From Dr Pedro Amorim
In countries all over the world, the COVID-19 epidemic has reached the stage when hospitals must receive and care for many patients in need of artificial ventilation, being treated in new spaces and requiring the care of anaesthesiologists.
I decided to write you this letter because we need to face the fear that threatens to paralyse us, and in the process, raise the morale, motivate, encourage and foster confidence.
I am 64 years old, an age that grants me experience, but also places me in a risk group as far as this virus is concerned. I work in Portugal, at Hospital de Santo António, Centro Hospitalar do Porto, a large university hospital. After Italy and Spain, the epidemic reached my country and probably yours.
Since March 23, routine surgical procedures have been reduced to a minimum in our hospitals and operating rooms have been converted into intensive care units for COVID-19 patients. Because of these measures, anaesthesiologists have been allocated mainly to emergency and other surgeries that could not be postponed, as well as to the new intensive care areas that have been created to respond to the epidemic.
Anaesthesiologists are particularly qualified to deal with airway and mechanical ventilation. They all have training and experience in intensive care. Hospitals need the direct involvement of anaesthesiologists in order to be able to provide mechanical ventilation and intensive care, to meet the demand from COVID-19 patients.
In my hospital and probably also in yours, the recent reorganisation allowed for colleagues in greater clinical risk to be dispensed from clinical activity, namely those with oncological diseases, who are immunosuppressed or are above the age of 60. Due to my age, I was given the option of staying away from the front line, that is, at home. I am healthy, so I made the decision to I remain on duty and work alongside younger colleagues, doing what we are asked to do according to the needs that we will face. I worked for several years in intensive care and trust that my contribution will be useful now.
My words should, therefore, be understood as coming from one of you and not from someone theorising in the comfort of his office. I am a full-time physician doing a 24-hour emergency shift every week, just like most of you. I am optimistic because now, in my country and presumably in yours, we see commitment, organisation and effective responses to the COVID-19 epidemic.
However, as we are being called into action, we need to counter fear. Fear is a constant presence that accompanies any discussions about COVID-19 among healthcare professionals, in my hospital and presumably in yours. The way to counter fear and break away from the vicious circle of obsessive and unproductive discussions is to promote attitudes and actions that raise morale. That essential step was clearly conveyed to Portuguese anaesthesiologists, in mid-March, by Paolo Pelosi, an Italian anaesthesiologist and intensivist, former President of the European Society of Anaesthesiology and an expert in the ventilatory support of ARDS patients. His message circulated among Portuguese physicians and reached the Dean of the University of Lisbon Medical School, who quoted Paolo Pelosi in a letter to the Prime Minister, urging him to take immediate action. Such a letter was key to trigger as early response to the epidemic in our country. Paolo’s message also told us about how tough it is to work in the frontline, warning us that at this challenging time, healthcare professionals’ psychological well-being must not be neglected and requires proper care and support.
Dear younger colleagues, you will realise how important it is to motivate those around you; to acknowledge the severity of the situation and out of that awareness promote a proactive, organised and creative attitude, proposing solutions adjusted to the reality at hand. This is the time to move on from the repetition of relayed conversations in self-enclosed circles to a more forthcoming attitude, contributing with ideas and initiatives, meeting adversity with resourcefulness. That, multiplied by each of you, will be an enormous contribution.
Yesterday, I wrote to a niece of mine who is a first-year resident in family medicine: “You now are a medical doctor and you can be useful; if you were still in the final year of medical school, you might feel frustrated at not being a doctor yet, at being unable to do anything but stay at home watching how other younger doctors were making their contribution. By appreciating the opportunity you have by virtue of being a doctor, you will feel all the more motivated to share in the effort to control this epidemic.”
Each of us must act as if we had been chosen to trigger a cascade of motivation, confidence and mutual support. If there are two of us, we will be all the stronger for it. If there are more, the group will become all the more confident and determined. We need to feel surrounded by highly professional and motivated colleagues and that requires everyone’s contribution. If each of us can focus on the step forward and not backward, a feeling of confidence and strength will emerge. Anaesthesiologists value and practice teamwork: we are good at forming teams and know from experience that teamwork and mutual support will provide us with a sense of reassurance and commitment.
Anaesthesiology is a leader in safety, so we are particularly well placed to raise safety levels in the present circumstances. Public health authorities and society at large are engaged in multiple initiatives that allow us to feel optimistic about having all the personal protective equipment we need.
At the present stage of the epidemic, I find it important to highlight something that sets us apart from most of our fellow citizens: during this crisis, we will keep our jobs and our income and will have more rest days than we usually do. I am aware that such a reminder may seem out of place, but there is truth in it, for the epidemic will leave many people in difficult predicaments, with a reduced income or no job at all. I know that we risk our health and to some extent our lives, but the tasks we will perform fall within the skills that we proudly acquired during our education and training. These tasks will be performed under the highest safety measures and, we must ensure, with adequate equipment. That contrasts with the situation of many of our fellow citizens, who experience economic difficulties and have no antidote for their fears.
It is equally important to bear in mind that we will be part of a team: no one will be abandoned or left unprotected, there will always be someone besides each of us. That is the best support we could possibly have, after years of helping one another face the most complex life-threatening situations. That is what we must do now. We also have the experience of working with our colleagues from intensive medicine and other specialities working in the ICU, as well as with nurses, our indispensable partners in everyday teamwork: our mutual respect and mutual solidarity will bring us even closer now. As Yuval Noah Harari reminds us, “The big advantage of humans over viruses is our ability to cooperate efficiently.”
The examples of our colleagues in China, Italy, Spain, and more recently the USA, the most affected countries so far, should inspire us. Like them, initial fear will give way to professionalism, team spirit, and the aim to save lives. Do not forget that in this epidemic most lives are saved. Even the lives of very ill patients. And there is nothing more comforting for those who are now ill than to know that hospitals and their professionals are prepared to receive them and treat them properly.
Apart from providing medical care, we must provide the care that would otherwise be provided by the daily presence of patients’ relatives and loved ones. Since they are placed in isolation, hospitalised COVID-19 patients are deprived of visitors and find themselves utterly lonely. It will also fall upon us to be their loved ones; that is what patients expect of us. That selfless and generous side of us is also something that our own loved ones are proud of. No one among you, young doctors, have reached this point in your career without the sacrifices and efforts of those who came before you, namely your parents and grandparents. Each of you is aware of how proud they are of your achievements. In the face of this crisis and of what is expected of us, overcoming our fear will earn us the pride of our loved ones and of society at large.
I know that each of us knows that we can do it and that will be able to find in our hearts the drive to act and the serenity to act well. That serenity and the peace we will find will allow us to put the resources Anaesthesiologists have at the service of patients. And those patients will be mostly your parents’ and grandparents’ generation.
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