How Kerala's Frontline Staff Are Battling It Out

Doctors, nurses and support staff at the Pathanamthitta General Hospital which houses five patients with confirmed cases of novel coronavirus. Across the nine COVID-19 affected districts in Kerala, nurses, doctors and cleaning staff are quietly going about their demanding isolation-ward jobs. Most of the nurses and the cleaning staff live within the isolation ward, at all times, never leaving so that risk of contagion is minimised.

Pathanamthitta: Anugeetha AG has not met her 10-month-old baby since 10 days. She is a staff nurse working in the COVID-19 isolation ward at the general hospital in Pathanamthitta, the southeastern district of Kerala that has the highest number of COVID-19 cases.

Her team of 13 are treating five of one family who have tested positive with the virus that has already killed three in India and more than 8,000 around the world. “I want to leave only after their tests are confirmed negative and they are discharged,” she told IndiaSpend, her voice gentle but confident over the phone line to the district collectorate a kilometre away. (Two aged family members, also infected, have been moved to another facility.)

The 27-year-old had completed her first year as staff nurse at the hospital in February 2020. Days later, on March 8, 2020, the family who had a travel history to Italy were detected as infected. They had arrived in India on February 29, 2020. India has screened nearly 1.4 million people at airports.

Anugeetha is the youngest in the team who work round the clock at the frontlines of India’s battle against the SARS-CoV-2 virus that has taken three lives in India, and 8,810 globally. As of 9 a.m. on March 19, 2019, India had 166 confirmed cases in 17 states and union territories, according to Conoavirus Monitor, a HealthCheck database.

Pathanamthitta district in south-eastern Kerala has 30% of the 27 positive cases in the state, which itself has 16% of all cases in India, the second highest tally. All nine cases in the district have been traced back to the same family.

Across the nine COVID-19 affected districts (of Kerala’s total 14), nurses, doctors and cleaning staff--who must remove all waste since no product is being allowed to be reused while ensuring no contact--are quietly going about their demanding isolation-ward jobs.

Most of the nursing and all cleaning staff live in isolation rooms on the same floor, at all times, never leaving so that risk of contagion is minimised--which is important because many of them have little children back home. Here’s a look at life in Pathanamthitta’s isolation ward.

Life in isolation

Since India’s first COVID-19 case was detected in Kerala on January 30, 2020, all patients with symptoms--primary and secondary contacts of the initial patients and those who have a travel history from abroad--have been confined in isolation until their test results come out negative. In all, 237 persons are housed in isolation facilities, as per state health department data from March 18, 2020.

The isolation ward at Pathanamthitta’s general hospital--located on the third floor and cordoned off--is not exactly dark and gloomy. Yet, “it is a scary environment”, said Anugeetha. “It is not easy to be cooped up, be it a patient or hospital staff. There are restrictions for a reason and even if people were allowed entry, I doubt anyone would dare enter.”

The corridor leading to isolation rooms in Pathanamthitta’s General Hospital. The windows in the ward are open to allow in fresh air, the only view of the world outside for the patients and the staff.

The pay ward of the hospital was converted into an isolation ward with two single beds in each of the 10 rooms, with an attached toilet.

The isolation ward team includes seven staff nurses, a head nurse, two nursing assistants and three cleaning staff, aged between 27 and 56 years. Five of the staff nurses have children below the age of five and stay 24x7 in the ward like Anugeetha, while two others go home and return each day.

A wide corridor leads to rooms on either side where the family of three--father, mother and son--share a room. The three had concealed their travel history and evaded airport screening, and as they travelled, they infected more relatives, two of whom--the father’s brother and his wife--are now housed in isolation in a room opposite theirs.

The first room is large enough to fit about four single beds and a couple of bedside tables, Anugeetha described on the phone. The windows in the ward are open to allow in fresh air, the only view of the world outside for the patients and the staff. Standard-issue green bed-sheets with white borders have been replaced with regular bed covers--each article the patients use is carefully and safely disposed of every day, never to be reused.

The district team traced the family’s travel history from February 29, 2020, after they landed in India. When the five swabs--one for each individual--and blood samples were taken for testing on March 6, 2020, the isolation wards had already been set up for other cases for which symptoms had been reported. None of the others had tested positive, until this family did, on March 8.

An empty isolation room at the Pathanamthitta General Hospital. The authorities have allowed the family of three who tested positive to be together in one room. A neighbouring room is occupied by two of their relatives.

“It was shocking when we heard the news because the other cases were negative,” said Anugeetha. “We were suddenly worried about handling five patients in the isolation ward because we only had a vague idea and no one had experience of handling such a situation.”

“Patients in the pay ward were either discharged or moved to the general ward based on the severity of their disease to create beds for isolation,” said Asish Mohankumar, Resident Medical Officer (RMO) at the hospital, in between answering multiple calls about suspected fever or illness or visitors bringing clothes and bedsheets to ensure supply of essentials. The panic around COVID-19 is palpable in the lives of the medical staff as every conversation veers towards it.

Like Anugeetha, Mohankumar too has not seen his six-year-old daughter since March 8, who is with his wife at their home in Thiruvalla, 30 km from the hospital. “I am exhausted after spending 12-14 hours a day. I want to keep away from home till the cases subside,” he said. ”Even if I were to go home, I think I would be spending much of my time on phone calls.” He has been staying in a guest house close to the hospital. 

Doctors Nazlin Salam and Asish Mohankumar at the Pathanamthitta General Hospital. Mohankumar has not seen his six-year-old daughter since March 8, who is with his wife at their home in Thiruvalla, 30 km from the hospital. “I am exhausted after spending 12-14 hours a day. I want to keep away from home till the cases subside,” he said. He has been staying in a guest house close to the hospital.

Immediately after the news broke of the positive cases, there was no one on the roads or at the hospital. “Can you imagine a hospital without people?” he asked.

In the initial couple of days, it was frantic attempts to arrange for food and water and essential supplies as he handled the day-to-day administrative work in the chaos of the news. “Initially, we were running around to get food and water as businesses closed and everyone was scared of the disease. Now, we are getting more and more support from the public,” he said, showing boxes of clothes and bed-sheets, and a bunch of the day’s newspapers that some locals had given him.

Personal protection is ‘uncomfortable’ business

Nazlin Salam, 36, looked happy as she brought back news that three other samples of patients in isolation had come out negative. This meant that there were only five positive cases for this isolation ward physician to tend to.

On March 8, Salam had been the one to break the news to the Italy-returned family that they had COVID-19. She remembered putting on the mandatory personal protective equipment (PPE) and going into the respective rooms, by herself, to convey the results. “Delivering unpleasant news is not something new for doctors,” she said. “I told them, ‘You have tested positive and will have to remain in isolation till your results are negative.'"

They were probably expecting the news, Salam said, and things carried on as they always do. “It was like any other day, except that we had to be more vigilant and sensitive.”

It is wearing the PPE, the layer of protection between the virus and her, that Salam finds most unpleasant. “It is uncomfortable and humid inside the PPE,” she said. She and both her doctor colleagues, Jayasree and Sarath, have examined the patients and taken swabs in this attire. The skin is not exposed, so it cannot breath, and the profuse sweating and fogging of the googles making the work difficult.

Mohankumar, who has worn the suit while training the staff, remembered the distinct smell of plastic, but Salam and Anugeetha said they were inured. “I think I am too used to smells in a hospital, but I’ll probably not notice the smell of jasmine flowers,” Salam smiled. The N-95 masks fade the smell, even if there is any, Salam and Anugeetha concurred.

The gear makes it difficult to tell between doctors and nurses. So Salam introduces herself to the patients afresh, every day: “Njan Dr Nazlin, ningaludey physician annu.” (I am Dr Nazlin, your physician.)

Until recently, there were 24 people under isolation in the hospital, including those who had symptoms but had not tested positive. Salam recalled visiting each of the 24 for a daily examination, starting with those who had not tested positive. The exercise would take almost two hours, including 15 minutes to wear and 15 minutes to remove the PPE.

Doctors and staff at the Pathanamthitta General Hospital wearing personal protective equipment.

“I find it hard to use the stethoscope because we cannot expose our skin to any air.” She leaves behind the stethoscope in the room, and cleans it with sanitiser each time it has to be used, and jots down from memory the notes from the examination after she steps out of the room and doffs the suit, as she cannot take pen and paper to the room.

In a non-airconditioned room, the humidity and the subsequent sweating makes it unbearable, Anugeetha said, adding, “I think 30 minutes is the most you can wear'' the plasticky protective layer, two layers of gloves, a mask, goggles and plastic protective cover over footwear stretching almost to the knees. But the examinations sometimes stretch on longer.

With practice, it now takes Anugeetha five minutes flat to don the suit, though while taking it off, the team have to be doubly careful--they must remove it in a designated room, ensuring they open the PPE from behind and roll it inside-out to below their knees, and then sit down to remove the rest of the gear, all the while avoiding any skin contact with the protective equipment. The PPE is then safely wrapped in a yellow biohazard bag. These safety precautions take about eight minutes. The nurses’ stations are at “maximum distance possible”--four rooms away--to ensure there is no exposure and contamination, Anugeetha noted. The nurses are required to assist with health examinations, and serve the food.

At its peak, the general hospital used 50 PPE kits a day, including for ambulance drivers and others who may have to come in close contact with suspected cases. This is now down to 40, Mohankumar, the RMO, said.

Food and mental health

The staff work three shifts: 8 a.m. to 2 p.m., 2 p.m. to 8 p.m., and 8 p.m. to 8 a.m. In the first three days, they worked extra time to create a foolproof, streamlined process. “We evolved by constantly speaking to health officials to clarify and understand what needed to be done,” said Anugeetha.

The morning shift tends to the medical needs including dispensing medicines, serving food  and ensuring cleanliness; the afternoon shift takes care of patients’ recreation needs by providing magazines or books, serving lunch, and providing psychological support if needed, as well as taking swab samples every alternate day. “The night shift is essentially preparing for the next day in terms of food or medicine or any other requirement,” said Anugeetha. 

Food includes rice, kanji (rice porridge), fruits and nuts, eggs, fish and meat, chapatis, and tea.

For patients who have been unable to step out of a room in close to two weeks, isolation can take a toll. They sometimes videochat with their families, which provides some relief. When needed, a PPE-wearing psychiatrist counsels them. “If they wish to speak privately, we step out,” said Anugeetha.

But it is not patients alone who find the environment depressing, said Anugeetha. “There are times when it gets difficult but we speak to each other with words of support, and try to be jolly”, she said. “But if the need for counselling arises, we will not hesitate to request for it.”

Doctors and nurses like Anugeetha, Salam, and Mohankumar are glad that they find support from their families under these testing conditions. “We have our families' support, but the team is the motivation,” said Anugeetha. “The head nurse is set to retire soon but she is as dedicated as ever and her experience is invaluable. So are the cleaning staff who do the crucial job of removing the waste each day.”

(Paliath is an analyst with IndiaSpend.)

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