I have been in touch with some mission hospitals in the last three months through a letter I circulated almost every week. During the last one month, I began to gather information about the different initiatives and activities some hospitals are engaged in to attend to the needs of COVID 19 patients in their hospitals or in the community. This is the second in that series of letters.
Let me share some information about the Methodist Cardiac Hospital at Nadiad in Gujarat, where Dr Snajeeth Peter is its director. Dr Sanjeeth Peter was known to me from his medical student days at CMC Vellore. He along with his classmates performed a musical recital during a governing council meeting of CMC of which I was a member from 1984. I remember how all of us felt enthralled by that performance. I met him after the performance to greet and thank him. He was gracious to say, ‘All of us enjoyed preparing and performing’!
Since then, I remember meeting him in the governing council meetings of CMC, Vellore, of which he too became a member. I noticed him to be a thinking person, and professionally highly skilled so as to have been able to bring the Methodist Heart Institute to the forefront in cardiac surgery in Gujarat, Bombay and adjacent places. He is known for his innovations and inventions. He is also a consultant to the local Medical College at Nadiad, helping them to organize their COVID care from the time of the lock down in March 2020.
Listening to Sanjeeth yesterday was a refreshing experience. During that hour- long interview with him, what touched me most was his efforts to equip the core team members in the Heart Institute and the Medical College Hospital to make them ready for care of COVID 19 patient care.
The news of the lock down in March, 2020 came at a time, when Sanjeeth was gathering information about the clinical, pathological and laboratory profiles of patients affected by COVID 19. He took upon himself the responsibility to make a clinical presentation to the staff at the cardiac hospital as soon as the lockdown was announced, which was the beginning of a long journey in informing and equipping his team in the hospital.
Initially fear gripped the staff and did not want to come to the heart institute. It gradually got diffused by the preventive steps they could plan to take as a hospital. By then the hospital was deserted and the surgical and angioplasty procedures had to be discontinued as patients did not come even for an emergency. The team in the hospital got involved in stitching PPE kits for which he had to get the fabric from the market. Only one wholesale shop owner offered to open his shop during the locked down period to supply the materials for the PPE kit and masks. The hospital staff brought their stitching machines from their home for use in the hospital. Another team got involved to fix pipeline to bring oxygen to another block in the hospital to use it in an emergency. A third group was fabricating foot-controlled sanitiser dispensers for easy use. Another group was responsible for planning for contaminated waste disposal. There was daily dry run in the hospital to prepare the staff and to ensure that all protocols would be followed as and when a COVID 19 or regular patient came to the out-patient service or got admitted.
With the income having dropped in April, Sanjeeth announced to the staff about the need to have a temporary salary cut. A few, whose spouses had regular government employment, offered to go without salary till the situation improved. That was an assurance to Sanjeeth that the staff was ready and forthcoming to support the initiatives of the hospital to welcome patients and continue the regular cardiac care work. After two weeks with all protocols in place and the staff ready to work, the hospital got gradually activated to move on to its regular pace of cardiac work from late April, 2020.
But COVID 19 testing was available only in Ahemmedabad, which meant if a patient were to come in an emergency with chest pain, there was no prospect of getting immediate results of the screening test. This reminded Sanjeeth of the universal precaution practice that he was used to, while under surgical training at CMC Vellore, years back, when all surgeries were done under ‘universal precaution’ to protect surgeons from contracting HIV infection accidentally. At that time too for emergency surgeries, the test results were not available on time and sometimes tests which were negative initially became positive on retesting. Sanjeeth got his team to grasp the principle of universal precautions for every admission to the cardiac hospital. As the hospital made mask and the PPE kit which costed only sixty rupees, the universal precaution practice was not going to be a burden to the patients.
With the moral of the staff regaining and the protocols in place with several dry runs, the lnstitute gradually picked up with regular surgeries, angioplasties and other Cath laboratory work, although less in number. This improved the income in the hospital and by June, 2020 full salary could be paid including the partially withheld salary of earlier months. None of the hospital staff contracted infection from the hospital, although two office staff had COVID 19 through contact with their family members elsewhere. The team work and the enthusiasm have surprised Sanjeeth as the first response in March was fear, anxiety and wanting to distance from being involved as everything about COVID 19 appeared frightening. Sanjeeth’s decision to meet with the staff almost every week and update them with recent information and current practices not only got the team ready and confident but made them feel involved in collaborating with each other to make the hospital safe for them and patients.
Sanjeeth’s attention was also needed to help the local Medical College which was the designated COVID care hospital for the town. That seemed a daunting task as getting ready with a COVID block of one hundred beds and forty ICU beds in a short time was too difficult even to think. When Samjeeth realized that it involved a huge upgrading of facilities, he got the clinical team in the hospital to come together for his first presentation about protocol of practices, clinical care, protective gears, treatment plan, oxygen availability etc. That is when the Dean of the hospital activated all the departments to come together to make it happen. From Sanjeeth’s enquiry he realized that the initial practice of intubation and ventilation was not the suitable modality of treatment of sick patients, but oxygen dispensing according to the need including high pressure oxygen administration. Even if ventilation had to be done by intubation, he realized that the technical and bedside skills to manage such a level of care would not be possible as the staff was not trained for that. That is when he turned his attention to look for alternative modalities of supplying oxygen. Being a cardiac surgeon, it was his field. He designed several practical ways himself and adapted some which were already in practice in other centres.
The whole clinical team in the Medical college designed the protocol of practice under Sanjeeth’s leadership. It evolved into what he now thinks is most suitable for the medical college. The prone nursing was introduced right from the time when a COVID positive patient was admitted so that when his or her oxygen saturation dropped it was easier for patients to be on prone position for longer time. I found it most innovative how three or four different creative ways of supplying oxygen were used by locally designed masks, nasal tubes, reservoirs, etc to provide high pressured oxygen supply to patients. Also, intubation and ventilation were advisable only in exceptional situations, according to the recent recommendations. His experience was that only 5 percent of patients needed invasive ventilation and 25 percent needed non-invasive ventilation. The Medical College has had a good outcome with low mortality rate.
What made it possible for Sanjeeth to be actively involved with clinical team in the Medical College was the virtual round he did every day with the professionals in the Medical College and regular review meetings with the team. There were difficulties with testing and tracing. There were challenges on reporting of the positive cases and deaths as the criteria that Snajeeth followed was not necessarily what was prescribed by the district administration. Without getting entangled in any controversies, the team in the Medical College followed the WHO guidelines and submitted reports to the district administration and left it to them to share to the media what they saw as appropriate. Almost all who needed hospital stay could be offered admission although on some occasions the ICU beds were not available on the same day.
I wondered how he managed overseeing the clinical services of two hospitals! He worked in the cardiac hospital during the day and rendered his time to the Medical College team in the evening. The medical college team found the PPE kit made in the cardiac hospital as a user-friendly attire. There were concerns of short supply of oxygen for which, the local Collector’s help was timely. Except a handful of nurses in the Medical College team, the clinical team in the Medical college did not need quarantine which helped the work to continue without too much of pressure, thanks to the response of the team to follow the protocols of practices strictly, including using three masks in a specially designed way.
At the end of six months of intensive activity, Sanjeeth attributes the smooth functioning of the COVID 19 care in both hospitals he was involved in, to teamwork, regular team meetings and updating knowledge and facilities. The usual fatigue of the professionals while on intensive involvement, could be partly overcome by ensuring in between rest, debriefing and supportive environment to take care of the special needs of some.
One thing that Sanjeeth was particular was to be present for the morning Chapel service every morning at 8 am, in the heart institute, which to him was the source of strength and guidance. In fact, one recent surgery he had to undertake was to repair the multiple aneurysms of Aorta on a woman who was diagnosed to have Marfan Syndrome. She had a recent childbirth and was COVID Positive. He operated on her when she was tested negative and had to replace whole of the ascending aorta, arch of aorta, and part of the descending aorta. He had to do part of the surgery with Total Circulatory Arrest by freezing the body to get a bloodless field of operation. He needed to repair the mitral valve and reimplant the native aortic valve. For the team, it was a demanding experience, but a great delight to see her recover. She came after having been refused surgery in couple of hospitals.
Sanjeeth summarised the interview by saying that he feels rejuvenated by his experiences of new learning, teamwork and the opportunity to have been able to help patients who had no other place to go to. He found the experience of asking and listening to others as a good way of building trustful relationships in the team. The challenges have been many. The dose of heparin is one of them. It varies from patient to patient.
Let me conclude by highlighting how a Methodist Heart Institute supported a medical College to deliver its COVD 19 care services! An example of private-public partnership! It was an innovative contribution in healthcare!
The Mission Hospitals would have a wider influence in India in the post-COVID season!
Sanjeeth is also a photographer of high calibre and creativity. He sends out a picture in a calendar format every month. Let me share the one I received this week of a Barred buttonquail. I do it without his prior permission, therefore avoid copying it for circulation.
M.C.Mathew (Text is mine and the two photos from the website of the heart institute and that of the bird is from Sanjeeth)
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