At the end of May, Elisa Estenssoro, head of the Intensive care service at the San Martín Hospital and member of the Executive Council of the World Federation of Intensive Care Societies, compared the pandemic with the plot of the movie “The Desert of the Tartars”: the intensive care units were then fortresses that awaited, in tension, an undisclosed enemy. At the end of June, the situation had changed to the point that Estenssoro assured that “the dust of the horses was already visible.” Today the pandemic is a tangible reality that dramatically materializes in the rhythm with which serious patients with COVID -19 arrive at the therapies: “They enter one after another, something unprecedented in our area,” says the doctor. And that speed is one of the most surprising aspects of this moment of the pandemic in critical care units.
Hand in hand with the rhythm of infections, the demand for intensive therapies increased strongly in the Region in the last ten days. To the point that some reserved for the treatment of patients with COVID-19 already work at 90% of their capacity in La Plata, while strategies are being implemented to expand them by adding beds and adding personnel. Quite a challenge if you consider that intensivists, nurses specialized in therapy and kinesiologists are considered difficult figures of the health system. A fact that forces the design of strategies to reinforce schools with doctors of related specialties and nurses from other areas specially trained since March for the present context.
This is indicated by Rosa Reina, who is president of the Argentine Society of Intensive Care (Sati) and also works at the San Martín Hospital, who adds that this situation is already perceived in that hospital, which is a provincial reference center: “the amount of The patients we serve in COVID-19 therapy grew so much that the level of occupancy jumped from 35% to 90% in the last ten days. That is why beds are now being added and special teams are being formed, under the command of therapists, to face what is to come. ”
For the specialist, it is a situation that, with some degree differences, is being experienced in all therapies in the public and private sectors of La Plata.
Reina does not doubt that the moment facing therapy is the most difficult in its history. A moment that brings to light long-standing problems related to one of the so-called “critical specialties” in which professionals have always been scarce.
According to the numbers handled by Sati, there are around 1,800 intensive care physicians in the country, 400 nurses specially trained to work in critical care units and around 350 specific kinesiologists in the sector.
“Intensive therapy has been, since its inception, an inconspicuous and unattractive discipline for physicians for reasons of income and working conditions. Now, the pandemic puts specialty in a key place. But training an intensivist requires four years and the ones there are not enough, ”says Rosa Reina.
An extreme indicator of the difficulties faced by therapies in obtaining prepared professionals was known in recent days, when therapists were asked from the province of Jujuy to other provinces (such as Córdoba) and to the Nation to fill the vacancies that the province had in the framework of the growth of the pandemic and that it could not cover.
In the Region, say the intensivists consulted, professionals reach for the usual structure of therapies (with the exception of some vacancies that were not filled), but things are complicated to cope with the extensions that were made to attend to the seriously ill caused by the pandemic. By case, nationwide, the number of therapy beds increased by 44%, while the number of recruited intensivists only did so by 15% (see graph).
The situation becomes even more difficult when faced with the possibility, always in force, that doctors go into isolation due to infections or because they are close contacts of a positive case.
In this context and according to what this newspaper could know, there are hospitals that are preparing to implement contingency plans to add doctors, especially cardiologists, anesthesiologists, clinicians and surgeons -considered related specialties- to collaborate with intensivists in expanded therapies during the pandemic.
From the Province it was indicated to this newspaper that more than 4,000 doctors joined the system to deal with the coronavirus. But they also recognized the difficulties that are encountered in obtaining intensivists.
They added that there are no contingency plans to add doctors from other specialties to the therapies developed by the Ministry and that these strategies are implemented from each hospital.
Work overload
The situation is of particular concern to intensivists, who acknowledge the existence of an overload of work that can become more pronounced with the advance of a pandemic whose course nobody knows: while there are specialists who believe that a peak is already rising, the end of which they locate somewhere. August point, others are considering the possibility of facing a kind of “high plateau” that could also last over time.
In this sense, they highlight that the present demand is already translating into particularly strenuous sessions due to the complexity of treating a patient with COVID-19, which always implies a long stay and additional care. Added to this is the stress of putting on and taking off the rigorous protective equipment.
The situation also imposes new and distressing routines in therapies: “one of the most difficult aspects to manage is the lack of family members accompanying the seriously ill. In the case of San Martín therapy, we had become accustomed to working with a strong presence of families, but now, given the circumstances and to prevent contact, they are prevented from coming to both COVID and non-COVID therapy. And the contacts are only through the cell phone, ”said Reina.
Critical specialty
The pandemic revealed, the intensivists say, the need to rank a specialty with little visibility, harsh working conditions and closely linked to vocation.
“There are multiple factors that make intensivists lack. Among them, that it is a specialty that is not known and that medical students do not see in most of the country’s faculties (the only exception is the University of La Plata, where Intensive Therapy is an optional subject). Working conditions also weigh and, finally, wages, which also show many differences between provincial, national, mixed public hospitals and the private sector, “says Reina.
Regarding working conditions, one of the most problematic features is the 24-hour guard. According to the leader, “under normal conditions it is already too long a day for a very stressful job and only some private clinics adhered to the trend of reducing it to 12 hours that is spread throughout the world.”
In terms of wages, meanwhile, it is indicated that “a 24-hour intensive care guard, the only form of work that the intensivist has, is paid between 17,000 and 20,000 pesos. And you cannot do more than two guards per week, “says Reina.
However, the value of wages is not uniform and the differences usually play against the public system and the Region, since, according to the professionals of the specialty, the mixed hospitals (jointly managed by the Province and the Nation) and those in the city of Buenos Aires pay better than the Province, and this caused many intensivists to migrate to these institutions.
While some hospitals finalize the details of their contingency plans to add doctors and nurses from other specialties to intensive care teams reinforced and always coordinated by an intensivist (a model that other countries such as Spain and Italy adopted during the worst of the pandemic), specialists prepare to live days to the limit.
And they expect a hierarchy of the specialty that will make more new doctors choose it and stop being one of the most critical in the system.
We intensivist doctors live exhausting days, because a patient with COVID-19 is extremely complex due to the time and additional care required by putting on personal protective equipment. ”
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