A doctor abruptly died in Assam on March 29, Sunday afternoon. Forty-four-year-old Utpaljit Barman, an anaesthesiologist at a private hospital in Guwahati, had consumed a 400-milligram dose of hydroxychloroquine about a week ago, his colleagues said.
Hydroxychloroquine, an anti-malarial drug, has been recommended by the Indian Council of Medical Research as preventive medicine for individuals at high risk of contracting Covid-19, the disease caused by the novel coronavirus. This includes “asymptomatic healthcare workers involved in the care of suspected or confirmed cases of COVID-19” and “asymptomatic household contacts of laboratory confirmed cases”, guidelines released by the ICMR on March 22 said.
There were no Covid-19 patients admitted to the Guwahati hospital where Barman worked. It is unclear what prompted him to take the drug.
An ominous message
At 1.04 pm on Sunday afternoon, Barman sent a message to a group of his colleagues over WhatsApp. “HCQS is not very good as prophylaxis,” he wrote. “Lots of issues. I think I am having some problems after taking it.”
Less than two hours later, Barman’s wife, a trained nurse, called one of his colleagues, Anudhriti Dutta. She said Barman appeared to have suffered a heart attack.
As word spread, several of Barman’s colleagues reached his home within minutes. They summoned an ambulance to ferry him to another private hospital in the vicinity.
According to the medical records at the private hospital where he was declared dead barely twenty minutes after being brought in, he died of a “sudden cardiac arrest caused by acute coronary syndrome”. In other words: his heart stopped working, because blood supply to his heart muscle was suddenly blocked for some reason, mostly likely a heart attack.
But the hospital did not perform an electrocardiogram – a test used to check heart function which can pick up signs of a heart attack or any other heart-related irregularities. The hospital did not conduct an autopsy either.
Doubts over the cause of death
In the absence of an autopsy or an electrocardiogram, doctors say it is difficult to attribute cardiac arrest to a specific condition with certainty. “Cause of death – whether it was a heart attack or whatever – can be ascertained through an autopsy,” said Pranab Jyoti Bhattacharyya, a cardiologist at the government-run Gauhati Medical College and Hospital.
An autopsy was not conducted as it was a treated as a case of natural death, said a spokesperson of GNRC Hospital where Barman was declared dead. The cause of his death was ascertained on the basis of “case history”, said the spokesperson of GNRC Hospital. “He was almost brought dead, there was no time to do any tests.”
Barman, according to his colleagues, was mildly hypertensive. “He did take some mild medicines for it, but it was under control,” said his colleague Anudhriti Dutta. Barman had never complained of chest pain or any other heart-disease related symptoms, she added.
“We are like family here,” Dutta said. “If someone is really hypertensive, we discuss it. [Barman’s condition] was not something that merited discussion even.” Hypertension is a known cause of heart disease.
According to Barman’s colleagues at Pratiksha Hospital, it was a classic case of a sudden massive heart attack. “The symptoms that the doctors saw on arrival were that of an acute MI [myocardial infarction] or what is called a heart attack,” said Nirmal Kumar Hazarika, medical superintendent at the Pratiksha Hospital where Barman was employed at.
HCQ and arrhythmia
In several quarters, Barman’s sudden death has led to the speculation over whether it was connected to his consumption of hydroxychloroquine. Doctors say that there is scant evidence to authoritatively answer that. Even if a postmortem was done, it would have only revealed the cause of death, but not what led to it.
Dutta said: “It is only the media which is connecting it to [HCQ consumption]. None of us think it has anything to do with one single dose of the medicine which he had a week back.”
Amith Viswanath, a doctor of medicine in Puducherry, said heart attacks were not one of the known side effects of hydroxychloroquine. The drug could, however, lead to arrhythmia: irregular beating of the heart, either too fast or too slow.
That is why, Viswanath said, medial protocol required patients on hydroxychloroquine to undergo regular ECGs.
Cardiologist Bhattacharya agreed. “This drug has some arrhythmic effects, so it is ideal to do ECGs while consuming it,” he said.
How does an arrhythmia manifest? “It could lead to the heart coming to a standstill – that is what you call a cardiac arrest,” said Bhattacharya.
A heart attack and an arrhythmic attack could have similar symptoms on occasions.
‘A death always makes you think twice ‘
The lack of clarity over the circumstances of Barman’s death has led to fresh questions about ICMR’s hydroxychloroquine recommendation – already a hotly contested subject in medical circles.
So far, many Indian medical workers seem to be consuming the drug as a precautionary measure, despite lack of solid evidence about its efficacy. However, many say that may change now after Barman’s death.
Sanjay Nagral, a surgeon at a private hospital in Mumbai where Covid-19 patients are being treated, said there was “a lot of confusion among doctors”. Yet many people consumed it to “play it safe”, he said. “Many people I know had started taking it thinking it was a routine anti-malarial drug, perhaps not quite aware of side effects even though they are doctors,” he said. “But after what happened in Assam, not too many people seem enthusiastic about it.”
A young doctor at the Guwahati Medical College said opinion on it had always been divided. “Some wanted to avoid, some did not,” he said. But he said the death of Barman may have made more people apprehensive. “A death always makes you think twice,” he said. “Of course, we don’t have a postmortem report. But linking the dots does make us believe it was a consequence of HCQ.”
Other doctors, however, seem to think it is their best bet. “From tomorrow onwards, we will start treating Covid patients, so we will have to have it,” said Faisal Khurshid, a doctor at the Sher-e-Kashmir Institute of Medical Sciences in Srinagar, Kashmir.
Even though ICMR’s HCQ recommendation is restricted to health workers who are directly involved in the treatment of suspected or confirmed cases of Covid-19, many doctors who are not attending to such patients are also consuming the drug.
Take for instance, Barman. He was not treating any Covid-19 patients. In fact, the hospital where he worked was not a designated Covid-19 hospital. So far, only one suspected patient, who subsequently tested negative, has been quarantined in the hospital’s isolation ward. According to the hospital superintendent Nirmal Kumar Hazarika, Barman was not part of the team that took care of the patient.
Besides, Assam reported its first confirmed case only on March 31.
Why did Barman then consume the drug? It turns out Barman was not the only one. Several doctors in the hospital, Hazarika said, had taken the drug.
Barman’s colleague Dutta said it was a precautionary measure. “Because he was attending to a lot of emergencies,” said Dutta. “We are an obstetrics hospital mainly, so there are always a lot of emergencies, so probably he was scared.”
No protection equipment
Doctors at Pratiksha Hospital are not the only ones to be having the drug without actually being high-risk as defined by the ICMR. “Most doctors in Kerala are taking it,” said Viswanath. “It’s mostly out of fear. They are not looking into evidence as such. They want something preventive.”
Some medical workers said they had no option as there isn’t enough personal protection equipment available and they “don’t know who we are dealing with”. “In an ideal situation, all health care professionals should receive N95 [masks] at the very minimum,” said a doctor at a government hospital in Madhya Pradesh. “But that probably won’t happen in another 20 years.”
This doctor said she was not yet directly involved in treating Covid-19 patients, but had taken a dose of the drug nonetheless. “I felt dizzy with first dose. So not taking it anymore,” she said.
A ‘demonstration’ study
The ICMR, for its part, has not yet issued a statement on Barman’s death. When asked about it at a press briefing on April 1, ICMR scientist R Gangakhedkar said HCQ was not meant to be used by everyone. “This is just a demonstration study for doctors and contacts of lab confirmed cases,” he said. “Only after data is collated from it will we able to decide whether to recommend it to general people or not.”
However, not everyone is convinced of the ICMR’s strategy. Dinesh Thakur, a drug-safety advocate, expressed shock at Gangakhedkar’s comment. “I know what an observational study is but this is the first time in my 21-tenure in drug development that I have heard of any study that is for ‘demonstration’,” he said. “There appear to be no ethical controls or oversight in what ICMR was saying today.”