epileptic baby to the ward; upon inquiry their village has been isolated, and they haven’t been able to come to the clinic to get the epilepsy medicine for the kid for months.
These are few examples of what doctors have to face on a daily basis, to make decisions regarding another life while safeguarding everyone else. Many decisions have been tough and continue to be so.
Keep the candles burning
Sri Lanka still continues to control Covid-19 reasonably well compared to many developed countries, not because we have better funding or resources, but mainly due to our exceedingly committed and talented healthcare workers.
All of them have been beacons of light like candles burning themselves to give light to the others in this storm of Covid-19. Let us all bear in mind to help these candles burn rather than let them be extinguished by this storm.
Dr. Neville Fernando, whose brainchild, The Neville Fernando Teaching Hospital, serves many Covid-19 patients, was a philanthropist and a visionary, and it is a tragedy that the virus, which his hospital is dedicated to combatting, took his life. Dr. Gayan Danthanarayana, similarly, was a very talented individual, both in his profession and as a human being, and both these lives were taken by a foe that shows no mercy, dealing a great loss to our nation.
The general public can help ease the burden in stemming the spread of the virus by safeguarding themselves, and also especially to be forthcoming and honest when giving information at hospitals. The media has stigmatised Covid-19 patients, but doctors are here to serve, thus the accurate information will help us make the best decision. Together we will weather the storm.