New Delhi: The death of Dr Asheem Gupta, a senior anesthetics consultant in the national capital’s LNJP Hospital, last month has brought to notice the critical role anaesthesiologists are playing in the Covid-19 fight across the country.
From intubating ventilator tubes into Covid patients to treating the most critical cases admitted to intensive care units (ICUs), these lesser known doctors are at the forefront of the public health crisis.
Overburdened due to a surge in the number of patients, they are facing an increased risk of infection to themselves and their families. Moreover, like others, they also have to manage mental health challenges as the pandemic wreaks havoc on lives all over.
On top of this, India is short of nearly 1.5 lakh anaesthesiologists, with only about 55,000 anaesthetists working in the country, according to the Indian Society of Anaesthesiologists (ISA) estimates.
Even in this resource crunch, anaesthetists are handling the bulk of the critically ill Covid-19 patients along with internal medicine specialists and chest physicians.
As of Saturday, India has recorded 6,48,315 cases and 18,655 deaths.
With the pressure growing on the medical force in the country, anaesthesiologists speak about their work and the challenges they are facing in managing the Covid load.
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What anaesthesiologists do
The general understanding of anaesthesiologists limits their role to administering doses of anaesthesia — to make patients lose consciousness so that they don’t feel pain during surgery — but the actual work these doctors handle is much wider.
On regular days, the work of anaesthesiologists begins when the patient is admitted to the hospital and ends only after their full recovery. They also play a critical role during the surgical process — keeping an eye on the fluctuation of vital parameters like blood pressure, oxygen saturation, urine output and respiration rate, apart from ensuring that the procedure remains pain-free.
However, amid the Covid outbreak, their role has increased as admissions to ICUs soar and cases on ventilators go up.
“We are called up for inserting intravenous injection lines, inserting food pipes, intubating ventilators and managing extremely critical cases. People know us for putting them to sleep during the surgery, but generally forget, we are also responsible for ensuring that they wake up, well,” Umesh Deshmukh, anaesthesiologist and director at the Fortis Hospital in New Delhi’s Shalimar Bagh, told ThePrint.
They also determine which patients need to be shifted to ICU, and work in operation theatres during surgeries, emergencies and routine procedures.
Moreover, their role is critical among patients who are on the verge of losing life. “We are specialists in reviving almost dead people through a medical procedure called cardiopulmonary resuscitation (CPR),” said Dr Neeta Taneja, head of department and senior consultant, anesthesiology, at Sri Balaji Action Medical Institute, New Delhi.
CPR is a life saving procedure, which is effected by compressing the chest along with an artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest.
The government is seeking an even greater involvement of anaesthesiologists in dealing with the Covid crisis now.
The ISA is currently in discussions with the government for developing guidelines for conducting surgeries on Covid patients as well as for giving their feedback on the specifications for ventilators set to be procured, said Dr Muralidhar Joshi, ISA president and head of department, anaesthesia and pain management, Virinchi Hospital, Hyderabad.
Availability and demand
Over 4,500 students complete post-graduation in anesthesia in India every year — with 650 students pursuing diploma, 2,800 Doctor of Medicine (MD) and 1,100 Diplomate of the National Board in anesthesia.
The demand for the course is increasing. According to Dr Dhruva Chaudhry, professor and head, pulmonary and critical care medicine at Pt. BD Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, “Eight years ago, there would have been 10 to 12 MD seats for anaesthesiology, now there are 36 MD seats for anaesthesiology at PGIMS each year.”
With 36 students graduating every year, PGIMS, Rohtak has 108 residents specialising in anaesthesiology.
Lesser salary, no recognition
In developed countries, anaesthesiologists are paid as much as surgeons, or sometimes even higher. But in India, the pay is often one-third of a surgeon’s fees.
According to salary aggregating website Glassdoor, the annual average salary of a cardiologist and anaesthesiologist in the US is $343,000 while that of a general surgeon is $301,000.
“An anesthesiologist would be paid just 30 per cent of the surgeon’s fees for a surgery. For instance, if a surgeon is getting Rs 10,000, an anesthesiologist will get Rs 3,000,” said Dr V.K. Monga, chairman of the Indian Medical Association Hospital Board of India.
These doctors don’t sit in outpatient departments (OPDs) where they can directly interact with patients. But no surgery can be performed without them. “For instance, Delhi-based Lok Nayak Hospital has 20-25 operation theaters for which they have around 100-150 anesthesiologists,” Monga said.
“In fact, in developed countries like the US, patients can choose their anesthesiologist as they choose their surgeon. Here, public glorification and gratification is absent,” Taneja said.
Despite this, many doctors choose this branch over other lucrative fields.
“I got a very decent score in my post graduation entrance and could have picked the sought-after courses in those days. But I wanted to become an anaesthesiologist,” Dr D.K. Sharma, head of anaesthesia department at Gurugram-based Paras Hospital.
Sharma had served the Army for three decades as colonel before starting private practice. In his tenure, he served at Siachen glacier and Kashmir’s Kupwara region where he saw that “the entire physiology of the body changes at high altitudes and the role of an anaesthesiologist becomes even more critical”.
Challenges in Covid-19 management
Amid overstressed resources during the Covid crisis, anaesthesiologists are doing most of the management of Covid patients in the ICUs, said Dr Anil Parakh, head of anaesthesiology, Global Hospital, Mumbai.
“Everyone, from our junior most residents to senior staff, is working round the clock and overstretched as they work in ICUs and operation theatres while dealing with staff shortages,” he said. “In normal circumstances, we are not worried about our illness or staff illness safety, but now we have to take extra precaution and despite that 15-20% of our staff is Covid positive.”
Further, since the actual work of taking care of critically ill Covid patients is left to anaesthesiology residents, they say this is taking a toll on them despite their training.
“We are seeing many patients without comorbidities who are getting worse suddenly and succumbing to the disease. That is mentally draining for clinicians,” said Dr Sayan Nath, a senior anaesthesiology resident at All India Institute of Medical Sciences, Delhi.
Apart from being placed in the Covid ward and donning the stifling PPE (personal protective equipment) for 6-7 hours a day, dealing with high load of patients, and living away from their families, many residents are also preparing for their postgraduate exams, said Dr Kamna Kakkar, senior resident, anaesthesiology, PGIMS, Rohtak.
Kakkar is a co-author of a paper that details the mental health challenges faced by anaesthesiologists during the pandemic — from mental fatigue due to overwork to facing harassment from landlords and the public.
What makes things worse is the fact very little is known about Covid and its guidelines are being revised on an almost weekly basis. “We could just open textbooks and know if there are complications in, say diabetes, but now we read up studies on Covid-19 every day to keep abreast with the latest research,” she said.
The high risk factor
Since they treat critical patients with higher viral load and work in the ICUs to intubate patients — insertion of tubes directly into the airways of the patients — anaesthesiologists are highly exposed to aerosols.
Aerosols are fine liquid particles that increase the risks of spreading Covid-19.
According to the Indian Society of Anaesthesiology (ISA), five anaesthesiologists have died due to Covid-19 so far, including a postgraduate student from Andhra Pradesh and a consultant from Guwahati. According to the ISA’s Delhi branch, two anaesthesiologists have lost their life in the last one month itself. However, ThePrint couldn’t independently verify these numbers.
While the role is becoming increasingly important, doctors are devising new ways to protect themselves from the infection.
For instance, a team of doctors at Sri Balaji Action Medical Institute in Delhi has devised an intubation box, where the face of a patient is completely covered under glass during the procedure to prevent viral spread.
The challenges for anaesthesiologists are many, but what makes everything worthwhile is the sight of old patients coming out of ventilators and discharged, said Nath. “The smile and sigh of relief of family members is the ultimate reward,” he said.
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