The Health Centrum healthcare workers during their training for the use of modified PPE. Alcohol wash is emphasized in many of the steps. Photo from Dr. Abundio Balgos
Culture Spotlight

How COVID-19 frontliners are improvising with personal protection equipment amid lack of supply

While private groups are working double time to source proper personal protective equipment, we must give props to good old Pinoy ingenuity that some of our hospital workers are able to make do with creative and efficient substitutes, from garden gloves to plastic raincoats. BY RHIA DIOMAMPO-GRANA
| Mar 17 2020

Probably one of our worst fears during this dreadful COVID-19 pandemic is finding out that the hospital operations in our city or municipality got paralyzed because a health care worker (HCW) got exposed to the novel coronavirus and infected other patients and HCWs, or that other HCWs on duty all had to go on quarantine because they are now considered as Persons Under Monitoring (PUM). 

This is, in fact, a highly possible scenario, if our HCWs don’t get the protection they need. Personal Protective Equipment (PPE)—mask (N95 or surgical mask), eye shield, cap, disposable non-permeable gown, booties, gloves—are necessary when attending to high-risk patients. And unfortunately, we have an obvious lack of these PPEs. The UP-Philippine General Hospital has recently called for donations for medical supplies for its health care workers, as they fear that their stocks can only last for two weeks.

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Why is there a shortage in PPEs?

According to Dr. Edsel Maurice T. Salvana, Director of the Institute of Molecular Biology and Biotechnology at the National Institutes of Health-University of the Philippines Manila (NIH-UP Manila), a lot of the hospitals had adequate PPEs. However, the surge of patients and the need to assume that they could be infected with COVID-19 led to increased PPE use, hence the shortage. 

“One possible COVID-19 patient will consume about 12 full PPEs in a day—six for the nurse who monitors every four hours, three for the resident who checks on him/her, one for the consultant who supervises, one for the lab person, and one for the x-ray person. This is if nothing urgent happens. So you can imagine with the influx of patients, even the most well-stocked hospital will be depleted in a matter of days,” he points out.

UP Medical Foundation, Inc. president Dr. Mediadora C. Saniel estimates that a hospital with 1,000 HCWs will need 90,000 masks; 2,500 N95 masks; 5,000 surgical gloves; 2,500 gowns; 2,500 hoods; 2,500 caps; and 300 gallons of alcohol in a month. The UP-PGH has 4,000 HCWs according to infectious diseases specialist Dr. Regina Berba.

The standard PPE from the DOH (left) and the modified version. Photo from Dr Omar Mejia of Roxas City

Dr. Salvana attributes the shortage of PPEs both to hoarding and to inadequate supply. He says the hoarding of masks is the most problematic, especially the N95s. There is also a global shortage of PPEs so it’s a nightmare in procurement. 

Dr. Geraldine T. Zamora, a consultant in three tertiary hospitals in Manila likewise laments the severe lack of PPEs. “We need N95 masks of all sizes, as well as gloves and fluid resistant gowns,” she shares. In the hospitals she’s affiliated with, they are overhauling their system, so that “layers of teams have been formed to answer the present need for frontliners and to prepare for the worst, since this may possibly go on for a while.”

She says they have to ensure that there will be continued manpower in the critical areas and the non-COVID areas. “We’ve been trying telemedicine because we also have to take care of our patients with other illnesses. This way, they won’t become critically ill, needing to be confined and therefore not need to compete for space in the hospitals. Keeping them away from the hospitals will also limit the possibility of being exposed,” she inputs.

Dr. Zamora observes that while there is an alleged inadequacy of supply worldwide, hoarding is also prevalent. “What hurts us most is how some people jack up the prices and demand wholesale purchase that can cost millions. For example, in order for a foundation I work with to be able to purchase N95 masks to distribute to frontliners, there was a requirement of purchase in the minimum of Php4M,” she confides.

Entrance of the Emergency Room in Aleosan District Hospital, Iloilo. Photo from hospital director Dr. Paz Calopiz

In the provincial hospital setting, pulmonary diseases specialist Dr. Abundio Balgos says they had followed the basic requirements for Department of Health (DOH) and PhilHealth accreditation, which is one isolation unit and at least 10 sets of PPEs. But this number wasn’t obviously projecting the pandemic that we are currently experiencing. 

“The Persons Under Investigation (PUI) have to be observed, and while waiting for the results from the Research Institute for Tropical Medicine (RITM), we have to protect our staff and our patients with comorbid illnesses (those with more than one health disorder),” says Dr. Abundio, who is also the president and CEO of The Health Centrum (THC) in Roxas City. “In our local experience, attending to patients with comorbid illnesses require 30 to 40 PPE kits every day. So you can just imagine how many PPEs are needed now that there are 140 confirmed COVID-19 cases all over the country—multiply the number of cases to an average of 10 hospital-day stay.”

Most of the PPEs that our local hospitals have, Dr. Balgos says, are manufactured in China, since they produce the cheaper ones that cost Php1,000 to Php1,2000 (price before the pandemic). The ones from the United States or Europe cost approximately US$1,000. “Some hospitals in Metro Manila I think have stocks of the PPEs. I cannot say this for many hospitals in the provinces,” he says. 

Entrance leading to the Outpatient Department Aleosan District Hospital, Iloilo. Photo from hospital director Dr. Paz Calopiz
 

Devising contingency plans

It is for this reason that the pulmonary and infectious diseases experts from THC headed by Dr. Balgos decided to utilize the modified PPEs they had devised for the Ebola, SARS and MERSCOV outbreaks a few years back. 

The set is comprised of:

• 2 pairs of clean gloves, used as initial double gloves

• 1 pair of garden gloves, used as final gloves, with length long enough to adequately cover end of gown sleeves

• 1 pair of clean gloves, to be used during end of doffing

• Plastic shoes (construction boots) 

• Non-porous knee-length gown made from plastic raincoat. Hood has been cut. The gown is worn with the opening at the back. If raincoat sleeve is short or without garter, they add an extension and/or garter with heat sealing 

• Shoe cover - ordinary plastic bag, big and long enough to serve as disposable boots to be worn over the boots 

• Surgical hood - ordinary plastic bag that can fit the head of the health worker; one side of which is cut 

• Face shield - made out of hard plastic. A garter is fixed on the top end; a thin foam may be added for comfort 

• The standard surgical masks are part of the set

HCWs at The Health Centrum in Roxas City practice donning and doffing of PPEs during their training.

In the powerpoint presentation that Dr. Balgos had prepared, a step-by-step guide is provided for the HCWs to follow, emphasizing specific steps on donning (wearing) and doffing (removing), the importance of having a second HCW to ensure that no steps are missed out in the checklist. Disinfecting with alcohol in many of the steps is also stressed. 

“Training and practice are crucial here,” he points out. “Kung di sila marunong, baka lalo lang makasama.” He also says that the steps on doffing should be strictly followed “because you assume that there are infectious elements already in the PPE,” he says. 

“A big no-no is yung nagmamadali sila. Every step of the way, paulit-ulit ang alcohol wash, even on top of the gloves. Yun ang di talaga dapat inii-skip,” he adds. The modified PPE kit will cost around P250 (could be higher now since there is a huge demand for items like plastic raincoat).

Dr. Mario Panaligan, an infectious diseases specialist and the vice president of the Philippine College of Physicians (PCP) says the modified PPEs are helpful when categorizing the risk transmission and classifying the types of patients they see—whether they are low risk or high risk.

Dr. Zamora says she is also coordinating with different hospitals and sharing ways on improvising the PPE. She says that while there are strict standards when it comes to this, “the improvisations come in handy because they're better than nothing.”

Dr. Balgos stresses that they would, of course, prefer the standard PPEs, but they cannot get a hold of these at the moment, and this is why they decided to improvise.

An intern from West Visayas State University trying on the face shield. Photo by Dr. Therese Rubi Nadala
Dr. Mary Gay Buliyat, Training Officer at Pines City Doctors Hospital and Assistant Chief of Clinics at Saint Louis University, testing an improvised face shield. 

How to help

Meanwhile, Dr. Salvana is happy to note that the private sector is stepping up to look for PPEs. “Some of those who stockpiled are now donating them. The DOH is trying to ensure a sustained supply. Everyone is pitching in,” he assures. Dr. Panaligan also confirms that orders have been made by the DOH, and that donations are coming in, to different hospitals, both government and private.

Dr. Balgos underscores the importance of public cooperation in the face of COVID-19 pandemic. “Please cooperate in the quarantine and social distancing measures. Yun lang talaga ang paraan para hindi natin ma-overwhelm ang health care system natin, the way the Italian health system was overwhelmed,” he appeals to the public. 

“Those who came from Manila and went home to the provinces have a social responsibility to inform the health authorities in their area so they can be monitored. Sana lahat ng Pilipino ngayon mag-cooperate kasi this is a national problem. Hindi ito problema ng doctor lang, ng provincial or municipal health officer, problema ito ng lahat,” he emphasizes. 

Dr. Salvana, on the other hand, advises those who have mild symptoms to stay at home and quarantine. “You WILL NOT get tested if you have mild symptoms because we are prioritizing the severe and critical patients. At some point, testing will be provided at the community level and so it is safer to stay put unless you are short of breath or are truly unwell.”

The Rizal Medical Center received 400 surgical masks yesterday from TOWNS Inc. and the UP Medical Foundation.

Those who wish to help, he says, could donate money or in kind to groups that are currently providing food, equipment, and support to the frontliners. TOWNS Foundation, Inc. and the UP Medical Foundation, for their part, are deploying small batch donations from private individuals to government and public hospitals. In-kind donations include medical supplies such as medical masks, gloves, gowns, alcohol etc. “Now is the time to unite against a common foe and do our best. Sacrifices are being asked from all of us and we should help one another during this trying time. We will survive if we work together,” he says.

While we rely on our HCWs for our well-being, they in turn are asking for our prayers. Three doctors had been in critical condition because they attended to patients who did not disclose travel history, but two are already getting better. “Let’s pray that this pandemic stops completely, for the safety of all, particularly the frontliners—our health care colleagues, manning and handling the sick. I’m truly happy with the kind words extended to us, and the motivational photos and videos that we receive, boosting our morale, supporting this deed that we ourselves are tasked to do. To prevent the spread of the virus, each or us must constantly observe and practice infection control measures like hand hygiene, cough etiquette, wearing masks when needed, as well as social distancing and proper home quarantine,” Dr. Panaligan reiterates.

 

***

 

TOWNS, on the initiative of Dr. June Lopez, has put out a call for donations in cash to buy PPEs in bulk from China through SM Foundation and source locally through our TOWNS procurement team. They are working with the UP Medical Foundation Inc. as its cash receiving partner. They are accepting donations in kind to deploy directly from donor to waiting hospitals. They have identified over 50 hospitals in NCR and nationwide (government hospitals in need who have point persons waiting, especially provincial and hospitals under LGUs) through their network of doctors like Drs. Medy Saniel and Dr. Geraldine Zamora. So far, they have deployed to 20 hospitals including San Lazaro (1000 N95 masks), PGH (300 gallons alcohol), RITM, Philippine Heart Center, Batangas Medical Center. These are from individuals and big corporations.

For those who wish to donate, you may deposit your cash donation to:

The U.P. Medical Foundation, Inc. 

Bank: BDO, Bocobo-Pedro Gil Branch 

Account No.: 00-353-0094-018

Swift Code: BNORPHMM 

For proper recording of cash donation, please email a picture of validated deposit slip with the name of donor to: upmf1980@gmail.com or VIBER +63922-338-8051. An official receipt may be issued upon request. For those who want a Certificate of Donation (for tax credit), please send a copy of the following to the same email or viber account: Validated deposit slip / Name of donor / TIN / Address. For those who want to donate/deposit and want to stay anonymous, just text to the same viber the amount deposited and date/time deposited. Lastly, for amounts P50,000 and above, the name and address need to be disclosed for SEC reporting. 

DONATIONS IN KIND are also welcome. If you have any of the following, in any quantity, please message +63977-240-1211 with your name / location / supplies and quantity: 

1. N95 masks

2. Surgical gloves

3. 3 ply mouth masks

4. Alcohol spray / alcogel

5. Face shield / disposable eye shields / goggles 

6. Disposable non-woven gowns

7. Disposable hoods

8. Disposable shoe covers 

They will match your supply to specific hospitals in need.