The number of healthcare workers getting infected with coronavirus is increasing everyday in Bangladesh, leaving the frontline fighters in extreme anxiety.
So far 50 doctors have died of Covid19 or related symptoms. Nearly 3,500 healthcare workers including doctors, nurses, technicians and others engaged in hospitals were infected. The Bangladesh Medical Association said the number is much higher than many other countries.
Concerns have been raised about the quality of personal protective equipment (PPE). Doctors are staying away from families and coming to the duty from hotels. They are also quarantining themselves after every roaster duty.
On the contrary, in the United States, doctors are doing hospital duty staying with their families at home. Same hospital is giving treatment to patients divided in covid and non-covid zones.
There is no voluntary quarantine system for healthcare workers like in Bangladesh. Then how do they manage?
“We could do it because our workplace ensured proper protection,” Dr. Chandan Mitra, who is working in a tertiary hospital in the state of Iowa in the United States, told Bangladesh Post.
“I know resources are limited in Bangladesh but there are certain things we can do and certain initiatives we can take. Transparency and evidence based information is the key,” he said. “I am concerned about the safety of our fellow frontline physicians.”
Dr Mitra is an Associate Director of Internal Medicine Residency at the Mercy One Medical Center and an Adjunct Assistant Professor, DesMoines University College of Medicine. He studied MBBS at Dhaka Medical College.
He said there are some key issues that need to be practiced to remain safe - from proper planning to proper use and disposal of PPE.
“But top of all we need to recognize the frontline workers at hospitals that they are the real hero. When I get this recognition from my hospital and from my neighbours where I live, I feel encouraged and this enhances my sense of responsibility,” he said in a telephone conversation.
Dr Mitra’s hospital with 400-bed was very busy until two weeks ago, as the health system of Mercy One provided care to more than half of the patients of the state of Iowa.
Currently cases are slowing down in Iowa. “Thankfully none of our physicians, residents, and nurses was affected during this unprecedented time while providing care to the patients,” he said.
Proper planning
“The first step we have taken is the proper planning of how to deal with the pandemic involving the representatives of all hospital staff from doctors to cleaners.
“We are learning every day. Treatment is changing with the new evidence coming up. But globally we all know and agree on certain issues which are how to prevent the virus.
“When the pandemic was announced, we did an assessment how many patients can be infected? Do we have the capacity to treat them? What will we need if we treat them? And how will we protect those who will treat them?
“The hospital formed a committee with the representatives of all staff. And they were telling their own situation.
“Our aim was to ensure maximum utilization of our internal resources. So we stopped all the routine procedures such as hernia, knee surgery or colonoscopy… I mean things that can wait a month or two and there is low risk of those patients' health.
“Then we found that many of the hospital beds became available. It also freed up some manpower – doctors, nurses and others who were attending those patients.
“This also helped them to get some more ventilators because in each operation room there are ventilators for those who need to be intubated. If we can stop routine surgeries, then we can free up some ventilators,” he said, giving an example of internal resource mobilisation.
“Then we focused on visitor control which is important to prevent infection. It’s difficult for Bangladesh because of low doctors, and nurses ratio. It's so low that patients need attendants because nurses cannot stay all the time.
“So in that case you can restrict to one attendant. And the attendant has to obey the protection rules to prevent the spread.
“All entrances of our hospital except two were closed. On the entry, temperature is checked and all, including doctors and other staff, are asked a few questions whether I was ill or not. It's the same for all from doctors to cleaners to attendants. Fewer visitors mean fewer crowds in hospital,” he said.
The hospital is divided into covid and non-covid floor.
“In non-covid we are a bit relaxed and in covid floor we work with personal protection.”
“In 90 percent cases patients get well with supportive care. Since we say visitors cannot stay. Then we doctors and nurses have to give the service all the time, preventing us from infection.”
PPE
PPE is a much-talked about issue in Bangladesh.
“We also have PPE shortage. But when we go to the field, we have to have some weapons. We cannot send an army without a tank or gun in the battlefield. Then it’s confirmed death. PPE is like that for healthcare workers during this war against the virus.
Supply of the PPE is a big factor, he said.
In the US, they don’t wear coveralls. They wear four things – face shield, masks, gloves and gown.
“We wear disposable gowns. Most of the cases we wear surgical masks. In aerosol generating places such as ICU, we use N95 masks.
“We have to ensure quality and adequate supply of PPE.
“But all healthcare workers need to know and should be trained on how to use it and remove it before disposal.
“Its not only for doctors. It’s for all – nurses, cleaners and lab technicians. If all do not use it and only doctors use it, then infection control is not possible.
He said there is no use of wearing PPE all the time. “This can spread the virus from one place to another and giving the person who is wearing it a false sense of security”.
“In our hospital, there is a room for us to wear PPE at the Covid zone before seeing patients. And completing the rounds, we enter another room for removing those and cleaning the stethoscope and other items before we leave the covid zone.
“And then again I have to wear another gown when I go to a new unit to see another round of patients.
“The idea is if I roam around wearing one gown and think that I am protected, basically I am spreading the virus among all. If I come to the duty doctors’ room with the PPE that I used in the patients’ room, then I can pass on the infection to my other colleagues”
“If I walk inside the hospital wearing the gown and then I can spread it to others because droplets can be there on the gown,” he said.
“For that, we need an adequate supply of PPE,” he said, adding that Bangladesh has the capacity to ensure that supply.
“Importing PPE is costly and it’s not feasible to ensure proper supply. Now Bangladesh is exporting PPE which means you can make it.
“Now someone has to take the lead and say yes we will do it. Then I think you will get so many philanthropists to donate for that purpose.”
He said in his state, workers of a tractor company who have nothing to do at this time of pandemic decided to make face shields for hospitals.
“In one month, they made 4.5 lakh face shields and supplied them everywhere,” he said.
Telemedicine
They are applying telemedicine technology to listen to the patients’ concerns all the time while minimising exposure among the hospital's own medical staff.
They use telemedicine carts that allow workers to roll cameras into a patient’s room or bed side and talk to the doctor directly.
“And then when we go physically there, we can complete checking everything within five or 10 minutes which usually takes 20/25 minutes. So we can reduce the exposure time drastically, lessening the risk of infection,” he said, adding that this can reduce the use of PPE.
“Many things patients want to say. If the patient is not critical, they can talk over telemedicine.
“We can cut the use of PPE. If we need to enter the room 10 times, we have to use 10 gowns. It's not possible since we have a shortage of PPE. So telemedicine gave us a huge benefit,” he said.
Transparency is the key
He said the hospital committee is so transparent that they keep them updated all the time with what they have or what they don’t have from PPE to beds or ventilators. All hospital related information we are getting.
“It’s very useful. Because then I feel like that I am part of the process.”
“And whenever anybody wants to say anything – they can speak. It comes from both sides. If the person does not know the problem, then how will they solve it? So it’s two-way information.
The hospital cleaner also sits at that committee and speaks on behalf of them.
“If I think what I am saying is always correct, it’s not correct. We need to acknowledge the mistake. If we acknowledge the mistake, then our acceptability will increase,” he said, emphasizing on trust building between the policy makers and the healthcare providers.