As Covid-19 death toll rises in Malaysia, bodies wait in queue for last rites

KUALA LUMPUR― The high death toll due to Covid-19 in Malaysia lately has caused the National Institute of Forensic Medicine (IPFN) to face a bitter situation when experiencing backlogs in the management of the bodies, as a result of the outbreak and non-Covid-19 death cases.

In contrast to the management of bodies of non-Covid-19 patients, the Covid-19 deaths need to be managed with the utmost care by the frontliners, and expedited for burial or cremation.

Kuala Lumpur Hospital (HKL) forensic pathologist Dr Salmah Arshad said that the existing space in the IPFN morgue was not sufficient, and the victims were now placed in containers which were turned into makeshift morgues that could store 12 to 20 bodies of Covid-19 patients.

She said that the IPFN morgue can store up to 36 bodies but there were additional spaces for this purpose, including the Tunku Azizah Hospital (up to 10 bodies), Tuanku Mizan Armed Forces Hospital (four) and the National Cancer Institute (two). There are 52 coffins, and back-up containers to store the bodies.

According to Dr Salmah, for the remains of non-Muslims, the next-of-kin can choose whether the body is to be buried or cremated, and each cremation process takes between two and three hours, compared with non-Covid-19 cases, which take 45 minutes to an hour.

The 41-year-old specialist doctor, who has been in the forensic field for 13 years, said that the increase in the number of brought-in-dead (BID) cases due to the outbreak was increasingly worrying.

She said that during the first wave of the pandemic, the death rate of Covid-19 outside the ward was only one or two cases a month, compared with now which reached three or four such cases daily.

“Compared with last year, we rarely receive cases (deaths) at home, (on the contrary) we receive cases at the hospital. That means patients are admitted to the ward, are treated, and die in the hospital. What worries me now is the deaths outside the hospital, which have not been treated. The symptoms are too rapid and this is depressing.

“Indeed, there have been changes. In the past, we expected deaths involving elderly patients, and diseases such as heart, kidney and obesity. In the first wave, those were the factors that contributed to the risk of death last year.

“We cannot predict the third wave because it involves both young and old. The youngest we received who died at home was in their 20s and had no illness. Now everyone has to be careful and follow the standard operating procedures (SOPs), because everyone can be exposed and die because of Covid-19,” she said, and advised people to be vigilant, even with the neighbours next door.

She did not rule out the possibility that mutations and variants in the virus contributed to changes in the categories of victims, including young people with no history of health problems.

Workers wearing personal protective equipment (PPE) carry the body of a Covid-19 victim at a cemetery in Shah Alam February 11, 2021. — Picture by Yusof Mat Isa

On the post-mortem process involving the case of BID Covid-19 or suspected Covid-19, Dr Salmah, who started working at HKL early last year, said that the CT (computed tomography) scanning method was used to reduce the risk of infection to staff on duty.

The method is to detect the condition of the lungs and other organs of the deceased, such as lung infection or pneumonia without conducting a regular autopsy.

“We only do external checks. Post-mortem via CT scan to see the condition of the lungs or other organs. Does the lung show severe bacterial infection or pneumonia due to Covid-19? So we can put the cause of death as ‘Covid pneumonia’ or ‘pneumonia due to Covid’,” she said.

Meanwhile, HKL IPFN assistant medical officer Hisham Mohd Nordin explained that the Covid-19 cremation process time doubled from normal as two layers of body bags made of thick, high-density plastic were used.

After nearly four years serving in the Forensic Department, Hisham, who was responsible for managing bodies, said that should a person die as a result of the outbreak there would be no immediate family members to pay their last respects to the deceased, as in most cases they were under follow-up quarantine.

“Mostly family members (living together) would be under quarantine. It is very sad when the next-of-kin cannot pay their last respects to the victims. We use our discretion with the health inspector to persuade the next-of-kin to send a representative (who is not a close contact) to deal with the remains.

“The condition of the staff here is that we are all very tired. There were times when we had to handle 15 cases in one night. My advice is to follow the precautionary measures and adhere to the SOPs. When the government suggests taking a vaccine, take it We want to achieve herd immunity,” he said.

He said that the public should assist all frontliners, not only from the Forensic Department but also in hospital wards, and especially in the Intensive Care Unit, by complying with the SOPs and applying self-discipline.

To follow the interview with Dr Salmah and find out about the management of the remains of Covid-19 patients, watch the second part of the documentary Gelombang Kembali: Bilakan Berakhir? produced by Bernama TV, to be broadcast on Friday at 8.30pm. ― Bernama

Doctors dread day they are forced to decide who lives and dies

There is a shortage of healthcare workers who can look after critically ill patients, such as staff nurses who tend to those in the intensive care units, say doctors. – The Malaysian Insight file pic, June 9, 2021.
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.

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.  THE MALAYSIAN INSIGHT