Dr. Anjan Kumar Basnet
On the fifth day of home-based telemedicine care in Dang, at around 10 pm, I was completing the patients' charts and planning to call it a day. Just then, I received a call. "My cough is getting worse, and I have difficulty in breathing," a male voice said in a very anxious tone. I immediately understood it was an emergent situation after I asked some relevant history. I provided the list of local hospitals and advised Abdul Miya (name changed) immediately to go to the nearby hospital. As he was headed to the hospital, different questions came to my mind: how long will it take for him to reach the hospital? Will he be able to make it in time? I waited for his call anxiously. But even after an hour, I did not get any response. I could no longer wait, so I called Abdul myself. I was relieved to know he was in the hospital waiting for a bed in the emergency room. He described the hospital scene where many patients were waiting for their turn to be seen at the emergency department. Some had been waiting for as long as 6 hours! There was a massive surge of Covid cases in hospitals in Nepal due to the rapid peak in the second wave. Oxygen was rationed because of the shortage of supply. Later, Abdul called and told me he did not qualify for oxygen supplementation and hospital admission despite having oxygen saturation at 90%; many patients were much sicker than him. So, he was given a COVID test and sent home with some prescriptions to continue care at home. In any normal situation, COVID patients with an oxygen level of less than 94% should be on oxygen therapy. Undoubtedly, the Covid pandemic had critically stressed the healthcare system, and many patients were turned down.
I went to bed past midnight and tried to get some sleep. But it was not easy, and I was constantly tossing and turning around. For the first time, the sound of the clock on my wall bothered me. I was visibly shaken by the current events, very sick patients, distraught families, and overwhelmed hospitals that could not accommodate and treat more patients. I wondered about Abdul, a patient with probable Covid pneumonia who was sent home from the emergency room due to a lack of hospital resources. Will he recover at home?
Abdul had developed weakness and cough for some days, but he continued to go to work to earn some money and feed his family. When he felt sick, he went to a local pharmacy and asked about the Covid test, but he was told that it was not available in any nearby facilities. Instead, he was given antibiotics for Typhoid fever which was highly prevalent as well. He thought he would improve with the expensive antibiotics he bought. In Nepal, antibiotics use is not restricted and is often available to buy at a pharmacy shop without a prescription. As a result, many people first try medication from a local pharmacy and visit hospitals and clinics only in a later and advanced stage of illness.
I called Abdul the next day and found out he was slightly better with the medicines prescribed by the hospital. I counseled Abdul on treatment measures, admitted him to a home hospital care program so that the treatment team would follow him regularly. As expected, his PCR result also came positive for Covid. On the 4th day of home isolation, his breathing worsened again, and the oximeter showed oxygen saturation readings around 80%. I asked to recheck with another oximeter which also showed similar low readings. I advised Abdul to go to a hospital for oxygen therapy because he could develop severe symptoms and even die. But he refused because of the poor experience he had during the last time he visited the hospital. My only option was to treat him at home with home oxygen. I prescribed steroids and antibiotics and called some suppliers for home oxygen. While there was an oxygen shortage nationally, finding home oxygen proved to be a mighty task. All the suppliers turned down my request, and I could not arrange home oxygen for Abdul. Over the next couple of days, with steroids and antibiotics, his oxygen level started to rise, and it reached 90%; the following week, it got to a normal level. I could finally take a sigh of relief. After he recovered, on the tenth day, I discharged him from home-based telemedicine care. After two weeks of the discharge, Abdul called me and expressed his gratitude for taking care of him. I was pleased and emotional at the same time. As a doctor, I have realized, I do not need big occasions to celebrate. Small things such as observing your patient recovering and receiving a thank you message from a family give us the reasons to be happy and motivated.
The overall experience of working with Covid patients has been an exciting journey. Each day, I talked with patients and their caregivers, sharing their pain and joys. Some inquired about general information regarding the Covid and PCR tests, while some were sick due to moderate or severe cases of Covid in need of immediate management. Every time my phone rang, be it during the day or night, I knew I had to be ready for everything. They not only shared their story of illness but also stories of their lives. I was connecting with my patients only virtually. However, I built a good rapport with many patients and their caregivers. The strong bond we shared and the relation we developed was very crucial in providing care remotely through telemedicine. In a developing country like Nepal, it is challenging to provide quality care to the patients at home because of a lack of adequate resources in the community. I believe that patients understood the gravity of the situation and resource constraints the Covid pandemic had created. So, everyone was very welcoming of our efforts to reach out to them to provide care at home. I now understand empathy is a crucial aspect of patient care, sometimes more powerful than any medicine. Working as a volunteer, I had an opportunity to experience the pandemic through patients and families. The learnings and success of the telemedicine project would not have been easy without solid support from peers and guidance from mentors, for which I am very grateful. This experience, I believe, has helped me become a better-rounded physician and a more humble person.
Dr. Anjan Kumar Basnet
Tulsipur, Dang, Nepal