Diary of a small town Neurologist

COVID-19 is perhaps the greatest disaster of all time, reported as a cluster of forty odd cases from Wuhan, China in December 2019 which culminated into a pandemic by March 2020, as declared by the WHO.  And we were at war with an invisible enemy who was clever and powerful and was spreading at meteoric pace and only way to survive was to confine and conceal ourselves until we knew how to combat. With that came life to a screeching halt with its tangible repercussions on just everything around.

Healthcare arena also got changed dramatically with entire focus being shifted towards combating COVID-19, and perhaps rightly so but very rapidly it consumed most of the healthcare resources, leaving little for the Non-COVID patients. With the surge of second wave, the conditions got further worsened with literally no bed left for non-COVID emergencies like Acute Stroke, Status Epilepticus, Traumatic Brain Injuries, Severe Neuroimmunological conditions, Acute Myocardial Infarction etc. adding woes to the already suffering humanity. And smaller cities are rather badly hit. What pains me more is lack of preparedness and dearth of planning as how to overcome this situation.

 In the current prevailing situation, as a Neurologist, I have following points to highlight with regards to Organization of care, Management of neurological disorders/symptoms, Management of neurological complications arising out of COVID-19 infections and Considerations for patients with chronic neurological conditions based on consensus statements of various scientific bodies:

Points to ponder regarding Organization of care

This is high time we realize that need for non COVID care is as much, if not more, as COVID care. This reminds me of a famous quote by Charles E. Hummel from Tyranny of the urgent“Your greatest disaster is letting the urgent things crowd out the important.”
Hence unlike before, now we should focus on starting and further strengthening non-COVID hospitals/facilities/wings for non-COVID emergencies where standardized treatment for various neurological/neurosurgical emergencies could be started without delay while taking due care to prevent contamination or spread of infections.

Teleconsultation should be encouraged for routine patients not requiring admission; however, those patients who may require in person consultation should be picked up from there and advised accordingly.

Postpone all elective EEG/EMG/imaging investigations unless urgent and likely to impact clinical decision making and treatment plans and contamination prevention guidelines must be adhered to if at all it’s necessary.

Special management issues

Acute Stroke is a time sensitive neurological condition therefore properly selected patients of acute ischemic stroke should receive IV thrombolysis/ endovascular treatment in timely fashion.

Treatment of Convulsive Status Epilepticus shoud receive top urgent priority as per recent ILAE guidelines.

While using Cell depleting therapy (Rituximab, Ocrelizumzb, Alemtuzumab etc.) for neuroimmunological conditions, risk-benefit ratio must be properly weighed against each other as they increase susceptibility to contract infection for several months after infusion.

Regarding use of IVMPS/IVIG/PLEX, though they do not pose any additional risk yet should not be started if there are signs of active infection

Neurological complications arising out of COVID 19 infection

We should also be mindful that severe neurological complications can occur in COVID-19 patients during hospitalisation, such as Seizures, Encephalopathy, Encephalitis and Cerebrovascular events including Ischaemic Stroke or Intracerebral Haemorrhage.

Prolonged ICU admission may cause development of Multifactorial Encephalopathy, Critical Illness Neuropathy and Myopathy.

 Post ICU-care syndrome develop in ICU-survivors in the form of cognitive impairment, psychiatric and/or physical disability.

There may be a higher risk of sub acute neurological complications, including GBS and other autoimmune diseases such as Necrotizing Encephalitis following COVID-19 infection.

Therefore, Neurologists must be kept in the loop while treating COVID-19 patients to detect and treat neurological symptoms and disorders at the earliest.

Care for patients with chronic neurological disorders is specially challenging

Patients on immunosuppressive medications should practice extra vigilant social distancing, including avoiding public gatherings/crowds and avoiding crowded public transport etc.

Patients of Parkinson’s disease may be particularly vulnerable to respiratory infections or pneumonia due to limited respiratory capacity related to reduced mobility of their thoracic cage. Therefore, it is important to counsel such patients to undertake all precautions for reducing exposure risk.

Epileptic patients may have drug–drug interactions between antiepileptic drugs (AEDs) and newer treatment options for COVID-19 including antiviral, immunomodulatory and immunosuppressive drugs. Hence, dose adjustments of AEDs or COVID-19 treatment might be necessary

Besides above specific measures, COVID-appropriate behaviours are the keys in keeping pandemic at bay. 

              There are many diseases but, in a sense, there is just one health. STAY SAFE!

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