BRAVING THE STORM

COVID-19 Journey

2

4

Malaysia’s COVID-19 daily cases

Malaysia COVID-19 Timeline 25 January 2020

: First confirmed COVID-19 case in Malaysia

18 March 2020

: Movement Control Order

1 October 2020

: Third wave outbreak

13 January 2021 : Movement Control Order 2.0

24 February 2021 : Vaccine rollout begins

6

1000 900 800 700 600 500 400 300 200

100

1-May-22

1-Apr-22

1-Mar-22

1-Feb-22

1-Jan-22

1-Dec-21

1-Nov-21

1-Oct-21

1-Sep-21

1-Aug-21

1-Jul-21

1-Jun-21

1-May-21

1-Apr-21

1-Mar-21

1-Feb-21

1-Jan-21

1-Dec-20

1-Nov-20

1-Oct-20

1-Sep-20

1-Aug-20

1-Jul-20

1-Jun-20

1-May-20

1-Apr-20

1-Mar-20

1-Feb-20

1-Jan-20

0

Sungai Buloh Hospital COVID-19 admissions

HSgB COVID-19 Timeline 25 January 2021 : Visit from YB Tengku Zafrul in Hospital Sungai Buloh 27 February 2021 : Opening of Vaccination Center Hospital Sungai Buloh 13 May 2021

: Visit from KSU Dato’ Shafiq in Hospital Sungai Buloh

9 July 2021

: Opening of Long COVID-19 wards in Hospital Sungai Buloh

14 July 2021

: Addition of vacuum insulated evaporator in Hospital Sungai Buloh

16 July 2021

: Convertion of Specialist Clinics and Radiology department to cater for the surge of patients

13 August 2021

: Malaysian Armed Forces helped with the logistics of oxygen tanks for patients in PKKN and management of the deceased in Forensics Department

30 August 2021

: Forensic Department used 5 body containers which can keep up to a total of 90 deceased COVID-19 patients

11 October 2021

: Officiating and opening 136 beds in Oxygenated Wards in PKKN Line B

16 December 2021 : Hospital Sungai Buloh Staff Appreciation Day

Editorial Board Members. From left to right : Ms Nurizzan Fakhrani binti Zulkifli, Dr. Suriyakala Balachandran, Dr. Swarna Lata Krishnabahawan, Dr. Shafiq Eiman Abdul Razak, Mr Mohamed Helmi Deris@Abdullah, Dr. Liew Boon Seng,

Dr. Kuldip Kaur Prem Singh, Dr. Benedict Sim Lim Heng, Dr. Akmal Hafizah Zamli, Ms Rekha Maryanne Louis, Dr. Ahmad Zawir Mohamad Sharif, Dr. Ng Kah Ting

The book Odyssey: Braving the Storm - COVID-19 Journey Sungai Buloh Hospital, Malaysia is published by Postgraduate Society of Sungai Buloh Hospital. Copyright © 2022 Postgraduate Society of Sungai Buloh Hospital. All rights reserved. This publication is copyrighted. Other than for academic research, criticism or review, as permitted by the Copyright Act 1987, no part or image from this publication may be reproduced by any process without written permission of the copyright holders. Requests for permission to reproduce this publication whether for commercial or for non-commercial distribution should be addressed to the Postgraduate Society of Sungai Buloh Hospital. The colours of artworks featured in this publication may vary from the original electronic version due to technical and reproduction limitations. Disclaimer: The details, views, interpretations, implications, conclusions and recommendations expressed in this book are exclusively from the authors and do not necessarily represent the opinions, views or policy of the Ministry of Health Malaysia. Published information in this book reflects the events that took place in the subsequent two waves of the COVID-19 pandemic that hit Malaysia until 30thApril 2022. All reasonable precautions have been taken by the authors to ensure the accuracy of all the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and uses of the material lies with the reader. In no event shall the authors be liable for damages arising from its use. Publisher: The Postgraduate Society of Sungai Buloh Hospital Jalan Hospital, Hospital Sungai Buloh, 47000 Sungai Buloh, Selangor Darul Ehsan. Perpustakaan Negara Malaysia

Cataloguing-in-Publication Data

Odyssey BRAVING THE STORM : SUNGAI BULOH HOSPITAL SELANGOR, MALAYSIA. ISBN 978-967-19838-1-2 (hardback) 1. Hospital Sungai Buloh--Anecdotes. 2. Hospitals--Malaysia--Sungai Buloh (Selangor)--Anecdotes. 3. Health facilities--Malaysia--Sungai Buloh (Selangor)--Anecdotes. 4. COVID-19 (Disease)--Anecdotes. 5. COVID-19 Pandemic, 2022--Anecdotes. 6. Government publications-Malaysia.808.882

Contents • Forewords 12 • Preface 20 • Chapter 1 : The Shipwright’s Tale 22 • Chapter 2 : Charting The Unknown Seas 46 • Chapter 3 : Braving The Storms 66 • Chapter 4 : Singing The Sea Shanty 134 • Chapter 5 : Shore Beyond The Sea 164 • Chapter 6 : Legends Of The Sea 194 • Chapter 7 : Our Memory Lane 222

YBMK KHAIRY JAMALUDDIN Health Minister Ministry of Health, Malaysia

FOREWORD YBMK KHAIRY JAMALUDDIN HEALTH MINISTER MINISTER OF HEALTH, MALAYSIA The pandemic did not just plague our citizens but also burdened our already overwhelmed public healthcare system in Malaysia. Hospital Sungai Buloh, in particular, survived the deepest and darkest challenges of being at the forefront of this pandemic with grace and fortitude. During my time as both the minister in charge of the National COVID-19 Vaccination Program (PICK) and in my current capacity as Minister of Health, I have had the privilege of closely following the nation and Sungai Buloh’s COVID-19 effort and to say that this is a hospital of great strength and robustness is definitely an understatement. As we are working towards a future-proof healthcare system that will ensure entities like Hospital Sungai Buloh will be able to better withstand the harshness of epidemics, we must not forget the past effort and strength of will of our healthcare workers. To the entire staff team at Hospital Sungai Buloh who deserve the highest praise, I personally thank you from the bottom of my heart. Thank you for your irreplaceable service to the nation.

KHAIRY JAMALUDDIN 13

DATUK HARJEET SINGH HARDEV SINGH Secretary General Ministry of Health, Malaysia 14

FOREWORD DATUK HARJEET SINGH HARDEV SINGH SECRETARY GENERAL MINISTRY OF HEALTH, MALAYSIA In my 33 years serving in the Malaysian civil service, never once did I imagine that we would be confronted by such a calamitous event as the COVID-19 pandemic. The nation, nay, the world, was brought to its knees, sustained by the blood, sweat and tears of our brave frontliners.

Through my service in the Ministry of Health since 2020, I have overseen and managed on a macro-level, the response of our healthcare system towards the COVID-19 pandemic. Shrewd and meticulous financial planning, management and procurement was paramount to combatting this pandemic, and I would like to express my gratitude to the government for allocating an additional budget in support of the Ministry of Health for this express purpose. My passion is photography, and I would like to say that “photography is the only language that can be understood anywhere in the world”, to quote the late Bruno Barbey. The photos presented here in this book are a visual monument that transcends words, to the spirit of the dedicated healthcare workers of Hospital Sungai Buloh throughout the COVID-19 pandemic. Words cannot adequately express how grateful we are as a nation to you.

DATUK HARJEET SINGH HARDEV SINGH 15

TAN SRI DATO’ SERI DR. NOOR HISHAM ABDULLAH Director General of Health Ministry of Health, Malaysia

16

FOREWORD TAN SRI DATO‘ SERI DR. NOOR HISHAM ABDULLAH DIRECTOR GENERAL OF HEALTH MINISTRY OF HEALTH, MALAYSIA THE COVID-19 PANDEMIC is one of the most significant global public health crises humankind has ever faced. Together with the worldwide healthcare community, Malaysia has stood and continues to stand steadfast against this unseen threat.

Since the beginning of this pandemic, the Ministry of Health has been at the forefront of the nation’s battle against this virus. Thank you for the indefatigable resilience despite overwhelming situations and the willingness to serve, lead and adapt to an ever-changing healthcare landscape; our COVID-19 response as a nation has succeeded. I have heard nothing but the highest praise for Sungai Buloh Hospital, especially from the countless grateful patients that have been cared for by the inspiring healthcare workers ever since the start of the pandemic. May this memoir be an eternal testament to your sacrifices.

TAN SRI DATO‘ SERI DR. NOOR HISHAM ABDULLAH 17

DR. KULDIP KAUR PREM SINGH Director of Sungai Buloh Hospital Ministry of Health, Malaysia

18

FOREWORD DR. KULDIP KAUR PREM SINGH DIRECTOR OF HOSPITAL SUNGAI BULOH What else can I say that hasn’t already been said about the grit and mettle of our Hospital Sungai Buloh frontliners? In all my years serving in the Ministry of Health, I have been incredibly privileged to work with talented, diligent, and courageous healthcare professionals, and the COVID-19 pandemic brought out the very best in us. As an institution given the solemn charge of managing this new pandemic, we dug our heels in and stood our ground, emerging triumphant. These precious memories of the challenges faced by Hospital Sungai Buloh are immortalized in visual form for you, the reader, to peruse. A picture is worth a thousand words, and we invite you to experience what we overcame throughout the COVID-19 pandemic. “…it ain't about how hard you hit. It's about how hard you can get hit and keep moving forward; how much you can take and keep moving forward. That's how winning is done!” – Rocky Balboa

DR. KULDIP KAUR PREM SINGH 19

Preface From emersion to odyssey the voyage continues with the nautical theme to depict the many facets of the pandemic, navigating through this waveform of uncertainties. The elements of nature, water and wind intertwines to illustrate both the harsh and calmness of the journey we were all enduring. As we all waited in anticipation for year 2022 to finally draw its curtain on this pandemic after a two year hiatus of what we once knew as normalcy, it seemed surreal that we were tested yet again with new variants emerging at warp speed and infection rates charting record highs. The only hope we had was with the rapid roll out of the national vaccination programme, we awaited the prospect of quick recoveries and less severe cases. If anything, these past two years has taught us to constantly be prepared, stay on guard and be quick on our feet. As the infamous saying goes “never say never”, just about anything can happen in a split second and so it did. This mirage of a nemesis we’re all fighting…so invincible in its existence, so swift in its domination and so unforgiving in its attack. The only armour we had was our experience and knowledge to accept, persevere keep rowing on. Vince Lombardi’s quote “a winner never quits” aptly portrayed situation where we had to brace this tumultuous storm with conviction contemplation, redefining our actions and reactions with continuous innovation exploration.

and our and and

As we yearn for an end to this chapter with an innate understanding and assurance that “all things passes”, we will continue to brave this storm with valour together. “We are one family”. With hope and faith, we will see that ray of sunlight beaming through these dark clouds and sailing us back to our safe haven. 20

Soldiers in the Trenches My steadfast soldiers in the trenches

Then I heard, amidst the blinding storm

Bleeding hearts

One voice, calm and strong

Scarred souls

"If we can't do this,

Yet eyes full of hope

nobody else will, lads"

At the battlefield they gallantly fought

Nobody else will…

Day turned to night And night to day

With eyes full of hope

Dr.enched in sweat, held back tears Uphill battle Unseen enemy Their eyes full of hope

by Dr. Norafizan Mohd Ali Consultant Emergency Physician

Emergency Department Hospital Sungai Buloh

21

THE SHIPWRIGHT'S TALES

Bewildering Hope The earlier Malaysian success of curtailing the second wave of COVID-19, which reached its high point in early August 2020 when we only had one case in the whole country, had long faded. Back then, we were lauded globally as a success story of how to battle COVID-19. However, there were already whisperings of concern back then as there was talk of a new COVID-19 virus variant circulating, called the D614G strain which had overtaken the native Wuhan strain (also called the wild-type virus) in terms of its ability to infect others more widely. By September 2020, cases had taken a big upturn, where cases began to spread drastically again to the whole of Malaysia. When November 2020 came around, Klang Valley had overtaken Sabah and afterwards, consistently topped the country with the most cases of COVID-19. On the local hospital scene, December 2020 saw an increase in the percentage of patients who required oxygenation in our hospital, which increased the amount of airborne spread of the virus.

The first version of the coffeebook. Emersion : Transcending The Tide

Cases in our hospital and nationwide fluctuated over the first 3 months of the year. This was understandably a source of frustration, especially for our hospital. Prior to the pandemic, Hospital Sungai Buloh was home to a host of specialties and subspecialties and was a tertiary and regional referral center for many disciplines. Converting the hospital into a fully COVID-19 hospital, while strategic at that time, came at a significant price. There were many patients who had their treatments interrupted or delayed. Some sadly ended up lost to follow-up. Others had to go to other hospitals that were less equipped to deal with their illness and were less familiar with their illness or the patients themselves. Patients from around the Petaling and Gombak districts (two of the most populous districts in the most populous state in the country) found themselves short of an emergency department to deal with acute illnesses and not having their regional hospital able to cater to them if they did not have COVID-19. Doctors, especially junior doctors in the front lines of COVID-19, were also in a limbo. Many had already served for a year seeing nothing but COVID-19 patients. There was concern that their training to be a full-fledged doctor, specializing in their field of interest was taking a back seat. Surgeons, anaesthetists, radiologists, and physicians were wondering when they will be able to go back to their patients and the field of medicine that they had chosen. Meanwhile neighbouring hospitals were overwhelmed with non-COVID-19 patients, our hospital had to remain calm, strong and focused to treat the rising COVID-19 cases.

23

Aiding Analysis – Strategizing Statistically by Dr. Imran Bin Abd Jamil Sungai Buloh Hospital’s Crisis Preparedness & Response Centre (CPRC) was previously disbanded late June 2020 after the significant drop of COVID-19 cases in Klang Valley specifically & Malaysia in general. Admission number was down to single digits daily. However, with the sudden surge of COVID-19 reemergence late September 2020, they were swift to reinitiate CPRC 2.0 officially on 2nd October 2020. Led by Chief Assistant Director, Dr. Harsheila Hasnan, the old gang was rounded up and some new faces joined in to take on the challenge again.

Third Wave Nightmares The pandemic wave hit Malaysia hard on the third round. From the tens, to the hundreds & finally over 20,000 new cases climaxed in August 2021. At Sungai Buloh Hospital, daily admission peaked close to 1000. The rise of new cases also meant increasing trend of severe COVID-19 cases & deaths, including brought-in-dead (BIDs). Sungai Buloh Hospital went into beast mode to deal with this nightmare. The Hospital expanded usage of all National Leprosy Centre facilities (PKKN) – PKKN East, PKKN West & even the Communal Hall. ILKKM was reopened for quarantine with double capacity of all 8 blocks, creating 2400 extra beds. ICU team worked tirelessly creating up to 100 critical care beds. This meant the dedicated CPRC 2.0 team worked around the clock, open 24/7 collecting data regarding all admissions, discharges & deaths. The worrying trend also led to other data collection for further analysis of the “invisible villain”. Hospital resources were also monitored to ensure sufficient supply for daily management. In the early stages of National Vaccination Program introduction, CPRC was also brought in to monitor vaccination of Hospital staff to add to their resume.

24

Breathing Space Despite the challenges faced by Sungai Buloh Hospital, CPRC 2.0 managed to run stronger & more smoothly. Tasks were focused on mainly data collections & analysis. The team was relieved of transportation duty, previously set to move patients to-and-fro the Hospital & quarantine centers. As time went by, the data collection method evolved & matured to be more comprehensive with more aspects covered. Established partnership with Bed Management Unit (BMU) & Infectious Disease (ID) teams made it even easier to convey & share information regarding related COVID-19 issues. Despite soaring number of new COVID-19 cases in Malaysia generally & Klang Valley specifically, the number of admissions saw a steady trend which was slowly coming down as the Ministry of Health (M)OH) began to allow stable positive patients to quarantine at home. The success of the National Vaccination Program also reflected by reducing number of severe cases & deaths. As the tide slowly subsided, Medical Officers were brought back into their own respective Departments. Hence, CPRC 2.0 began sizing down their scale & working daytime while continuing to collect & provide necessary data for the Hospital & MOH. Recognitions Everyone played a role tackling the COVID-19 pandemic, and that also included CPRC. Working closely with ID team & MOH, collecting & sharing their analysed data. By mean no small feat, this became part of evidence for propagating the National Vaccination Program. This became a key moment in the war against COVID-19 that showed drastic reduction in severe COVID19 cases & deaths.

Bewildering Hope : Bed Management Unit meetings – matters pertaining to the speed and efficiency of bed allocation were discussed and planned out

25

26

Bewildering Hope : Intensive Care Unit meeting on expansion of ICU capacity and capability in anticipation of increasing COVID-19 critically ill patient numbers

Bewildering Hope : Disaster patient evacuation drills facilitated and coordinated by the fire department

27

28

Bewildering Hope : Disaster patient evacuation drills facilitated and coordinated by the fire department - hospital emergency response team pictured

Bewildering Hope : Patient resuscitation refresher training – crucial for safely managing unstable COVID-19 patients

29

30

Bewildering Hope : COVID-19 patient placement and bed allocation planning by the Bed Management Unit

Bewildering Hope : Regularly scheduled Continuous Nursing Education sessions on the latest COVID-19 updates

31

32

Bewildering Hope : Regularly scheduled Continuous Medical Education sessions

Bewildering Hope : Interdepartmental/inter-hospital video conferencing –the pandemic hastened the widespread use of new technologies like video conferencing

33

34

Bewildering Hope : A glimpse of MECC (Medical Emergency Call Centre) – the control centre for our emergency response services

Bewildering Hope : Installation of ventilation fans in the wards for the safety and comfort of patients and staff by improving air circulation and removing contaminated air

35

36

Bewildering Hope : Enhancing electrical socket and wiring installations for the sharp increase in medical devices needed in COVID-19 wards

Bewildering Hope : Donations of hospital beds and other vital equipment through CSR – crucial and timely to accommodate the expansion of hospital bed capacity

37

38

Bewildering Hope : Our extreme last option, converting clinic space into wards, pushing COVID-19 patient bed capacity to the extreme

Bewildering Hope : Contribution of medical consumables from various bodies as part of Corporate Social Responsibility (CSR) – all Malaysians contributed to the COVID-19 fight

39

40

Bewildering Hope : Additional supply stock of oxygen tanks for utilisation in PKKN – essential and life saving

Bewildering Hope : Installing the new vacuum insulated evaporator (VIE) tank in ED as part of Hospital Sungai Buloh care optimization measures

41

42

Bewildering Hope : New oxygen panels built in PKKN, expanding the number of hospital beds to manage category 4 COVID-19 patients

“Fight the good fight, run the good race, always keep the faith. By uniting and working together, we will emerge stronger” Dr. Benedict Sim

43

CHARTING THE UNKNOWN SEAS

The Unprecedented Continuum As 2020 came to a close, it was obvious to everyone that COVID-19 wasn’t going anywhere and would continue to play a significant role in our hospital, country and world. So the start of 2021 was greeted with a lot of trepidation. By this time, we had also heard of different variants of COVID-19 in other countries. Variants then were not named according to the Greek alphabets yet, and we referred to them as the UK variant (later known as Alpha), South African variant (Beta) and the Brazil variant (Gamma). These variants were of concern because they could cause one or more of 5 things. Either they could spread more quickly than the original virus; or they could lead to more severe disease; or that they could evade immune defenses of patients more easily (immune defenses either from prior COVID-19 infection or from vaccination); or that they were more difficult to detect (by evading the standard diagnostic tests that were used to detect COVID-19) or they were more difficult to treat and were resistant to antiviral medications. By April 2021, alarm bells started ringing. Reports were coming out of India about another variant of the virus, which would later be known as the Delta variant. The Delta variant came packed with a whole host of trickery. It was later discovered that to be infected with Delta means that one had 1000 times more virus in your body than if you had been infected with the wild-type virus; it infected the next person 2 days earlier on average (compared to wild type) meaning that people were getting infected faster and thus had less chance of being isolated. Many more young people who were considered at lower risk of severe disease, still came down with severe disease when infected with Delta. Most importantly though, Delta brought more deaths. Significantly more deaths. Some of these deaths could be attributed for by increased virulence of the virus, which was later proven in many papers. But the other huge contribution to deaths was because it spread so rapidly that health care systems in the country would very soon be swamped and overburdened to breaking point. We saw that happening very vividly in India, especially in late April and May 2021.

COVID-19 Delta variant first hit Malaysia in early May 2021. During that first week of May 2021, there were around 25 thousand new COVID-19 cases and around 100 deaths. It will take us till the end of December 2021 for the number to come down to those levels again. The tsunami truly hit us from mid June 2021 and lasted till September 2021. Numbers then exceeded 150,000 cases a week with mortalities reaching 2,600 a week. Within a few weeks, Hospital Sungai Buloh had reached full capacity and other hospitals had to cater for their own COVID-19 patients that turned up at their doorstep. Thousands lost their lives during these months. The memories of those months were very, very painful. Wards were full. Hospitals were full. ICU had expanded manifold and still did not have enough beds. There were at times more patients on ventilators outside ICU than within. The emergency department was overflowing with patients. 3 beds were squeezed into cubicles meant for one. So many patients everywhere that we had to convert clinics and the radiology department into makeshift wards. Anywhere, as long as it had oxygen supply. Some patients seemed well one day but the next morning, they were no longer there. Some were admitted with their whole families - fathers and sons being intubated side by side; husbands and wives dying within days of each other; children being left orphaned; patients fighting for their lives in ICU while their family members were being brought in already dead. So many nightmarish memories. I remember arguing with my ICU colleagues to bring in a 32-year-old previously healthy man with good prognosis to ICU but they could not because there were two other younger pregnant women who also needed ICU care. Having to call up relatives to tell them that we very likely could not save their father and whether they like to video call him in his last hours. Trying to encourage and cheer up a patient who had just managed to get off a ventilator while hiding the fact that her husband had passed away the day before. The worst was waking up every morning and remembering that you were still stuck in this on-going horror and not knowing whether we had even reached the worst yet. Doctors and nurses were at times like walking zombies. This was the closest to war that I had ever witnessed.

47

A Year Like No Other by Dr. Siti Suhaila Binti Hamzah, Dr. Sarah Binti Shaikh Abdul Karim, Dr. Shah Jahan Mohd Yussof, Dr. Azlean Norzan, Dr. Ummar Qayyum Ahmad Bin Ibrahim Ahmad, Dr. Soo Kok Foong, Dr. Khalid Othaman, Dr. Sonia Roy Palanisamy, Dr. Mohd Anas Mohd Nor, Dr. Tengku Nurlisa Binti Tengku Azelan Shah, Dr. Wendy Ong Yun Ru & Dr. Dina Suraya Binti Mustafa Rawther. INTRODUCTION

EMERGENCY DEPARTMENT

‘As our understanding on this virus improves, we must revise our practice both clinically and residentially to better serve the community’

‘Desperate times called for even more so desperate measures’

The Emergency Department and Trauma of Hospital Sungai Buloh has clear and essential visions in 2021: to continually improve emergency services and accessibility to emergent care for patients from all walks of life during the pandemic. These visions which are laid out by Dr. Siti Suhaila Binti Hamzah, our head of department, drive every aspect of our clinical practice and we are pleased to report that we have made some amazing progress in these areas. Hospital Sungai Buloh Emergency & Trauma department spearheaded by Dr. Siti Suhaila Binti Hamzah, our Head of Department, alongside consultants, specialists, medical officers, staff nurses, medical assistants and attendants and all its supporting staff, has seen glorious and difficult days, but none quite so as the one that hit us in the months leading from the time we learnt of this pandemic. Beginning from late January of 2020, when COVID-19 was virtually novel and so much of it not yet understood, we had already begun to prepare our staff for the worst. The innumerable training & drills, the perpetual change & innovation, of evolving protocols and of treatment. We were constantly preparing, training, ever-adapting and would like to somehow believe that it has indeed helped us to some extent when we really had to step up to the plate and was put through the wringer.

48

Our department as we know it, has evolved so much within the span of 2 years. With the ever-dynamic and turbulent times, we too, alongside the rest of the nation, had to make adjustments to continuously adapt and navigate through uncharted waters. The overhaul of our emergency services slowly morphing into COVID19 critical care and more, was certainly out of anybody’s prediction prior to this pandemic. But desperate times certainly called for even more desperate measures. Somehow or other, these tough and trying times necessitated the need for adaptability and resilience for all our staff members, from topmost to bottom. Being in emergency services, we are certainly used to things being at an ultra-fast pace. Patients come in and out of our resuscitation bays within the span of hours from first contact to stabilisation and disposition to primary teams. However, as the statistic of cases rose at a frighteningly rapid exponential rate, and the mismatch of ill patients and available beds, particularly ICU beds became more apparent, patients began to slowly pile up in our emergency cubicles, staying on for days on end something rather rare or unheard of before. Suddenly our knowledge of acute management of emergency cases had to extend to encompass the virtuoso of critical care. We had to take care of intubated patients for days, some even up to weeks, until either they were being taken up to ICU in the chance that a bed freed up, or at the other end of the spectrum, they unfortunately succumbed to the virus and its sequelae and complications it entailed. A handful of patients were also notably, successfully extubated in ED, and slowly weaned back to health. In a grey and dreary time, we certainly took the wins we could get.

Some things certainly needed getting used to. Suddenly we had to do long, detailed rounds with consultants, a practice quite common in wards but not in the fast-paced tempo of any emergency department worldwide. We had to juggle both tasks of still being the receiving end of very ill-patients presenting to our department, while also taking care of patients being lodged and warded in our observation bay as they had no available beds to house them in the normal wards above. In these rounds, sometimes multiple in a day, we had to scrutinize each patient’s progress and response to our treatment and adjust accordingly as seemed befitting.It was indeed a stressful time, as there were plenty to do, yet sick patients kept streaming in by the dozens, and our skeleton staff was already stretching thin – in energy and in patience. Most of our paramedics had to pull double or even triple shifts, nurses had to increase the ratio of nurses to patient care and doctors stayed way beyond the end of their shift times. It was a challenging time for everyone. Despite all that, we had to rise up to the occasion as we knew we had a gargantuan task ahead of us. Armed with whatever moral support we could gather and our Hippocratic Oath, we persevered and were ready to learn new things to help give our patients better care. First and foremost, because of the given number of manpower and resources we could offer, we learnt that it was necessary for us to stratify our patients via the Advanced Care Planning score. This score was borne out of the necessity to assess the global premorbid status of patients and decide the best treatment trajectory for them – some for palliation or best medical care. This situation was later made better with generous contributions such as ventilators, oxygen concentrators, high flow nasal cannula and ultrasounds, syringe pumps and volumetric pumps gained from both government and non-governmental organisations which were pivotal for patients to continue their daily battle in fighting this invisible enemy. In response to a period of significant growth in patient volumes during the peak of the outbreak, we have fostered a culture of data driven improvement, rooted in lean principles, and strengthened collaboration with various departments, that allowed us to produce innovative models of care which were essential to meet the current challenges and demands. Our specialists too had to work around the clock, becoming thinktanks coming up with new protocols and guides to better our treatment plans and ultimately leading to better patient outcomes.

We have incorporated services and expertise in advanced airway management, ventilation strategies, prone oxygenation, bronchoscopy, critical and point of care ultrasound skills, ICU care bundles, continuous and intermittent enteral feedings, inpatient medical treatment for COVID-19 and emergency dialysis in our emergency department. On paper it seemed so easy, but it was certainly a task that needed team effort and physical endurance. Taking prone ventilation as an example, from the step of preparing patients for it by padding potential pressure-sore prone areas, to the team-coordination of carrying it out, to the close monitoring that ensued, it was certainly a delicate task that needed finesse. EMERGENCY COVID-19 SCREENING CENTER

ADMISSION

(ECA)

IN

HOSPITAL

One of our emergency physicians, Dr. Noorul Hashimah has served as a coordinator overseeing all services run by the hospital screening center ever since the birth of it on 3rd February 2020. The screening center plays a crucial role in detecting infected individuals and breaking many transmission chains within the community. As part of the service expansion in screening center to cope with the pandemic surge, Emergency COVID-19 Assessment (ECA) was introduced in early 2021 to assist with patient risk stratification, clerking, examination, testing and sample collection, treatment initiation, admission and other logistic issues such as relocating patient to step-down facilities. All these services are accessible around the clock to the public; 24 hours and seven days a week including public holidays. Patients who require medical attention or oxygen therapy can be assessed and stabilised in this center, thus providing the emergency department an extra surge capacity area or holding area for admission - which was crucially-needed in the overwhelming peak of this pandemic which has certainly challenged our healthcare system capacity. Serving a pivotal role in combating the pandemic, this center has achieved a historical level of success with almost 62000 patients treated and screened in the year 2021. This success was a reflection of the huge amount of handwork and commitment by all our staff working in this center. To them, we applaud this commendable achievement and triumph.

49

PRE-HOSPITAL CARE COVID-19 has revolutionised the face of pre-hospital care worldwide forever, especially in Hospital Sungai Buloh. Prehospital care providers play a vital role in initiating disease isolation precautions and are instrumental in preventing contagion at ambulance receiving facilities. Services also had to be adapted to face the burgeoning numbers of COVID-19 cases while catering to emergency non-Covid cases as well.

As Hospital Sungai Buloh stands as the only pure Covid hospital in the Klang Valley, diversion of simple non-Covid medical cases and mild trauma cases to other neighbouring hospitals had to be carried out. Clinical acumen of the triagers were put to the test besides having to explain to patients and family members who might not be aware of the new pathway of the Emergency Department of Hospital Sungai Buloh during the pandemic.

EMOTION AND PSYCHOLOGICAL IMPACT The TANGO operation had been established to stratify COVID-19 patients based on severity to aid their disposition. Each team deployed is made up of a medical officer, a medical assistant and a staff nurse from the Emergency Department. Teams were activated on a case to case basis by the regional Emergency Physician and would need to be deployed to specific locations for the important mission of screening COVID-19 patients, especially in areas of outbreaks and clusters. Identification and screening of a huge number of patients at unfamiliar and sometimes suboptimal locations during the spike of COVID-19 cases were among the daunting challenges we faced during the TANGO team activation. MAEPS (Malaysia Agro Exposition Park Serdang) was repurposed as PKRC MAEPS; the main multi-hall quarantine and treatment centre in 2020 to isolate and treat low risk COVID-19 patients initially before the third wave of Covid hit where more and more patients presented with more advanced severity and presentation of the disease. Therefore, it was imperative that the services of PKRC MAEPS were branched out to include the medical emergency unit (MEU), mass screening area (MSA), MAEPS resuscitation and isolation area (MARIA), a specialized ward for oxygenated patients awaiting transfer and also step-down cases from MARIA (Anak MARIA) and multiple halls utilised as wards/isolation areas. To ease the continuity amongst the various units and also the hospital, a specialized medical transportation unit (MTU) had been set up to coordinate transfer within the PKRC facilities as well as relocation of patients from there out to designated hospitals. Our PHC team was entrusted to run most of the operations there especially on the medical and transportation aspects.Whilst triaging has always been at the forefront of prehospital care; never has its emphasis been made so clear when the pandemic hit hard and fast.

50

We have, collectively, struggled with feelings of loss, grief, anxiety, desperation, anger and disappointment over some limitations and the deaths of our patients. This situation is further complicated by the loss of family members and friends among our staff, in addition to the separation from our loved ones due to movement control orders (MCO). It is vital for us to acknowledge that this pandemic has affected all of us in many ways in which our lives have stretched beyond what we thought we would have to endure and experience. Our souls and our character have been stretched and shaped by this experience, and it will never again return to the way it was before. With the introduction of COVID-19 vaccination, we had our hopes high that we would finally be able to overcome this ongoing war. However, despite this, sporadic cases still occurred within the department. We were compliant to our PPE and we were strict with our SOPs but somehow, this invisible enemy was still able to find its way around to infect some of us. In total, throughout the year of 2021 we had a total number of 36 staff being infected. Fortunately with our revamped shift system, the manpower working on the floor was not poorly affected. However, the mental anguish and stress on those who were infected was undeniable especially when it came down to family. “Will my spouse get infected?”, “How about my children? I just gave them hugs before I was symptomatic”, “I’m living with my parents who are old and have co-morbids. What if they also tested positive?” These are some of the questions that embroiled the minds of our staff, because after all, we are only humans - with validated feelings and fears natural to our Godgiven instinct and reactions.

Other than that, the stress on our staff working on the floor proved to be high. With arrival of cases not only from prehospital services, we also catered for cases from Covid Assessment Centers (CAC) and MAEPS, the bulk and severity of the patients were unexpected. At times, the number was too large to be treated within the modified cubicles which resulted in patients being placed and treated outside the cubicle - right in the middle of our zones - which we fondly refer to as “islands”. This definitely posed a huge health-risk to our frontliners. We had to create and utilise all available spaces to accommodate our excess and overflowing patients. Our green zone, asthma bay and fever center were converted into treatment areas for our oxygenated patients. There was a point in time in which the load of cases was just too high that we had to borrow some space from our radiology counterpart to become part of our treatment area. These modifications and collaborations resulted in positive outcomes in terms of patient’s monitoring and care. But there are times, in the bustling and heat of our overwhelming work of seeing and treating patients day-in dayout, we ask ourselves; who will be there for us when we are not okay? Our staff were feeling the heat. They were tired and they were burnt out. Dr.enched in sweat in our PPEs for a long duration of time was a challenge especially with the continuous waves and waves of arrival of very ill COVID-19 patients. The workload showed an upwards surge as ED started to cater for long stay COVID-19 patients as ICUs were filled to the brim. The demotivation was real with each passing patient feeling that they feel helpless to help the patients. We came to work dragging our feet feeling tired and uninspired. The department and hospital were quick to notice this. Words of encouragement and positive messages flew in from the consultants and specialists lifted our spirits. Cards with thank you messages from previous patients and various organizations keep us driven. The hospital set up a “Psychological First Aid (PFA)” hotline to provide psychological support to those in need. Of course, it could not miraculously fully remedy our mental, physical and emotional-exhaustion, but we dipped into this encouragement and inspiration bucket as much as we could, and grow each day ever-more thankful for it. “Alone we can achieve little, together we can accomplish much more”

LEADERSHIPS IN A TIME OF CRISIS ‘Most of the world run away from this disaster; a proverbial storm - We, emergency services, run towards it’ The coronavirus pandemic has placed extraordinary demands on leaderships in disaster response and beyond. The massive magnitude of the outbreak and its sheer unpredictability make it extremely challenging for emergency services to respond. Dr. Siti Suhaila saw the need to mount an early response since the outbreak began. During a crisis which is dominated by uncertainty, effective responses require improvisation. She has set clear priorities within the department, empowering and allowing us to mobilise as a team and to implement solutions that serve these targets. With her support, Dr. Sarah Karim, head of pre-hospital care services and a consultant emergency physician of Hospital Sungai Buloh had led the pre-hospital care services in the Klang Valley by coordinating and improving on the patient accessibility for hospital admission through the regional emergency physician command system. We are also grateful that in this difficult time, Dr. Shah Jahan and Dr. Rossman Hawari have stepped forward by participating in the Greater Klang Valley Task Force to help the community to navigate the coronavirus pandemic. CONCLUSION

To state that 2021 was a challenging year would be a colossal understatement. There has been little in our department left untouched by the COVID-19 pandemic - from clinical practice, patient care, work environment, training and education to administrative work – all had been transformed to adapt to the challenges posed by the pandemic. Despite many challenges in 2021, the Department of Emergency Department of Hospital Sungai Buloh has demonstrated time and time again the remarkable capacity of the entire ED team, to pull together to accomplish extraordinary tasks. What is even more gratifying is to see the team stepping forward, exhibiting leadership in various aspects, caring for each other and working earnestly to achieve common goals and uphold the work culture of the department in difficult times.

51

Coming out from this arduous time, one can certainly call upon salient learning points we can gather from. We learn that a department is only as good as the people in it – that our best resource is and always will be, our manpower. Take away the frills and fancies, the only way that the department is still standing throughout the whole ordeal is because of our human resources who are quick to adapt and persevere together. Thus, we should invest further in our team, to increase skills and knowledge, and celebrate and recognize the sacrifice each and every team member had put in for the fight for our people. We also recognize the potentiality of Emergency Services of being versatile in fields beyond that which was traditionally relegated to them. Given the appropriate resources and opportunities, we could certainly prove our mettle and step up to challenges with much fortitude.

Looking back, and walking through the halls of our emergency department, it seems almost unrecognizable now with all the changes that have taken place. From the renovations and reassigning of spaces, to the scope and span of cases that we now manage, we wonder if things will ever go back to normal – whatever normal means. What will be our future trajectory and course? What future challenges will we need to prepare ourselves for? Is there a hope that this will end, or will we continue to ride this ever-turbulent whirlwind of a wave? Time will tell…. “The Covid Pandemic has taken much away from everyone, however it has left us with many important lessons. The least we do is to learn from it” - Shah Jahan

52

The Unprecedented Continuum : Necessity of converting and mobilizing the green zone in ED waiting area into an observation bay

53

54

The Unprecedented Continuum : Massive influx of patients in the ED observation area during the peak of the pandemic

The Unprecedented Continuum : As the COVID-19 pandemic surged, a rapidly rising number of patients lined up to seek treatment in ED

55

56

The Unprecedented Continuum : The agony of a Stage 4 COVID-19 patient arriving at the hospital

The Unprecedented Continuum : The frequency of ambulance calls surged rapidly, threatening to overwhelm our healthcare workers

57

58

The Unprecedented Continuum : Yellow Zone remodelled into Red Zone to accommodate for the spilling over of severely ill COVID-19 patients

The Unprecedented Continuum : Bagging and resuscitation of an intubated COVID-19 patient

59

60

The Unprecedented Continuum : Makeshift isolation cubicles in ED – for the safety of other patients and healthcare workers

The Unprecedented Continuum : ED staff were often overwhelmed and fatigued – such was the impact of the pandemic on healthcare workers

61

“Our experiences teach us to be a better version of ourselves in the future. Persistence, Hardwork, Criticism and Passion will take us to new heights.” Dr. Yasmin

“Verily, with every difficulty, there is relief” (Al-Insyirah 94:5) Encik Muhammad Fadhlan 63

BRAVING THE STORMS

Enduring Endeavours Airborne spread of the virus is much more infectious than the hitherto assumed droplet spread. The former requires full time usage of N95 where else for the latter, surgical face masks would suffice for the majority of clinical scenarios. Prior to that point, N95 masks were only donned when “aerosol generating procedures” were carried out, e.g. when intubating a patient that needed to be put on a ventilator or when a patient required pressurized oxygen delivery. Compared to standard surgical masks, N95 masks were more uncomfortable to be used round the clock because they were more difficult to wear; it required proper user training and testing to see one was wearing it correctly; it was tighter and thus more uncomfortable around the face; it required more effort to breathe through which led to increased fatigue (staff wearing a full-time N95 would need breaks every couple of hours to recover); the wearer had to speak louder as one’s voice would be muffled; and because N95 masks were more expensive, it required greater care by the wearer. And amidst all of this – there was still a lot of debate on what is the optimal way to treat COVID-19. So far the only medication that had been proven to work for COVID-19 till that point had been steroids. This was seen in a landmark trial back in mid 2020 that steroids usage cut down deaths, something that had been hinted at before but not proven. However, there were still so many questions unanswered. How early do we start the steroids? Were all steroids the same or did one type of steroid work better than another? How much steroids do we give and how fast? Is more steroids better or more harmful? After all, steroids are known for many side effects e.g. predisposing a patient to secondary infections, causing uncontrolled sugar readings, muscle wasting etc. How long do we give it for? And these were questions that were asked just for this one drug, which was used for only one phase of the disease. This disease had at least 3 phases for severely affected patients. What about other modalities of treatment like antivirals or monoclonal antibodies? Or other “immune modifying agents” apart from steroids? How do we reduce other life- threatening COVID-19 complications like blood clots (causing heart attacks, strokes or pulmonary embolisms); lung damage; renal failure; encephalitis etc? Was there any other drug that worked just as well or in addition to steroids? Steroids cut down deaths by 8% among critically

ill patients. But what about the remaining 32% of people that still succumbed? What else would be of benefit? So while we were all busy planning for how to prepare for COVID-19 – we also had to prepare for how to answer all these treatment questions that arose. Answering these questions was not easy. It required firstly a master plan on how to answer these questions. Then the dedication of whole teams of researchers, scrutiny of protocols and how to implement them, good statistical knowledge, seamless teamwork while all the time ensuring proper ethics so that whatever clinical trials are conducted will be fair to the patients involved and done with their full consent. As one medical news commentator had put it – much of treatment in COVID-19 was akin to learning how to make an airplane while flying it. All these clinical questions were also related to how this virus behaved. Unfortunately, there was still so much that was uncertain. What we knew thus far was most young healthy people breezed through without problems when they contracted COVID-19. The elderly and those with comorbidities were much more badly hit. But this was not universally true. So, who was at highest risk of complications and what complications did they get? When did these complications arise? What were the warning sign to pick up these complications? How did the clinical picture tie up with regard to clinical symptoms and signs; laboratory tests, radiology findings and patients vital signs (temperature, heart rate, respiratory rate, pulse oximeter levels)? How did vaccination change this picture? Was the picture the same with different variants of the illness? The same uncertainties were also reflected in the testing strategies of COVID-19. Which diagnostic tests were best? The expensive and long turnaround-time but more sensitive PCR test? Or the less sensitive but cheaper and faster rapid test kit? Were PCR tests considered too sensitive since it remained positive long after the patient was no longer infective? How do we interpret the CT values that come with a PCR test? How do we optimize these tests so that we do not unnecessarily run up the costs? Once again, did these tests vary in accuracy according to whether a patient was vaccinated or whether a variant of the disease affected the test results? Although most of these questions were eventually answered, they were far from clear even up to that point. It proofed very stressful trying to guide the hospital, and by extension the rest of the country (we were the largest COVID-19 treatment center in the country) through these dilemmas.

67

One Moment In Time by Dr. Kang Ker Cheah As year 2021 began, COVID-19 ICU admissions peaked with a staggering number of 288 patients that month. Hospital Sungai Buloh at this time, was the main powerhouse for Klang Valley COVID-19 patients and was a fully COVID hospital, with non COVID patients being decanted/diverted to non COVID/hybrid hospitals. As ICU referrals for COVID-19 from both government and private facilities in Klang Valley became relentless, we had no choice but to increase our ICU capacity to 150%. Otherwise, it would not have been possible to shoulder the burden of Category 5 COVID-19 patients in the Klang Valley.

Help still came but with less vigour than before, for the reason mentioned. We used every single manpower resource we had by up-skilling more frontliners to assist us. Examples were, non ICU trained staff ranging from freshly graduated nurses to nonanaesthetic doctors from other departments such as ophthalmology, dental, dermatology, ENT, neurosurgery, orthopaedics and general surgery. This would not have been possible without the support from Dr. Kuldip and other heads of department. We continue to be grateful for all the help we received during this time.

From the beginning, our biggest enemy was the lack of manpower resource. With the support of our hospital director, Dr. Kuldip Kaur, an “S.O.S” call was made by our head of department, Dato. Dr. Shaiful Azman to our fraternity of Anaesthesiology and Intensive Care and the Ministry of Health (KKM), for more manpower to cope with the increase in ICU bed capacity. Soon, we received prompt assistance from gazetting anaesthesiologists, intensivists from both government and private hospitals, where nurses and medical officers joining the ICU team, in our battle against the pandemic surge.

Donations in the form of ventilators and HFNC swooped in, but, though we had an abundance of machinery, this could not guarantee good patient outcomes as ICU bed demand exceeded its capacity and supply. We began to see more patients from younger age groups (twenties to fourties in age) and pregnant severe COVID-19 cases. ICU triaging and critical care resource allocation became the physical, mental and emotional burden of our department. When we decide on one patient to be admitted to ICU, it has meant that there are 3-5 patients outside the ICU walls, whom will not be able to receive ICU care. This has meant to many of us, that we were somehow indirectly responsible for their deaths (though in reality, we were not). How ever objective the medical decisions we made, it could not erase the guilt and helplessness we felt. This has permanently scarred many of us.

As we entered the Lunar New Year in February and then March, the number of severe COVID patients had a declining trend and it felt like we were now dealing with remnants of the second COVID-19 wave. The frontliners batallion, received our first COVID-19 vaccine in March 2021. We felt relief and were ecstatic, thinking that the worst was over. What felt like a brief period of hope was soon replaced by looming fear and devastation as the COVID-19 numbers started escalating again.

By mid April, the Delta variant was upon us, transmitting faster and affecting our patients more severely. The entire Klang valley had to join forces and centralise command to deal with this COVID apocalypse. We became stewards of this central command. By that time, our ICU capacity had swelled to 200% with a record of 362 ICU admissions in May. This third surge was overwhelming nationwide with manpower resource being stretched to beyond its limit.

68

Simultaneously, we had a Multi-Resistant Organism infection outbreak following the surge. We moved into swift action and joined forces with the infection control team to eliminate this threat. Unfortunately, despite collective efforts, there were many patients who lost their lives due to this additional ruthless enemy.

While in ICU, we never held back on our patients and pushed beyond the mental and physical limits we had. Proning and supinating during a surge, with many of our patients morbidly obese has made many of our staff suffer from long term orthopaedic ailments. We would hardly complain or take a sick day off, as we feared about the extra burden our fellow colleagues had to shoulder if we did so. Working together during a pandemic has really brought the department closer than it ever was before. For us, we are like family, trying our best to look out after each others wellbeing since no one else other than those who went through the journey we had, would ever understand.

We, as a department, alongside other departments of this hospital will continue to work together as one and tackle whatever new variant surge comes our way.

From the ICU COVID-19 treatment aspect, we stuck to the fundamental knowledge we had of the virus and relearning that one size never fits all. It was a dynamic learning process for all of us, as we needed to keep up with the ever-evolving COVID-19 virus, which in 2021, proved more resilient and vicious than before. It was a process of constantly reassessing the varying COVID-19 patterns and our patient subgroup responses, even after their deaths. As September rolled in, cases began to slowly decline due to nationwide vaccination. Despite that, our healthcare worker burnout was still on a rise. We are collectively exhausted as a department from being a fully COVID hospital, with our ICU only catering to COVID patients. Many have begin to lose essential work skills (imagine an anaesthetists not being in operation theatre for almost two years) with being fixated on only COVID19 patients. Towards the end of year 2021, we were more than ready to move forward into the endemic phase of COVID-19.The news of the Omicron variant concerned many, but to us, it was just yet another variant and will not be the last of its predecessors. The last surge has proven that it was not only our department which were able to rise up to the challenge, but every other department, particularly emergency medicine and medical. It was not only Hospital Sungai Buloh which rose up during the surge but every other hospital in the country even smaller district hospitals.

69

The Fury of the Invisible Enemy by Dr. Preetiba Rani Vijaya It was July 2020 and we were getting back to business. We got back our 6th floor wards. Labour suite was back in action. All the equipment and beds were shifted back to its original places. Operation Theatre (OT) lists were sorted out and our Medical Officers (MO) who were in the COVID pool were back to the department. It was indeed a joyful reunion. It’s like coming back to our home sweet home. We beamed with pleasure as we have won the war over COVID. Everyone was relieved that the fight was finally over and we can now be with our families and friends. We welcomed everyone back into the team and started the hybrid mode with enthusiasm. We conducted vaginal deliveries, instrumental deliveries and gynaecological surgeries with so much joy as we truly missed those procedures during the COVID era. This joy however did not last long as we saw the number of COVID cases steadily climbing up. We were naturally worried for our fellow comrades in East Malaysia. Some of our colleagues have spouses who are Health Care Workers (HCW) and were sent there. The look on their faces showed how much anguished they were. Some of us who were planning for a long awaited family vacation had to cancel our plans as we witnessed a sharp rise in the number of cases. We knew the storm was getting closer to us and true enough within the next few weeks, we in West Malaysia were once again hit with the disastrous pandemic. This time it appeared like a volcano eruption, spewing its hot lava and ashes! “OK everyone, we are changing back into full COVID. Clear off the 6th floor again please”, that was the order we received and it hit us like a Déjà vu. Haven’t we got through this exact situation in March? Oh no!! Not again!! Everyone was moaning and groaning. Our laughter sessions turned into a mourning one. We had to relocate all the equipment and beds once again, rescheduled our OT lists and clinic appointments. We also had to transfer our inpatients to other hospitals in Klang Valley. We kept receiving new orders everyday as the situation was getting worse. Our children were perplexed looking at our faces as we went to work everyday. “Isn’t everything back to normal?”, they kept asking. Little did they know we were about to fight a war worst than the first one.

70

Slowly our MOs left the department and joined the COVID pool. The House Officers (HO) were sent to other hospitals and we bid farewell to them too. The Obstetrics & Gyanecology (O&G) family is once again torn apart. This time we didn’t know when we will be together again. That feeling sent chills along our spines. The uncertainties were slowly killing our courage.

Day by day the number of cases were rising. We were very overwhelmed with the number of obstetric admissions. This was the result of Movement Control Order (MCO) in March 2020 and now we are flooded with loads of pregnant ladies who sadly became infected with the ruthless virus. We saw a wide range of clinical presentations among the infected pregnant population. Most notable ones were pulmonary embolism and raised liver enzymes. More and more obstetric patients were presenting with tachycardia (abnormal elevated heart rate) and tachypnoea (difficulty in breathing). The number of ladies with Category 3,4 and 5 were more (17%) compared to the first wave.It feels like we have conjured the wrath of this virus and now it’s spreading like a wild fire with full force! Hospital Sungai Buloh was reaching its full capacity and we had difficulty in coping. We delivered more and more premature babies in order to assist maternal ventilation. We were at one point having 4-5 caesarean sections daily as more obstetric patients were down with the infection. Our team members were exhausted and we hardly had time to catch up with each other. There were no more laughter, joy and fun. There were only sadness and anxiety in each and meltdown and had to seek help from the Psychological First Aid Team.

Managing obstetric covid patients was not an easy task at all. Counselling the woman and her partner was a challenge. Some couples were very rude to us and blamed us for the situation. We just bit the bullet and continued to march on with our duties. Some couples on the other hand were very understanding and offered their full co-operation. We saw the fear in their eyes as we explained the risk of death to them and their babies. We also had the challenge to counsel women regarding vaccination. Many were reluctant to vaccinate due to the uncertainties. Yes.. we don’t have any long term data but at this point of time this is the only way we know to protect our mothers and their unborn babies. The indomitable spirit within us just crashed when we had our first maternal mortality due to COVID on 1st February 2021. We knew she was going downhill but death is something all of us are not ready to face and certainly not in obstetrics. The thought of the little baby not seeing its mother is truly heart wrenching. Day by day our obstetric morbidity and mortality due to covid kept increasing. By the end of 2021 we have reached a total admissions of 3660, mostly young patients in the 20s and 30s. Hundreds of pregnant mothers were admitted to ICU throughout 2021. It’s truly devastating to see these young mothers struggling to breathe. We reached an ugly figure of 15 maternal deaths by the end of 2021 and sadly this is the highest maternal mortality ratio in the state for the last 5 years. This wave is indeed different. Morale was all the time low. There was neither pride nor excitement of being a frontliner. In fact there was no fear either! We were more troubled by the uncertainties. How long more? How many more ill mothers will we encounter? When can we go back to the arms of our family and friends? When can we breathe without wearing this horrible Personal Protective Equipment (PPE)? We were drained to the core. We were angry at so many levels as we felt we were fighting this battle alone. We got so furious when we see the public behaving in ignorance and happily took part in social gatherings. All of us did not take a break since early 2020 as we worked continuously. We felt betrayed!

A year ago our trainees in the department were learning how to perform surgeries and brushing up their skills in performing an ultrasound scan. They were studying and sitting for exams. They were getting somewhere in their career. Now… everything came to a halt and all they see is COVID everyday and everywhere! The trainees got really exhausted, burnt out and at the brink of giving up. Some were more affected than the others and resorted to resign abruptly and seek the greener pastures. Many others choose to just bear with everything in lonely silence. No doubt that doctors should be noble at all times and this is our calling. We couldn’t just sit idle and let things happen. Unprecedented times call for unprecedented measures we say and with that in mind we gave our services no matter how hard it was. We have loads of questions running in our minds. When is all this going to end? When can we sit together as a family and have our lunch together? When can we start having joyous laughter in labour suite hearing the newborn babies cry? As of now, the numbers of COVID cases are coming down very slowly but it is still a four figure number. It will be a long journey for us to reach a single digit. We have yet to see any light at the end of the tunnel. Despite the ambivalent situation we face, we know that one fine day all this mayhem will end! The light will eventually brighten the darkness that we are in now, till then we just need to hold each others hands (Well… practically we can’t do that due to social distancing!) and march bravely knowing that deep in our hearts we are doing this for our beloved country and most certainly for humanity!

71

The Little Warriors by Dr. See Kwee Ching Entering the new year after a very busy 2020 handling the SARS COV 2 pandemic in newborns and children, we were hoping for a lull in the storm. The initial few months of the year showed a silver lining , indeed a drop and plateauing of new admissions. This was due to the long awaited implementation of home quarantine for SARS COV 2 cases, especially families infected with SARS COV 2. As the cases stagnated in the first few months, a more sinister variant of concern emerged out of the ashes, the Delta variant.B1.617.2 This variant is more contagious and transmissible, and it showed its sinister agenda in the deadly Indian second wave in February, 2021. We knew it will hit our shores soon. Then there was more promise in the SARS COV 2 vaccination rollout in March, 2021 which heralded a new milestone in the fight against SARS COV 2. The healthcare workers and the elderly were the first group to be vaccinated and this shifted the pendulum towards a more positive outlook. Of course, children will be the least serious cohort to be under the vaccination radar at that time. The surge in paediatric SARS COV2 cases due to the Delta variant soon emerged in the Malaysian community by May, 2021 and the mortality and morbidity spiralled out of control especially in the elderly population and those at risk. The paediatric cohort was also not spared and the surge in paediatric cases overwhelmed the number of beds at our hospital. Other nearby hospitals has to be converted into hybrid hospitals to cater for this surge. We also see an increase in MIS-C cases in the following months after the peak in August, 2021. The other high risk group that was badly affected was the SARS COV2 infected obstetric patients. This group demonstrated increased respiratory issues and many had to be ventilated due to their condition. The babies had to be delivered early resulting in many premature babies, mostly ELBWs.

72

Both this phenomena accounted for the highly packed paediatric admissions up till the opening of PKKN West and East to cater for these families and obstetric cases. The paediatric human resource was augmented by the good network of assistance offered by the Klang Valley paediatric departments resulting in adequate paediatricians and medical officers based in MAEPS and Hospital Sg Buloh. The downtrend in paediatric admissions occurred in October, 2021 and plateaued after that. Adolescents received their first dose of SARS COV2 vaccines in September, 2021 and schools finally opened again in November 2021 and a semblance of normalcy started to materialize.. Then, Omicron, another variant of concern emerged in South Africa. The odyssey continues...

Agile Experiment by Dr. Tuan Suhaila Binti Tuan Soh It has been 2 years since Covid first appeared on our shore. We are still battling the pandemic while making major changes in the way we live our life and do our work. Over the span of 2 years our lab underwent several phases of development. We first started our Covid test with Covid PCR in February 2020. We later included Covid Antigen, Covid Antibodies as well as rapid Covid PCR in our service. As we battle the fast evolving enemy, we outsource some samples to institute of medical research (IMR) for genome sequencing in order to identify different variants. Throughout this battle, we face various challenges in terms reagent supply, manpower size, longer working hours and the need to produce faster results to meet the demand of the doctors treating these covid patients. We experienced several low moments in our journey when few of our staff and their family members were infected with covid. This had led to the situation when we were severely understaffed but we still carried on with our work. Being humans as we all are, we do feel down and burnt out from time to time and it is a real challenge to stay motivated at times. Dr. Kuldip Kaur our hospital director has been our strength and pillar of support from day 1 we started our Covid test. She does everything in her power to ensure smooth operation at the lab by ensuring sufficient manpower, conducive lab environment for the staff to work long hours while wearing PPE and enough reagents for all tests offered at the lab. We are very thankful for all her support, assistance and guidance. Moving forward, we need to adapt our lifestyle and our work to continue living with covid in the community. We need to continue working as a team and become each other’s cheer leader to get through this battle. Finally, we shall strive to improve our service for the benefits of the patients.

73

Beyond The Vision – Into The Depths of The Unknown by Dr. Andre Yee Yue Meng We stepped into 2021 with high hopes that the pandemic will slowly recede and things will start anew, however we could not have been more wrong. Ushering the new year with another MCO and new standard operation procedures, things had taken a turn for the worse. We were greeted with heaps of outbreaks and cases. We the radiology department had to remain resilient to continue to provide the clinical support to aid in the management of COVID-19. Within the first few months of 2021, our new daily cases of COVID-19 were spiking beyond four figures daily and as a consequence, so did the bed occupancy rate in HSgB. Our department sent staff in rotation to help our fellow colleagues in the COVID-19 ward. A total of 4 medical officers and 3 staff nurses were dispatched at a time. We had to further divide staff into different teams and shifts to avoid cross exposure and infection between our own staff members.

The sharp increase of new cases saw an increased demand for oxygen ports in HSgB. As a result, our ultrasound bay and also angiography suite recovery area were converted into a COVID-19 temporary ward in view of the availability of oxygen delivery ports available there. Our MRI and interventional radiology services could only be made available for COVID-19 patients as the designated area to house COVID-19 patients blocks off access for other patients to the MRI and interventional radiology area. This caused the need to reschedule our MRI and Interventional radiology outpatient appointments indefinitely as we could not foresee the end of the current wave. The regular outpatient ultrasound services rendered for the nearby health clinics were however still continued at the national leprosy center (the PKKN). This was done to ensure that non COVID-19 patients were not neglected. Inpatient ultrasound services were continued, with our radiology staff performing ultrasound examinations by pushing the portable ultrasound machine to the COVID-19 wards at the bedside.

74

Chest x-rays are the most used modality in this pandemic as it is readily available, fast and reliable. Statistically, our total number of chest x-ray request increased by 4-fold for 2021 in comparison to 2020. At the peak of our third wave, we were doing approximately 10000 chest radiographs per month. This workload had to be accomplished using 4 portable radiography machines in our main building and one in the external wing at the leprosy center. Utilising digital radiography, which eliminates the need of processing films or and the use of intermediary cassettes managed to make efficient our workflow. Careful planning was also required to manage the time taken to accomplish the tasks while adhering to operating procedures for containment of contagions. The radiologists and radiology MOs then prepared reports for all the radiographs done so that the patients can be stratified into various risk categories to decide the next course of treatment. The severity of cases also increased in conjunction with the quantity. More severe cases required advanced imaging technique, which are the high-resolution CT and CT pulmonary angiography. We had 2 CT machines; so one was used for COVID19 patients, and the other was used for non COVID-19 patients or COVID-19 patients who were no longer infective. These imaging studies were imperative in deciding the duration of medication give to reduce the risk of developing long term complications from COVID-19. Performing CT imaging during the pandemic requires much effort and coordination between radiology and ward staff as both parties need to don up and the entire pathway from the ward to the scanning machine needs to be cleared. Ill patients are more difficult to transfer to the imaging department as they are usually attached to many external devices such as cardiac monitors, infusion pumps, IV drips, feeding and oxygen tubes. Occasional hiccups occur as ward staff can be overwhelmed at times when unexpected ward emergencies cause delays in sending patients down. Hence, we attempted to smoothen our workflow by allotting time slots for each scan, marking arrival and scanning times and also our communication with fellow ward staff.

MRI scans for COVID-19 cases were challenging as well as cleaning and disinfection of the MRI gantry could only be done with non-ferromagnetic tools. Cleaning it was also challenging due to the shape of the machine, having a large surface area to house the large tube shaped superconducting magnet, as well as a long tunnel within to place the patient within the magnet in order to be imaged. Despite having need to reschedule appointments, our interventional radiology department spearheaded by Dr. Zulkifli and Dr. Arvin did not rest as they continued to provide life and limb saving procedures for COVID-19 patients who developed complications to the disease. Previously unseen complications such as arterial blood clots in the extremities, stroke and bleeding into the abdominal muscles were on the rise in tandem with the rise of cases during the third wave.

It is always darkest before the dawn, through our perseverance somehow we caught a glimpse of light at the end of the tunnel. Towards the last quarter of 2021, we were moving to achieve herd immunity and endemicity of COVID-19. Seeing that the amount of cases were gradually reducing, we elected to start outpatient services once again. In accordance with newly adapted SOPs, we took small steps by filling our morning shifts with outpatient service, and afternoon shift for inpatient COVID patients in order to avoid cross infection. Halted services like mammography and fluoroscopy were recommenced. By the end of September we were able to use our ultrasound bay once again, which gave us the chance to restart our ultrasound sessions for the public. And thus, continues our odyssey into the endemic.

Besides in clinical practice, we also had to make adaptations for our non-clinical activities as well. Due to strict SOPs, we had to organize webinars and online courses to replace our physical seminars. The activities were especially important as we were discovering new disease processes and complications when we were handling COVID-19 patients. Among the activities organized were online talks to aid in understanding and deciphering COVID19 chest radiograph findings which was done by our radiologist Dr. Chai Jan Jan for all our fellow colleagues in COVID rotation. Not limited to CMEs and webinars, our fellow radiologist Dr. Aida Abdul Aziz made progress by producing multiple papers and studies, among them “The relationship between serum biomarkers and viral load of COVID-19 with severity of lung involvement on chest computed tomography” and “imaging findings of organizing pneumonia and fibrosis on COVID-19 patients. At the departmental level we organized three webinars, namely the National Covid webinar(two parts, on the 10th of April and the 18th of September) as well as the Selangor update in chest infection on the 28th of August 2021.

75

Cloud of Apocalypse by Dr. Tan Ran Zhi Introduction Department of Forensic Medicine is the department that manages the dead bodies in the hospital including those patients that passed away due to COVID-19 infection as well as brought in death (BID) cases. Forensic Department works together with various units in the hospital such as Spiritual and Health Unit, Infection Control Unit and Public Health Unit in order to make sure that COVID-19 bodies are managed according to SOP. Our Challenges It is no secret to anyone that 2021 has been a very difficult year for Forensic Medicine Department. As compared to year 2020, in 2021 there was a sudden spike of COVID-19 death. The peak was in the month of July and August 2021. In July 2021, there was a total 466 hospital death and 73 BID cases that were received. Whereas in August 2021, there was a total of 361 hospital death and 114 BID cases that were received. At that point of time, the number of bodies that were received exceeded the department body storage capacity. There were also other problems associated with the sudden increase of COVID-19 death, such as shortage of body bag, lack of human resource, malfunction of the equipment due to heavy duty and so on. The department had to overcome these challenges before the system collapsed. Our Response and Strategies To make sure that the bodies were properly kept and prevent further decomposition, the department received a total of 5 mobile body containers which consisted of 2 40-feet length body containers and 3 20-feet length body containers. The department also received body bags and new equipment through the hospital and from NGOs.

76

In terms of human resource, the department received assistance from Jabatan Pertahanan Awam Malaysia and Angkatan Tentera Malaysia. Their presence significantly reduced the workload of the Forensic staffs and the department was really grateful for their work efforts. For those COVID-19 death cases that required post mortem examination, Forensic Department Hospital Sungai Buloh had a consensus with Forensic Department Hospital University Teknologi MARA (HUiTM), Puncak Alam. COVID-19 deceased body will be autopsied in negative pressure Post Mortem Suite HUiTM by post mortem team Hospital Sungai Buloh using Powered Air Purifying Respirators (PAPRs). Despite of the busy working schedule, throughout the year, Forensic Department persistently monitors the quality of funeral service providers (muslim and non-muslim). Training in COVID-19 body management, donning and doffing PPE and also hand hygiene were conducted. Conclusion In conclusion, although the department was struck with multiple challenges in the year 2021, the staffs worked hand in hand together and continue to provide Forensic service to the community.

Enduring Endeavours : Receiving new infusion pumps for ICU usage 77

78

Enduring Endeavours : The ICU equipment, beds and bedside medical devices were upgraded specifically for COVID19 patients

Enduring Endeavours : ICU isolation room, where attempts to save patients were made. Some procedures needed to be done in these isolation room to minimise contamination to the wider ward

79

80

Enduring Endeavours : Preparing a deteriorating patient for intubation – never easy in the best of times, frightening in the time of Covid

Enduring Endeavours : Suctioning of secretions blocking the airways was essential to keep patients breathing 81

82

Enduring Endeavours : Category 4 COVID-19 patient on high flow nasal cannula to deliver as much oxygen to a patient as possible

Enduring Endeavours : HCW working together to nurse a COVID-19 patient prone in ICU. A tricky manouvre where a sedated patient has to be placed lying on his stomach in order for his lungs to expand more

83

84

Enduring Endeavours : Readjusting an intubated COVID-19 patient’s endotracheal tube, crucial for ensuring that the oxygen was going down the right path into the body

Enduring Endeavours : Comfort caring - adjusting COVID-19 patient’s position in the isolation room. As the saying goes – to cure sometimes, to comfort always

85

86

Enduring Endeavours : Measuring endotracheal tube cuff pressure of COVID-19 patient – too loose and oxygen will be leaking out, too tight and pressure on the trachea can lead to damaging it

Enduring Endeavours : Treating intubated and ventilated COVID-19 patients in the ICU – by the army of nurses, never tiring; constantly serving

87

88

Enduring Endeavours : Beds were frequently fully occupied in the ICU. Paradoxically, by providing excellent care, patients survived longer but leading to lesser beds being available for others

Enduring Endeavours : ICU nurses were constantly on their feet providing care to critically ill patients

89

90

Enduring Endeavours : Measuring endotracheal tube cuff pressure of COVID-19 patient

Enduring Endeavours : Preparing a new endotracheal tube - some COVID-19 patients required weeks to months of support from a ventilator

91

Enduring Endeavours : Taking a toll - the mental burden of health care workers through out the pandemic 92

Enduring Endeavours : Dr. Kuldip Kaur, the Hospital Director, performing her rounds in the wards to monitor the situation on the ground

93

94

Enduring Endeavours : The community home for psychiatric patients was repurposed for the temporary placement of pregnant women that had contracted COVID-19

Enduring Endeavours : Conducting caesarean section for mothers infected with COVID-19 in a dedicated operating theatre - while there was death around us, we did not forget to celebrate life

95

96

Enduring Endeavours : Special Care Nursery (SCN) for maternal COVID-19 newborns

Enduring Endeavours : Donations of colouring books for COVID-19 paediatric patients

97

98

Enduring Endeavours : Making the hospital a second home for COVID-19 paediatric patients – shown here, a healthcare worker teaches children about dental hygiene

Enduring Endeavours : COVID-19 paediatric patient receiving treatment in ICU. It was important to celebrate any small success; for example, getting patients off a ventilator

99

100

Enduring Endeavours : In some cases, babies were fighting for their lives in the Neonatal ICU while their mothers were struggling to survive in the adult ICU

Enduring Endeavours : Safety protocols were strictly observed when passing dangerous specimens of COVID-19 patients from contaminated to clean areas

101

102

Enduring Endeavours : Protocol for retrieving specimen of COVID-19 patient by laboratary scientific officers - even something as small as opening a container could be a delicate task to prevent contaminating the surroundings and oneself

Enduring Endeavours : Handling test of specimen of COVID-19 patient in a biosafety cabinet requiring full attention and n room for mistake

103

104

Enduring Endeavours : Performing chest X-ray using a portable X-ray machine for COVID-19 patients – through imaging, essential for gauging the course and severity of the disease

Enduring endeavours : Transferring COVID-19 patient for chest CT imaging – a complex and precarious task, especially when a patient was on a life support ventilator

105

106

Enduring Endeavours : Preparing COVID-19 patient for chest CT imaging – balancing getting the right angles, performing the scans quickly and keeping the patients calm and safe

Enduring Endeavours : Reporting chest CT imaging of a COVID-19 patient by radiologist. Knowledge, experience, training and skills were needed to read the films correctly so as to point the treating doctors in the right direction

107

108

Enduring endeavours : Radiologist conducting tele-radiology of chest imaging of COVID-19 patient - being the referral centre, our radiologists also worked to provide support to surrounding hospitals needing their expertise and know-how

Enduring Endeavours : Transporting portable X-ray machine from main building to PKKN. Transporting these sensitive, expensive machines were a delicate task – to ensure they are not damaged during transportation

109

110

Enduring Endeavours : Safety zoning was implemented to avoid cross contamination - safety procedures and training was essential to ensure that one did not inadvertantly stray from a clean area to a dirty one and vice versa

Enduring Endeavours : The Infection control team performing routine tasks - keeping the environment clean was key in ensuring there were safe spaces where the staff could rest and to avoid the transmission of germs from one patient to another 111

112

Enduring Endeavours : Hand hygiene audit using glogerm powder for staff treating COVID-19 patients - in the face on an unknown pandemic, hygiene protocols took the highest priority

Enduring Endeavours : Interactive hand hygiene, environmental cleaning and contact precaution practice session in ICU conducted by the infection control team, HSgB

113

114

Enduring Endeavours : Regular disinfection of devices in the ICU - for the most vulnerable patients, a lapse in hygiene could lead to a cross infection which can cost them their lives

Enduring Endeavours : Disinfection process of the surrounding area in the ICU by trained cleaners who were also essential staff in the whole process – keeping the environment safe for all

115

116

Enduring Endeavours : Carriage bag to transfer the deceased to mortuary

Enduring endeavours : Ultraviolet sanitisation of the CT scan suite – to clean the quite in between patients to prevent cross infection

117

118

Enduring Endeavours : Bereavement counselling for the family of a deceased COVID-19 patient

Enduring Endeavours : As the death toll mounted, additional space was needed for the deceased - delivery of 40 foot refrigerated body containers for those who succumbed.

119

Enduring Endeavours : Transporting a deceased body to the mortuary 120

Enduring Endeavours : ”Solat jenazah” by the hospital staff for a patient who succumbed to COVID-19 121

122

Enduring Endeavours : Process of “kafan” for a deceased Muslim COVID-19 patient

Enduring Endeavours : Spraying 0.5% sodium hydrochloride as disinfectant on the body bag 123

Enduring Endeavours : Funeral workers spraying disinfectant before sealing the coffin cover 124

Enduring Endeavours : Bodies kept inside designated COVID-19 body container while waiting for family members for body identification

125

126

Enduring Endeavours : Body identification prior for release by the Forensic Department

Enduring Endeavours : High volume of medication dispensing in the Pharmacy Department during COVID-19 pandemic

127

128

Enduring endeavours : Medication counselling by a pharmacist for a COVID-19 patient prior to discharge

Enduring Endeavours : From healthcare workers to Malaysians – spreading words of encouragement to comply with infection control protocols

129

“Paediatric COVID-19 is not about kids only but their families and other community issues that my Team Sg Buloh need to handle. Kudos to them for an excellent historical work!” Dr. See Kwee Ching 130

“If you fail to plan, you plan to fail” Dr. Rofiah binti Ali

SINGING THE SEA SHANTY

Evolving Preparedness Throughout the pandemic there was a lot of mathematical modelling and sometimes crystal ball gazing into what the future would have in store for us. Whenever the number of patients came, should we proceed to open up the hospital again? If so, how fast shall we do it? How do we rotate the doctors within our hospital to keep them fresh? How do we keep people motivated and focused on SOPs? How do we prepare for this tsunami should and when it hit us? How do we prepare enough hospital beds? Where were the staff going to come from? How to get all the doctors ready for this? Were the medications and protective equipment adequate? Was the hospital oxygen supply able to cope? Were there enough ICU beds? Enough emergency department beds? Enough mortuary space for bodies? Could our laboratories and radiology services cope with the surge? How could we help other neighbouring hospitals prepare for this tsunami as it emerges and when Hospital Sungai Buloh ran out of beds? The other big news that had been floating around toward the end of 2020 was the emergence of COVID-19 vaccines. While these early reports was initially greeted with caution and skepticism – borne partially from novel scientific methods in producing these vaccines and the speed at which these vaccines emerged (vaccines typically take at least 5 years to evolve from conceptual stage to final production while these new vaccines were produced within 9 months) – there begin to be some excitement when the early trial results of these vaccines were initially reported. But more on that later. Just when we thought we would never see the end, the tide started to turn in early August. How this came about was managing to achieve the critical mass of people in the Klang Valley who completed their vaccinations. As mentioned earlier, the vaccines were first licensed at the end of 2020. The initial clinical trial results far exceeded expectations. Not only were deaths and severe illness curtailed by the vaccines, but the results also showed that the vaccines could cut down transmission of the virus very effectively, leading to audible whispers that perhaps we can achieve herd immunity and put COVID-19 to rest once and for all, provided there were enough vaccines to go around. Crucially, the clinical trials had demonstrated that the vaccines were very safe with minimal severe side effects. However, despite the early enthusiasm which replaced initial skepticism, there were still unanswered questions surrounding the vaccines.

These clinical trials were conducted in controlled settings, where many who were old and frail, and those who were pregnant or too young were excluded. Would it work in a real world setting amongst peoples of different backgrounds and characteristics? Furthermore, the trial was conducted during a time when the main circulating strain was still the wild-type virus and not the variants. Would the safety of data of the vaccines hold up when it was administered in the millions and not the tens of thousands during a controlled clinical trial? Over the next few months, data from other countries started coming in to show that the vaccines were indeed very effective in real life settings and that it was safe as well. Malaysians had to wait slightly longer than other countries, but we finally got ours in before the end of Feb 2021. There was understandably still some hesitancy about the vaccine initially but overall, most health care workers recognized the importance, the effectiveness, and the safety of the vaccines. Initially it was thought that the only people who needed the vaccines were the elderly and those with significant comorbidities. Most of this group were only getting their vaccines from May onwards and unfortunately some did not manage to get their vaccines in time before the delta wave hit. The Delta variant exposed the weaknesses of the vaccines and showed that while they did protect to a large degree against severe disease, it was less likely to protect against getting infected with COVID-19 – meaning people who had completed vaccination could still contract COVID-19 and although they might escape the worst of its effects, they could still pass the virus on to others (although less likely) and cause household outbreaks. It quickly became obvious that despite vaccinations, we would not be able to reach the vaunted holy grail of herd immunity with Delta. Still, with the massive roll-out of vaccinations, the scourge of Delta finally came under control.

135

The Comforting Cure by Dr. Norsuzana Maslinda Binti Hj Sukardi On March 11, 2020, the World Health Organizations declared COVID-19 a global pandemic, calling it “one of the most significant health challenges in the last 100 years”. With an estimated death worldwide of 5.5 million, it showcased an unprecedented challenge especially to public health. Various measures have been taken to control the spread and reduce death cases which includes vaccination. COVID-19 vaccination rollout program in Malaysia is a coordinated multidisciplinary effort involving the public and private healthcare sectors, led by COVID-19 Immunization Task Force (CITF). When the COVID-19 vaccines first rolled out in February 2021, most of us had doubts and skepticism specifically against the mRNA vaccines. Countless questions arose around the fact that the vaccines had been developed rapidly, the testing process was rushed through and people were unsure if it would be safe in the long term or would it be effective in preventing COVID-19 infection. The most challenging part that we, as healthcare providers faced was tackling the public fears, overcoming the misconceptions and educating them to understand the COVID-19 mRNA vaccines and its benefits. The misleading and false information being widely dispersed in social media especially by anti-vaccine group heightened the fear and doubt among the community hence, slows down the uptake rate and delays the effort to curb COVID-19 infection.

136

A robust COVID-19 vaccination educational and awareness campaigns were done nationwide to combat these dilemmas and promote understanding and acceptance among the public. The outcome from these campaigns successfully boost the vaccination uptake rate especially during the ramp up period between June to October 2021. As of January 2022, 78.6% of Malaysian populations were fully vaccinated and the trend of ICU admissions and fatal cases was declining rapidly, proving that vaccinations are highly effective at preventing hospitalization and death. Despite the breakthrough cases of multivariate viruses, vaccinations are still our best bet in staying safe and in minimizing the complications from COVID-19 infection. At the present moment, booster doses are being administered globally to enhance the immunity protection against COVID-19. It would seem that the pandemic is far from over and we still have yet to win the war.

Evolving Preparedness : Phase 1 of Vaccination Programme - vaccination for HCW and frontliners with prior counselling session

137

138

Evolving Preparedness : Phase 1 of Vaccination Programme - post vaccination observation bay in staff clinic, ensuring no corners were cut with regards to safety

Evolving Preparedness : Phase 1 of Vaccination Programme - our hospital director led the way by being the first recipient of the newly arrived vaccines

139

140

Evolving Preparedness : Phase 1 of Vaccination Programme - receiving the vaccines kept in a top loading freezer from pharmacist. Some vaccines required extreme temperatures to ensure that it remained effective

Evolving Preparedness : Phase 2 of Vaccination Programme - vaccinating the high risk groups at Zone A (Shown here is a volunteer from an NGO, Tzu Chi helping with the vaccination programme)

141

142

Evolving Preparedness : Phase 2 of Vaccination Programme - observation area designated for high risk vaccinees at SPPV in Zone A

Evolving Preparedness : Phase 2 of Vaccination Programme – mobile team vaccinating inpatients who cannot go to the SPPV to ensure no one was left behind, patients admitted for other conditions were vaccinated in the ward

143

144

Evolving Preparedness : Phase 2 of Vaccination Programme – mobile team vaccinating bed ridden patients

Evolving Preparedness : Phase 2 of Vaccination Programme - vaccinating patients with special needs in their car

145

146

Evolving Preparedness : Phase 2 of Vaccination Programme - vaccinating patients inside an ambulance

Evolving Preparedness : Phase 2 of Vaccination Programme - vaccinating patients in the leprosy ward

147

148

Evolving Preparedness : Phase 2 of Vaccination Programme - vaccinating ex-leprosy survivors who continued to reside in PKKN

Evolving Preparedness : Phase 2 of Vaccination Programme - taking vital signs for drive through vaccinees catered for the disabled and elderly

149

150

Evolving Preparedness : Phase 2 of Vaccination Programme - drive through vaccination (Another initiative to upscale mass vaccination)

Evolving Preparedness : Phase 3 of Vaccination Programme – non high risk citizens waiting in line for registration at Zone A SPPV

151

152

Evolving Preparedness : Phase 3 of Vaccination Programme – Vaccination also done in the “Dewan Orang Ramai”, PKKN to cater the increasing number of vaccinees

Evolving Preparedness : Phase 3 of Vaccination Programme – setting up the “Dewan Orang Ramai”, PKKN

153

154

Evolving Preparedness : Phase 3 of Vaccination Programme - registration area at the Dewan Orang Ramai, PKKN

Evolving Preparedness : Phase 3 of Vaccination Programme - waiting area in “Dewan Orang Ramai”, PKKN (Hospital Sungai Buloh doing its part to ramp up the vaccination rates in the Klang Valley to reach the critical mass)

155

156

Evolving Preparedness : Phase 4 of Vaccination Programme - booster dose for hospital staff

Evolving Preparedness : Phase 4 of Vaccination Programme - photo taking booth 157

158

Evolving Preparedness : Phase 4 of Vaccination Programme - booster dose vaccination for the elderly

Evolving Preparedness : Phase 4 of Vaccination Programme - adolescent vaccination

159

Evolving Preparedness : Promoting herd immunity through vaccination 160

“Silo is the suppressor, teamwork is the catalyst to an organization” Dr. Siti Suhaila binti Hamzah

SHORE BEYOND THE SEA

The Proclamation This story does not end there. COVID-19 still remains very much present today and why that is so can be traced to some remaining problems. Firstly, it has become obvious that not all vaccines have the same efficacy. The inactivated vaccines did not do as well as those of later technologies in terms of effectiveness, and as such a sizeable percentage of the population remain somewhat susceptible to the virus, particularly if they had not been boosted. Secondly, even those who received the more efficacious vaccines, saw their immunity drop over time. While this immunity was still strong enough to prevent against severe infection in most individuals, some who had risk factors were still susceptible to getting quite ill. Others who were immunocompromised or immunosuppressed, also ran the risk of contracting severe disease, despite receiving both doses of vaccine. Thus, the recommendation of getting boosters. Thirdly, the emergence of variants that might not respect the body’s previous immunity. Such a variant has already emerged with the Omicron variant – a variant even more transmissible than Delta, an even shorter incubation period (which leads to a more rapid upswing in cases during an outbreak) and a variant that has little respect for previous immunity, whether to vaccines or previous infection. Fortunately, so far it has proven to be a less deadly virus in terms of severity. It is hoped that eventually we will be able to ride out the storm. Many initiatives have been developed to ensure a sustainable and practical implementation at the hospital with regards to strategies, methodology, work process, staff empowerment and management support. In spite of the many challenges faced, we always received assistance where needed. Many effort came from our own staffs who truly understood what was happening on the ground and thus needed to patch any loopholes swiftly. Immense support also came from organizations, private and NGOs, from other ministries and mot importantly and strategically, from the various entities within the Ministry of Health (KKM).

165

Peak of The Waves … Towards The Survivors’ Journey to Recovery by Dr. Akmal Hafizah Binti Zamli As wave after waves of COVID-19 continuing relentlessly for over 2 years in our shore, with more and more cases being admitted, rehabilitation needs surmount ably escalated. This is to cater for survivors who were critically unwell as well as for those who continue to suffer from the long-term consequences of post COVID-19 infection. The term ‘Long COVID’ has gained fast widespread global recognition that led the World Health Organization (WHO) to acknowledge the phenomenon. This has led to the amplified awareness on rehabilitation as an important component in comprehensive COVID-19 care, hence shall be integrated throughout the spectrum of management from the subacute phase to beyond hospital discharge in the community. In November, as Malaysia approached a tally of a million COVID19 infected individuals, there was urge to prepare for the long haul of Long COVID symptoms as it has been predicted and becoming evident that soon after, Long COVID shall be of public health concern. Recognizing the demand, HSgB pioneered the initiative to provide the multi-disciplinary care for Long COVID. The acronym CROSS stands for COVID-19 Rehabilitation Outpatient Specialised Services. The birth of this new service stemmed from Dato’ Dr. Suresh Chidambaran recommending the article published by the British Society of Rehabilitation Medicine entitled ”Rehabilitation in the wake of COVID-19: A phoenix from the ashes” to the Rehabilitation team on the 16th October 2020. We were tasked to explore the running of the first outpatient rehabilitation medicine services in Malaysia for severe COVID-19 cases especially those who required ICU care. These patients are often associated with multi-system medical impairment hence complex rehabilitation needs.

On the 6th November 2020, the need to formalize a specialized, structured and comprehensive services to cater for the intermediate and long term effects of COVID-19 survivors hence their rehabilitation needs was agreed upon between the multidisciplinary medical specialities led by Dato’ Dr. Suresh Kumar Chidambaran. Involved in the decision were Infectious Diseases, Internal Medicine, Geriatric, Neurology, Psychiatry & Mental Health, Respiratory Medicine (HUiTM), Rehabilitation Medicine, Physiotherapy and Occupational Therapy services. With the approval of HSgB Director, Dr. Kuldip Kaur the service takes effect almost instantaneously. With the aim to reduce the magnitude, if not the incidence of Long COVID, the importance of early rehabilitation intervention was recognized. Hence the commencement of COVID-19 Rehabilitation inpatient Specialised Services acronym as CRISS. The framework model of CRISS and CROSS involved integration of care between multi-disciplinary medical specialties with that of inter-disciplinary rehabilitation team led by Rehabilitation Physician and comprises of core rehabilitation personnel including Physiotherapist, Occupational Therapist and Nurses. Others such as Counsellors, Speech Language Pathologist, Medical Social Worker, Dietitian are also involved as indicated. The key goals of these services are to identify and manage residual multi-system impairments expected primarily in the pulmonary, musculoskeletal, cardiovascular and cognitive domains to optimize the COVID-19 survivors’ return to their best functional level or in severe cases to adapt to living with residual disabilities. Comparable to the other specialised rehabilitation medicine services, the ultimate aim of rehabilitation medicine response in COVID-19 is for full re-integration of the survivors back into society. In October 2021, the CRISS and CROSS framework model had been presented at the Post COVID-19 Global Webinar “Expanding Our Understanding of Post COVID-19 Condition Web Series: Rehabilitation Care” organized by the World Health Organization (WHO). At the time of writing this article, since its establishment, CRISS had catered for over 500 referrals while CROSS had served for beyond 3,000 COVID-19 survivors.

166

The Proclamation : Post COVID-19 thoracic mobility exercises – essential for making a full recovery from COVID-19 among hospitalised patients

167

168

The Proclamation : Incentive spirometry exercise for post COVID-19 to assist the lungs in expanding back to its former self

The Proclamation : Training for trainer course by Rehabilitation Medicine Department which led the fight against long covid and led the way to bringing patients to full recovery

169

170

The Proclamation : The official launching of Post COVID-19 rehabilitation guidelines – helping former COVID-19 patients get back on their feet

The Proclamation : Visit by YBhg Tengku Zafrul, Minister of Finance, Malaysia 171

172

The Proclamation : Visit by YBhg Datuk Dr. Hishamshah Mohd Ibrahim, Deputy Director General of Health, Malaysia

The Proclamation : Courtesy visit from Dato Seri Dr. Adham Baba 173

174

The Proclamation : Meeting with YBhg Datuk Mohd Shafiq, previous Secretary General for Ministry of Health, Malaysia

The Proclamation : Visit to HSgB by the Malaysian Armed Forces – by working hand in hand with the army, police, and other organizations, the COVID-19 effort in Hospital Sungai Buloh was a success

175

176

The Proclamation : Visit from the Ministry of Health delegates, together with YBMK Khairy Jamaluddin, Minister of Health and Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia

The Proclamation : Inspection of the vacuum insulated evaporator in PKKN which enabled a drastic expansion of oxygenated bed capacity

177

178

The Proclamation : YBhg Datuk Mohd Shafiq visiting the new wards with medical oxygen pipeline system in PKKN

The Proclamation : Launching of the new magnetic resonance imaging (MRI) suite at HSgB – increasing the imaging capabilities of HSgB

179

180

The Proclamation : Reviewing the scanning process in magnetic resonance imaging (MRI) suite by YBMK Khairy Jamaluddin and Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia

The Proclamation : YBMK Khairy Jamaluddin attending to the COVID-19 corner during his maiden visit

181

182

The Proclamation : YBMK Khairy Jamaluddin attentively examining the videos and artefacts at the COVID-19 corner

The Proclamation : Signing the visitor book by YBMK Khairy Jamaluddin

183

184

The Proclamation : YBMK Khairy Jamaludin officiating the upgraded medical oxygen pipeline system in PKKN

The Proclamation : Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia visiting the Counsel Hall gallery

185

186

The Proclamation : Photoshoot in front of Counsel Hall with Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia

The Proclamation : One for the books - Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia with HSgB staff

187

188

The Proclamation : A gift of appreciation by the representative of leprosy community to the Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia

The Proclamation : Tan Sri Dr. Noor Hisham Abdullah, DG of Health, Malaysia signing the visitor book

189

“Life is about embracing its every challenges, striving to overcome it with your best abilities, being grateful and adoring every single moment along the venture…” Dr. Akmal Hafizah binti Zamli 190

“Don’t work for recognition but do work worthy of recognition” Dr. Tuan Suhaila Tuan Soh

LEGENDS OF THE SEA

Pillar of Heroes In the darkest moments, light still shone. Many junior doctors gave their all during this time, even though many were uncertain about their job futures, having been on contract employment. Some contracted COVID-19 as well whilst some others had to manage their own family members who were admitted, while juggling their own responsibilities. Many gave up festive periods and annual leave just to care for patients. Doctors from other fields like orthopedics and surgery joined hands to assist. Emergency physicians were heroic in their stamina in organizing for care in situations where even basic medical facilities were sometimes lacking. And my medical colleagues and nurses in the wards – both junior and senior – working hand in hand and sacrificing together, trying their best for patients that they did not know, not complaining, helping, and encouraging each other get through their shifts. Sometimes, even patients who were recovering helped out, knowing the hospital was at its knees. This challenging journey was braved together, one in purpose with the ultimate aim to ensure the best care possible for each and every patient who came through our gates.

195

The Stealth Stewards by Dr. Noor Shahimi Bin Shahidan Prologue Here within the corners of the hospital grounds, lie a small but efficient, silent but essential, compassionate but strict, unit managing the health and welfare of all the hardworking frontliners of Sungai Buloh Hospital. The Occupational Safety and Health Unit of Sungai Buloh Hospital has its gears and cogs empowered by a workforce of less than 15 people. This amount of workforce is after it was beefed up significantly during the first wave of the worldwide pandemic of 2020, COVID-19. Under the leadership of Dr. Noor Shahimi Sahidan, in 2021 the unit was split into three separately ran sub-units, mainly the Occupational Safety and Health division, the COVID-19 Staff Vaccination division and the Staff Clinic division. The Vaccination programme which started off as a vaccination programme in late February of 2021 for healthcare workers was expanded under the Ministry of Health (MOH), Program Imunisasi COVID-19 Kebangsaan (PICK), to cater for the public thus breaking off into an independent unit. Albeit separate, all three divisions operated with one main goal and focus, to uphold the health and safety of all the manpower serving in this hospital.

ln early 2021, the OSH Call Centre ventured into digital territories by applying the use of online forms to efficiently stratify staff and provide management through the use of digital communication. The process, which was applied through meticulous planning, streamlined the calling process significantly thus enabling the crew to apply the use of their time into pandemic preventative actions such as internal audits and engineering interventions. This was achieved amidst managing nearly 8 thousand cases of exposures of the staff to COVID-19 risks with proper documentation of plans and data conservation. On the other side of the card, OSH doctors with their knowledge of the disease transmission and engineering control measures intervened into many aspects of hospital renovations and modifications. Places like the Hemodialysis Unit, Radiology and Emergency zones that were altered to accept COVID-19 patients went through many layers of discussion involving OSH and Engineering Department to achieve the best possible construct within the urgency of a pandemic situation. All the new places were setup with the concept of minimizing the risks to as low as reasonably achievable.

Occupational Safety and Health Unit The OSH Unit of Sungai Buloh Hospital in the early stages of the COVID-19 pandemic of 2020, had pre-emptively setup a special taskforce dubbed the Safety Alliance For Employees Taskforce (SAFE-T) under the helm of the Hospital Director, the honorable Dr. Kuldip Kaur. The main branch of this unit, which was the OSH Call Centre, focuses heavily on the management of Sungai Buloh healthcare workers directly or suspected to be exposed, COVID19 –like symptomatic staff, travelling staff and so forth. The main goal has always been to maintain the number of workforce while treading carefully to keep the formation of a cluster from occuring. This taskforce moved steadfast into the year 2021 with some loss of manpower, and the need for a quick, efficient, noncompromising healthcare worker management system was required.

196

Although being hit with a massive wave of cases past the middle of 2021, Sungai Buloh Hospital and it’s ever-faithful staff weathered the onslaught of public cases while being thoroughly challenged internally as well. The months of July through September besieged the whole unit as cases of healthcare workers who became infected shot up mainly in response to the rising cases in the community. Through extremely careful planning, OSH unit treaded carefully to allow safe and clean cases to continue working. The manpower in clinical areas were kept at optimal levels to operate with nearly none to minimal disruptions. The cooperation among multiple other units allowed for mobilization of staff to cater to the minimum workforce of each area. A huge commendation to the staff of Sungai Buloh Hospital for their cooperation in trying their utmost best in following the universal precautions while pouring their heart into patient care.

Albeit all precautions, cluster formations were known to be an inevitable fact. Sungai Buloh Hospital faced a number of clusters during this period but all the while OSH managed to keep number of quarantined staffs to allow for continuation of service. All the while, OSH unit had also managed the swabs of the family members and household contacts of the staff. Wellbeing of the psyche and welfare were also taken into consideration with great cooperation among other departmental team players. All the while, as COVID-19 continued to ravage the country in 2021, staff health and wellbeing were not overlooked, the everfriendly and warm faces of the Staff Clinic doctors and nurses continued to look at cases of chronic illnesses and general wellbeing. No single disease were ever treated lightly for the attendees of the Staff Clinic and communication between Staff Clinic and OSH were often optimized to allow for job reallocation and redistribution accordingly. The responsibility of looking after staff in an Infectious Disease hospital during a global pandemic is a monumental effort in the year that was 2021. But with the prayers from all, and in the name of “Agama, Bangsa dan Negara”, the OSH Unit of Sungai Buloh Hospital shall muster its strength and brave into the year 2022.

197

198

Pillar of Heroes : Dr. Kuldip Kaur receiving the SEBA 2020 Outstanding Service & Leadership Award

Pillar of Heroes : Receiving the Malaysia Top Achievers 2022 Award 199

200

Pillar of Heroes : Dr. Kuldip receiving the Community Leader of the Year Award

Pillar of Heroes : 3-star achievement for Hospital Sungai Buloh under the Energy Management Gold Standard

201

207

208

14-6-2021 SELAMAT PAGI MALAYSIA

22-6-2021 BERITA PERDANA

20-2-2022 BERITA PERDANA

“We are now mindful that we need to use this ‘now-ornever moment’ to change the way we have been practicing hospital medicine and emerge from this pandemic stronger, leaner and healthier” Dato’ Dr. Suresh Kumar Chidambaram

“I did what needs to be done. That is all that matters at the time”

Dr. Sundar Gugan a/l Santhana Dass

219

OUR MEMORY LANE

Cherishing Memories Lastly though, the review of COVID-19 in 2021 would not be complete without a mention of another epidemic which rivals that of the virus, and which is just as tragic if not more. The epidemic of fake news and conspiracy theories. While is it wise to have a healthy skepticism about medical advances like vaccines, there exists enough safeguards within the medical and scientific communities to prevent fraud, especially widespread fraud. When this chain of trust is broken, wild and bizarre theories abound. This fake news epidemic has spanned from fake cures of COVID-19 (eg; ivermectin) to claims about the vaccines (eg; severe side effects are common; the vaccines are useless against COVID-19; the vaccines cause more severe COVID-19 infections) to claims about COVID-19 (getting the disease is better than getting the vaccine). Unfortunately, these conspiracy theories have directly or indirectly led to many deaths The past two years seemed like eternity, being trapped in isolation, fear, uncertainty. Many were overcomed emotionally, physically and mentally. This experience was unlike any other that we would likely face in our lifetime. Many took up this challenge with their head held high, tackling one challenge after another. Most of us hope never to have to encounter this phenomenon again. We will treasure all the good that came from this, the comradery, the resilience and the new doors opened. There was sadness that we will keep close to our hearts and learn lessons from. There were also opportunities for us to grow stronger and more resilient to face any new challenge ahead.

223

The Guiding Compass by Dr. Yasmin Binti Mohamed Gani This COVID-19 pandemic made a devastating impact globally and changed the lives of many in the world, which shows that being flexible in times of heightened stress is an important quality for an infection control practitioner. Our healthcare system was already overwhelmed by the repeated waves of infections since 2020, but little did we know that the worst was yet to come. We were left in a very dire situation when we had PPE shortages, N95 respirators in particular, which are essential in COVID clinical settings. We immediately resorted to newly developed guidelines on how to reserve our N95 respirator stock. This included extending the use and reusing N95 respirators, which required multiple sessions of hands-on training and road shows involving staff, as well as continuous effort in reassuring them that this will not have a negative implication if practiced appropriately. Unfortunately, there were more and more outbreaks among healthcare workers from October 2020 to January 2021. Luckily, with the help of our infectious disease team, we stepped up the PPE requirements of staff, which was, upon entering a ward with COVID patients on oxygen supplementation, staffs are encouraged to use eye protection equipment with N95 respirators to better protect themselves against airborne transmission. Besides that, regular ward rounds were conducted to ensure the compliance of these practices in the ward, while we also worked hand in hand with the ward sisters to answer concerns and overcome challenges. Much to our relief, after a few hiccups in the start, these practices were slowly but successfully incorporated into day to day routine. In addition, our facility received PPE donations from many generous companies and NGOs, and all this allowed us to cope with the high PPE demand. There were also research articles showing the importance of good ventilation in reducing transmission of COVID surfacing. We too adapted that principle and implemented several modifications to our ward settings, like placing air purifiers at high risk areas, and encouraging wards to open all the windows for better ventilation. Exhaust fans were even installed to air flow, and some rooms in critical care areas were converted into negative pressure rooms. This helped reduce the number of infections among staff by a great number.

224

Just as we thought we were managing well and the situation was settling, another problem hit us hard during mid 2021: the emergence of multidrug resistant infections among COVID patients in the intensive care units. We scrambled to mitigate the situation, which is where the gaps in infection prevention practices during this pandemic surfaced. Audits on infection control practices showed that compliancy were all actually below par. In response to that, our team started conducting bedside teaching sessions for staff in intensive care wards. However, as the cases kept rising, we realized that that was not enough. In order to complement hands-on training, we created our own website, and started producing teaching videos and posters to make the information more accessible to healthcare workers. When we notice that the cases were still persistently high, we knew something drastic had to be done to really make a difference. After consulting with our infectious disease experts, we decided to collaborate with various relevant departments, with one mission in mind: to reduce multidrug resistant infections rates. To achieve this, we decided on a multidisciplinary approach, which involved the cooperation of staffs from other departments such as intensive care, infectious disease, microbiology and Radicare cleaners. To assimilate this into part of their routine work, the intensive care team took novel initiative to encourage staff in their daily duties to give importance to infection control practices. As staff adapted to the new practice, there was a marked improvement in the trend of infection, and in the subsequent months, rates continued to remain low. Everyone was thrilled when all the hard work paid off, and staffs were given their due appreciation. Moving forward into year 2022, this is what we learnt during 2021 in a nutshell: preparedness is always the key to mitigate an emergency situation. What’s more, infection control policies have to evolve with time, as our super bugs do too. One should be aware of the latest updates, as so not to do disservice to our patients. And finally, teamwork definitely works better than sloughing away alone, as the saying goes ‘united we stand, divided we fall’.

Cherishing Memories : Frontliners appreciation day 2021 225

226

Cherishing Memories : Frontliners appreciation day 2021

Cherishing Memories : Frontliners appreciation day 2021

227

228

Cherishing Memories : Retirement of Dr. Sobani, Head of Ear, Nose and Throat Department

Cherishing Memories : Retirement of Matron Lai (Head of nursing unit) 229

230

Cherishing Memories : Celebrating our beloved Hospital Director, Dr. Kuldip’s birthday

Cherishing Memories : Cake cutting session during Dr. Kuldip’s birthday 231

232

Cherishing Memories : Hari Raya Aidilfitri Celebration 2022

Cherishing Memories : Hari Raya Aidilfitri celebration 2022

233

Cherishing Memories : A gift from both Datuk Harjeet Singh and Datuk Mohd Shafiq during difficult times 234

Cherishing Memories : Nurses Day 2022 235

236

Cherishing Memories : Appreciation from patients

Cherishing Memories : Appreciation from patients 237

238

Drawing by Lokesh Ishaan Dipak and Regin Atienza Gargoles depicting the battle against the pandemic

239

“Every champion was once a contender who refused to give up” Dr. Kuldip Kaur Prem Singh

241

Hospital Sungai Buloh Tribute Song for Frontliners Pasti Menang by Dr. Mohd Khairul Baharin bin Abdul Rasid and Dr. Faiqah Nastasha binti Mohamed Sam

Verse

Chorus

Dikala kau tersungkur Lemah tiada bermaya Jangan kau sekali berundur Takkan bulan jatuh ke riba

Bangkitlah semua Jalan bergandingan Terus berusaha Kita jaga kita Impian dan harapan Kami juangkan Putus asa bukan kita

Prechorus Final Chorus Usah biarkan matlamat mu di ragu Ikhlaskan hati teruskan perjuangan Dengan tangisan dunia Yang sengsara… 0ooohhhh…

244

Bangkitlah semua Jalan bergandingan Terus berusaha Kita jaga kita Impian dan harapan Kami juangkn Kemenangan milik kita.

SYNOPSIS This coffee book cum memoir started with a humble intention to have a memory keepsake of this unprecedented event which brought the whole world to a standstill. The initial meeting between Dr. Benedict Sim (Infectious Disease Consultant) and our Hospital Director Dr. Kuldip Kaur who introduced another documented journey of the SARS pandemic, sparked a deep aspiration to have our very own compilation of experiences, challenges, strategies and lesson learnt for the future generation. Hence the birth of our first volume “Emersion: Transcending the Tide” published in 2021. Dr. Kuldip formed a team to facilitate all aspects of production. The first edition was portrayed in the style of a storyline, emphasizing personal experiences and endeavours. It depicted the inception of Covid pandemic entering our shores; from receiving our first patient in March 2020, witnessing high peak of cases, strategizing within scarcity of resources, managing the intensity of emotional and physical stressors, maintaining the wellbeing of all hospital staff and the forging of a strong camaraderie. We always had to be quick on our feet, adapting and adopting best practices to cope with the ever changing landscape of uncertainties. As the trend of new cases was starting to show a promising decline by year end 2020, we were stunned by even greater challenges ahead in 2021, charting highest record of admissions (despite the change in policy of only admitting those who were at risk of severe illness) and significant sharp uptick in death statistics. We had to regroup our teams, redefine our preparedness strategy and reinforce our treatment & care plan. The road to recovery only begun only after the national vaccination programme went into full gear. This second edition “Odyssey: Braving the Storm” encapsulates our journey in a multifaceted snapshots interwoven with illustrations to bring life and meaning to this voyage. Sailing from bleakness to light, we kept our spirits high with hope and faith to brave this storm together. In 2022, we were mindfully ever-ready to soldier on and face any possibilities with our experiences and new found knowledge as an armour. Dr. Kuldip’s hope for this second edition is that it will serve as a a finale to this expedition drawing its sail to safe shores, to cherish these memories in a scenic album compilation. The themes chosen for both editions uses oceanic imagery to showcase the many forms and stages of the sea – from calm to turbulent. As was the pandemic that we had to endure.

245

Acknowledgements SPECIAL THANKS TO Ministry of Health

Selangor State Health Department Clinical Directorate and Clinical Support of Sungai Buloh Hospital Administrative and Non Clinical Support of Sungai Buloh Hospital The talented and insightful article contributors, masterful photographers, each and every Sungai Buloh Hospital staff who had directly or indirectly contributed to the publication of this book System Televisyen Malaysia Berhad, The News Straits Times Press Malaysia Berhad, Pertubuhan Berita Nasional Malaysia Last but not least, all frontliners, volunteers and donation contributors, who put others before themselves

246

GLOSSARY ICU - Intensive Care Unit BMU - Bed Management Unit PKKN - Pusat Kawalan Kusta Negara ED - Emergency Department CT - Computed Tomography PPV - Pusat Pemberian Vaksin OT - Operation Theatre HCW - Health Care Worker HSgB - Hospital Sungai Buloh YBhg - Yang Berbahagia YBMK - Yang Berhormat Menteri Kesihatan DG - Director General NGO – Non Profit Organization SPPV – Special Pusat Pemberian Vaksin

247

“ The sun always

shines after a storm ”