WITH more Covid-19 patients being admitted into intensive care and the death toll at an all-time high, doctors are living in fear of the day they will have to decide who lives and who dies.

Already overwhelmed with physical pressure, doctors told The Malaysian Insight they dread the day when they will face the ethical dilemma of having to decide who gets to use the ventilators, which are already running short of supply.

Though Malaysia’s infectivity, or R-naught (R0) has dropped below 1.0 for the past two days, the country has been steadily reporting more than 5,000 cases daily. In recent weeks, the number of daily cases has even shot up to 9,000.

Doctors said as the pandemic continues to surge and the national vaccination programme plays catch up with the number of daily infections, they foresee the situation getting worse before it gets better.

An anaesthesiologist said when he was posted in a hospital in the Klang Valley in early December last year, he was intubating around 10 patients weekly. By January, the number had grown to 20 or 30 patients a week.

The doctor, who is currently based in Kuching, said by his estimate, he had intubated more than 100 patients since the start of the pandemic and lost more than 30 patients to the virus.

“To be honest, nowadays when you have to select who gets the ventilator, who you intubate, who you actually save, it takes a toll on us.

“For patients in their 80s or 90s with heart disease, hypertension, usually even if you intubate and ventilate for three to five days, they won’t make it.

“Right now, with more young people coming in everyday, we have to (choose),” said the anaesthesiologist speaking on condition of anonymity.

He said healthcare workers needed to look after critically ill patients are also in low supply, especially staff nurses who are needed to tend to patients in the ICU.

As an anaesthesiologist, he could potentially be the last person a patient sees and speaks to before they are sedated for intubation and so, makes sure that they video-call their families before that.

“We allow a video call between the patient and the family. Some of the patients’ families will ask us to do our best and they will say whatever last words they want to say.

“We are always giving them hope. We always tell them they must be able to make it,” he said.

He recounted the happy ending of a patient who was intubated for 10 days before he was well enough to be taken off the ventilator.

“I remember one uncle, before Chinese New Year, we needed to tube him and 10 days later, when we extubated him, he woke up happy.

“We were able to discharge him just before Chinese New Year. He was very happy. He ‘belanja’ (treated with gifts) a lot of us in the ICU. He brought oranges and he ‘belanja makan’ (bought us food).

“Some of them, we have a very happy ending, some of them couldn’t make it,” he said, adding that a patient he had, died three days after being intubated.

He said Buddhist patients often request that a talisman is placed under their pillows and the doctors will oblige to give them comfort.

False hope

Several doctors told The Malaysian Insight that when they intubate a patient, they feel they may be giving the patient false hope as the reality is some of them may not get better.

A doctor based in a Seremban hospital spoke of a patient who, despite being put on oxygen, was deteriorating quickly leaving them with no choice but to intubate him.

“One Malay uncle was gasping on face mask oxygenation, we managed to get him a high flow nasal cannula but oxygenation wasn’t picking up and he was becoming more and more lethargic so we had to intubate him.

“I pushed him to the high dependency ward, forced him to video-call his son and daughter before we did anything further.

“Just before intubating, as my specialist was administering the drugs, she said, ‘Pakcik, saya akan bagi pakcik tidur sekarang dan saya akan bangunkan pakcik nanti bila sudah baik’ (Uncle, I will make you sleep now and will wake you up when you are better).

“That one line hit me hard. That hope, it may be false hope, but it’s all we have right now. I’m just glad I forced ‘Pak Cik’ to video call his children that day,” he said.

Drawing parallels with their own families

Another doctor based in a hospital in Shah Alam said patients who have young children at home remind her of her own children and of how fortunate she is that she and her child are safe.

She had a patient who had contracted Covid-19 from a family gathering. The patient had a six-month-old daughter whom she missed terribly while at the hospital.

“I was in full PPE (personal protective equipment) and this patient was talking to me with the oxygen mask attached to her. She was getting more and more breathless as she was telling me her story.

“As a mother myself, I could feel how much she was missing her little daughter. Watching her cry, tears were rolling down my cheek. Thanks to the PPE, no one saw my tears.

“That night I couldn’t sleep. I kept looking at my own two-year-old daughter, hugging her and thanking God that I’m lucky enough to be with my child.

“I still pray for that unfortunate lady and her baby. I hope that she recuperated and is happily and safely living with her daughter,” she said.

Duty above all

The coronavirus changed the face of medical services everywhere and for a doctor posted to a district hospital in Sabah, it proved challenging to fight a virus that was so virulent and spreading fast among the community.

At the start of the pandemic, the doctor who was put in charge of a quarantine centre, said he found it hard to accept that an N95 face mask was sufficient protection against the virus.

Nonetheless, his Hippocratic Oath to save lives kept him going.

“Deep in my heart, I wanted to uphold my oath and my calling to serve the people and garnered my strength to carry on and be resilient in facing future challenges.

“It was an entirely different experience handling patients under such circumstances, where one has to be wrapped up in PPE for prolonged hours.  Clinical routines that were previously effortless were now an endeavour when coupled with constant vigilance and adherence to SOP, especially when a patient requires certain medical procedure or is transferred to a tertiary centre.

“Many in the field would agree that this pandemic has collectively taught us many valuable lessons and will definitely make our healthcare more resilient in the future,” he said.

Bearer of bad news

Breaking the news to families that a patient might not make it is a difficult thing to do, especially when the person may not have been critically ill when they were admitted.

A specialist at a hospital in the Klang Valley said the situation was made even harder when they had to inform the family that they will not be putting the patient on a ventilator as the risks outweighed the benefits.

“It was sad that it had come to this, but I made this call (not to ventilate). I spoke to the family, made sure they understood.

“It was a difficult decision. The last time they would have seen their parents would have been 10 days ago and at that time they were still okay. Then, I had to tell them I would not be able to do anything more.

“I always think of what would happen if these were my parents, if somebody called me to tell me this. I cannot imagine it,” he said.

He added that such decisions were made with a lot of caution.

He spoke of an incident where a close friend, someone he had known since he was a child, died in his care despite his best efforts.

“We did everything for him, he was 55, with no medical problems, and jogged every day. We treated him for almost three weeks to a month in the ICU.

“To break the news to his children and wife, it was very sad for me, but they knew we tried all that we could. I gave it my best, but still he didn’t survive,” he said.

On the bright side however, the doctor said the number of people who survived were more than those who succumbed to Covid-19. – June 9, 2021.