Journal of Data Mining in Genomics & Proteomics

Action Plans for Medical Professionals to Fight COVID-19

Sasidharan PK^* Former Professor & Head, Division of Haematology, Department of Medicine, Government Medical College, Kozhikode, Kerala, India
^*Correspondence: Sasidharan PK, Former Professor & Head, Division of Haematology, Department of Medicine, Government Medical College, Kozhikode, Kerala, India, Tel: 9847005177, Email:

Received: 26-Nov-2020 Published: 17-Dec-2020, DOI: 10.35248/2153-0602.20.s6.003

Description

The entire human species and the medical profession was hijacked by the Covid-19 scare and the Covid care plans, which diverted all our human and financial resources. It made us forget all other issues in the society and even other illnesses in the patients. Covid-19 had made its presence all over the world, but it produced no symptoms or only mild symptoms in the majority and those who developed severe symptoms were those with several comorbidities, subclinical malnutrition and wrong habits or wrong lifestyle (already detected or which went unnoticed). No one living at this moment has had any experience of handling a situation like this. A similar issue had happened in 1918, when Spanish Flu struck the world. By the massive lockdowns all over the world, we are doing exactly the same thing as was done a century ago. But conversely, the people would have faced it more calmly those days as compared to now, since the fear psychosis would have been minimal, due to the poor communication networks and perhaps a little more common sense those days. Now the locked-down people are listening only to the death tolls, which is updated every hour and brought to the people live, in the TV channels, which generated and perpetuated a huge fear psychosis and mass hysteria all over the world.

Eat a balanced diet always; never eat to full stomach, high fiber vegetables should form the major portion of the food (Figure 1) [1]. High fiber vegetables are not a side dish, but make it a main dish. Take fruits daily, vegetables and fruits should be there each time, fill only half the capacity of stomach, never go for a refill when we eat-maximum three times a day only (Figure 2) [2].

Figure 1: Flow chart showing dietary food intake.

Figure 2: Proportion of food that should be consumed in a day.

Avoid snacking never forget to include a protein containing item, every time we eat, 20-30 grams per meal (fish, meat, whole egg, curd/ nuts, mushroom, pulses). Do not take whole milk, instead use as curd only. Drink at least 2-2.5 liters of water a day-we need to avoid dehydration at any cost every day to prevent several diseases in one go-like urinary tract infection, renal calculus, venous thrombosis, drying of respiratory secretions and so on. Avoid all junk foods and fast foods-including the health drinks, both indigenous and Use all the physical and mental defenses of stress-that includes balanced diet too. Do some physical activity every day, at least for half an hour. Take rest when tired or fatigued-just lie down flat, listen to music, or watch some laughable scenes. Avoid listening to news coverage and the frightening warnings on Covid 19 Never be lazy and become like couch potatoes. If in case, you are already overweight, start weight reduction plans, today itself. Even one Kg weight loss could save us from a disaster. The lowest weight after completing growth (at 18 to 20 years) and while remaining healthy is the ideal weight to achieve-do not go by the BMI alone to decide our normal weight.

Whatever diet and lifestyle we practice must be prescribed to the patients as well, it must be done positively without any hesitation, even if there is no proof from double blind studies. The concept depicted above is a complex logic derived from scientific principles, four decades of observation and studies on patients, myself and my family, and after studying the diet and lifestyle of healthy individuals and of patients during my life journey. These observations are difficult to be tested with any artificially created study protocols to satisfy the present generation of scientists who depend too much on existing evidence.

Scientific management of Covid-19

Since any infection is due to Agent-Host – Environment interactions-focusing on all the three are essential.

• Prevent the agent from developing by proper nature conservation, of which we doctors can also be a part of-a strategy for future.

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

• Reverse quarantine for the extremely vulnerable people only to avoid overwhelming the health care facilities.

Prepare the hosts to face the infection, fight the infection and get well naturally-even the extremely vulnerable people would benefit by this

• Eating a balanced diet and adopting healthy lifestyle and thereby maintaining the body immunity and not by magic remedies and short cuts.

• Prepare the healthy people to face the infection. We cannot shut down for long, and nothing can prevent the organisms from coming in. It is inevitable, and we cannot run away from it.

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.

• Realize that the people who develop serious symptoms have diagnosed or undiagnosed health problems. The presence of such health problems can be easily predicted by studying their diet and lifestyle and by a good physical examination, combined with some easily available laboratory tests (complete haemogram, ESR, SGPT, RBS, serum protein). With these measures, all the vulnerabilities are easily picked up and managed by doctors who manage all kinds of diseases(Family doctors/GPs/Internists).

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

• To diagnose a disease like Covid 19 or any other disease, the golden rule in Clinical Medicine is that only the symptomatic people are subjected to laboratory tests. That too only after a careful history and physical examination and only after deciding on the diagnostic possibilities. In other words, no laboratory test should be done without good history and physical examination and without a clinical judgement. If there are no symptoms and no abnormalities on clinical evaluation there is no question of doing laboratory tests except in some rare settings that too the indications for doing that tests are obtained from history only.

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

• Prescribe a balanced diet to all of them.

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

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

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

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

• Ensure adequate sleep and rest.

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

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

•-Vitamin D 2000 units daily+Calcium supplements [3].

• -Those with high MCV-(>90)/strict vegetarians/those who do not take meat needs injections of B12-but give only Cyanocobalamin or hydroxocobalamin [4].

• -Give tablets of folic acid, B12, B1 and B6 supplements to allto correct the hyperhomocysteinemia or to prevent it universally present in those who develop thrombotic episodes.

• -Multivitamin tablets with vitamin C (75-100 mg) and 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.

Scientific protocol for those with severe disease

• Follow all the previous measures given in [4]as for those with minor symptoms, but modify them as applicable to the ICU set up.

• Always give injection B12 (cyanocobalamine/hydorxocobalamine) and folic acid or At least give tablets of cyanocbalamine or hydroxocobalamine with folic acid, since their deficiency is universally so common [4].

• 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.

• Hydroxychloroquine 200 mg Bid as an immunomodulator may be started in all with respiratory symptoms, in the overweight/ obese and those with NASH, or any evidence of an underlying autoimmune disorder; it helps control the hyperinflammatory stage with cytokine surge.

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

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

• Fresh frozen plasma to all in severe respiratory distress or the so-called happy hypoxia because it is due to pulmonary thromboembolism. It is to provide protein C and Protein S which are synthesized in the liver, and act as natural anticoagulants which are universally deficient in those who are overweight (even 2 Kg excess weight matters), or in those with SGPT elevation or 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 and other missing components in the patient mitigating the thrombosis along with heparin. It is not essential to collect plasma from people who had recovered form Covid-19 in the past (convalescent plasma), hoping to provide antibodies against the virus since the ARDS is not due to the virus.

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

• Use universal precautions by health care workers and doctors.

• They also should follow good diet and lifestyle.

• Stop projecting the covid account and death score to prevent mass hysteria/fear psychosis.

• Do not pin hopes on vaccine at the moment or in future too as the disease does not appear to be that serious by itself.

• 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.

• Test only the symptomatic ones to decide on isolation to others even that can be avoided by intelligent planning.

• Isolate the vulnerable by reverse quarantine, when necessary, that too only to avoid accumulation of those who require critical care. When a ‘safe and effective’ vaccine is available, then too the vulnerable people alone may be considered for the vaccine, if at all it is effective. It is meant for them only.

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

• All clinical problems should be approached by an ‘outside-in approach’-history, physical examination in all, before ordering any test-we should not make decisions based on laboratory tests alone. But the laboratory tests should be done only after a clinical judgement, by people who are capable of making it.

• All covid positive people and patients are to be educated on following good diet and lifestyle and that is the only way to prevent the so called Post-covid syndrome too.

• With the routinely available universal precautions alone we can continue to practice medicine in any calamity-PPE kits, gloves and masks should not be misused, they are for use only in exceptional situations.

• As doctors, our primary responsibility to patients is to console them and not to frighten them.

The Genesis of Post-Covid Syndrome

Some people walk around with irrational fears by attributing everything in their life to some event that happened in the past. For example a coconut fell on someone’s head, or he might have hit his head somewhere. Later this person attributes every symptom to this probable unrelated event. Especially so anything that happens in the head afterwards would be attributed to that by the ignorant patient. This mindset is now becoming a universal phenomenon. These days any symptom or any sign developing during or after a significant event, like covid-19 tested positive, is attributed as due to that by everyone including the doctors.

One Case History of A Post Covid Syndrome

This 80 year old male was Covid-19 positive and was admitted in a Covid care centre on 17th September and discharged after 10 days when Covid-was tested negative on 28th Sept 2020. He was referred to me for extreme tiredness and fatigue and loss of balance while walking. He and his children were genuinely upset about the possibility of a post covid syndrome after reading the frightening description of it in the media. He started having fatigue and tiredness after admission itself, which only increased after discharge to become very severe afterwards. In addition he had palpitation on exertion and decreased sleep too, since the time he got discharged from the covid care centre. The story was that his son had rhinitis and fever and he was tested positive for Covid-19 and on screening other members of the family, including this patient, who were asymptomatic, were tested positive. After discharge from the Covid care centre, he started developing fatigue, tiredness, and his blood pressure, which was normal, had increased. On taking history he was always upset, even while he was in the covid care centre, anxious and worried of the disease. He was a strict vegetarian for 3 years and his diet did not contain adequate vegetables and fruits too. At the centre, being a strict vegetarian, he took only rice with some side-dish and nothing else. He started developing tiredness at the covid care centre itself and it increased slowly and slowly developed extreme fatigue and tiredness. He had defective hearing for 4 years, Blood pressure on examination was 180/90, already on Telmisartan 40 and because of the increase in blood pressure cilnidipine 10 mg daily was added at the centre. On evaluation he was found to have severe anxiety, fear of death due to covid, both of which had increased his blood pressure. After discharge, naturally patient and his family were worried of the post Covid syndrome too. On examination he had all features of B12 and folic acid deficiency as well as non-alcoholic fatty liver disease. It was obvious that his fatigue was due to the stress that he was undergoing and also due to the underlying B12, folic acid and vitamin D deficiency due to the poor diet he used to take 3. Besides the daily chores, including exercise which he used to have was upset too-in short these were responsible for the post-covidsyndrome in this patient, and it would be the same for others too because these days patients are evaluated with a prejudiced eye and that too evaluated organ wise, and no one would see the whole picture. He was given reassurance, convinced him that nothing will happen, gave advice on proper diet, B12 and folic acid, and vitamin D and at the first review itself he showed remarkable improvement and became symptomatic at the next visit.

Epidemic of Weight Gain During Covid 19 Lockdowns

Already we had been facing the problems due to overeating and obesity, and often these were the people who had problems after covid-19 infection. During lockdowns almost all developed weight gain ranging from 2 Kg to 22 Kg, personally collected from the records of my patients seen during the pandemic. These were all patients with chronic ailments who did not come for follow up for varying periods from three to nine months, due to the fear of visiting hospital. This issue has to be seen in the context of severe illness developing in people with overweight and obesity. The patient with maximum weight gain of 22 Kg was a manual labourer. He never went outside the house due to the fear of getting COVID 19. But he consumed food in the same quantities as he used to take as a manual labourer. In addition to this he also had snacks in between and recently he came for abdominal distension and dyspepsia which was due visceral adiposity and fatty liver with NASH. All due to the excess intake of carbohydrates coupled with absence of vegetables consumption and no physical activity. He would have been more vulnerable, had he got covid 19 infection during that period.

The point I am trying to make is that unless we study the patient, we will never know what the patient is suffering from. It is not enough to know that the patient was tested positive for Covid 19. If we study the patient (body, mind, diet, lifestyle and environment), we will get the answer to the cause of the symptoms. It may not have anything to do with covid at all. Covid-19 positive often is an incidentaloma. Doctors are to console always, comfort often and to cure the disease when possible. Post covid syndrome often is an issue generated by the people who do not have a holistic approach and even dangerous lack of common sense. It is true, like any other viral infection, Covid also could cause some residual organ damage, that too due to multiple other confounding factors peculiar to that patient not due to Covid alone. If at all genuinely there is something, it is a very rare event, just because 90% do not even have any symptoms, and hence it is not worth informing the public and frightening them further. The symptoms in any patient, even during the active disease, or after recovery, are due to multiple other factors, as in the patient described before. The problem of post-covid syndrome often is the outcome of single system specialists directly accepting and evaluating patients without a proper referral and focusing on each organ and trying to pin the cause of a symptom as due to the virus.

Doctors should stop the practice of generating panic in the public. For this to happen, even among the clinicians, those who do not have the generalist mindset should stop advising the society on Covid management. To avoid such wrongs from happening, we should encourage and popularise the family doctors and should put in place a strong referral system. If someone calls themselves as a consultant, they should accept only referred cases. Only generalist doctors should be enabled to accept patients directly without a referral, since they alone are competent to evaluate the patients coming with undifferentiated problems. Nevertheless, I should tell my doctor-friends that the fear of Covid never made me stop working, in spite of the guidelines preventing me due to my chronological age (but as always, I saw only referred patients).

REFERENCES

1. Jemsheena P, Sasidharan PK. Management of Non-alcoholic fatty liver disease with diet and lifestyle modification. Annals of Clinical Medicine and Research. 2020; 1(2):1009.
2. Smrithy D, Sasidharan PK. Diet and Lifestyle to prevent, control or reverse type 2 Diabetes. Annals of Clinical Medicine and Research. 2020; 1(3):1013.
3. Sasidharan PK. Vitamin D deficiency causes and solutions. Journal of Family Medicine Forecast. 2018; 1:1008.
4. Sasidharan PK. B12 deficiency in India, Archives of Medicine and Health Sciences. Wolters Kluwer. 2017.