The Covid experience in Kathmandu

Close medical friends in Kathmandu have given us permission to share this vivid and moving account of their experiences treating Coronavirus affected patients at Patan Hospital in Kathmandu. We hope reading it will help our supporters to understand what the women WWR helps may experience if they are admitted to hospital for Covid-19. Our friends also need as much prayer as possible while they are on the frontlines dealing with this crisis.

Your rod and your staff, they comfort me.
Psalm 23:4

Dear Friends,

1 September 2020

Draped in blue, we trundle down the hall, knock on a wooden door marked by a paper number 6, and enter to find a masked woman sitting cross-legged amidst rumpled green bedsheets. Used to our patients being strangers, I’m briefly startled to meet Shanta, our operating room nurse. I’ve known her for twenty years, since the days we did bronchoscopies together. Curtains hang limply in the windows of the faded cinder block room; her bedside table is cluttered with bottles, snacks and toiletries. [Name changed.]

“No, I don’t have a cough or fever. I’m fine, Dr. Mark.” But her voice lacks its usual chirpiness and over the mask her eyes fix on me. “I need a report on my mother and father in the ICU.” Though symptom-free, Shanta is in the COVID isolation ward awaiting her PCR test report. Both her parents have been admitted to the COVID ICU one floor above, a zone she’s not free to enter. “Sure, Shanta. We’ll see them at the end of rounds. Don’t worry. I’ll let you know how they are.”

The COVID surge crept up on us. In early May, emboldened by Nepal’s lack of cases, I drafted an article postulating local resistance to the virus. Fortunately, my coauthors convinced me to delay submitting it to a medical journal. By early July, Patan Hospital’s COVID ward held 40 patients, but only two were serious, so some of us still clung to the notion of a mysterious protective effect. Now, with each subsequent week of August, it’s become apparent Kathmandu is not going to dodge the pandemic. Transmission of large numbers of cases in this bee-hive of a city has prompted the government’s strictest lockdown yet, allowing only food shops to open until 9AM. Patan is a COVID referral hospital and, with 110 PCR-positive patients, its COVID wards are now full. Over the last weeks, we’ve seen an average of two deaths a day. And our ICU’s 15 COVID-dedicated ventilators have proven to not be the final line of defense we’d hoped – not one mechanically-ventilated patient has survived.

We don our personal protective equipment (PPE) in a converted nursing station off the surgical ward. While nurses and doctors sit and chat over patient charts or cups or tea, I enter the bathroom and change into a fresh set of surgical scrubs. Back in the main room, I open a plastic PPE wrapper and lay out its royal blue contents on the counter. The procedure, focused and introspective even in the midst of others, reminds me of suiting up for a basketball game, of preparing to enter some arena. I start by dangling five strips of paper tape from an adjacent stand. I remove one and, in front of a mirror, tape my N95 mask evenly to the skin below my eyes, add a second surgical mask over it, pull on booties and tape them to my scrubs, put on my first pair of rubber gloves, wrap myself in the plasticized robe which my partner Dr. Sunny ties three times in the back, put on my second pair of gloves which I tape over the sleeves of the robe, don a hood and then a plastic visor. I tie up Sunny and when he’s ready, we set off.

With the gradual increase of cases, Patan Hospital’s leadership has had time to prepare, cordoning off a four-story section of its main building, into which healthcare workers enter only in PPE. In order to protect the non-COVID parts of the hospital, this area also houses all ‘suspect patients’ until they test negative. With limited resources, irregular supply lines, and challenged infection control, our administration has performed admirably in the face of an unprecedented, evolving ordeal.

As there are no stairways in the COVID section and because we must move from least- to most-infected patients, Dr. Sunny and I will take the elevator six times during the course of our three hours of rounds. He is a Family Practice resident, a soft-spoken man from southern Nepal, and he carries a stapled bundle of green papers on which he’s written patient information. We enter the ground floor Fever Clinic where a junior doctor shows us two patients, one a man with chronic leukemia and fever, the other a woman with emphysema. Neither seems to have COVID, but they’re suspect enough to prevent their entering the main part of the hospital, where they’d have received better, more continuous care with their relatives close by. Over the last five months, we’ve watched the COVID shadow exact a price far wider than the disease itself.

Each COVID ward is an open hall containing 20 beds with windows on three sides, bright and mercifully airy during a hot summer day, with communal bathrooms at one end. All the patients in here are positive, so they pose no risk to each other. An alert lady in her thirties without worrisome symptoms asks me to look at some red spots on her shins before admitting they’ve been there a long time. Like many others, she just wants to talk, even to someone concealed in a blue cloak with only eye slits. Neighboring patients, now compatriots, chip in their opinions. Sunny and I do our best to chat them up and say a few encouraging words, but there are many more to see and the sense of being in a viral miasma propels us onward.

We enter the sluggish freight elevator, which is large and dusty, with two abandoned boxes to one side.
“How are you doing with all this, Sunny?”
“The COVID thing? I’m okay, sir, but I always feel this pressure to get done rounds as fast as possible.”
“Yeah, I have to say my favorite part is at the end when the nurses spray us down with disinfectant.”
He laughs. “I love that, too. The cool mist on your arms and body and knowing it’s all over for the day.”
“I want you to know you guys really inspire me.” He tries to shrug off my comment, but it’s genuine.

The COVID section has recently expanded into the private ward to house seventeen Patan Hospital staff who’ve tested positive. Out of concern for their families, who often live in close quarters, no one will go home until they become negative. As we enter room after room, I’m surprised to find yet another colleague and old friend. “You, too?!” I exclaim. Our laughter is a cover-up. More than the ICU’s mounting death toll, it’s all these colleagues testing positive which punctures any illusion of immunity. Proceeding down the hallway I remark to Sunny, “Well, at least no one’s symptomatic here,” sliding a mental barrier against worry, but he replies, “Yeah, but I just heard our medical officer Dr. Saurav [who worked in COVID ICU] has a high fever.”

Rounding on wards with serious COVID patients presents challenges. Because we do 3-day-on and 3-dayoff shifts, many patients are new to us. The previous team gives us a handover, but there’s no substitute for spending repeated times at the bedside, getting to know a patient and her problems. Also, the PPEs preclude our using a stethoscope and garble our speech. A 64-year old woman wears a nasal cannula connected to an oxygen cylinder bubbling furiously. Sunny informs me she has chronic kidney disease and is getting regular dialysis. I check her medicine list and write a quick note on her chart. Despite her breathing problem, she manages a few spoonfuls of rice curry between breaths and nods saying she’s better.

By the time we reach the ICU, I’m hot and tired. Despite the solemnity of this long ward – full of sick patients hooked up to monitors, tubes, and various devices – the air conditioning momentarily conjures an oasis. The medical resident Dr. Khusal hurries over with his green papers and we commence at bed 1, a man just coming off dialysis, who’s thrashing about, with low oxygen level despite getting high flow through a mask. Though every last patient in this ICU is short of breath, some have stabilized, ‘turned the corner,’ and will gradually get better, while for those who’ve just come in, we don’t know in which direction they’re headed. Today there’s only one patient, a 32-year old man, on a ventilator, three others having died last night.

As I move down the line, asking questions, making suggestions to the resident, looking at x-rays, and checking monitors, Khusal points out Shanta’s mother. She’s 67, with a round face and white-flecked hair. Though only needing a relatively small amount of oxygen, she looks anxious, glancing back and forth at the patients on either side. She brightens when I tell her Shanta is my old colleague and that she’s asked about her mom. “Don’t worry. You’ll get better.” In here, though, it takes an extra measure of hope to say it.

Directly across the center aisle is her husband, who, having failed escalating levels of oxygen support, is now crowned with a ‘Hood CPAP’. Made of the clear plastic of bouncy castles, this inflated cylinder with two tubes rises from his shoulders to a foot above his head, making him look like a space man. Just in the last two weeks, someone laid hold of these positive pressure devices and we’re trying them out, hoping they’ll avert the need for ventilators. Casting about for a ‘game changer,’ we’re encouraged by the first results of this trial. The nurses have just opened the hatch on his ‘hood’ and he’s taking gulps of a thick potato soup before his blood oxygen level plummets too far.

Rounds completed, I return to the first floor, but before beginning the meticulous ‘doffing’ process, I walk back down to room 6. Shanta looks up quickly as I enter. “I just saw your parents, Shanta. They’re not doing badly. Your mom only needs a small amount of oxygen, which is great. Your dad was eating when I saw him. Don’t worry. They’re getting better.” The softening of her eyes is the best part of rounds, maybe of my day.

Thank you for praying for us at Patan Hospital, including for Deirdre, who remains its lone dietician.
Mark and Deirdre

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