Residents and the COVID-19 Caregiver Duty

Recently, we received a beautiful greeting card signed by the otolaryngology residents of the outgoing batch. They thanked the department for standing beside them during the trying times of the coronavirus disease (COVID-19) pandemic and for helping them learn the subject against all impediments.

It is a matter of introspection. The COVID-19 pandemic, undoubtedly the most major health problem of this century, has challenged our existence and livelihood in every possible way imaginable. Residency training in medicine has also received its share of deprivation. Many discussions have been made on how the present difficult times have failed the training system and on its potential implications in the future of healthcare. On a different note, we also need to realize how this undaunted youth force helped our healthcare system ward off the evils of the pandemic.

Currently, with nearly 34 million confirmed cases and .45 million deaths, India is one of the top 3 nations, along with the United States of America and Brazil, where the pandemic has had a catastrophic effect. ¹ Healthcare infrastructure, already burdened by catering to a third of the world’s population, seemed momentarily stunned when the pandemic unfolded in early 2020. The supply of hospital essentials and consumables was under strain, but most concerning was the predicted shortage of trained manpower. With the number of new cases and casualties alarmingly increasing, with as many hospital admissions, the authorities were forced to deploy residents from all disciplines for the care of COVID-19. The wards and intensive care units (ICUs) were rapidly filled up and needed to be manned with professionals. The government soon came out with standard operating procedures that provided a structured and clearer perspective on this issue. ²

The reasons for calling up residents were out of necessity but bore logic in that they occupied the wide base of the healthcare delivery pyramid, in hierarchy, but more importantly now, in numbers. During the better times, they formed the primary workforce in busy government hospitals. The present situation, however, had its own compulsions, and they represented the saving face in this crisis. The emerging emergency demanded that senior faculties collaborate with administrators to design management protocols and ensure their implementation. The coronavirus was novel, and its management aspects were being modified throughout the world, keeping the government and hospital think tank engaged to remain cautious and up-to-date. Consequently, the field situation, which also included the nonCOVID-19 sections of a hospital, was left to be managed by the relatively large resident population. Another practical reason for this division of workload was that residents were much younger and had fewer or no comorbidities, making them less vulnerable to COVID-19. A seemingly harsh logic, but nonetheless practical at a time when vaccines did not roll out. In addition, prolonged hours in personal protective equipment (PPE) suits resulted in considerable stress that could be better tolerated by young residents.

The COVID-warriors accepted the responsibility with sheer courage and motivation that moved and inspired us. Regular online orientation modules were organized to train them on management guidelines in wards/ICUs, the need and methods of maintaining personal and work area sanitization, proper ways to wear and remove a PPE, maintaining inter- and intra-departmental liaison, and monitoring updates. The government issued circulars summarizing these training/capacity-building programs from managerial perspectives, providing online links from the ministry and from reputed hospitals with autonomous governance. ³ These also highlighted avenues for proper utilization of human resources and, more importantly, for psychological support.

The challenge of the hour generated unique leadership qualities in many residents who instilled purposeful and professional camaraderie in their colleagues. Together, they drafted and followed the roster duties in the COVID-19 wards/ICUs. These included morning and evening rounds, history-taking and documentation, decision-making regarding drugs/fluids, managing interdepartmental referrals, maintaining round-the-clock first-on-call care, supervising swab collection for reverse transcriptase-polymerase chain reaction for COVID-19 (often assisting technicians at the kiosks in case they need help), and ensuring that biochemical and imaging procedures were performed properly. They were well supported by nursing staff and ward-boys—the other essential COVID-warriors. The entire patient care and ward management were supervised at a time by 1 or 2 senior faculty members who headed the rounds.

Residents as caregivers had to be extremely cautious during their stay in the wards/ICUs regarding fomites and aerosol-mediated spread of the virus. Instead of personal cell phones, communication, reports, advice, and referrals were executed using tablets dedicated to the purpose. Each shift consisted of 8 hours, and except when in their restroom, residents needed to be in PPE suits. Since repeated donning/doffing was cumbersome, and also because PPE kits might not always be readily available, they usually spent more time in the ward, often nonair-conditioned, once they were within the PPE suit. This was quite an ordeal, affecting their physical and mental state, and professional performance. Many complained of fatigue, dehydration, and posture-related physical strain. There were practical problems in maintaining personal hygiene and toilet necessities. Some complained of claustrophobia, while some had depression. A week off following a series of shift duties seemed too short to recover! Furthermore, the nonCOVID-19 wings of a hospital, except for facilities designated for exclusive COVID-19 management, were never closed, although there was much less footfall during the complete or partial country-wide lockdown of routine non-essential public services. Hence, a section of the residents had to serve there in turn, in addition to their COVID-19 duties.

Although residents of all disciplines were deployed for caregiving, anesthesia, internal medicine, otolaryngology, and pulmonary medicine were given the primary responsibility for closer care that extended beyond what could be provided in routine rounds. This included monitoring of the ICU, interventions such as endotracheal intubation, open and percutaneous dilatational tracheostomy, maintaining support in extracorporeal membrane oxygenation, and helping the nurse on duty in maintaining general patient care, such as Ryle tube insertion. These were obvious or potential aerosol-generating procedures. Alertness and personal protection were the keys to safety, but as was easily realized, simply being aware of them was not sufficient to relieve caregiver stress.

The impact of the resultant loss of academic days on the careers of residents cannot be ignored. It added to their stress quotient and distracted them from their learning curve. Understandably, virtual/online evening classes arranged from time to time could not substitute real-time clinical experience. Nevertheless, the predicament was unforeseen and proved to be a necessity in a demanding situation. None of us had ever witnessed a pandemic in his/her lifetime and perhaps would ever again. The deadly pandemic also taught us a few life lessons. Residents witnessed suffering and death close and intense. They learned the importance of PPE, and what it took to tread between life and death. Some cried, some lost hope, some were afraid of death, and nonbelievers started believing in destiny. We even lost some young professionals. But most of them stood up and fought the war bravely. It was overall a character-molding experience for them. Acts of acknowledgment from the authorities—prioritization in vaccination, providing life insurance cover, and monetary compensation—were appropriate and appreciable. But no reward is greater than what our residents experienced during this tumultuous period—the gist of the philosophy of patient care as put by Sir William Osler—“We are here to add what we can to life, not to get what we can from life.”

We happily replied with a big “Thank You!” to the greeting card our beloved residents prepared for us!