1. Yusuf, Saldy PhD

Article Content

On March 2, 2019, the COVID-19 outbreak became headlines news in Indonesia. The President announced the first confirmed case in Indonesia. As a wound care nurse, I had to decide whether Griya Afiat Clinic should keep running or be locked down. We did not have any experience working under a pandemic, everything became uncertain and unpredictable. The fear, denial, bargaining, and finally acceptance process led us to decide to keep the clinic running. If we locked down, where will patients receive treatment?


We increased our safety protocol, including use of personal protective equipment (PPE), such as cap, face mask, gown, and boot sandals, and disinfecting the room and furniture. We also prohibited family members from entering the clinic. Regarding home visits, we reduced our schedule, from daily to three times a week. Moreover, we performed initial screening through online assessment to screen eligible patients. Patients who have fever, cough, and/or dyspnea were directly referred to the hospital. We also asked patients to send wound pictures. Patients with clinical signs of spread of infection were also referred for hospitalization.


An increasing number of COVID-19 patients in Indonesia was reported in news. The number of confirmed cases gradually increased in Makassar city (capital of South Sulawesi) and became the highest in eastern Indonesia, increasing the warning status to red. The local government increased the security level and the border of the city was tightly controlled. It became difficult to distinguish fact from fake news. A half month after the outbreak in Indonesia, nine nurses died due to COVID-19. There came to be a negative stigma against healthcare professionals, including nurses. Neighbors didn't want them to return to their apartments, drivers declined to pickup of nurses, and the body of a dead frontline nurse was even refused at the grave.


Time arrangements were needed to separate noninfected from infected cases. The majority of our patients reside outside the city (> 30 km), whereas some reside outside the province (1 hour by plane). Arrival times can be hard to predict. As the majority of wound care is conducted in 1-hour sessions for each patient, it was important to arrange the admission times to avoid multiple patients arriving at the same time.


Regarding the payment, as Griya Afiat is a private wound care and home care clinic, the payment was not covered by insurance. Thus, we classified our payment into three categories. The payment was 100% for those who have economic ability and 50% for the middle economic class. For patients who have economic inability, we provide care free of charge (this concept is known as "sadaqah" in Islam).


At 08:30 a.m., Mr. H visited the clinic due to venous ulcers. The patient reported that the wound had existed for 1 year. He visited a public health center, but there was no improvement. Our clinic was suggested by his brother (who previously visited our clinic and had healed a diabetic foot ulcer [DFU]). Pedal pulse on the affected foot was palpable and there was no pain or odor. We used hydrogel silver to perform autolysis debridement and four-layer bandaging to provide compression therapy. We also educated the patient regarding his wound etiology, process, and prognosis.


At 09:30 a.m., Mr. Y came with diabetic ulcers on the left second finger. The patient had DFUs on the left heel 5 years ago, which healed after 5 to 6 months of treatment. The current ulcers were present about 1 month, indicating that the patient delayed the decision to attend the wound clinic, despite having a positive experience with the previous ulcer. We noted presence of slough, associated with strong smelling odor, and bone exposure. The clinical appearance indicated presence of local infection. Silver dressing was selected as primary dressing, followed by dry gauze and adhesive tape. The DFU is considered a major chronic wound in Griya Afiat.


At 10:15 a.m., Mrs. E visited the clinic due to delayed wound healing. This was a postoperative wound (hip fracture with pin). The patient underwent surgery approximately 1 to 2 months prior. Due to the COVID-19 pandemic, the outpatient clinic in the hospital was closed. The wound size was 4 x 3 x 4 cm (length, width, and depth), painful with pale granulation and purulent exudate. Hydrophobic dressing impregnated with honey was selected as the primary dressing, followed by dry gauze and adhesive tape. The patient was crying and hopeless about the 3-month delayed healing.


At 11:00 a.m., Mr. S had recurrence of DFU. Previous ulcers were noted about 1 year ago and healed after 5 to 6 months of treatment. This case also emphasized the increasing recurrence rate of DFU and reminded us that education is an essential approach in prevention of both new and recurrent ulcers. Similar to Mr. Y, it took more than 1 month for Mr. S to decide to visit the clinic. Personal and cultural beliefs might contribute to the reluctance to visit the clinic. We noted that almost half of patients attempt to use a nonmedical approach, such as traditional therapy, before deciding to seek professional healthcare service.


At 11:30 a.m., Mrs. N arrived with a complaint of gangrene. The patient looked pale, breathless, and apathetic, indicating reduced sensory perception. The daughter reported that the patient refused to undergo hemodialysis in the hospital. Both legs had 4+ edema and bulging with some small lesions on the pretibial area. The hallux valgus and first right phalanx were necrotic and had foul odor (indicating presence of gangrene). The patient and family seemed afraid to be hospitalized due to COVID-19. We explained that the current problem is not solely ulcer but also a systemic infection, which urgently required antibiotic therapy and is beyond our competence as wound care nurses. Our protocol recommends hospitalization for the patient who has infection spread above the ankle. This protocol had been introduced, and we had some collaborators with physicians, including surgical and vascular physicians. We believe the collaboration will increase the odds of healing.


At 1:00 p.m., a home care visit was arranged. During the pandemic, we reduced the frequency of home visit. An uncomplicated wound was recommended to be treated by the family via online coaching.


The end of pandemic is unpredictable, prevention becomes an essential approach. Working from home, maintain physical distancing, handwashing, and using face mask become basic education for all. Even though some healthcare services are locked down, it is difficult for us to look down, maintain universal precaution, use PPE, and keep praying to God for a healthy condition. Using PPE creates some limitations in activity. Goggles become foggy due to breathing, and impair vision; tightness of the N95 mask leads to disturbance in breathing and causes erythema of the cheek and nose, and frequent handwashing poses a risk for irritant dermatitis. Maybe this is the answer, why the World Health Organization designated 2020 as year of the nurse and midwife.