KUALA LUMPUR, May 5 — An anaesthesiologist and intensivist-in-training at Hospital Kuala Lumpur (HKL) recounts her challenges in caring for seriously sick Covid-19 patients in the intensive care unit (ICU).
Dr Julie Eileena Abdul Razak is one of 15 intensive care trainees in Malaysia. There are only 25 intensivists in the Ministry of Health (MOH) practicing in government hospitals, with a ratio of 0.078 to 100,000 population, much smaller than in developed countries.
This is Dr Julie’s story, as told to CodeBlue:
As intensivists, we are committed in providing comprehensive care to the critically ill patients in ICU and other critical care areas. Most patients requiring ICU care have severe or life-threatening conditions that require constant care and supervision. A large proportion of them require some form of support either mechanical ventilation for respiratory failure or other organ support like dialysis for renal failure.
An intensivist has to be competent not only in a broad spectrum of conditions common among critically ill patients but also with the technical procedures and devices used in the intensive care setting such as intubation, central venous access, arterial cannulation, mechanical ventilators, dialysis and percutaneous tracheostomy.
During this Covid-19 pandemic, we have managed around 30 Covid-19 patients in our ICU. We also co-manage some patients in the wards that are referred earlier in anticipation of deterioration due to disease progression.
A Day In The Life Of An Intensivist
Our typical day starts with a pass-over session early in the morning to discuss the progress of the patients through the night, followed by our routine rounds in the ICU. During rounds, we will examine the patients, review the blood/ radiographical investigations and medications, and plan our clinical management.
For ventilated patients we will assess the need for sedation, oxygen requirement, adjust the ventilator settings accordingly and assess if they can come off the ventilator support. We also conduct procedures as required such as insertion of invasive lines, chest tubes, dialysis etc. In the afternoon once rounds are done, we will update the family members either via phone calls or video calls.
Being a hybrid hospital in this pandemic, we manage both Covid-19 and Non-Covid-19 cases. We rotate between doing 12-hour shifts whilst being in the Covid-19 team and 24-hour on-calls in between rotations of treating Covid-19 and non-Covid-19 patients.
During a 24-hour call, we are on standby to attend to emergency referrals for intubation (the process of putting a breathing tube down the patient’s airway so they can be placed on a ventilator to assist with their breathing) or resuscitation of patients from the wards and other areas in the hospital. As it is an aerosol-generating procedure, it is during an intubation or cardiopulmonary resuscitation (CPR) that we are at the highest risk of exposure to the virus.
The management of Covid-19 patients places additional physical and psychological burden to our daily practice. This includes repeated donning and doffing of PPE (personal protective equipment) followed by showers. There are also physical restraints to routine practice due to PPE.
Being in a PPE makes you feel hot, sweaty, and thirsty, very much like being in a sauna. Imagine working in these conditions for hours.
The act of donning and doffing presents a great challenge in our daily routine. In particular, doffing the PPE is associated with the greatest risk of contamination especially when we are tired and cognitively overloaded.
There are also communication challenges with PPE and changes to standard practice that we have to adapt to.
Managing Complications Due To Covid-19
The duration of our patients being on a ventilator can vary from a few days to weeks. The incidence of reintubation is high in Covid-19 patients. Some develop complications either directly from the disease process of Covid-19 or side effects of treatment. Unfortunately, some do develop hospital-acquired infections from being in the hospital too long.
Among the usual complications our Covid-19 patients have are kidney failure, venous thromboembolism (a condition in which blood clot forms and travels in the circulations, sometimes lodging in the lungs, causing cardiorespiratory collapse and sometimes heart failure).
These thromboembolic events are quite prevalent even in the young ones.
For our chronic patients with critical illness polyneuropathy (a complication that manifests as limb and respiratory muscle weakness), we focus on a lot of physiotherapy to get them off the ventilator soonest and back on their feet.
We have had a few mortalities in our ICU and what they all had in common was having a pre-existing medical condition prior to contracting Covid-19. In the course of their disease, some rapidly deteriorate and develop cardiac arrest, while some develop multiorgan failure and despite our best efforts, succumb.
Delivering Bad News On The Phone Has Scarred Us
Covid-19 patients that are in our ICU are mostly more than 50 years of age, with underlying pre-existing illnesses such as diabetes, hypertension, heart disease. Covid-19 patients are isolated due to the nature of the disease being highly infectious. They are alone, most of them afraid, and not knowing if they’ll be able to see their loved ones again makes it a highly stressful condition for them.
In our centre, those requiring oxygen are already placed in a specific ward. We have a high level of alert for these groups of patients, as they can be comfortable one moment and gasping for air the next.
In cases requiring emergency intubation and ventilator support, we might be the last person they speak to or see. We are very much aware of the fact that this is a potentially terminal event. I have had patients calling their family prior to intubations, saying their tearful goodbyes, asking that we take good care of them so that they can see their loved ones again. This can be a lot and it is difficult to hold back tears sometimes.
It’s never easy when a patient’s life is lost and even harder when we have to break the news to their loved ones. Family members of Covid-19 patients are not allowed to handle the body after death. There are strict protocols to be adhered to. The burden of delivering bad news on the phone has scarred many of us immensely.
I can still hear the wails of sorrow and the audible sobs.
The pain of hearing the families howling at the other end of the phone is something that haunts us, which is why we have broken out of our norms by enabling video calls for the Covid-19 patients, so that families can see their loved ones even at their deathbeds. In doing so, we hope they find some closure.
On the other hand, some patients who do get better and more stable are able to interact with each other. Some made friends and it’s heartwarming to see them cheer each other on. Those who get better and whose repeat tests become negative are eventually transferred to a different area. Sometimes, the remaining ones will ask us how their new friends are doing and hopeful they’ll be able to join them soon.
Other than carrying out our clinical work, we have to be present for them as the compassionate bedside friend since their families aren’t allowed to visit. It’s hard to watch our patients go through this without their loved ones by their side. We do our best to help them and show them that we care.
Our patients and their families usually look forward to our daily updates when they get to see them via video calls. It has somehow been therapeutic for them and a boost of emotional support and motivation for them to get better soon.
Covid-19 has changed the process of communication that we traditionally use — face-to-face with occasional tactile touches to comfort the patient and family members. Now, communication with family members are relayed over the phone.
We are devoid of the ability to look at a family member in person to update them on the progress of their loved ones. A major telco provider, Digi, has kindly provided us with two mobile phones during this pandemic, so our Covid-19 patients remain connected with their families.
Working through this pandemic has been mentally and physically exhausting.
We try to disconnect when we get home, but it’s a disease that follows you.
With two young children and elderly parents at home, the constant worry that I might pass the disease to them is emotionally draining. Due to this fear, many health care workers have been self-isolating and not seen their loved ones in a while.
Lack Of Intensive Care Expertise In Malaysia
There are currently 25 intensivists in the Health Ministry practicing in government hospitals (0.078 to 100 000 population) and some practicing in the university and private hospitals. This ratio is much lower than the numbers in developed countries. Like me, there are around 15 intensive care trainees nationwide currently.
Being a demanding specialty, the intensive care unit is a highly stressful environment intertwined with delicate family interactions and complicated end-of-life discussions. This entails making complex ethical decisions, advanced directives, and counselling of patients and caregivers.
Intensivists are often leaders of multi-disciplinary teams of care providers during medical crises, coordinating an entire team of doctors, nurses, pharmacists and physiotherapists. Working in ICU requires a special set of skills in performing intricate, life-saving procedures. It also enables us to acquire skills and knowledge in handling cutting-edge medical equipment.
Strong Team, Stronger Members
In the face of this pandemic, the Department of Anesthesia and Intensive Care of Hospital Kuala Lumpur has mobilised and adapted so quickly that I am so proud to be part of such an efficient and supportive team. We are blessed with such an amazing team of doctors, pharmacists, nurses, medical assistants and ancillary staff.
It is also heartwarming to see how our fellow Malaysians have banded together in supporting the frontliners and vulnerable communities. From making PPEs from scratch to all the food donations and support given.
I am fortunate enough to have been given the opportunity to work with two very inspiring and well-respected figures in the Intensive Care fraternity in Malaysia — senior consultant intensivists Dr Shanti Rudra Deva and Dr Tai Li Ling. The Intensive Care fraternity in Malaysia are filled with the most dedicated, selfless, compassionate people I have ever met in my line of work.
These are the people that have inspired me to take up the challenges that come with doing Intensive Care full-time. I find it fulfilling and rewarding when our patients get well and return to their families.
An anesthesiologist by training, I am currently pursuing my fellowship in Intensive Care to be a full-fledged intensivist in Malaysia.