A DOCTOR in Kelantan, who was recently summoned to an isolation ward at a public hospital, found that the personal protective equipment (PPE) suit she was about to wear was missing several parts.

“So I went to get one part from the operating theatre, and another part from another department.

“I spent 15 minutes to half an hour just finding parts to suit up. It wasn’t a life-threatening situation, but it was still a waste of time. And that was just to see one patient,” the doctor, who declined to be named, told The Malaysian Insight.

This raises the question on the supply of PPE for public hospitals and clinics, when the Health Ministry has said there is enough.

Doctors on the front lines, however, are saying otherwise.

Those interviewed by The Malaysian Insight said they feel they have to stretch their facilities’ supply of PPE due to uncertainty as to when new stock from the ministry will arrive.

PPE stocks at hospitals have to be “shared” among staff in Covid-19 wards, intensive care units, wards for suspected cases, frontliners taking swabs in the mass-screening area, the accident and emergency (A&E) department, paramedics handling ambulance services, as well as cleaners.

“In the A&E, we see new patients, some with symptoms, others without, who may or may not be infected with Covid-19, and we won’t know until we assess the patient fully,” said a doctor in the A&E department of a major hospital in Sabah.

“Ambulance staff also need to go out in PPE as you don’t know if it is a potential Covid-19 case.

“I don’t know if there’s an actual shortage, or why. But my best guess is that we are using PPE too quickly.”

All the doctors interviewed did not want their names published and spoke on condition of anonymity because civil-service protocols do not authorise them to speak to the media.

How much protection is enough?

A doctor at University Malaya Medical Centre (UMMC) said staff follow internal directives, with higher-ups deciding how much PPE should be used and whether to stretch or save the items.

This sometimes leads to different opinions on how much protection is enough.

“One department says using one layer of gloves is enough. Another department feels two layers is better. I know that at Queen Elizabeth Hospital in Sabah, they are using three layers.

“There must be a balance between protecting health workers and ‘saving’ or stretching PPE supplies.”

The A&E doctor in Sabah said the hospital’s policy is for every staffer to be limited to one three-ply surgical mask per shift that lasts seven to 10 hours for doctors, and 12 hours for nurses.

“While the mask’s effectiveness can last between eight and 12 hours, the longer you wear it, the ‘dirtier’ it gets.”

He said the best practice would be to discard a used PPE outfit and don a fresh set for every patient.

“In reality, we just change our plastic apron and gloves between patients.”

The doctor at the Kelantan hospital said staff there are reusing face shields and goggles, but discarding items such as gowns, which are porous.

Her hospital is also rationing the use of N95 masks, the gold standard when dealing with Covid-19 cases or suspected infections.

“For my department, we are given however many pieces (of N95 masks) the hospital apportions to us, and told to ‘make it last for the next few days’.

“The average use of an N95 mask is four to six hours. But we just use it for the whole shift. If I have a double shift, I’ll use it for 24 hours.”

DIY parts

A fourth doctor interviewed, who deals with Covid-19 patients at a Sabah hospital, said “intermittent shortages” of certain items have occurred. 

There are also times when PPE sets arrive incomplete because the supplier for a certain component could not meet demand.

“We supplement the procured sets with do-it-yourself (DIY) parts, for example, clinical waste plastic bags as boot covers. Some sectors within the hospital are making head covers, boot covers and face shields,” he said, adding that the Covid-19 ward at his hospital requires around 100 PPE sets a day.

He said the hospital’s supplies team sent material to prisons and activist groups to make boot covers earlier this week.

“In the interim, we’re using rubbish bags or plastic aprons as makeshift covers,” he said, adding that the hospital’s management has said the procurement of proper boot covers is in progress.

The doctor in Kelantan said her hospital began making DIY face shields a month ago in anticipation of supply disruptions. Now, they are also making their own hood or “tudung” covers.

“Whoever is available makes them, mostly the medical assistants, nurses and technicians if they don’t have duties to perform.”

The push for DIY items comes as her hospital waits for an order of PPE suits made to the ministry two weeks ago, which has still not arrived.

“We aren’t able to wait, so we started making our own. I’m not blaming anyone; everything is unprecedented and nobody expected the PPE turnover rate to be so high.”

She anticipates a spike in the consumption of PPE suits and protective items, following the Health Ministry’s directive to treat all patients as Covid-19 cases until they test otherwise.

As of Thursday, 181 healthcare workers were infected with Covid-19, but Director-General of Health Dr Noor Hisham Abdullah said none of them contracted the virus while in the Covid-19 ward or ICU.

Instead, their sources of infection were either from attending weddings, or patients who did not disclose their travel history or close contact with Covid-19 cases.

Equal distribution, better coordination

The doctors’ personal accounts can explain why photos of hospital staff making DIY protective gear are still going viral on social media, and why appeals for donations are still being made.

Dr Noor Hisham has said supply is enough while acknowledging problems with distribution. He also said the ministry is still welcoming donations.

He also said distribution problems are partly due to the high rate of use in “fast-moving hospitals”  like Sg Buloh Hospital, the country’s main Covid-19 facility.

But, the UMMC doctor said if the ministry had said there was enough supply, it must ensure equal distribution to all health centres.

“Having enough PPE supplies is also not ‘enough’ without proper guidelines on how to use them in a crisis situation,” he said, referring to the debate on how many layers of gloves to wear and how often an item should be reused as examples.

“There should also be centralised coordination so that donations are sent to facilities that really need PPE items, and not to those that may have just received a whole batch of donations, leaving other centres deprived.”

The UMMC doctor and Kelantan doctor said they know of smaller clinics in districts that lack supply resorting to making their own items or using garbage bags as gowns.

“They may not be Covid-19 admitting centres, but they have patients walking in all the time. How do you know if someone is infected or not?”

The lack of guidelines, as well as monitoring of smaller public clinics, have seen one case of a complaint letter written to Health Minister Dr Adham Baba by medical officers (MOs) at a Selangor government clinic in a red zone about the lack of professionalism by the resident family medicine specialist (FMS).

The letter, dated April 8 and seen by The Malaysian Insight, said the FMS was indecisive for more than 24 hours on whether to decontaminate the facility after one MO tested positive for Covid-19.

Among the other complaints, the nine clinic staff who signed the letter said some employees were not quarantined; morning- and evening-shift staff were made to share the same face shields; staff were rationed one face mask per day; there was no effort to procure PPE supplies, leaving staff to appeal to local donors; and, the FMS’ habit of keeping PPE supplies under lock and key, making them inaccessible to staff.

The Covid-19 pandemic, which has brought the country to almost a standstill, has shown no signs of abating.

As of yesterday, the number of cases stood at 4,436 with 70 deaths.

This has resulted in Putrajaya extending the movement-control order, which was enforced on March 18 to curb the spread of the virus, to April 28. – April 11, 2020.