COVID prolongs transplant surgeries, leaving critical patients in the lurch

On a mundane afternoon in 2016, Kolkata resident Sohini Basu (name changed) suddenly felt trapped and was unable to move at all. Sitting upright on a ‘divan’, she struggled to bend even a finger as her heart began to beat at an unusually fast rate. Having a history of cardiac ailments, Ms Basu had experienced minor episodes of rapid heart rate before, but this was different and much worse.

“I felt like being choked by thin air. It was hard to breathe and the ‘divan’, on which I was sitting, seemed to be shaking though it was my body that was trembling. I was rushed to a big and reputed private hospital where the doctors found that my heart was beating at the rate of 232 beats per minute,” said Ms Basu, who was just 10 minutes away from death.

In 2010, the 55-year-old was diagnosed with dilated cardiomyopathy (DCM), a condition that makes it difficult for heart muscles to pump blood to the rest of the body. The disease is chronic with no lasting cure. After about a decade of consulting doctors, a device called implantable cardioverter-defibrillator (ICD) was planted inside her chest to monitor chaotic heart rates and she was advised to undergo a heart transplant.

Ms Basu was put under the care of Kolkata Medical College, the premier government hospital in the city, because that’s where organ donations cases are usually first referred to. Besides, it made sense to go to government hospital because her family couldn’t bear the cost of prolonged treatment at a private hospital.

In 2019, Basu was enlisted on the Regional Organ and Tissue Transplant Organisation (ROTTO) list and by early 2020, she had climbed to the second spot, very close to finally getting her surgery scheduled. But that’s when COVID stuck and Kolkata Medical College, like most premier hospitals, responded to the global emergency by turning itself into a COVID-only hospital.

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Two years hence, Kolkata Medical College is still largely a COVID-only hospital and patients, like Basu, with terminal maladies, remain uncertain of their future.

“We recently had to shut our department again after a few patients contracted COVID. It is very difficult to do other such operations in a COVID hospital. Transplant patients are at a higher risk since they’re immunosuppressed and prone to infection,” said Dr Prakash Sanki, head of the Cardiothoracic and Vascular Surgery (CTVS) department at Kolkata Medical College.

On the pandemic’s impact on transplant patients, Dr Sanki said, “The prolonged wait has had obvious adverse effects on these patients, but currently we aren’t even aware of how they’re doing, barring one or two. We would have been more certain had they been admitted, but as of now, we aren’t sure when the department will reopen.”

Presently, due to the Omicron variant’s low mortality rate, many public health policymakers and virologists are suggesting it is time that India takes a look at prioritising other diseases, especially the near-fatal ones.

Virologist Dr Amitava Nandy said, “The new variants of COVID are very mild and almost non-fatal. And there is a chance that a patient admitted to a hospital for surgery might end up contracting COVID. But nosocomial or hospital-acquired infections aren’t new. We have seen multiple cases of that in the past decade. COVID is just another addition to it. But that shouldn’t mean we stop treating patients with other serious diseases.”

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“Despite the risk, it is expected of the hospital staff to take utmost precaution in making sure a patient doesn’t fall fatally ill to nosocomial infection. Every hospital nowadays has an infection control committee precisely for this,” Dr Nandy added.

Epidemiologist Dr Tanmoy Mahapatra believes that given the current infrastructure and rationalisation of the healthcare system, there is no need for COVID-only hospitals to keep other patients waiting. “Even though it’s true that COVID is complicating the situation more than it should, by waiting we are losing the right time to treat patients with chronic diseases like cancer or a cardiology illness,” he said.

Dr Mahapatra suggests that all hospitals should create separate sections for COVID and non-COVID patients. “Treatment should commence assuming the patient may or may not be COVID-infected. The moment a COVID-positive patient turns negative, the patient should be transferred to the non-COVID ward,” said Dr Mahapatra.

“The government has reasons for classifying hospitals as COVID and non-COVID. Due a lot of doctors succumbed to the pandemic, coupled with lack of physicians, the government doesn’t have enough working doctors to manage the entire medical system. But this information isn’t well-circulated among people, which leads to a lot of confusion,” said Dr Mahapatra. He added that they’ve now reached the stage where all hospitals can function as general hospitals.

The idea of having separate sections for COVID and non-COVID patients, which Dr Mahapatra talked about, is exactly what Seth Sukhlal Karnani Memorial Hospital (SSKM) has done with their COVID-annex Sambhunath Pandit Hospital. The hospital had conducted two successful heart transplant surgeries during the pandemic — on December 9, 2020 and September 25, 2021.

Transplant surgeon Dr Shilpa Basu Roy said that proper COVID screening of the donor as well as the recipient must be done. There are two kinds of donors: live and deceased. Live donors are members of the patient’s family, and these surgeries are pre-planned. Deceased donors, on the other hand, have no blood relations with the patient, and these are emergency surgeries. In the latter’s case, protocols need to be followed to ensure the organ donating patient, after being declared brain dead, is not COVID positive.

For instance, in the heart transplant surgery conducted at Seth Sukhlal Karnani Memorial Hospital in 2020, two recipients had come to the hospital for operation. However, one of them turned out to be COVID positive and was sent home. The second patient was selected for surgery.

“One of the aspects that is unique to the pandemic is that RT-PCR tests are now mandatory before any surgery. After a transplant surgery is done, the patient is given high doses of immunosuppressants. So, if the donor was COVID-positive, the immunosuppressive recipient would also contract the virus and the infection may flare-up, which could prove fatal,” said Dr Shilpa Basu Roy, who said, adding that another challenge that emerged during the pandemic was that many transplant patients weren’t able to reach the hospital at night due to curfews from 11pm to 5am. “When we get a donor, we usually notify the recipients. But some of them aren’t able to make it to the hospital due to the lack of transport. This is a pertinent issue that persists even to this day,” Dr Basu Roy said.

“Being a transplant surgeon, I would suggest that such operations should not be kept on hold. A patient in need of an organ transplant is in the terminal stage where the transplant is the only option for survival. So, these operations must go on and proper precautions must be taken by the hospital staff,” said the doctor.

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The hospital also needs to follow up with their patients long after the transplant surgery is done. They need to make sure that the patient follows COVID protocol like wearing masks and avoiding crowds. If these immunosuppressive patients end up contracting COVID, the virus might flare up, potentially killing the patient.

Dr Basu Roy is also part of the Seth Sukhlal Karnani Memorial Hospital’s team that conducts live kidney transplants every Tuesday.

Sohini Basu was shifted from Kolkata Medical College to the Seth Sukhlal Karnani Memorial Hospital recently. “Once all the proceedings are done, I’m hoping the surgery happens soon because the pain can become unbearable at times,” she said.