What strikes you immediately on entering the intensive care unit at the Nesco Covid Field Hospital in Mumbai is the sharply elevated ambient sound. The incessant beeps from mechanical ventilators and cardiac monitors can leave you disoriented.
Studies have shown the noise levels in an ICU could go up to 83 decibels, more than double of the recommended level by the World Health Organisation. Prolonged exposure to these levels could have a negative impact on healthcare professionals, researchers say. Nurses are the most affected. While doctors go in and out of the ICUs, they stay within the confines from the start to the end of their 6-hour shift.
Inside the 12-bedded ICU Bay 2 at the field hospital, however, staff nurse Shahin Mujawar brushed aside these concerns. Patient monitor alarms need to be loud enough to be heard by the nurses taking care of them, she said. “It is essential for timely clinical intervention. Besides, we are used to it. It is only disconcerting the first few times.”
For the nursing workforce in India, dangerously overstretched by the pandemic, sensory overload has taken a backseat to other concerns.
India is a major supplier of nursing staff globally, but the nurse to patient ratio within the country is a poor 1:483. Inadequate even in pre-pandemic times, this ratio is now leading to a crushing work overload, captured in a survey of nurses in Maharashtra, done by the Support for Advocacy and Training to Health Initiatives in December 2020. Nurses from civic and medical college hospitals reported a nurse to patient ratio of 1:40-80 per shift. Some even said they handled upto 150 patients per shift. More than half the nurses surveyed also said they had worked without adequate safety gear.
The Nesco field hospital, with 2,000 beds, came up in Mumbai’s suburb of Goregaon in May. It is among the six jumbo facilities in the city established by municipal authorities to expand capacity at a time when the city was witnessing a surge in coronavirus cases.
Managed by the dean of the municipal-run Nair Dental Hospital, Dr Neelam Andrade, the facility has 487 nurses, allowing for a relatively healthy nurse to patient ratio. The facility has been able to recruit and retain nurses by offering a competitive remuneration of Rs 50,000 per month, higher than the average salary of Rs 13,000-35,000 in city hospitals.
Members of the nursing staff told this reporter that the raised salary, akin to a hardship allowance, made them feel valued. As did access to requisite safety gear, which is the bare minimum for frontline healthcare workers in a pandemic.
But the nurses had complaints about food and accommodation.
In May, 200 nurses had gone on a flash strike to protest the decision to shift them from an apartment building of the Maharashtra Housing and Area Development Authority in Goregaon to a school in neighbouring Dindoshi. The nurses, many from districts like Ratnagiri, Ahmednagar and Beed, were already living in cramped housing: five to ten of them shared a tiny apartment with a single bathroom. The proposed shift, they said, was to a facility similarly cramped, but worse, with no connectivity and no basic provision stores or eateries close by. In contrast, doctors working at Nesco have been put up at hotels.
The strike was withdrawn within hours after Dr Andrade convinced the nurses that all their concerns would be addressed promptly.
Sukhdev Singh, originally from Mathura, Uttar Pradesh, now a resident of Mumbai for the better part of the last decade, is a staff nurse incharge of one of the ICU bays at the Nesco Field Hospital. Singh points out that among healthcare workers, nurses are most at risk by virtue of being in closest contact with Covid-19 patients. Everyday duties in intensive care, for instance, involve cleaning the mouths of patients using chlorhexidine and gauze, suction of intubation tubes in mechanically ventilated patients to clear secretions, sponge baths and providing perineal care – the cleaning the private areas of a patient at least once a day, and multiple times if the patient suffers from incontinence.
“Having said that, it is part of the job, we are trained to do this,” said Singh. “What is tougher to deal with, particularly in the ICU, is the loss of hope among patients. It is compounded by the fact that they are cut off from their family. Ek tareeke se, yahan aane ke baad, unka ghar walon se rishta khatam ho jata hai.”
He contends that when a patient in the ICU witnesses the death of another – as they are bound to in Covid-19 ICUs, since multiple beds are stacked together in the bay with no partitions – it strikes terror in them. He recalls a conversation with a patient in his early 50s, admitted to the ICU in the last week of April. The man told Singh that his marriage anniversary was coming up on May 4 and asked if he didn’t make it, could the nurse call his wife and tell her that her husband wanted her to remember the many good years they had? “He died on May 3,” Singh said, choking on his words.
The unbearable loneliness of Covid, nurse Shahin Mujawar reflects, is only known to those who experience it or witness it at close quarters. “The only ones the patients meet, us, the nurses and doctors are indistinguishable in the PPE kits, faces barely visible,” she said.
Mujawar was inspired to take up nursing from the accounts she heard from her grandmother Miriam Shaikh, a nurse for over 30 years, who spoke of the satisfaction she got by helping comfort people when they are at their most vulnerable. “She used to get so attached to her patients.” Mujawar recalled. “I now know that first hand. When you have taken care of a patient for days and they die, you return home and get ready to sleep and images of that patient come up before your eyes. It doesn’t matter that you have been a nurse for many years. It doesn’t make you inure.”
“Covid has made it worse in some ways,” she added, quietly. “We also experience psychological distress.”
Nurses don’t just form the backbone of patient care in this Covid-19 facility. They are also responsible for maintaining inventory in the many stores across the field hospital. The stores stock medicines, syringes, and other medical paraphernalia. The nurses in charge of the stores ensure seamless supply as per requirement to the wards, the High Dependency Units, the Intensive Care Units and the vaccination centres. They liaise with the pharmacy to secure necessary supplies.
“I don’t recall there being a shortage of medicines,” said Suman Malwankar, nurse matron in charge of wards and stores. “Importantly we have never had to contend with oxygen shortage.”
“We would watch the news from Delhi in horror.” she continued. “We would talk amongst ourselves: ‘Imagine patients dying because we couldn’t give them oxygen while they were under our care. It is unconscionable.’”
As she helped set up a video call with a relative of a patient admitted to the ward, Malwankar echoed her colleagues’ thoughts on the special challenge thrown up Covid-19: patient anxiety.
“Clinical knowledge and competency is of course paramount, but we are dealing with patients, many of whom experience extreme anxiety in this alien environment,” she said. “We have to be good listeners, we have had to assume the role of family members at times.”
Malwankar said her most satisfying moment in recent memory was bonding with an elderly woman from an old age home who was admitted to her care. “We allow phones in wards, so most patients were getting calls from friends and relatives. She had nobody checking up on her.” Malwankar recalled. “We made sure she knew we cared. We would chat with her, motivate her. When she was discharged she was very emotional and said she will forever remember us in her duas (blessings).”
Sickness, Malvankar remarked, is the most intimate part of human experience, perhaps why bonds form so quickly between caregivers and patients. Even in death, the nurse forms a vital part of a dignified goodbye. Most deaths happen in the ICU. Nurses remove all tubes, catheters, disinfect any puncture wounds, plug orifices, clean the body and wrap it up before sending the body to the mortuary.
“Dealing with the physical and mental exhaustion, even burnout would be impossible without support from our families,” said Amruta Kambli, nurse matron in charge of all ICUs bays in the field hospital. Kambli’s husband, an animation compositor, works from home and has managed their daughter’s online schooling needs. “This is my second year caring for Covid patients. My daughter has grown so much in this time but she doesn’t resent my absence. She even proudly told her class that her mother takes care of Covid patients. Maaji aai ICU matron aahe,” Kambli beamed.
Dr Andrade, who took up the challenge of transforming what was essentially a bunch of open exhibition halls into a functional field hospital containing fully equipped ICUs in tertiary care mould in just a matter of a couple of months, admits the pressure has been relentless. The work never stops, even after she leaves the centre following a 13-hour shift. She has had to solicit contributions from corporates, issue tenders, negotiate with vendors and architects, hire doctors, nurses, ward boys and girls – the last task being particularly tough since the pandemic has led to an acute shortage of trained and experienced personnel.
Andrade said she had no existing template to bank on, so she created processes and put protocols in place. “There was a fear in me that I shouldn’t make mistakes, particularly in procurement. There wasn’t much clarity initially on how you go about doing it.” She brought along people known to be reliable and honest who she had worked with for the last two decades. “The audit team was with us for 45 days, going through all the paperwork.” she recalled. “I have passed the municipal audit with an appreciation for the processes I followed.”
But with the bouquets come the brickbats. Andrade doesn’t deflect criticism, instead acknowledges that keeping the mammoth facility running involves daily firefighting – like the strike by the nurses over accommodation or the matter of alleged inadequate sanitation facilities in the general wards. Earlier this year, Nesco also began serving as a vaccination centre, with around 5,000 people vaccinated here everyday.
Inside the vaccination enclosure, 27-year-old Priyanka Bangar, staff nurse, patiently explained the potential side effects following vaccination to a middle-aged man waiting to get his first dose. “It may seem repetitive, but we are mandated to explain this to every person we vaccinate,” she said. Each nurse here administers the vaccine to between 400-500 people daily. “We are bent over for most of the day, so our backs hurt.”
Bangar broke into laughter when asked about the kinds of questions she gets asked. “This morning an elderly man persistently asked me if this was really a Covid injection. He was convinced it was water in the vial and was furious he had been made to wait so long to get it,” she recounted. “Most people, though, just say thank you. They are really happy to have got access to a vaccine that will keep them safe.”
All photographs by Smitha Nair.