CME INDIA Presentation by Dr. H. D. Sharan, Ranchi, Cardiologist, Ranchi.

“My idea behind making this public is to tell people that there is no shame in being anxious or depressed. It does not even mean that you are a weak person. Post-Covid is known for causing anxiety and depression and just as I consulted my doctor, do not hesitate to consult your doctor” – Dr. H. D. Sharan

What will be your advice to your patients under the same circumstances?

  • 7 days after testing Negative, I attended the hospital today. One question, my wife always asks me is what will be your advice to your patients under the same circumstances?
  • Well, my advice to my patients depends on the guidelines. And the guidelines are that these patients may require up to a month to get over the after effects of this disease.
  • Weakness, fatigue, body ache can persist for weeks. I had no body ache. Fatigue is something you will realize only after going through the grind. And weakness is more related to the psyche than soma. On Sunday, I went down for my warning walk. The speed almost 2/3rd of my normal speed and time half that of normal. And yes, fatigue was there.
  • Today was my first day in the hospital since the 20th of April and 14 days of Covid. I had to climb the stairs to the first floor OPD and my flat 3 times and came down 3 times. After returning from the hospital and after we had lunch, we finished “The Family Man” web serial.
  • And now, at 5pm, I find myself totally fatigued. I am writing this in bed. The fatigue is real. Especially at this age. But I am not going to tell my wife today.  If only because that she always has to answer to her friends’ question, ” why did you allow Dr Sharan to do this?”

I will like to give you a little history

  • 1984 or 85. I was operated for multiple ureteric stones. The post-operative period was also not very smooth. But I was back at my desk on the 5th day after discharge. 2019 Jan 25th.  My second Angioplasty. On the 26th I went up to the terrace of the hospital for flag hoisting. Everyone was so overwhelmed that they asked me to hoist the flag. After the flag hoisting, I came home and was back to my duties on the 29th.
  • But this is different. After walking for 5 mints, every step is difficult. I force myself to continue and after another 5 to 7 mints, I give up and return. I would be very concerned about my health if I had not known to expect it. It feels as if the lower back and legs have given in and are refusing to bear the weight of the upper body.
  • We must remember that this may continue for weeks. If anxiety and depression are added to this, it will become more severe and may stretch to months. There lies the importance of getting the courage to get up from bed and start doing what you are best at. Continue walking for as long as you can and get back to light duties as soon as possible.
  • I am my own doctor and I will follow my doctor’s advice.

Does not fit into anything

  • Another symptom that is bothering me is lower abdominal pain. It is an intermittent fleeting pain that moves from one end of lower abdomen to the other. Does not fit into anything. At times this pain extends all-round the body to involve the lower back too. Hot water bag gives relief. Many of my patients have complained of abdomen pain in post Covid period.
  • The SARS CoV2 is known to affect Pancreas and cause Pancreatitis. Pancreatitis causes upper abdominal pain and is a serious condition. Another condition that can cause abdominal pain in post Covid period is a condition called AMI or Acute Mesenteric Ischemia. This is caused by clot formation in Mesenteric Artery. The clot can be dissolved if clot dissolving injection is given in time. If gangrene sets in, there is no alternative to surgery.
  • I am not being a scarecrow. These things do happen though rarely and we must remain alert for them. Consult your doctor if you have persistent abdominal pain.

The severity of symptoms of Covid has nothing to do with post Covid complications.

  • Two of our family friends lost their lives after recovering from Covid. One was a known heart patient who had undergone Bypass surgery of the heart. His entire family was infected. He was hospitalized because of his history of heart disease but succumbed to a cardiac event.
  • The other had no history of Heart Disease or for that matter no history of any co morbid condition. He recovered from Covid and just before he was discharged, he had a massive heart attack and succumbed to it. Both these cases are examples of formation of clot in the arteries of the heart. Just as in the heart, this clot formation can occur in the brain causing paralysis, in the intestine causing gangrene.
  • Although guidelines do not mention taking oral anti-coagulants for a long time following Covid, I personally have reached the conclusion that we should take this medicine that prevents clot formation for as long as the risk of clot formation persists provided there is no contra indication like bleeding tendencies. So, after stopping it, I have restarted this medicine. And I will advise all my patients who have recovered from Covid in the last 3 months and do not have any tendency to bleed should contact me. I am sure that day is not far away when this advice will be included in the National Guidelines. Many of my doctor friends agree with it. In fact, this was first mooted by Dr P N Singh.
  • Lack of sleep and headache are also very common complications. There is no harm in taking a sleeping pill for some time. I take Diphenhydramine 50 mg which is basically an anti-allergic but produces good sleep. A combination of diphenhydramine and paracetamol is an OTC medicine in the USA. This lower back pain and stiff legs are still bothering me. Will have to take care.

One needs to be extremely cautious about taking the decision when to return to work

  • I have to attend to an important job today. Normally, I would have taken care of both, the OPD and the other job. But, the more I thought about it, the more my mind dissuaded me and I decided not to attend the OPD today.
  • This was directed at friends and family members who are worried about my returning to duty so soon. One needs to be extremely cautious about taking the decision when to return to work and how much work load to shoulder. One has to be attentive about the signals one’s body is sending and react to it. I am very alert to respond to these signals.
  • Sitting in the outdoor is not a problem at all. It is not physically tiring and acts a great stimulus to the mind. Post Covid cases have now started to report to the hospital OPDs and it is very interesting to treat them with the new insights that I have acquired about the disease.
  • What hurts is the car journey and climbing the stairs. My residence and my OPD are both on the first floor and I try my best to avoid the lift. But I do not hesitate to use the lift if my body demands it.

My answer invariably is “absolutely fine.”

  • When a patient says, ” अच्छा नहीं लगता है” and fails to elaborate on it, we usually attribute it to depression and most of the times we are right too. But these days, we must take history of Covid and reassure them accordingly.
  • When someone asks me, ” How are you today?,” my answer invariably is “absolutely fine.” Am I really just fine? I do not think so. The smell and taste, especially the smell keep playing hide and seek with me. And I just do not feel 100 percent of what I was on the 14th of May.
  • From the 15th afternoon, I was just “not feeling well.” My sons asked me what was happening and I replied just ” lot of melancholy.” My sons took some time to respond and when they did, they said jokingly that the delay was caused by the fact that they were looking up the dictionary for the meaning of the word melancholy. Melancholy means ” a feeling of pensive sadness typically without any obvious cause”. Well, it was not without cause, I thought. I had lost a close friend just a week ago.
  • By night, I had started coughing with a wheeze and next morning, I tested positive. What I have tried to convey through this story is that, ” not feeling well and a feeling of pensive sadness may be a symptom of both Covid and Post Covid. In post Covid cases, and must be treated.

Post Covid Blues

  • Those who tried to dismiss this disease as another influenza could not be farther from the truth. Yes, many remain asymptomatic and when the dust settles down on this pandemic, we might realize that the mortality rate is nearer to 1 percent than 2.
  • But the cost in terms of the man-days lost, the jobs gone, the migration of workers, the loss to the economy, the cost of hospital treatment, the mental trauma of isolation caused by this ” cold” is immense. Then, for some people there is a social stigma attached to the disease, the main cause for its spread.
  • For 3 months or even more after getting rid of the infection, one remains in danger of getting a heart attack or paralysis or gangrene of intestine, peripheral neuritis causing burning sensation in souls etc. If one develops Covid Pneumonia, it may take months to resolve causing cough and breathing difficulty and keeping patient dependent on oxygen.
  • There was such intense burning sensation in soles during Covid that I had spent 2 nights sitting up and putting my soles on the floor. It has diminished with treatment but has not gone totally. Let us see how long does it persists.

New Mantras, be alert for Mucormycosis

  • One should always look for pain in the face, oral ulceration, bleeding from nose and redness of eyes etc. as these are the warning signals for Mucormycosis or black fungus. We are still not sure of why we are seeing an endemic of Mucormycosis now. Many hypotheses are being floated for the cause but the fact is that we do not know the exact cause. The treatment is very costly and mortality is very high.
  • The lower back is still quite tender but slowly I am getting used to the one-hour OPD. I will very gradually get back to my Pre Covid levels of exercise and work.
  • We have the example of Executive Director of the Bird Group, Ankur Bhatia. He had recovered from Covid a few weeks ago. He was on his daily routine of cycling when he died of an Acute Cardiac Event.
  • The pic represents the gravest complication of Covid. For them, the rest of their lives will be Post Covid. They not only lost their bread earner but spent all their savings in an attempt to keep their bread earners alive. Not many people will be aware that Living Will is now legal. The usual will expresses your desire about how the family should divide its property after your death. The living will express one’s desire while he is alive.
  • The Respiratory Distress Syndrome caused by Covid is different from RDS caused by Sepsis and other Corona Viruses. High mortality seen in early part of Pandemic esp. in New York has been attributed to early intubation and ventilation which saves many lives in other varieties of RDS. I have not seen many intubated patients of Covid surviving. Therefore, I was very clear in my mind what my living will be. ” No further consent needed till NIV. Nothing beyond that. Under no circumstance, will I be intubated. My family members will not have the right to override this decision of mine.” I had to use my own language as my lawyer friends found it too embarrassing to frame this while I was suffering from Covid.

The take home message

1) Post Covid complications can involve all vital organs.
2) Many of these complications are caused by clot formation in the arteries that supply blood to these organs.
3) Post Covid is characterized by severe weakness, fatigue, body ache, loss of taste and smell which may continue for weeks.
4) Get back to your exercise routine very gradually.
5) Do not hesitate to take the help of your doctor if you have loss of sleep, anxiety and depression in post Covid period.
6) Make sure that your life’s savings are not spent on days on ventilator as your chances of coming out of it are not very bright. This is an extremely personal view, may not be backed by science.

In between I cry or make sounds of grief

  • There have been moments in life when I have been very anxious but anxiety has never affected me for long. It always took me some hours to work the things out and overcome that anxiety. At least 50% of my patients suffer from Anxiety and Depression.
  • I have treated a lot my friends and their families for Covid since May last year. It was stressful. I once told my wife that I did not know how long will I be able to continue doing that. All my friends in Ranchi and my childhood friends scattered all over the country, my batchmates they all wanted me to treat them and their families. Throughout April and till early June, every morning, I used to call them early in the morning and advise them.
  • And then, on 7th May, I lost a very close friend, a doctor, fully vaccinated, to Covid. Both of us were in mental turmoil and before I could come to terms with it, I tested positive. Isolation takes its toll but I managed it quite well. 2 days ago, I lost another young friend, a doctor again who was infected for the second time. A well-known doctor in Piparia in M. P. and a hugely respected Hindi poet.
  • Treating lot of my friends’ long distance, getting infected and then loosing 2 people who were part of me has ultimately broken my defenses. I feel extremely anxious. I have never slept well in my life but these days, I keep talking in my sleep. My wife tells me that my speech is slurred so it is difficult to decipher what I say. In between I cry or make sounds of grief. I dream of strange happenings but all are related to some Virus. I dream that people I know are not listening to my advice so I try to speak loudly. That wakes up my wife. I dream that some of my friends are trapped in a glass House that is full of the Virus. They cry for help but I am not able to reach them.
  • I see this dream every day. I am scared as the night approaches. I talked to my psychiatrist friend Dr Anil Kumar today. He confirmed that it is Post Covid Anxiety. Added to that is the grief reaction to losing my friends. I am a fighter and fight my way out of this anxiety.
  • My idea behind making this public is to tell people that there is no shame in being anxious or depressed. It does not even mean that you are a weak person. Post Covid is known for causing anxiety and depression and just as I consulted my doctor, do not hesitate to consult your doctor

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