Desperate times, exceptional measures – Dr. Anish Shah

When she became disturbingly short of breath, we had no choice but to take her to the hospital. But as we reached there, a long queue of people in much worse condition than my mother — some groaning in the heat of high-grade fever, while others gasping for bouts of air as if it were their last — awaited on that hospital gate for as basic of things as oxygen and hospital bed. Everyone had one thing in common, one relative stood beside them; worried, sobbing, or wailing like desolate children amidst the rubble of a disaster. And I stood beside my mother, confused and utterly hopeless” said Kush (changed name) when he called for our telemedicine service at around 8 PM that night asking for some help. He was one of the many stranded by the overwhelmed health system when the second wave of COVID-19 hit Nepal. The people who would be ideal candidates for admission in critical care units were sent back home, some with oxygen and others with just vapid refusals. All the hospital beds were occupied. ​

Kush’s mother Sita, a 73-year-old woman from a small village in midwestern Nepal, had been short of breath for 3 days. Her breathlessness had worsened that day, compelling Kush to take her to a local pharmacy to test her oxygen level. Her blood oxygen level was detected to be fluctuating at 83 – 84 percent. “Anything below 90 percent is considered as severe COVID and requires immediate hospitalization” was advocated by the national experts and Kush had heard people announcing it over the radio. The saturation of 83 percent came to him like a bolt from the blue and he immediately called an ambulance. After he was refused a bed at the hospital due to unavailability — his mind all distraught — he took the same ambulance to return home. His wife Kumud had also started coughing for a day and he felt the world collapsing at him all at once. “I have heard about this group of doctors providing service over the phone. This is the pamphlet, here. Why don’t you give them a call?” said the driver, breaking the chain of calamitous thoughts of Kush.

Dr. Vaidya was preparing for his dinner in Kathmandu when his phone rang. He had already consulted 8 patients that day over his phone — all with a mild disease that could be managed at home, but with the lurking possibility of getting severe. Kush sounded desperate. After a short depiction of what had happened at the hospital, Kush broke into a hopeless sob. He didn’t know how to help his mother — who was single-handedly reaping the season’s harvest a week back — who was fighting between life and death at the moment. Dr. Vaidya calmed him down and asked about Sita’s progression of the disease. She was a case of Severe covid-19 and needed immediate hospital care, if not with ventilator support. But she laid in her bed, in that dark, two-bedroom house of brick and mud and a common kitchen; where isolation was out of the question. Dr. Vaidya started Sita on steroids immediately, prescribed medications for symptomatic relief, educated and advised about prone positioning and how it helped improve the oxygen levels, and asked to monitor her oxygen levels more frequently while also looking out for oxygen and hospital bed. [1,2] He also asked Kush to monitor the symptoms of Kumud, his wife, as well and assured a follow-up call the next morning to overview Sita’s response to the treatment. 

Two days into the treatment, there were no signs of improvement in Sita. Kush had asked for a pulse oximeter, a device to measure oxygen level, from a neighbor and Sita’s oxygen levels often reached as low as 77 percent. Meanwhile, Kumud had also developed a fever of 101 degrees and was being treated through the same telemedicine service. Dr. Vaidya had also tried to arrange for a hospital bed or oxygen for Sita through his contacts in that area but unfortunately, this was to no avail. However, miraculously later that day, he received a call regarding the availability of a hospital bed in a nearby town. He immediately called Kush. 

Sita was lying in her bed, her belly down, gasping for air in one room; Kumud, unable to work because of severe weakness and fever lied in another room; Kush — although with his minimal medical knowledge — driven by frequent advice by Dr. Vaidya, was caring for them day in and day out, very much like a qualified health practitioner. When he received the call from the doctor, he said he felt the most helpless at that time. Although the bed was available, he couldn’t leave his wife alone at home as there was nobody to care for her. The helplessness could be felt even from one end of the call to the other. Dr. Vaidya, who had stopped eating in the middle to call Kush after knowing that the hospital bed was finally available, lost his appetite after the call. 

Not very often in medical practice, we realize how little things are under our control. No matter how much we try to, we can only reinforce or resist, for the time being, for things to happen in due course. And then there are times when very grim situations take a turn for good, as if a miracle, and that sustains our faith in the strength and resilience of the human spirit, especially during the time of crisis. On the fifth morning of her consultation, Sita sounded better. Her oxygen levels had started to reach 87 to 89 percent, without any oxygen, without any hospital care, with only hope: hope to live, hope to fight. Hers was an exceptional case in a desperate time which no one should have to endure but still a story to reflect on so many negatives: deficiencies in the health care in low-middle income countries, our unpreparedness to pandemics, the added hardship to the poor and middle class; but one great positive: the ruggedness of human spirit to survive. 

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