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What to do with Covid 19 second, third or fourth waves? Insights from a renowned professor in Internal Medicine

by satcit

(Warning: These are not clinical guidelines to be followed as such. These are just opinions written on a social media platform)


This was posted on the Facebook profile of Dr. P.K. Sasidharan


https://www.facebook.com/100000280476437/posts/4160374117315230

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SCIENTIFIC MANAGEMENT OF COVID-19


(1) Since any infection is due to agent- host–environment interactions- focusing on all the three is essential.


a.Prevent the agent developing by nature conservation- strategy for future.


b. Prevent agent entering the body by respiratory hygiene, cough etiquettes, hand hygiene and physical distancing.


c.Reverse quarantine for the extremely vulnerable people, only to avoid overwhelming the care facilities.


(2) Prepare the host’s body to face the infection, fight the infection and get well naturally. Even the extremely vulnerable people would benefit by this.


a. Eating a balanced diet and adopting healthy lifestyle and thereby boosting the body immunity and not by magic remedies and shortcuts.


b.Prepare the healthy people to face the infection, we cannot keep shut down for long, nothing can stop the infection coming in, it is inevitable, we cannot run away too.


(3) Prepare the medical profession to fight the disease- but disease means only those with symptoms, those asymptomatic people tested positive, are not patients. Best policy is to presume that everyone could be having the virus and take universal precautions till herd immunity is established
.


a. Realize that the people who develop symptoms have diagnosed or undiagnosed health problems, this is easily predicted, by studying their diet and lifestyle and by physical examination and some easily available simple laboratory tests (HMG, SGPT, RBS), easily picked up by people who manage all kinds of diseases(Family doctors/GPs/Internists).


b. Doctors and health workers should prepare themselves by following healthy diet and lifestyle.


(4) Protocol for those with minor symptoms to prevent them ending up having severe diseases

i. Prescribe a balanced diet to all.


ii. Educate them about the need to restrict carbohydrates and the need to include more high fiber vegetables to avoid weight gain and achieve weight loss, if they are overweight.


iii. All those who are overweight should be advised about scientific methods of weight reduction, not by short cuts like fasting, dieting and the keto diet.


iv. Inform them about the need to maintain good hydration to prevent thrombosis.


v. Educate them for good oro-dental hygiene to prevent aspiration pneumonia.


vi. Ensure adequate sleep and rest.


vii. Practical tips to manage their stress/ counselling when needed.


viii. Prescribe multivitamin tablets- to correct existing deficiencies (should not go for blood levels to diagnose nutritional deficiencies – good dietary history and complete hemogram is enough).


– Vitamin D 2000 units daily + Calcium supplements
-Those with high MCV-(>90) /strict vegetarians/those who do not take meat need injections of B12- but Cyanocobalamin or hydroxocobalamin only
– Give folic acid, B12, B1 & B6 supplements to all- to correct the hyperhomocysteinemia or to prevent it- universally present in those who develop thrombotic episodes
– Multivitamin tablets with vitamin C (75-100mg) & riboflavin
– Avoid use of NSAIDs at any cost in febrile patients and even in others -this could trigger organ damage in case they develop fever


(5). Scientific protocol for those with severe disease


i. Follow all the previous measures given in (4)as for those with minor symptoms, modify them as applicable to the ICU set up.


ii. Always give injection B12 (cyanocobalamine/hydroxy cobalamine) and folic acid.

iii. Injection Heparin 2500 to 5000 units S/C twice daily – it can be increased to the full dose if they already have respiratory distress and there are no contraindications.


iv. Hydroxychloroquine 200 mg Bid as an immunomodulator may be started in all with respiratory symptoms, all overweight/obese and those with NASH, or any underlying autoimmune disorders.


v. If they have respiratory distress- give injection dexamethasone 4mg 8hourly but make sure that there are no contraindications- reassess the need before each dose.

vi. Antibiotics to those in respiratory distress as many have aspiration pneumonia- choice to be individualized (Azithromycin/ Doxycycline/Amoxycillin/Ampicillin + gram negative cover if needed with quinolones/ cephalosporins).


vii. Fresh frozen plasma to all in severe respiratory distress – or the so-called happy hypoxia- is due to pulmonary thromboembolism- it is to provide protein c and Protein s which are synthesized in the liver, acting as natural anticoagulants- which are universally deficient in those with overweight (even 2Kg excess weight matters), or in those with SGPT elevation, established liver disease- acute or chronic)- the benefit observed with plasma therapy is not due to the antibody itself but due to Protein C and Protein S mitigating the thrombosis along with heparin–we need not go after people who had Covid in the past for FFP.


viii. Avoid the use of Tocilizumab and Remdesivir and other antiviral drugs unless you have enough money to waste- it may not work at all.


(6) Use universal precautions by health care workers and doctors
.


(7) They also should follow a good diet and lifestyle
.


(8) Stop projecting the covid- account and death score to prevent mass hysteria/ fear psychosis
.


(9) Do not pin hope on vaccine.


(10) We should have a plan to avoid use of ventilators- ventilatory care is the last resort to the unfortunate few- Don’t be in a hurry to put the patient on a ventilator too.


(11) Test only the symptomatic ones to decide on isolation to others- even that can be avoided by intelligent planning.


(12) Isolate the vulnerable by reverse quarantine, that too only to avoid accumulation of those who require critical care- when available, these people alone may be considered for the vaccine, if all it is effective, is meant for them only.


(13) Decentralized patient care -we need large number of family doctors, working in adequately equipped Primary care centers, with a good team of health workers.


(14) All clinical problems should be approached by an ‘outside-in approach’- history, physical examination in all before ordering any test- we should not decide what to do after doing the tests blindly- but the test itself should be done only after a decision making.

(15) With the routinely available universal precautions alone we can continue to practice medicine in any calamity- PPE kits are for use only in exceptional situations


(16) All Covid positive people and patients to be educated on following good diet and lifestyle and that is the only way to prevent the so called post Covid syndrome.


(17)As doctors our primary responsibility to patients is to console them and not to frighten them
.


Dr.P.K.Sasidharan

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