Dr. Hari Neupane, Physician, Dang, Nepal
Govinda, a 35-year-old male with PCR positive COVID-19 contacted us on the tenth day of his illness due to continuous high fever. His head was burning with 102 degrees Fahrenheit temperature, his throat was hoarse due to a persistent cough. He could not sleep at night due to severe shortness of breath. Getting up to go to the bathroom was an ordeal due to generalized body ache and weakness. He had lost his sense of smell and taste; his appetite was poor and he was hardly able to eat a mouthful of rice. In addition to his physical illness, he was very stressed and anxious which made his condition even worse. When he called me, he was severely ill and in very poor shape, so I wanted to transfer him to a hospital immediately.
The whole nation was gripped with crisis, the situation in Dang was horrible due to a severe scarcity of beds and oxygen in hospitals. Govinda was not able to get a hospital bed and was left alone at home to suffer. Earlier, once he was diagnosed with COVID, he had gone to a local pharmacy and was given loads of medicines, some of which were of doubtful benefit. After reviewing his case, I explained to him the natural course of COVID-19 along with its treatment. I counseled him on home isolation techniques, sleeping positions, and breathing techniques. He was a known case of hypothyroidism and was taking thyroid supplements daily which he had stopped taking after he got sick with COVID. This put him at an increased risk so I asked him to resume the hormonal supplement and discontinue the inappropriate medications. He managed to borrow a pulse oximeter from his neighbor and his saturation was found to be very low, only 85% on room air. Therefore, I advised his wife to arrange for home oxygen immediately.
Oxygen was short in supply. Along with him, his elder brother and sister who lived nearby were also affected by the disease and needed home oxygen. Oxygen cylinders, which they were able to manage with much difficulty, were barely adequate. As oxygen supply ran out quickly and it was difficult to fill the tanks, they were forced to use a minimum amount of oxygen to keep the oxygen supply last longer.
Although Govinda was started on treatment with oxygen and steroids, he was continuously having shortness of breath and was unable to get out of the bed without help. With 2-3 liters of supplemental oxygen via nasal cannula, his saturation reached up to 91%, but without oxygen support, it dropped to the 80s. Meanwhile, a salbutamol inhaler, which is supposed to help in opening up airways, did not provide much relief to his shortness of breath.
Due to his worsening clinical condition, I wanted to run a couple of investigations on him. Going out for any type of test was very difficult. Finally, with some help, he was able to get a chest X-ray done on the seventh day which showed severe bilateral pneumonia. With this severe disease, his chance of getting better at home was slim.
Fortunately, on the fourteenth day of illness, his family was able to manage a bed in a hospital about 150 km away from his hometown and was transferred there. In the hospital, he got a CT scan which revealed severe lung damage. His liver was affected as well and liver enzymes were elevated. Along with continuous oxygen supplementation, he received intravenous antibiotics, steroids, and anticoagulant therapy. Slowly, he recovered, and finally, he was discharged from the hospital after a week. Although physically weak, his spirit was high after he won the battle.
B.1.617 variant of SARS CoV-2, which is also known as the Indian variant, caused the second wave of infection in India and its neighboring country Nepal. This mutant virus which was first detected in India in December 2020, spread rapidly and widely to become the dominant variant. In Nepal, during the last peak of the second wave in April and May, there was a huge surge of newly diagnosed COVID cases. On April 5, 2021, the daily census of new cases was just 266 which increased dramatically to 8606 on May 5, 2021. Nepal was not well prepared to handle the second wave and hence with a rapid rise in cases, the healthcare system was fully paralyzed. Unavailability of hospital beds, medical equipment, and adequate oxygen supply to the hospital claimed many lives during the early phase of the second wave of COVID-19.
Due to rapidly increasing cases of COVID-19, thousands of patients with mild to moderate symptoms were not able to get beds in hospitals and had to stay at home in isolation during their illness. They were not only deprived of hospital care but also could not even see a physician, get prescriptions for medicines, and even accurate information about the illness and treatment measures. To provide care to those patients and reduce pressure on hospitals, a team of physicians at Health Foundation Nepal, a non-profit organization working in Dang, started telemedicine service.
Telemedicine team coordinated with local governments to identify newly positive COVID cases and called them through the telephone. At first, some expressed disbelief as physicians had never reached them in the past asking about their health. But, slowly they agreed to virtual physician visits and thanked us for reaching out to them during difficult times. After interviewing patients, based on WHO severity guidelines, we triaged them and provided appropriate counseling, treatment, and support. People who needed follow up were enrolled in our care and monitored daily. We also sent prescriptions for medications and provided resources for the family to arrange for medical equipment and oxygen at home. Our team was available 24/7 which helped to reduce their anxiety and fear of being left out and alone. We also provided psychological support and counseling to people who had mental health problems due to the illness.
Providing hospital care at home was a new approach for Nepal. Before the pandemic, patients had to come to health centers to visit healthcare providers for service. Telemedicine was neither well developed nor widely used. However, during the pandemic, we were not knocking people on their doors but reaching out to them through the phone asking about their health and illnesses. As we approached them virtually, they did not have to open their front doors for us, but they welcomed us with their open hearts.
There were indeed numerous obstacles while providing service through telehealth. We reached out to people in rural areas through the phone and often used internet platforms to exchange information. Unfortunately, many people in remote locations did not have access to the internet and had only a little knowledge of its usage, thus, it was challenging to share pictures and prescriptions. However, we always found helping hands - some family or friends would come for rescue. Grandchildren would help their grandparents to connect with us. With technology solutions, we were able to provide our service effectively and safely while maintaining a safe distance.
In medical school, professors used to tell us - the soothing voice of a physician acts as medicine for a patient. I realized that this was even more important while providing care through telemedicine for patients with COVID who had very few treatment options. Because we provided our service via virtual platforms, it was quite difficult to establish a strong physician-patient relationship, thus, I needed more time and patience. Regardless, I was able to create a strong bond with my patients and their families who were very thankful for the service. This whole experience will always be very memorable and uplifting for me.