Mumbai: The number of COVID-19 positive cases continues to rise, particularly in cities like Mumbai and Delhi. One of the outcomes of the rising number of cases is the increasing load on hospitals, and their seeming inability to admit all the patients--both COVID as well as non-COVID. How are hospitals coping, and how are they responding to rising case levels?

We speak with Vernon Desa, medical director at the 254-bedded Saifee Hospital in Mumbai.

Edited excerpts:

What is the split for COVID and non-COVID beds in your hospital, and what load are you working at right now?

We have bifurcated our beds based on the Municipal Corporation of Greater Mumbai’s guidelines. We have provided about 100 beds for COVID patients--74 for stable patients and the remaining 26 for critical patients.

We have not opened out or commissioned all the remaining beds. We have provided 100 beds for non-COVID patients. But of these, we have about 60 to 70 beds occupied. So, we still have spare capacity on the non-COVID side, which we have kept [for use] depending on exigencies, etc.

Do you have enough doctors, nurses and support staff to manage those spare beds?

Yes. We have not been hit very badly by this COVID crisis because we made sure that the staff, the nursing staff and resident doctors are available for managing the patients for the whole hospital. We have provided them residential quarters and we have had hardly any attrition by way of nurses leaving and going to other hospitals or going back to their native places.

We had to do a surgical operation on the hospital building, because we have separate access points, separate lifts and separate floors for COVID patients. That is all at the northern end of the building. At the southern end, we have provided various floors for non-COVID patients with separate access points and separate lifts. 

We made it clear to all our patients, doctors and visitors that there is no risk whatsoever if you enter the hospital. COVID and non-COVID patients enter from separate entrances. We have a fever clinic established on the ground floor next to the Emergency Medical Service (EMS). We also have a full-fledged staff in the EMS--round-the-clock postgraduate doctors who attend to patients at all times of the day or night. By and large, this formula has worked for us.

You mentioned 74 beds for stable patients and 26 for critical patients. What is the occupancy rate there? Are your critical care beds all occupied?

All occupied. As a matter of fact, we are seeing a different picture now since the past week or so, wherein [the numbers of] our stable patients have been going down, but the critical patients have been increasing. 

Maybe now, with this the curve sort of flattening a little bit, it appears--at least for us, I don’t know about the other hospitals--[that] we have fewer stable patients and more critical patients. We upload our data on the MCGM site on a daily basis.  

Can you give us some insights on the critical patients? Are they going into intensive care or ventilator?

The patients with comorbid symptoms--such as diabetes, hypertension, pre-existing heart disease, etc.--sometimes deteriorate, and we have to move them from the stable side to the critical side. 

Sometimes, patients--who we presume will get well and go home fast--develop severe breathing problems and we have to put them on BiPAP ventilation. Many times, they recover with that BiPAP; or [if] they don’t recover, they go on to the ventilator. We have had patients who we thought were young, presumably fit, and [they] suddenly developed some complication, severe breathing difficulty; even on 15-litres-per-minute high-flow oxygen, they have not recovered. And some way or the other, they get into a spiral, develop multi-organ failure, kidney failure and things like that, and their lungs get completely opaque due to this ground glass appearance on the CT scan and they crash. 

So, it’s a paradoxical situation. We thought that young people would be more resistant to this infection, but [some] young people have developed it, come and passed away; whereas [some] older people, whom we thought [would deteriorate], with comorbid features, have managed to pull through and recover and go home. We are learning as the days go by, because nobody can claim to be an expert in this. COVID is a new entity.

If I come back to those 74 stable patients, in what condition are they coming to your hospital? Are they showing symptoms? Are people coming too late to the hospital?

I would not say that people are coming late, but the BMC has changed the guidelines now. Asymptomatic patients, they say, you should not get [a] test. When they have symptoms, they come to the hospital. We set up a fever clinic in the first week of April, where all the patients come in through one gate of the hospital. We examine them. If we have a suspicion [that they may be COVID-positive], we get their testing done right on the spot. 

There is a flow of these [stable] patients, but as I told you earlier, the flow is lessening. We are getting more critical patients--either coming in critical or coming in stable and becoming critical after hospitalisation.

What is that telling you, even at an early stage right now, if you were to try and draw some conclusions?

See, we have to live with this problem. It [COVID-19] is spread through the community. We ourselves spend about 8 hours a day in the hospital. So, we ourselves are at risk. 

My view is that after a period of time, this virus will mutate. What we are seeing now is a different type of virus than what was there in Wuhan or Europe and what is currently in the USA. This virus which is now specific to Mumbai has moved in such a way through certain communities, and its potency has gone down to a considerable extent. This is my personal view, and this is the view of some experts even in the US and the UK, that after some time, this virus loses its potency. 

Do you feel that you are already seeing that loss of potency in Mumbai?

I feel so. In the past two months (April and May), we had so many calls and so many emergency cases. Now for the past week or so, we are hardly seeing that type of firefighting like we had in those two months. It's sort of slowing down. 

And [we are] looking at the literature, discussing with experts. My own daughter is an expert in the US; she runs two ICUs in San Francisco and I discuss with her regularly. She tells me that we are seeing a complete change. Now her patient load has come down from say 50 patients to hardly four patients in her own hospitals. So, the curve is flattening, or the curve is even going down and maybe towards the end of June, we will see a remarkable change in the scenario in Mumbai.

What is the kind of inflow that you see among non-COVID patients? Broadly, how does the load in your hospital at this point compare with the same month last year?

Year on year, we do see a dip in our occupancy. That is indisputable. We have to face it because, in the first place, patients are scared to come. So, we get only emergency cases like patients with a myocardial infarction or patients with preemies [preterm labour]. We had some patients in preterm labour, who were not registered with us and yet we took them in on humanitarian grounds; and later on, we tested them and found them to be positive. So, all these permutation-combinations are there. 

But by and large, our heart department works, our cath lab is functioning, our non-interventional cardiac department is functioning. All other diagnostic services are functioning. 

We are getting only emergency cases like patients who crash, fractures, trauma cases, etc. We have, on average, about 60 non-COVID patients per day who come in. Whether the patient is COVID positive or negative, in an emergency, we do not discriminate. We take them in. 

There are reports of patients being turned away at hospitals. Why do you think that is happening? You, for example, are saying that you have very little load and you are accepting almost every patient who comes to you. Is it also because of where you are located, much deeper in south Mumbai?

We have a heavy load on the COVID side. We don’t refuse any COVID patient or suspected COVID patient. 

As I told you, we have our triage outpatient department (OPD). Over and above that, I have set up a general triage OPD at a separate entrance of the hospital wherein all the patients who walk in are triaged and checked. In case they have come for an emergency investigation, or to see some doctor, or to undergo some procedure, we send them through a different access into the hospital. They do that procedure, see the doctor, and then they leave. 

But that has really proved to be a boon to us because we have managed to segregate patients and ensure that a potential case will not be missed out.

Let me rephrase the question. We are reading reports of patients who are not getting admission into hospital, regardless of what condition or what illness they are facing. Is that something that you are also encountering? If not, is it because of where you are located, in deeper South Mumbai?

We have not encountered that type of experience, because as I told you, we have set up a triage and we have set up a fever clinic. So, we segregate and we make sure that patients are adequately triaged and if we have a doubt, we do the test right on the spot. To my knowledge and through the experience of the past two months, we have not refused any patients. 

We have even had patients who have come desperately by car, who have collapsed in the car, and we have taken them in and assisted them and admitted them to our ICU without knowing whether they were COVID positive or negative. And later on, we do the [COVID] test. 

Just four days ago, I admitted a patient in the ICU with a similar problem. She was so breathless that she had an oxygen saturation of 60. I thought she would collapse and die. We took her in, kept her in the ICU and now she has stabilised. And now she is negative too. So, with that type of breathlessness and collapse, the first thing you always think is the patient is COVID positive. But still, on humanitarian grounds, we do not turn anybody away. We do not tell any patient to go away from the ambulance, from the gate of the hospital, never.

You are not saying, for instance, like some other hospitals are alleged to be doing, asking for money upfront in several lakhs, and only then would you admit them?

These are the horror stories we get from Delhi and other places, where reporters go on ringing up and asking, “Do you have a bed? What is the cost?” We tell them upfront [that the cost is] whatever the BMC has laid down—80% beds are price-controlled, regulated beds; the other 20% are unregulated beds. We follow that mandate strictly. 

There is no question of telling them some exorbitant rate and getting away with it. We do not mind losing money, but our first focus is to save lives. That is what we doctors are, in the profession of saving patients, treating them and saving lives. 

When do you see your capacity of nurses and doctors returning to pre-COVID levels? 

We may be back to normal sometime in the first week of August. Right now, we are sitting on the cusp [of the COVID curve]. And we do not know which way things will turn. If there is more community spread and more clusters formed and more containment zones, then we will go on and on and on and it will not end. But if we have to let the curve flatten and go down in Mumbai, all the norms have to be followed, which are repeatedly told to us on television and all over. 

Unfortunately, people tend to go a little off-board and that may cause a problem in the next two months. By around the first week of August, if people are disciplined, and things happen in the right way, maybe we will get most of our non-COVID and our regular work back. And maybe we will start doing normal work even.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: The number of COVID-19 positive cases continues to rise, particularly in cities like Mumbai and Delhi. One of the outcomes of the rising number of cases is the increasing load on hospitals, and their seeming inability to admit all the patients--both COVID as well as non-COVID. How are hospitals coping, and how are they responding to rising case levels?

We speak with Vernon Desa, medical director at the 254-bedded Saifee Hospital in Mumbai.

Edited excerpts:

What is the split for COVID and non-COVID beds in your hospital, and what load are you working at right now?

We have bifurcated our beds based on the Municipal Corporation of Greater Mumbai’s guidelines. We have provided about 100 beds for COVID patients--74 for stable patients and the remaining 26 for critical patients.

We have not opened out or commissioned all the remaining beds. We have provided 100 beds for non-COVID patients. But of these, we have about 60 to 70 beds occupied. So, we still have spare capacity on the non-COVID side, which we have kept [for use] depending on exigencies, etc.

Do you have enough doctors, nurses and support staff to manage those spare beds?

Yes. We have not been hit very badly by this COVID crisis because we made sure that the staff, the nursing staff and resident doctors are available for managing the patients for the whole hospital. We have provided them residential quarters and we have had hardly any attrition by way of nurses leaving and going to other hospitals or going back to their native places.

We had to do a surgical operation on the hospital building, because we have separate access points, separate lifts and separate floors for COVID patients. That is all at the northern end of the building. At the southern end, we have provided various floors for non-COVID patients with separate access points and separate lifts. 

We made it clear to all our patients, doctors and visitors that there is no risk whatsoever if you enter the hospital. COVID and non-COVID patients enter from separate entrances. We have a fever clinic established on the ground floor next to the Emergency Medical Service (EMS). We also have a full-fledged staff in the EMS--round-the-clock postgraduate doctors who attend to patients at all times of the day or night. By and large, this formula has worked for us.

You mentioned 74 beds for stable patients and 26 for critical patients. What is the occupancy rate there? Are your critical care beds all occupied?

All occupied. As a matter of fact, we are seeing a different picture now since the past week or so, wherein [the numbers of] our stable patients have been going down, but the critical patients have been increasing. 

Maybe now, with this the curve sort of flattening a little bit, it appears--at least for us, I don’t know about the other hospitals--[that] we have fewer stable patients and more critical patients. We upload our data on the MCGM site on a daily basis.  

Can you give us some insights on the critical patients? Are they going into intensive care or ventilator?

The patients with comorbid symptoms--such as diabetes, hypertension, pre-existing heart disease, etc.--sometimes deteriorate, and we have to move them from the stable side to the critical side. 

Sometimes, patients--who we presume will get well and go home fast--develop severe breathing problems and we have to put them on BiPAP ventilation. Many times, they recover with that BiPAP; or [if] they don’t recover, they go on to the ventilator. We have had patients who we thought were young, presumably fit, and [they] suddenly developed some complication, severe breathing difficulty; even on 15-litres-per-minute high-flow oxygen, they have not recovered. And some way or the other, they get into a spiral, develop multi-organ failure, kidney failure and things like that, and their lungs get completely opaque due to this ground glass appearance on the CT scan and they crash. 

So, it’s a paradoxical situation. We thought that young people would be more resistant to this infection, but [some] young people have developed it, come and passed away; whereas [some] older people, whom we thought [would deteriorate], with comorbid features, have managed to pull through and recover and go home. We are learning as the days go by, because nobody can claim to be an expert in this. COVID is a new entity.

If I come back to those 74 stable patients, in what condition are they coming to your hospital? Are they showing symptoms? Are people coming too late to the hospital?

I would not say that people are coming late, but the BMC has changed the guidelines now. Asymptomatic patients, they say, you should not get [a] test. When they have symptoms, they come to the hospital. We set up a fever clinic in the first week of April, where all the patients come in through one gate of the hospital. We examine them. If we have a suspicion [that they may be COVID-positive], we get their testing done right on the spot. 

There is a flow of these [stable] patients, but as I told you earlier, the flow is lessening. We are getting more critical patients--either coming in critical or coming in stable and becoming critical after hospitalisation.

What is that telling you, even at an early stage right now, if you were to try and draw some conclusions?

See, we have to live with this problem. It [COVID-19] is spread through the community. We ourselves spend about 8 hours a day in the hospital. So, we ourselves are at risk. 

My view is that after a period of time, this virus will mutate. What we are seeing now is a different type of virus than what was there in Wuhan or Europe and what is currently in the USA. This virus which is now specific to Mumbai has moved in such a way through certain communities, and its potency has gone down to a considerable extent. This is my personal view, and this is the view of some experts even in the US and the UK, that after some time, this virus loses its potency. 

Do you feel that you are already seeing that loss of potency in Mumbai?

I feel so. In the past two months (April and May), we had so many calls and so many emergency cases. Now for the past week or so, we are hardly seeing that type of firefighting like we had in those two months. It's sort of slowing down. 

And [we are] looking at the literature, discussing with experts. My own daughter is an expert in the US; she runs two ICUs in San Francisco and I discuss with her regularly. She tells me that we are seeing a complete change. Now her patient load has come down from say 50 patients to hardly four patients in her own hospitals. So, the curve is flattening, or the curve is even going down and maybe towards the end of June, we will see a remarkable change in the scenario in Mumbai.

What is the kind of inflow that you see among non-COVID patients? Broadly, how does the load in your hospital at this point compare with the same month last year?

Year on year, we do see a dip in our occupancy. That is indisputable. We have to face it because, in the first place, patients are scared to come. So, we get only emergency cases like patients with a myocardial infarction or patients with preemies [preterm labour]. We had some patients in preterm labour, who were not registered with us and yet we took them in on humanitarian grounds; and later on, we tested them and found them to be positive. So, all these permutation-combinations are there. 

But by and large, our heart department works, our cath lab is functioning, our non-interventional cardiac department is functioning. All other diagnostic services are functioning. 

We are getting only emergency cases like patients who crash, fractures, trauma cases, etc. We have, on average, about 60 non-COVID patients per day who come in. Whether the patient is COVID positive or negative, in an emergency, we do not discriminate. We take them in. 

There are reports of patients being turned away at hospitals. Why do you think that is happening? You, for example, are saying that you have very little load and you are accepting almost every patient who comes to you. Is it also because of where you are located, much deeper in south Mumbai?

We have a heavy load on the COVID side. We don’t refuse any COVID patient or suspected COVID patient. 

As I told you, we have our triage outpatient department (OPD). Over and above that, I have set up a general triage OPD at a separate entrance of the hospital wherein all the patients who walk in are triaged and checked. In case they have come for an emergency investigation, or to see some doctor, or to undergo some procedure, we send them through a different access into the hospital. They do that procedure, see the doctor, and then they leave. 

But that has really proved to be a boon to us because we have managed to segregate patients and ensure that a potential case will not be missed out.

Let me rephrase the question. We are reading reports of patients who are not getting admission into hospital, regardless of what condition or what illness they are facing. Is that something that you are also encountering? If not, is it because of where you are located, in deeper South Mumbai?

We have not encountered that type of experience, because as I told you, we have set up a triage and we have set up a fever clinic. So, we segregate and we make sure that patients are adequately triaged and if we have a doubt, we do the test right on the spot. To my knowledge and through the experience of the past two months, we have not refused any patients. 

We have even had patients who have come desperately by car, who have collapsed in the car, and we have taken them in and assisted them and admitted them to our ICU without knowing whether they were COVID positive or negative. And later on, we do the [COVID] test. 

Just four days ago, I admitted a patient in the ICU with a similar problem. She was so breathless that she had an oxygen saturation of 60. I thought she would collapse and die. We took her in, kept her in the ICU and now she has stabilised. And now she is negative too. So, with that type of breathlessness and collapse, the first thing you always think is the patient is COVID positive. But still, on humanitarian grounds, we do not turn anybody away. We do not tell any patient to go away from the ambulance, from the gate of the hospital, never.

You are not saying, for instance, like some other hospitals are alleged to be doing, asking for money upfront in several lakhs, and only then would you admit them?

These are the horror stories we get from Delhi and other places, where reporters go on ringing up and asking, “Do you have a bed? What is the cost?” We tell them upfront [that the cost is] whatever the BMC has laid down—80% beds are price-controlled, regulated beds; the other 20% are unregulated beds. We follow that mandate strictly. 

There is no question of telling them some exorbitant rate and getting away with it. We do not mind losing money, but our first focus is to save lives. That is what we doctors are, in the profession of saving patients, treating them and saving lives. 

When do you see your capacity of nurses and doctors returning to pre-COVID levels? 

We may be back to normal sometime in the first week of August. Right now, we are sitting on the cusp [of the COVID curve]. And we do not know which way things will turn. If there is more community spread and more clusters formed and more containment zones, then we will go on and on and on and it will not end. But if we have to let the curve flatten and go down in Mumbai, all the norms have to be followed, which are repeatedly told to us on television and all over. 

Unfortunately, people tend to go a little off-board and that may cause a problem in the next two months. By around the first week of August, if people are disciplined, and things happen in the right way, maybe we will get most of our non-COVID and our regular work back. And maybe we will start doing normal work even.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.



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