MANILA, Philippines – Gelza Zabat wakes up an hour before the start of her 8 am rounds. The house is empty now – her mother had to move out when she started to treat patients with coronavirus disease (COVID-19). She gets into her car that no one else can ride, and drives off for another day of duty.
39-year-old Gelza, just one of the many doctors in the country who treat COVID-19 patients, enters the hospital wing quietly. Everyone wears masks, so they smile with their eyes.
The hospital buzzes with doctors, nurses, nursing aids, medical technicians, respiratory therapists, and janitors. Gelza asks her colleagues how they are today, but more importantly, if they are okay.
There is a long line of patients hoping to be tested for the novel coronavirus, each fearful for their lives and families. Healthcare workers put on calm faces, explaining why they have to be sent home, why they need to be admitted, or why they have to be transferred due to the hospital’s full capacity.
“Inside the emergency room (ER), it is organized chaos. Everyone helps each other. Everyone knows their place, each one trying to uplift each other so no one gets exposed…so that we, doctors, do not become patients,” said Gelza, an infectious disease specialist.
Once an “unexplained pneumonia” rising in a Chinese city, the novel coronavirus was declared a pandemic by the World Health Organization (WHO) on March 12. Frontline healthcare workers across the world brace themselves to treat a disease with no known cure yet.
Confirmed cases in the Philippines spiked from 3 to 202 in less than two weeks. The pandemic pushed the government to impose a community quarantine first in Metro Manila, and then the entire Luzon 3 days later.
Gelza works in public and private hospitals, and notes that all hands are on deck, regardless of specialization. “This is not a fight anymore of just infectious disease specialists, pulmonologists, or internists – this has become a fight between the healthcare system and a minute virus that is spreading oh-so-rapidly.”
While many Filipinos are confined to their homes, health workers, in intervals, enter the battlefield with the virus daily.
Every shift a risk
Dave Dato is probably among the high-risk in the frontlines, working in the emergency room (ER). Dave can be found in the ERs of one public and two private hospitals: the Department of Health (DOH)-affiliated Rizal Medical Center (RMC), East Pateros Medical Center, and Medical Center Taguig. He said he wants to be wherever the action is.
On mornings he works, he brings his wife, a teacher, and two daughters to school. He does not see them until 24 hours later, when his shift is over.
In the emergency room, Dave dons his protective gear and isolates patients who are potentially at their most contagious state. After initial examination, the ER team uses a DOH-supplied decision tool to determine whether a patient needs surveillance or would be sent home instead. This decision tool guides healthcare workers in categorizing a patient as either a person under investigation (PUI), person under monitoring (PUM), or neither.
Entering the special areas with COVID-19 patients takes much more time, with a process of sanitizing and wearing personal protective equipment (PPE): a gown, masks, face shield, goggles, hair cap, boots, and gloves.
COVID-19 patients are afraid, Gelza said. “Their question is always if they will get better. Unfortunately, this disease does not have a cure yet, and we can only say that we are doing the best we can to give supportive care.”
Dave said there are some PUIs that are fatalistic – even those without results yet. Since the coronavirus is new, doctors themselves are learning more about it and can only do so much to reassure their patients. But they try to the best of their abilities.
When some patients get into an asymptomatic, stable condition, they are free to be discharged to continue recovering at home, subject to a 14-day home quarantine. However, doctors still have to calm their fears of possibly infecting their families.
At some point, doctors go home too. When Dave gets home from his 24-hour shifts, he removes his clothes in the garage, goes straight to the shower, and only after then greets his daughters. “I have to avoid kissing and hugging them even if I want to. Minsan nakakalimutan (Sometimes I forget),” he said.
Meanwhile, for Gelza, the day doesn’t end when she gets home. This is when she starts answering messages from friends or relatives with questions about the outbreak to make sure they get the right information.
“Even in the wee hours, we’re always on call in the triage to assess if someone is a PUI, for sending home, or whatever disposition,” she said.
When asked about what concerns healthcare workers have, even in private hospitals, the mention of insufficient PPEs resounds. Ideally, each PPE set is used for treating one patient and then discarded, according to Dave. But now whatever can be used again by the same individual is just sanitized.
The Philippine Hospital Association told the House of Representatives on March 11 that there is a “grave deficit” of PPEs, causing doctors to improvise. Old linen is used to make cloth masks, and raincoats are used as bare-minimum hazardous material suits.
Private hospital doctors understand the need for the government to prioritize public hospitals in providing supplies. But with coronavirus patients and PUIs divided among both public and private hospitals, even the latter experiences shortage. Dave attributed one of the causes to consumer hoarding of face masks. “Even the suppliers don’t have supplies,” he said. (READ: Left in the dark: Little protection for government’s coronavirus frontliners)
Dave said RMC has begun using ambulances as transportation for duty personnel due to Luzon’s enhanced community quarantine. It hasn’t been much of an issue yet, but Dave, who is also a supervisor at RMC, said they foresee issues arising if ambulances are used to transport personnel when they could be transporting patients.
Dave thinks the country’s healthcare system was not prepared for a pandemic. In 300-bed capacity RMC, there are only 4 isolation rooms readily available for COVID-19 patients.
Philippine College of Emergency Medicine (PCEM) president Pauline Convocar backs this up. She said hospitals with no specialization in infectious diseases like the Research Insitute for Tropical Medicine, whether public or private, generally lack isolation facilities.
Dave also said citizens should be “more disciplined.” Even with limited resources for infectious diseases, he thinks the contagion would not have turned out this way if people behaved with self-quarantining and social distancing.
Dave was on duty during the outbreaks of SARS (Severe Acute Respiratory Syndrom) and Influenza A/H1N1, and said that what we are experiencing today is far from what happened then.
“Ito talaga nakikita mo sa TV or movies. Inaantay ko na lang na may zombies na darating. End of the world na ba? Babalik na ba tayo sa simple life? Ito na ang pinaka-worst epidemic na nakita ko sa 17 years na experience ko,” he said.
(This is the kind of things you see on TV or movies. I’m just waiting for zombies to come out. Is it the end of the world? Will we go back to the simple life? This is the worst epidemic that I’ve seen in my 17 years of experience.)
Pauline of PCEM asked, “Who really is prepared?” The virus knows no socio-economic class. She pointed to the case of first-world country Italy – with around 30,000 cases to date, just second to China.
According to a 2017 WHO report, there are only roughly 4 doctors for every 10,000 people in the Philippines. On top of this, Pauline said there are only around 300 active emergency medicine physicians in the country at present.
“We recognize the fact that there were gaps in the beginning. But the emergency department is the safety net of the public health system. ‘Pag meron nang gap doon, saan sila pupunta (If there is a gap there, where would patients go)?” she said.
Fears and strengths
As an emergency medicine specialist and father, Dave embodies a mix of resilience and uncertainty in his thoughts about contracting the virus.
“Personally, accept ko na ‘yung fact na puwede na ako mahawa. Pero pinagdadasal ko na sana hindi – gusto kong maka-serve ng maraming tao. Hero daw ako. Eh, trabaho ‘to eh… Nagiging overwhelming na ang patients na nagiging PUIs, PUMs, and eventually nagiging COVID-positive. Pero ready na kami,” he said.
(I personally accept the fact that I can contract the virus. But I pray that I won’t get sick – I want to serve many people. They say I’m a hero, but this is just my job… The number of patients that are becoming PUIs, PUMs, and eventually COVID-positive is already becoming overwhelming, but we’re ready.)
“It’s my calling and my passion – manggamot (to cure). I’m voluntarily giving my life to serve my country. Ito pinasukan ko, at alam naman ng family ko (This is what I got myself into, and my family knows that),” Dave added.
As much as health workers are glorified as heroes, they shy away from being portrayed as such. Away from the eyes of their patients, they worry for their own safety.
“I think everyone is afraid. Combine that with fatigue… I fear I might miss an infection prevention protocol. But above that, I fear for those I can infect should I be infected by the virus,” said Gelza.
Protecting the frontliners
On March 14, PCEM sent the DOH a position statement outlining how frontline workers can be better helped when the lockdown kicks in. Among their requests were adequate PPEs, support when exposed or when PPEs are breached, hazard pay compensation for both public and private hospitals, and psychological aid and debriefings for the healthcare workforce.
Gelza turns her fear into energy, similar to how the idea of serving more patients grounds Dave.
“I think we [healthcare workers] should channel this fear in such a way that we check, double-check, triple-check our PPEs, that we make sure that infection control is in place, that we make sure other healthcare workers are protected as well. We should take this opportunity to educate and lessen fear of the public as we ourselves feel it… and to commend other [frontliners] and boost their morale and confidence,” Gelza said.
She sheds tears when she sees initiatives on social media to help healthcare workers. She knows that with this, healthcare workers, along with the hospital staff and maintenance, will never face this pandemic alone.
“As we take care of the sick, the Filipinos take care of us too,” she said.
Some healthcare workers need to step back and quarantine, especially when they suspect their protective equipment were breached. On those days, doctors who are still fit to work need to courageously fill the void left by their colleagues.
“Strength is finite. The numbers (in manpower) are decreasing, but we still show up. We took an oath. If you ask me if we cry behind closed doors, we do. But we show up,” said Pauline. – Rappler.com
TOP PHOTO: PREPARING. The Quezon City Disaster Risk Reduction and Management Office demonstrates to barangay first responders how to use protective gear properly in case COVID-19 hits their barangays. Photo by Darren Langit/Rappler