Calm down, isolate at home and don’t unnecessarily block hospital beds: Dr V Ramasubramanian As the second wave of the Covid pandemic ravages India causing trauma, panic and paranoia, a voice of calm, common sense and sane medical advice is that of Dr V Ramasubramanian, a specialist of 30 years in infectious diseases. A member of the Rotary Club of Madras, he frowns on the noise and “sensationalisation” of the media, the lack of empathy in so many people who should know better. In an interview to Rotary News, the good doctor, who was seeing over 150 patients a day by May-end, said “first and foremost we all need to calm down”. Excerpts...

Why did you decide to specialise in infectious diseases?

My father is a GP; he is 90 and still practises at his clinic in Chennai. After completing an MD in general medicine from the PG Institute of Medical Education and Research in Chandigarh in 1992, I didn’t want to narrow down my focus to a single specialty such as cardiology or neurology, so I specialised in infectious diseases, which is an integral part of general medicine.

 

In your 30 years in the medical profession, have you ever seen a virus-inflicted pandemic such
as this?

No, neither has my father! But it was inevitable, and on the cards, and not something which came out of the blue. We’ve had episodes like this starting from 1918 and we have improved tremendously in medicine but our memories are very short. We never prepare ourselves for what can happen.

Most people with Covid can do well if they isolate at home. Rushing to hospitals and blocking beds which a person with oxygen requirement cannot access, or refusing to vacate a bed after they get well, is the sad part.

Were we caught on the wrong foot; could we have handled this better?

In retrospect, we could always have done better. But in any epidemic or pandemic, any measures done beforehand seem too much, and any measures done later seem too little.

 

It looked as though India had handled the first wave rather well, and then like a tsunami, the second wave hit us. Did doctors like you think we are celebrating too soon?

I was always sure that the second wave would come, and had no doubt in my mind. I was the odd man out in my fraternity or field. But I expected the second wave to be milder. The numbers are higher this time, but there were many reasons for the low numbers in the first wave… difficulty in getting tests done, expensive tests and the stigma attached to anybody testing positive, with boards and barricades at their homes, so people were very scared to get tested.

Also, that time, the working classes got infected, and got better in a few days, so they didn’t bother too much. I would guarantee that for every one person tested, there were at least 10 who were not tested but were positive/infected.

 

Was the higher cost a reason for lower testing?

Yes, even the cost — ₹4,000. So very few did the test initially. At that time the elderly went down; the younger ones did very well. I have counselled several people saying you’re only 30, isolate yourself, don’t do the test and you will do well. And they’ve all done well.

I am appalled at the righteous attitude of the western world towards India because they have all gone through far worse during the peak of their first and second phases. Their pointing fingers at India and being condescending is not right.

But the second wave hit the more affluent, the middle classes, people working from home… they had the money, the knowledge and knew they had to take care of themselves. So anybody with an itchy throat, a slightly stuffy nose, heavy head, immediately took the test, now available and cheaper.

 

Are you saying the numbers reported are more now because of more tests?

Absolutely.

 

But the way our medical system and health infrastructure, of which we were once so proud, has crumbled is surprising. People lining up outside hospitals for oxygen, no hospital beds, people dying in Casualty. Why and how did this happen?

Even the best of places, Spain, Italy, England or even New York, went through the same experience in the first phase when they were badly hit. Now they may turn around and say the Indian government did badly. Rubbish. They were far worse during the peak of their first and second phases. I have seen pictures of their emergency departments and people falling dead on stretchers in the developed countries. They just did not have the hospital beds or facilities to cope with the numbers. I am appalled at the righteous attitude of the western world towards India because they have all gone through this. When you are equipped to handle 10 people and you get 1,000, nobody can handle it.  Yes, let us accept that we have all made mistakes, and not point fingers at India. That is not only condescending but not right. Considering our population which is 10, 50 or even 100 times more than theirs, we have done reasonably well.

 

At least from 4 lakh our daily numbers have come down to around 2 lakh; are you optimistic that the numbers will come under control?

Absolutely! In Chennai we have already seen a decline in the outpatient load and the inpatient numbers always lag behind the OP numbers by two weeks. I am sure in two weeks the inpatient numbers will come down.

 

Do you think there is more panic than warranted?

Yes, we would be reasonably better, not well off, but reasonably better, if people calmed down and understand that most people with Covid can do well if you isolate at home. Rushing to hospitals and blocking beds which a person with oxygen requirement cannot access is the sad part.

I have patients in hospitals who get well, I tell them to go home as we need the bed for somebody else and they say but today is Tuesday, an inauspicious day, or the ninth day of my admission; I can go only on the 11^th day. Or I don’t have anyone to take care of me at home; I’ll be here for three more days. Depriving a bed for somebody else more deserving when you are already well is something I feel very sad about. The empathy is lacking.

 

So as usual the privileged corner everything? 

(Smiles wryly) Everybody is equal; but some are more equal than others!

 

There is so much of information and misinformation floating around. What do we believe?

We are in a situation of information overload. When I was young, I had to go to a library for information
I needed. Now four taps in the comfort of your home and you can access anything you want. Add to that Whatsapp, FB and Instagram! After practising medicine for 30 years, I find it difficult to analyse and chronicle so much information. How do you think a lay person is going to process it?

 

I have a healthy regard for alternative systems of medicine. But I only wish they had a little more scientific rationale in analysing and coming to a conclusion.

 

Do people come and ask you all kinds of crazy questions, should they do a lung scan, a D-dimer test, etc?

(Laughs and nods his head).

 

Are you still seeing 100 patients a day?

More like 150 — both inpatient and outpatient in Apollo Hospitals and my clinic. But with the lockdown, in the last three days the numbers have dipped. It is sheer madness out there.

 

In the second wave, more people are dying; do we know why this variant/mutant is more lethal and dangerous to the lungs?

We still don’t know the entire reason, but have some hypothesis. The second variant has more mutants which are definitely more infectious than the first one. If in a household two people were infected in the first wave, this time at least 4–5 tend to get the infection. With the numbers, the mortality rate goes up too. We also know it is causing more harm to the younger people than the first time, and their mortality rate is high, but we still don’t know the reason.  Is it because this time the virus is targeting people who are a little more affluent and less robust, I don’t know!

 

Do you see a third wave coming?

Yes, it will come by the end of this year, but I don’t know how severe it will be. But it is inevitable and
will come.

 

And those vaccinated will be safe?

Yes, they will be safe but the infection cannot be prevented. We might see less severity, hospitalisations and death. No question about it. Infections will happen, but they will definitely be milder.

 

Coming to a lay person, if I have a cold, cough, low-grade fever, what should I do?

The first thing to do if you suspect Covid infection is to isolate yourself. You can wait for a day or two to reassess whether you need to do a test. After the stuffy nose the first day, if you feel absolutely fine the next, I wouldn’t worry. But if you still feel feverish, lethargic, have a severe headache, backache, diarrhoea, loss of smell and appetite, then do the test. But isolate yourself first.

And if you test positive, don’t panic. Stay calm. People call me at 10 pm after testing positive, saying they need to see me immediately! You have to see the doctor the next day and let him/her decide if you need any tests. CTs and blood tests are not mandatory for everyone.

 

You, the AIIMS director and so many specialists have said that the CT scan exposes you to radiation levels 300–400 times more than that of a single x-ray. Is that so?

Absolutely.

 

So when is that indicated?

Medically speaking, we do that for people with persistent symptoms for 7 days. If the cough is persistent or worsening, people whose oxygen levels are dropping slowly, if there is a sudden drop in saturation or pain. A routine CT is not necessary; less than 10 per cent need it.

 

Can there be complications after recovery?

Almost 30–40 per cent of the infected who recover, after two weeks of the onset of Covid symptoms, will have some issues. Maybe something as trivial as a dry mouth, a heavy head, a little bit of a joint pain, disturbances in sleep, lack of sleep or too much of sleep. Some might have more serious symptoms such as absolute loss of appetite, tightness of chest, disabling cough, sudden loss of hair, panic attacks, inability to concentrate and work, fear and paranoia. All of these are possible. We have to treat individual cases.

 

Have you asked your patients to seek psychological counselling?

Absolutely; because people can’t sleep, they have paranoia. They think they will die.

 

How do we handle the third wave if such a rush on hospitals again occurs?

Unless we tone down the social media and the press, unless the media tones down the severity of the assault of bad news and negativity on the public, things will not improve. I keep repeating; handling the physical fallout from the infection is easier than dealing with the psychological issues. If patients insist on getting admitted when there is a lack of beds, how do doctors convince them they don’t need hospitalisation? It is very difficult.

 

What kind of food does one take during and after this infection?

Doesn’t matter. Food plays the least role in Covid, it just needs to be a balanced, nutritious diet; vegetarian or non-vegetarian.

 

Which vaccine?

Whichever is available. All of them are safe and found to be effective.

 

How do we deal with the fear of blood clots?

Any intervention, be it just a paracetamol, has side-effects. The question is what are the chances. When you drive on the road can’t you die or get a head injury in an accident? You can. Does that prevent you from travelling on the road and just staying at home? No. So this is also like that. You have to weigh the benefits and the risks. To me the benefits far outweigh the risks.

 

What is the window of safety after taking a vaccine shot?

Two weeks after the second dose. First dose doesn’t do much.

 

The interval between two jabs?

For Covaxin it is 4 weeks, and Covishield at least 12 weeks.

 

Will a booster dose be required after a year or so?

Let’s wait and see. Probably it will be like flu where you will need annual shots but no data is yet available.

 

What do you feel about the fantastic claims made by different kinds of medicine promising wonder cures for Covid in the background of the controversy between the IMA and a yoga guru?

I have a healthy regard for alternative systems of medicine. There are situations where homeopathy is better, or Ayurveda, no question about it. But I only wish they had a little more scientific rationale in analysing and coming to a conclusion. You can’t just say I have given this to 50 patients; they all survived and hence it is working. No, there should be some scientific analysis. The fact is that they have survived for centuries, which means they have made effective interventions.

 

Do they help in treating infectious diseases?

Oh yes, they do, but usually for acute situations, allopathy is better. This is my feeling.

 

You are a Rotarian, what do you feel about the way Rotary, and the larger community has responded… with so much of kindness and generosity during this pandemic?

Despite criticising the media for creating panic, I have phenomenal faith in human beings. Both Rotary and the larger community have rallied around splendidly, giving oxygen concentrators, trying to get beds for people, running vaccination camps. On similar lines we need to tone down the panic and this is the best thing the media can do.

Coming to Rotary, it is making a huge difference in the lives of so many people, earlier and now during this pandemic. Whether it is helping somebody to survive, or feel better… showing empathy which is so important, and getting a warm glow which only helping others can bring. Rotary is a fantastic organisation, so well organised and regulated.  I am proud to be a Rotarian.

 

I know you’re really working long hours. What does your day look like?

(Smiles) I get up at 5.30 am, go to my clinic (Capstone Clinic, a multispecialty clinic he initiated) at 7 am, leave it at 9, reach Apollo Hospitals (Greams Road) by 10.15 am, where I attend to both OP and inpatients, return to my clinic at 3.30 pm and work there till 7 pm. So it is 12 straight hours of work. And then in the evening I talk to people like you, attend Zoom calls, meetings, committee meetings, print and electronic media interviews, Insta and FB chats… all that goes on.

 

How do you get your exercise?

Physical exercise is not a problem at all. I clock at least 10,000 steps a day walking around the hospital. I am exhausted when I finish for the day, and within 5 seconds fall asleep until the alarm wakes me up. I also do yoga thrice a week, each session being 45 minutes.