Dr. Anjan Kumar Basnet
Odyssey through a doctor's eyes
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
Dr. Hari Neupane, Physician, Dang, Nepal
The art of healing through 'words'
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.
Dr. Shila Neupane, MBBS, Sunsari, Nepal
Telemedicine - My reflection
It was an early morning on the 16th of May, my first day on Telemedicine duty, quite unlike other shifts where I would go to a clinic to see my patients. I was in my study room waiting for my patients. I turned on my laptop, I could hear the ticking of the clock on my wall. At exactly 7 am, my phone rang; it was an anxious male voice saying, "Hello doctor, my mother has been having difficulty in breathing since last night, now she is not even able to talk”. I was prepared for a difficult situation, but this sounded like an emergency. For a moment, there was total silence, I could hear my own breath. Finally, I recollected myself, and after a long pause, I was able to talk. He pleaded, "Please save my mother!" I reassured him and asked his name. He responded in a worried tone of voice - “My name is Ram and my mother, Sanumaya, is 68”. I enquired about Sanumaya and slowly was able to understand the detailed picture. “Okay, Ram, could you please check the oxygen saturation of your mother?” I said. After some time he came back and replied that it was 88%. With severely low oxygen saturation, possibly due to COVID pneumonia, I had to urgently find an ambulance and send her to the nearest hospital. I gave him a list of hospitals that took care of COVID patients. After an hour of frantic search, to Ram's dismay, he was unable to locate a hospital with an available bed. I then gave Ram a list of phone numbers of oxygen suppliers and sent him some prescriptions. Our only hope was to start her treatment at home until she gets a hospital bed. Sanumaya was subsequently kept in 2 liters of oxygen and was kept under close observation at home. I called Ram and followed her regularly. Eventually, she began to feel better; later that day, Ram was able to locate a hospital with a bed and transfer his mother. After few days, I called Ram; I could hear Sanumaya's low voice in the background. She grabbed the phone and began to talk to me, and for the first time, I could hear her voice, soft and shaky "I'm well, doctor, how are you? Thank you for your help." I took a deep breath and sighed with relief, "Oh, finally, she's getting better. All that effort and work helped save her life... " I responded that I was fine as well and assured her not to hesitate to contact us if she had any problems in the future. A few days later, after Sanumaya was discharged, she called me and left a kind ‘thank you’ message. Like many other patients, Sanumaya helped me become a better person and inspired me to continue to serve to the best of my ability to make others feel as good and happy and save lives.
The second day of duty, on the other hand, did not go as planned - I was nervous. The night before my duty, I could barely get any sleep due to the sticky heat, buzzing of mosquitoes, and howling of the dogs on the streets. My alarm went off at 5:30 am without me having a wink of sleep. I answered a follow-up call from Sakuntala, my 59-year-old patient, whose husband was admitted to the hospital due to a high-grade fever. She was worried, and she wanted to know if her husband would be okay. After 20 minutes of counseling, she was reassured and became calm. During follow-up next week, I found Sakuntala's husband had been discharged. They were happy that their life was normal again.
Following patients through Telemedicine has now become an integral part of my daily routine. When following up with patients, it's usually heartening to hear that they're getting better. However, things don't go as planned all the time; Tshering Sherpa 79-year-old male, whom I was following, took his last breath at a hospital following a complicated course of COVID pneumonia. It was heartbreaking to hear that my patient, with whom I was talking a few days earlier, passed away. This situation made me more determined and provided me with a better understanding and acceptance of death in human life. I developed a greater appreciation for life and its beauty as I constantly juggled between the happiness of saving a life and the sorrow of losing a patient. I get a lot of compliments from my patients, which keeps me motivated to be a better me than I was yesterday. "I never knew a doctor cared for a patient to this extent; you have changed my opinion regarding doctors," one of my patients said.
I want to take this opportunity to express my gratitude to Health Foundation Nepal for guiding me to become a compassionate doctor and for assisting me in improving my communication skills. I am not just treating a patient; I am also treating the entire family during the illness. Overall, I am very pleased with what I am doing. Telemedicine, in my opinion, can be used to reach out to many people who otherwise do not have health care access. Healthcare is expensive enough; on top of that, travel costs can be prohibitive. Nepal's hilly landscape and poorly developed transportation infrastructure make travel difficult in many places. In some remote places, a person has to travel 2 to 3 days to reach a proper health care facility or to meet a doctor. To battle this pandemic, I am helping my patients by listening to their concerns and by minimizing their hospital visits, and providing healthcare through telephone breaking all physical boundaries. I have provided care to people from all over Nepal who otherwise might not have the means to visit a healthcare facility. I am delighted to be a part of this initiative and serve people all over the country during the pandemic.
Please note: Names of the patients have been changed to protect patient's privacy.
Dr. Shila Neupane.
Itahari, Sunsari, Nepal