TB patients’ struggle for ICU bed is real, unfortunate

Mumbai: On August 23 morning, Mansi Bhagat, 44, suffering from multidrug-resistant tuberculosis (MDR-TB), died at Asian Institute of Medical Sciences (AIMS), Dombivli, about 45 kms away from the city, to where her Prabhadevi-based family had taken her to get an ICU bed.

The Bhagats were made to go from one hospital to the other in Mumbai before Mansi became yet another casualty of the country’s financial capital’s woefully inadequate preparedness to deal with TB.

Mansi, who ran a small-time fashion designing business from her Prabhadevi home, was admitted to the state-run Sir JJ Hospital-Byculla on August 18 with breathlessness, low-grade fever, and cough.

Manish, 50, her husband said a day before her admission to JJ Hospital, they found her test reports positive for MDR-TB.

“We had initially admitted her to a local hospital but had to transfer her to Sir JJ Hospital for further treatment. All the required tests were done, and she was about to start on the MDR-TB treatment from August 20 but that’s when her condition started deteriorating,” said Manish.

With her oxygen saturation level dipping, doctors from the hospital’s pulmonary medicine department advised that she be shifted to the intensive care unit (ICU) for critical care management.

“That’s where our ordeal began. The pulmonary medicine department doctors had suspected her to have type II respiratory failure and asked for ICU admission. But the hospital’s ICU in-charge said she can’t shift Mansi to ICU because of her MDR-TB positive status. She said it would mean risking other patients,” said Rohan Vartak, Mansi’s brother.

While the ICU in-charge allegedly repeatedly refused an ICU bed for Mansi, doctors in the ward kept her on a Bipap machine, which supplies pressurised air into the airways for positive pressure ventilation.

Vartak said doctors suspected acute respiratory distress syndrome (ARDS) — a life-threatening lung injury that allows fluid to leak into the lungs-and will need ICU management.

“We tried all ways to convince the ICU-in charge but then started to check other hospitals in Mumbai including private hospitals,” he said.

In the next 24-hours, Mansi’s family checked with at least five hospitals including the Group of Tuberculosis Hospitals (GTB Hospitals) in Sewri (popularly known as Sewri TB Hospital) run by the Brihanmumbai Municipal Corporation (BMC).

“None of the hospitals agreed to admit her because of the MDR-TB status. We were shocked that Sewri TB Hospital, which is Asia’s largest TB hospital, didn’t have an ICU bed. They told us they send their patients to KEM Hospital in Parel or LTMG Sion Hospital,” said Vartak.

Failing to get an ICU bed in Mumbai, the Bhagats finally found a ray of hope in AIMS, Dombivli, and took DAMA (discharge against medical advice) from JJ Hospital and shifted her August 21 evening. She died on August 23rd.

“If she had got the ICU bed and critical care management started early, she would have perhaps been alive,” said Vartak.

“When we were struggling to get an ICU bed at JJ Hospital, we got to know there were many TB patients’ families who had previously suffered the same agony.

“It is shocking that a city like Mumbai has no ICU facility for TB patients, especially when we have just dealt with the Covid-19 pandemic. We had to travel 45-kms out of the city to get my sister an ICU bed,” said Vartak.

Dr Pallavi Saple, dean of Sir JJ Hospitals, said they do not turn down any patients if the ICU beds are full.

“We keep them in the general ward and do what is best till the time something can be managed. ICU demand is high in general and ICU patients are immunocompromised. With an MDR-TB patient, the risk of other patients in the ICU contracting it increases,” said Dr Saple.

“We are planning to put forward a proposal for an ICU with negative pressure and positive pressure ICU room which will be helpful for patients with such highly infectious diseases,” added Dr Saple.

‘Sewri TB Hosptial has only two ICU beds, but under repair’

GTB Hospitals - Asia’s largest TB hospital, was inaugurated in 1942 and has 1,000 beds. At any given point, it has more than 800-bed occupancy. Three months ago, the hospital’s 300 beds were given away to KEM Hospital to treat non-TB patients. This, after six wards in KEM hospital went for repairs. At present, GTB Hospital has 500 TB patients admitted.

The two-bed ICU at GTB Hospitals is said to be under repair and will be functional with an additional eight beds within a month.

“We are planning to start 10 bed ICU but struggling to get human resources, especially intensivists. For the dedicated ICU facility, we will need a dedicated team of healthcare professionals too,” said a senior BMC health official.

“These patients require a high flow of oxygen. We send them to KEM Hospital. When they stabilise, the patient is moved back to the facility,” said the official.

Doctors said the most common indication for TB-related ICU admission is acute respiratory failure due to pneumonia or ARDS. As per medical literature, up to 3% of all patients with TB require ICU admission, a high proportion considering the availability of curative treatment.

Dr Lalitkumar Anande, respiratory medicine specialist and former medical superintendent of GTB Hospitals, said, “Pulmonary tuberculosis presenting as ARDS is a rare phenomenon, but it is the most common cause of admitting TB patients to the ICU.

Drawing parallels between Covid-19 and TB, although the latter is an ancient infection, Anande said, “Like Covid-19, TB too is an air-borne disease. Whether it is the use of N-95 mask, quarantine requirement, loneliness in the ward, lonely death, X-Rays and C-Scans showing lung fibrosis, everything is so similar.

“If we could manage Covid-19, why not TB? Why can’t we have a good ICU facility at Sewri TB Hospital? Why should patients like Mansi suffer and die?” asked Dr Anande.

Dr Lancelot Pinto, pulmonologist and epidemiologist consultant at PD Hinduja Hospital-Mahim, said the struggle to get an ICU bed for TB patients is real.

“Our hospital sees the highest number of TB patients in the private sector. There have been times when we have struggled to get an ICU bed for our TB patient because our isolation beds are full. We call other hospitals for help,” he said.

He said most hospitals in the private sector have one or two isolation beds and often the same number of isolation ICU beds.

“There is competition for these beds too as they are also being used for other respiratory infectious diseases like Covid-19, H3N2, Swine Flu. So, any disease which needs isolation, will end up in these earmarked isolation beds at the hospitals,” said Dr Pinto.

He said a dedicated TB Hospital should definitely have an ICU set-up as do other public hospitals as very often patients come in the advanced stage.

“In private hospitals, patients still come in at an early stage and may not require ICU. But, in the public sector, there is a requirement. Mumbai is a high endemic zone for TB. If you want to serve all your patients, you need to have a dedicated ICU facility too,” said Dr Pinto.

Ganesh Acharya, TB survivor and TB activist, said he receives at least five to six calls in a month from patients pleading for ICU beds.

“TB is still not given priority in public hospitals. It’s ironical that in Mumbai, which is home to Asia’s largest TB Hospital, a TB patient couldn’t find an ICU bed and died,” said Acharya.

Back at Mansi’s home, her 19-year-old daughter Durva, son Atharva, 15, alongwith her brother and mother, Manish said no other family should lose their loved one like they did.

“A week before her death, she was fine. Our world turned upside down with her being detected with MDR-TB followed by struggle to get her an ICU bed. The government should do something at the earliest so that no other Mansi dies,” Manish said.