Vojislava Neskovic, Md, PhD, DEAA
On the March 2nd 2020 World Health Organization has declared that COVID-19 has become a pandemic disease. In Serbia, on March 15th, the State Government has declared the State of Emergency regarding the outbreak of the disease. This action has led to the implementation of the very strict measures of control and prevention of the disease spread. Although the majority of patients are known to have mild illness and recover uneventfully, it is expected and also experienced in many countries that the number of those infected who will seek hospital care and eventually intensive care for respiratory failure, oxygen treatment and mechanical ventilation, is substantial. This may overwhelm the health care system and hospitals, leading to a tremendous burden for the health care providers.
In Serbia, mechanical ventilation is, aside from a few exceptions, completely covered by anaesthesiologists. In the absence of formally established intensive care speciality, anaesthesiologists in our country are the only driving force of care for the most critically ill patients. As expected, a lot of responsibility has been placed on the shoulders of our profession, particularly knowing that the number of doctors is limited. Altogether, Serbia counts around 1000 anaesthesiology specialists and residents. They are working in very different hospitals, in terms of organisation, infrastructure and availability of intensive care units. But even more so, the number of educated intensive care nurses is quite low (somewhere as low as 3 nurses per 10 ICU beds), which makes even regular work, out of the outbreak, very challenging. The number of available mechanical ventilators has been continually counted and became the primary focus in the public eye, while everybody seems to forget that machines are not independent and that mechanically ventilated patients need intensive and very demanding care from educated professionals.
On the day this text is prepared, over 8000 COVID 19 confirmed patients with around 200 deaths have been reported in Serbia, out of close to 7 million inhabitants. Selected hospitals have been allocated to become “COVID hospitals”, dealing with confirmed infected patients only. The largest is located in the big cities: Belgrade, Nis, Novi Sad and Kragujevac. The largest proportion of the patients has been treated in these hospitals. Some centres have received the first impact very early, with the great number of sick patients admitted in the very short period of time. At the same time, not all parts of the country are affected at the same rate: the south of Serbia seems to be under the most immense attack.
The number of anaesthesiologists suddenly became very visible and the span of duties was difficult to cover. One of the Belgrade hospitals fought at the beginning with 20 specialists, who were taking care of nearly 50 intubated patients at the time. In Nis, 70 specialists with the help of 20 residents and 22 specialists from nearby cities treated 150 intubated patients. Usually, 24-hour duties are cut into 4 hours shifts and covered by the teams consisting of various numbers of doctors. In one location, a team of 7 doctors was covering 4 hours shift in the row (one doctor and one anaesthetic technician per shift), while larger teams had up to 25 specialists for 24 hours duties, again separated in 6 turns for 4 hours. Hence, it may happen that a single specialist is actually in charge of a large number of intubated patients, between 7 and 15. Redistribution of anaesthesiologists all around of Serbia according to actual hospital needs was essential to cope with the outbreak. And the doctors did follow their duty as it was placed on the table. Anaesthetic nurses, who were following doctors, were essential in caring for respiratory compromised patients.
Additional difficulties have been experienced due to the poor infrastructure of the hospitals not suitable for epidemic: patients are spread in the different floors, different parts of the hospitals, small-improvised rooms or even newly open buildings adapted for COVID patients only. Also, a shortage of trained personal resulted in recruiting young inexperienced nurses, often having their first intensive care practice in the last couple of weeks.
Although personal protective equipment (PPE) is available, the majority of hospitals received them almost at the same time as COVID patients. The consequence was lack of time for practice and training in donning and removing PPE. Very few hospitals had the opportunity and enough time for simulation training for their COVID teams. On many occasions, anaesthesiologists were leaders in hospital organisation, planning green and red zones, again being the profession most concerned for the safety of both patients and workers.
A huge burden has been placed on anaesthesiologists that are not working in the COVID hospitals since all emergency and oncology surgeries have to be performed under these new circumstances. Now, those teams have fewer people working, while dealing with changed protocols and trying to identify patients that might be infected.
Unfortunately, around 10% of all COVID patients in Serbia are medical professionals. There are various reasons for that and the problem deserves more analysis in the future. The exact number of infected anaesthesiologists and ICU nurses are not known, but our society has committed to reaching out to all our colleagues who have put their health and lives on the line in the course of their duty.
The Serbian Association of Anesthesiologists and Intensivists (SAAI) was very much involved in dealing with COVID-19 outbreak in our country. Our set of recommendations was published immediately and made available on our website (open access), including comprehensive guidelines on managing the airway, mechanical ventilation, using PPE, taking care of equipment and patient management (http://www.uais.rs/en/covid-19-preporuke-2/). Some of them have been updated with the newly available information. Our society has nearly 500 members, all of them are involved in getting the job done. Members of the Board are included, either as the coordinators and supervisors in the hospitals and country regions or as the frontline fighters.
We have no other choice but to work and fight for our patients as we always do. However, we also hope that this example will serve as a proof of the obvious need for many more trained, acknowledged and valued anaesthesiologists, who can deal successfully with any unexpected disaster as well as increasing regular work in our country.
And just before I put on my spacesuit, I wish to send the message to all my fellow anaesthesiologists wherever they are: Stay strong, healthy and dedicated as always. This world needs us.
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