“Not being intubated when it is essential to kill in minutes” | International

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Borja Quintana (Madrid, 1962) and Antonio Planas (Valladolid, 1959), experienced the first wave of the covid-19 in their hospitals, the Universitário de Móstoles and La Princesa, in Madrid. There are heads of service in Anesthesiology and Reanimation. The first is also president of SAR Madrid, the community’s Anesthesiology, Reanimation and Pain Therapy Society; the second, secretary of SEDAR, the Spanish Society of the area. In March, hospitals started to work with the available resources, but in just three weeks they were already far exceeding the capacity of their sectors of critically ill patients and their ICUs, the intensive care units. Some sixfold their original space for the most seriously ill. They started to use resuscitation spaces [unidades de críticos pós-cirúrgicos a cargo dos serviços de anestesiologia] and transformed places that previously did not have this use: operating rooms, post-anesthetic recovery areas, gyms, corridors.

The involvement of anesthesiologists was crucial in the great choreography started by all hospitals to fight the virus, in a flood of patients as the health system had never suffered. More than 900 professionals in this specialty have dedicated themselves to assisting the critical covid-19 to complement the teams of Intensive Care Medicine, and the care of non-postponing and urgent surgeries. Quintana and Planas jointly answer questions about the past, the present and the future of the pandemic.

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Question. In March, the virus surprised the health system, which had to reinvent itself in hours to contain an avalanche of patients that collapsed hospitals. Seven months have passed, what has changed?

Answer. In hospitals, so-called “elasticity plans” have been developed to adapt the activity to the assistance pressure, if material has been acquired for critical care, such as respirators; strategic drugs were stored; new spaces were planned and equipped to be used as covid-19 critical care units; contingency plans were developed and coordination between the different anesthesia services was much better structured. But obviously each hospital has its particularities and must identify its strengths and weaknesses. In relation to human resources, the same human force that in the first wave knew how to be in the very first line, would now be willing to work for the population and ensure the highest possible quality of care.

P. In this crisis, anesthesiologists are part of the Intensive Care Unit teams that deal with critical patients. What obstacles did they encounter?

R. The main obstacles in the first wave were those caused by a catastrophe. If in Madrid there was an earthquake with the same number of victims, the health system would have the same difficulties. The anesthesiologists had a role in the care of the critical patient and, being one of the most numerous staff in hospitals, we were able to offer this service to the population by diverting a large part of our usual activity to very urgent and critical care. Doubling the number of beds in a few days was difficult, but we think we were able to step forward as was our duty, and vocation, and as other professionals did.

P. Many specialists were removed from their routine to treat patients with covid-19, something that paralyzed part or all of some areas of routine activity. How has it affected and affects your specialty?

R. Faced with a situation like the one experienced in the first wave, there is no option. In hospitals, what was done was done. Every minute of delay in the care of a patient who came down from the sector and arrived breathless in the emergency room could mean the loss of a life immediately. This leaves little room for almost anything. Numerous surgeries have been suspended to save lives immediately. And we must take into account that not all surgical interventions have a vital character, that is, that either the operation is performed as soon as possible or the patient dies. But don’t be intubated when it is essential to kill in minutes. It is true, however, that it was also necessary to suspend many oncological and non-postponing surgeries. This is very hard. We live with great concern and sadness. Regarding this second wave, each hospital is flexibly adapting surgical activity to the workload. Oncological and non-postponing surgery are prioritized and urgent activity is maintained. The pace of hospitalizations has nothing to do with the previous wave and in most hospitals, work is being done with better organization and less immediacy. What will happen from now on? We do not know.

P. How did you deal with uncertainty again, what is the emotional situation and in relation to the workload?

R. Currently the workload is quite normal for anesthesiologists and, with the exception of some hospitals, anesthesiologists did not take action with covid-19 critical patients in this second wave. Regarding the emotional situation, they suffer and enjoy their lives and the work overload and traumatic experiences affect them like anyone else. They are as afraid as anyone, and besides, there is something that perhaps nobody has evaluated. Covid-19 did not forgive family members of health care workers. Among them are many who have lost a father, a brother and a friend. And yet they did not abandon the struggle, working for others and doing their duty. The Preventive Medicine and Psychiatry and Clinical Psychology Services conducted research in Anesthesiology and Reanimation Services during the first wave of the pandemic, including medical staff, nurses, assistants and caretakers. 20% of respondents had scores that suggested they might need emotional help. The answer that obtained the highest score in these surveys and reflected the highest degree of anxiety, among all professionals without distinction, was: “I am afraid of infecting my family”. Others became infected with the virus and some continue to have sequelae. Like the rest of the population. Many have had post-traumatic stress and many are already better.

P. Was it possible to carry out any training for professionals who are not used to dealing with critically ill patients who can see these critically ill patients again?

R. By the European Union and through ESICM (European Society for Critical Care), a training program on basic concepts of critical care was launched for health professionals not used to this work. In Madrid it was done in anesthesiology with doctor Fernando Ramasco. Training groups were created in 15 hospitals in Madrid and training activities began that month. This should improve the workers’ capacities and, with that, the assistance results. It is necessary to take into account that the need to work with untrained people does not only affect patients, it generates enormous stress on the professional. This training was essential.

P. What can be done and what do the institutions ask at that moment?

R. The COVID-19 manifesto in favor of a coordinated, equitable response based on scientific evidence is very enlightening in this regard. It asks institutions that have responsibility for the management of the pandemic to make decision-making guided by strictly sanitary criteria and based on the best available scientific evidence. The pandemic made it clear that science must play a more relevant role in the public sphere.

P. What do you think about the institutional messages of “pandemic control”?

R. Communication is a fundamental pillar in the fight against the pandemic. The public expression of messages should always be sufficiently nuanced, guided by strictly sanitary and knowledge-generating criteria. Awareness raising and health education for the population are essential to face new threats with better perspectives. About this we refer again to the COVID-19 Manifesto [chamado Em saúde, os senhores mandam, mas não sabem] that 55 scientific societies signed after the first covid-19 virtual congress. There is the answer to that question.

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