Tinsukia: A 47-year-old railway employee was admitted to civil hospital in Assam’s Tinsukia district on March 26, a week after railway doctors diagnosed him with fever, cough and advised him home quarantine. He was diagnosed with chronic obstructive pulmonary disease (COPD), acute exacerbation and fever before he was discharged under medication on March 27. He tested negative for malaria and his liver function test (LFT) showed mild jaundice.
He died within the next 24 hours in the early hours of March 28. He was, however, not tested for COVID-19.
Doctors said they did not treat him as a suspected COVID-19 patient because neither he nor his family disclosed any recent travel history and he was not in contact with any positive case. “He had a chronic respiratory disease,” joint director of health services doctor Altaf Ahmed told EastMojo, negating any suspicion for COVID-19. “It is not possible to test each and every person with mere fever and cough, there are guidelines to be followed,” he added.
EastMojo was unable to speak to the family.
The official protocol laid down by the Indian Council of Medical Research (ICMR) initially restricted COVID-19 testing to those with international travel history or those who had come in contact with confirmed cases. However, on March 20, ICMR revised its strategy for COVID-19 by expanding it to include hospitalised patients with severe acute respiratory illness: fever and cough, or fever and shortness of breath.
But if the revised strategy on March 20 makes it clear that even patients without travel history must be tested for COVID-19, why did that not happen in this case?
“We did not have the COVID-19 testing kit until then, nor the required training. The expert to train the procedure to be adopted was also not available. Perhaps, we were in the initial stages of coronavirus,” superintendent of civil hospital doctor Mridul Gogoi told EastMojo in a candid discussion.
“Had the Covid-19 testing kit available with the required training, I would have definitely got him tested to remove the doubts,” Gogoi said, adding, “The nurses got nervous and angry after hearing the symptoms of the patient that sounded like a suspected case of COVID-19 in the first impression. However, hearing that the patient had no travel history and he was not a direct contact of coronavirus positive case, they breathed easy.”
Since he was suffering from chronic respiratory disease, the case did not grab importance for COVID-19, he added.
More than 4,000 people have tested positive for coronavirus in the country till April 6 with the death toll crossing 100. Assam alone has recorded 26 positive cases.
From 75 districts on March 22, the outbreak has now spread to over 200 of India’s 720 districts; many of the cases have emerged in rural areas as per media reports.
Gogoi said there is a gap between receiving of guidelines or protocols by ICMR and the receiving of required training to that effect at the rural hospitals. “Those — right from the doctor to the sweeper — involved in dealing a pandemic need timely training to deal with the situation. The gap, may lead to lapses, for which no one can be held responsible. It is a pandemic and all are bracing to cope with it.”
Gogoi added, “Today, kits are available, training is going on and we are prepared in a better way to handle the situation.”
The patient was admitted in MMW ward of the civil hospital — a COVID-19 designated hospital. General patients are admitted in this ward. “Doctors of various government health centres should be directed to join Tinsukia Civil Hospital to help us,” he said.
The deceased railway employee, tech-II grade staff under carriage & wagon, was a station field staff deployed at the coaching sick line at Old Tinsukia railway station.
Coaching sick line is a term used for the place where maintenance of coaches, including those of outstation trains, is done. Here, field station employees come in contact with train coaches including those coming from out of the state, according to railway sources.
On March 9, he first visited the railway doctors. But as he was running a fever, we advised him to go to the civil hospital for check-up before heading back home, but he hesitated, said railway doctor JK Doley, who was supervising the case, adding: “We explained him about COVID-19.”
According to Doley, he again came back for check up on March 19 and was sent to sub-divisonal hospital of railway at Hijuguri. “He was examined with fever and cough, and advised self home quarantined. He was also asked to go to civil hospital to get himself checked.”
The employee did not and returned home instead. The next few days, he seemed to have kept suffering only to return to health unit of Tinsukia railway division on March 26. “This time he was joined with his wife,” the doctor added.
Doley said, “He was looking sick. I strictly asked his wife to take him to civil hospital and sent them to sub-divisional railway hospital from where they went to civil hospital.”
When asked about his chronic disease, Doley said that during his multiple visits he never narrated about any chronic respiratory disease infront of us, hence, cannot throw more light on it.
“On March 28, I learnt about his demise at his quarters. His family called me to come and check him, but I could not immediately go there as I did not had the required protective gears,” the doctor added.
“I informed the chief medical superintendent of Tinsukia railway division and the epidemiologist of Tinsukia district”, said Doley, adding, “I joined a team of doctor from district administration along with epidemiologist, who informed me, that, the patient was not a suspected case of Covid-19. The patient diagnosed with chronic respiratory disease, hence, post mortem is not needed, Pathak suggested.”
“Had I been at their place, I would have gone for COVID-19 testing,” added the railway doctor.
Contradicting the railway doctor on post mortem, epidemiologist Anjan Pathak said, the district adminsitration had discharged him under medication after his condition improved. “Since, the patient, who was a railway employee, died at his home it was the call of railway doctors to decide for post mortem.”
“The patient was diagnosed for chronic respiratory illness on the basis of which doctors ruled out COVID-19 suspect case,” Pathak added.
According to medical experts, the discharge of the patient from hospital suggests that his condition improved by March 27 and did not warrant hospitalisation any more. “Had the patient insisted for discharge, it would have been reflected in discharge certificate,” they added.
So, what happened within few hours that led to his dead remains a big question.
Searching for answers, EastMojo spoke to a Delhi-based doctor. “His chronic respiratory disease may have led to heart failure. The doctor who treated the patient can best throw more light,” doctor said.
The death of a patient with primary symptoms of coronavirus may have raised “eyebrows”, the doctor said, adding, “In the given scenario of pandemic, testing could have been done to erase the possibility of slightest of doubt.”
Had this been a case in New Delhi, the doctor said, the patient would not just have been tested for Covid-19, but a series of testing depending on the symptoms, including his chest CT scan and blood test in the present case, underlining the vast healthcare difference between urban and rural India.
“The gaps in COVID-19 testing can be only plugged with real time training at rural level hospitals dealing with pandemic and making COVID-19 testing kits available in abundance with other facilities to them,” another doctor added.
The 48 hours leading up to his death paint a grim picture of rural India’s health infrastructure and the lack of preparedness and training to handle the pandemic, and came at a time when Assam’s testing rate for Covid-19 was considered too low.
The state stepped up its testing for COVID-19 immediately after reports broke out that several participants of Nizamuudin Markaz, a religious congregation held in Delhi, are testing positive for Covid-19 after having returned to their states.
Till April 6, Assam has tested 1,976 samples.