Desperate Times Call For Desperate Measures — Dr Musa Nordin, Dr Mafeitzeral Mamat & Asst Prof Mohd Farhan Rusli

A few unpopular but necessary immediate actions must be taken to fight the pandemic.

“My uncle passed away just now at Hospital Ampang while waiting for a ventilator since this morning.”

‘Please sir, come down and join us fight this inside our halls. See our patients on the floor, see our nurses crying for help.”

I am sure you have witnessed the grim and desperate situation in our emergency departments (ED), intensive care units (ICU) and at the Low-Risk Covid-19 Quarantine and Treatment Centre (PKRC) at Malaysia Agro Exposition Park Serdang (MAEPS).

Many have written or spoken about the upsurge of Covid-19 cases since October 2020, and have sounded like broken records since the beginning of this year. In January 2021, when the hospital and ICUs were overstretched and near the break point, we had suggested various strategies to protect hospital services and ensure cases would not overrun the capacity.

The Malaysian Medical Association (MMA) organised a webinar on February 1, 2021, to address this specific issue, which featured the Association of Private Hospital Malaysia (APHM), MMA, an infectious diseases specialist, and two of us, one an anaesthetist, the other a neonatologist (intensivist of sick newborns).

The recommendations from the College of Anesthesiologists, Academy of Medicine Malaysia (COA, AMM), the Malaysian Societies of Anesthesiologists (MSA) and Malaysian Society of Intensive Care (MSIC), dated May 17, 2021 were met with the standard bureaucratic reply.  

If only the Ministry of Health (MOH) had heeded some if not all of the ideas which were suggested, we would not be in the deadly mess we are in today.

As of July 5, 2021, based on official MOH press statements and media reports:

  • The usage of Covid-19 ICU bed (including probable cases) is 1,224. Prior to the pandemic, the Malaysian Registry of Intensive Care (MRIC), inclusive of university hospitals, had approximately 1,000 beds. The latest in their plan was 60 to 70 per cent for Covid-19 cases and 30 to 40 per cent for non-Covid-19 cases.
  • In Klang Valley hospitals, the Covid-19 ICU beds, including repurposed ICU beds, are 85 per cent filled (567/667). This does not include the transit ventilated patients in the ED, which might take a while before they are transferred to the Covid-19 ICUs or repurposed ICUs.
  • As of July 7, 2021, 948 Covid-19 cases are being treated in ICUs, with 441 cases on ventilatory support.
  • Currently, 17 public hospitals in the Klang Valley are treating Covid-19 cases. The dedicated Covid-19 hospitals are Sungai Buloh and Ampang. The rest are hybrid hospitals. Hospital Kuala Lumpur (HKL) has 70 per cent of Covid-19 patients in the wards and a full Covid-19 ICU.

The COA, MSA and MSIC recommendations have deliberated extensively on the process of decanting patients from public hospitals to private hospitals. The health minister, in a media report on July 4, 2021, had alluded to the MOH decanting patients to private hospitals.

We would like to suggest a few unpopular but necessary immediate actions:

1. Make it mandatory for all the private hospitals to accept non-Covid-19 cases from all the public hospitals. Not only must national duty be done, it must also be seen to be done. This must not be under the auspices of the MOH, since their leaders have proven themselves to be failures. Instead, appoint one of the CEOs from the APHM to monitor this exercise and ensure an equitable distribution of all the non-Covid-19 patients to the private hospitals.

2. Convert more public hospitals as fully designated Covid-19 hospitals. We have illustrated the process of planning for the surge of critical capacity in the latter part of the article.

3. All the Categories Three to Five cases must be sent to these Covid-19 hospitals. Only in this manner can we guarantee quality health care for the sickest patients, and protect the safety of doctors, health care workers, allied health professionals, supporting staff and the other clients in our health care facilities.

4. Make all the PKRCs, especially the largest one, namely MAEPS, to undertake what they were originally designed to do, which is to nurse the Categories One and Two cases who, for various reasons, are unable to be quarantined at home

It therefore makes perfect sense that HKL should be designated as the next Covid-19 hospital. They have enough medical gas terminal units, including oxygen gas outlets, electrical points and other paraphernalia to create more than 200 repurposed Covid-19 ICU beds. Hospital Tunku Ampuan Rahimah (HTAR) in Klang is the other hospital with this kind of facilities and capacity.

To do this, the 4s, namely Space, Staff, Stuff and Standard must be put in place. This demands an urgent brainstorming session among intensivists, anesthesiologists and infectious disease physicians to finalise the plans.

In fact, it should have been done earlier, when the planning for Categories One to Three patients was drawn up by the Covid-19 Assessment Centres (CAC) and PKRCs. We simply fail to understand why the MOH and all its experts did not prepare for this worst-case scenario!

Our gut feeling is that the clinicians had planned for all of these eventualities, but the plan was not acted upon by the MOH top brass, both medical and administrative. This is reflected in today’s rant from a clinician to the minister:

“If help is promised, it must be provided within 24, 48 or 72 hours. Deployment of manpower should be easily in place within 24 and 48 hours. It should have been yesterday.”

The bottleneck is obviously due to the 100 per cent utilisation of Covid-19 ICU beds, and though measures would now be ad-hoc, we still need to marshal some form of order. We would have to operate like the astronauts in the 1995 movie Apollo 13. Flight Dynamics Officer Jerry Bosstick wrote in an email:

“One of their (scriptwriters) questions was ‘Weren’t there times when everybody (people in Mission Control), or at least a few people just panicked?’ My answer was ‘No, when bad things happened, we just calmly laid out all the options, and failure was not one of them’.”

A powerful message indeed from Apollo 13: Failure is not an option!

If we can carry out this plan successfully in the Klang Valley, it can act as the template for other states to increase the critical care capacity in other public hospitals.

There are two excellent references for the MOH to plan for the surge in their critical capacity.

The first, this article talks about the features of an effective response which demands coordination, anticipation and solidarity — all of which seems to be sorely lacking in the present response due to a failed political and health leadership.

Meanwhile, this article focuses specifically on key questions about how to manage ICU surges during the Covid-19 pandemic.

As for space and stuff, the MOH needs to prepare for this expeditiously. Staff and standards need to be rapidly retrained to administer a pandemic-centric style of care.

HKL and HTAR ward staff are fairly experienced in handling critically ill patients, and they will fit into the retraining plan for the Covid-19 crisis.

Medical personnel in Italy, the US and the UK have done all of these in 2020. Why can’t we?

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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