Holistic approach to patient care in COVID-19: Need of an hour

Dear Editor,

SARS-CoV-2 is the causative agent of respiratory tract illness, termed as COVID-19. Neither the respiratory tract infections with coronavirus nor the outbreaks (even pandemics) due to coronavirus or any respiratory virus, for that matter, is a new concept.[1] The virus, however, due to its high transmissibility, undefined risk factors for severity initially, unpredictable course, and lack of directed antiviral therapy presented challenges in the management of disease as well as pandemic. Strategies like barrier precautions, social distancing, minimizing unnecessary healthcare contact, and telemedicine were deemed important and adopted. These strategies, how much desired or necessary, are having an unforeseen effect on patient care with regard to non-COVID conditions.[2,3,4]

We read with interest the editorial “Community-based palliative care during the COVID 19 pandemic” by Atreya et al., in which they have expressed their perspective on the impact of COVID-19 pandemic on palliative care delivery and opinion regarding management of the same.[5] We would like to highlight our concern on the negative impact of COVID-19 pandemic on acute care of coexisting conditions through three different case scenarios, which we faced, each one representing affected patient's clinical assessment, evaluation, and management.

Case 1 (Clinical assessment)

A 40-year-old male, known case of diabetes mellitus and hypertension, presented with complaints of low-grade fever, dry cough, and sore throat for five days and central chest pain (nonpleuritic) for three days. He was screened for SARS CoV-2 infection and was referred to our center for management after testing positive. On admission, he had persistent chest pain with pain in the left upper limb. On examination, he was hemodynamically stable; a general survey revealed cold and clammy left upper limb with the absence of peripheral pulses and weak peripheral pulses in bilateral lower limbs; the systemic examination was within normal limits. Further evaluation revealed features of evolved myocardial infarction in ECG and elevated Troponin I. Doppler ultrasonography revealed intraluminal contents with 90% luminal obstruction and minimal residual flow in the left subclavian artery suggestive of thrombus and atherosclerotic changes in bilateral common femoral arteries and popliteal arteries. Screening 2D ECHO did not reveal any intracardiac clots. He was immediately started on unfractionated heparin and referred to CTVS enabled center for further management and intervention.

Case 2 (Evaluation)

A 45-year-old male, chronic alcoholic, was brought to the hospital with complaints of low-grade fever, cough with expectoration, anorexia, and significant weight loss for four months and gradually progressive shortness of breath. He was referred to our center after testing positive for the SARS-CoV-2 RT-PCR test. On admission, he was in a cachectic state (BMI-10.5), his vitals were GCS–15, PR-120/min, BP-100/60 mmHg, SpO2-80% on room air. Initial investigations revealed severe anemia, thrombocytopenia, hypoalbuminemia, and deranged kidney function tests. Further chest radiograph revealed bilateral diffuse infiltrates, and ultrasonography revealed ileocecal thickening and abdominal lymphadenopathy, overall findings suggestive of disseminated tuberculosis (TB). Following sputum collection collected for bacterial culture, influenza RT PCR, and TB (CBNAAT), he was started on antibiotic therapy with treatment specific to COVID-19, empirical antitubercular therapy, oxygen supplementation, and other supportive therapy. However, the patient succumbed to suspected disseminated tuberculosis, malnourished state, and COVID coinfection.

Case 3 (Management)

A 25-year-old male, without any comorbidities, presented to emergency with an alleged history of a road traffic accident and complaints of pain and swelling in the right thigh and right index finger. He also had complaints of a sore throat for five days. He was screened for SARS-CoV-2 and was referred to our facility after testing positive for the same. On presentation, he was hemodynamically stable; a note of tender, swollen area around mid-right thigh and right index finger was made. Further evaluation revealed a displaced fracture of the right femoral shaft and base of the distal phalanx of the index finger. The patient was referred to the trauma center for definitive management.

In the above scenarios, Patient 1 and 3 had mild symptoms of COVID-19 and presented to healthcare due to unrelated causes. However, in Patient 2, coexistent disseminated TB confounded the clinical categorization of COVID-19 to severe illness. All the cases had one or the other condition leading to their hospital visit. However, due to concurrent SARS-CoV-2 RT-PCR positivity, the management of COVID-19 was considered a priority despite the fact that all cases had mild COVID illness (not requiring any COVID specific treatment). This led to inadequate clinical assessment and evaluation at first healthcare contact in the first two cases and delayed management of fracture in the last case, overall affecting the morbidity in 2 cases and leading to mortality in 1 case, which could have been prevented, had the evaluation and management started early.

These cases highlight the importance of a holistic approach to patient care and utmost consideration to coexistent lung conditions or respiratory tract coinfections such as TB.[6] Pandemic like scenarios demand strict adherence to protocol and guidelines pertaining to precautions (for infection control); however, maintaining clinical competency and focusing on the management of non-COVID illnesses is equally important and indispensable.

To conclude, the restoration of the functioning of healthcare services to the norm is very much desired. Till that time, it is crucial to individualize the management, prioritizing it based on the clinical nature of either disease COVID or coexisting non-COVID condition and balancing the risk of infection as well as any intervention (medical or surgical) to possible benefits on overall clinical outcome in a given patient.[7]

Written informed consent was taken from the patient/relatives.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.