Covid-19 stellt unsere Gesundheitssysteme vor besondere Herausfoerderungen. Als Teil eines internationalen Netzwerks hat sich der BVRD.at bei Kolleginnen und Kollegen auf der ganzen Welt umgehört, wie es ihnen in der aktuellen Covid-19 Pandemie geht. Der Blick ist auf das gerichtet, was wir voneinander lernen können.

Bruno aus dem Elsass, Frankreich, schildert aus einem der Hot-Spots eindrücklich den Ablauf auf der Intensivstation, die Triage nach Überlebenschancen, das Intubieren von Menschen in dem Wissen, dass sie wahrscheinlich nicht mehr aufwachen und wie Bestände von Narkosemitteln knapp werden. Obwohl der Zusammenhalt und Bereitschaft zu helfen enorm ist, befürchtet er, dass die psychologische Belastung ihre Spuren hinterlassen wird.

Vladimir aus Serbien warnt davor, dass wir uns auch für die Zukunft noch besser für neuartige Erkrankungen vorbereiten müssen.

Alberto aus Italien kommt zu dem Schluss, dass Training und Equipment ausschlagebend sind.

Stefano ebenfalls aus Italien sieht genau in Situationen wie diesen den Grund und die Motivation für viele, diesen Beruf gewählt zu haben. Vorbereitet zu sein gehört für ihn zum Wesen der Notfallmedizin.

Matteo aus Italien sieht eine große Herausforderung darin, das durch das An- und Ausziehen der Schutzausrüstung bei Notfällen viel wertvolle Zeit verstreicht, doch die eigene Sicherheit geht natürlich vor.

Jeremy aus den USA sieht ein Problem darin, dass sich die Bevölkerung nicht an die Vorgaben hält und mitunter falsche Angaben macht. Ihm ist bewußt geworden, dass Schutzausrüstung bis zum Zeitpunkt von Covid-19 nicht korrekt eingesetzt wurde und man sich – was die Vorhaltung angeht – in falscher Sicherheit wog.

Des aus Irland fragt sich, ob das die neue Normalität wird und sieht unter anderem Herausforderungen in der Aufrechterhaltung eines Normalbetriebs neben sich ständig ändernden dynamischen Lagen. Für ihn stellt die Krankheit jede Organisation auf den Prüfstand, woraus auch neue Initiativen entstehen werden.

Jan aus den Niederlanden sieht für die Zukunft, dass bei allen Patienten mit Fieber und Husten Schutzausrüstung Verwendung finden wird. Eine Frage, die derzeit bewegt, ist, ob es genügend Schutzmaßnahmen und Ressourcen gibt.

Igor aus Slowenien kann auf Ausrüstungsrückstände des Ebola-Ausbruchs zurückgreifen. Unter Kolleg*innen ortet er viel Unsicherheit, er vermutet auch aufgrund der exzessiven Medienberichterstattung mit Fokus auf die Todesraten.

Where are you from? What is your profession? Which line of work are you in?

🇫🇷 Mulhouse in France (Alsace), Emergency doctor, first line in the A/E dpt and the pre hospital mobile service (SAMU)

🇷🇸 Republic of Serbia, Anesthesiologist, Anesthesia, intensive care

🇮🇹 Italy, Registered Nurse, Emergency Medical Services

🇮🇹 Italy, Registered Nurse, Emergency Dpt. /Ambulance Service

🇮🇹 Italy, I’m an Emergency Medicine Doctor working in a rural Emergency Department and Emergency Medical Service of Veneto region.

🇺🇸 Austin, Texas USA. I am a Paramedic in an ambulance based 911 emergency service for a large urban area.

🇮🇪 Ireland (Dublin specifically) – Out of hospital practitioner (Advanced Paramedic) – Educationalist

🇳🇱 Netherlands, RN on the ambulance and chairman of the „Dutch association for ambulance care (EMT)“ (V&VN Ambulancezorg)

🇸🇮 Slovenia, RN, chief nurse EMS unit

What safety precautions are there in your emergency medical services?

🇫🇷 FFP2 mask, gloves, glasses, hat, protective over bluse

🇷🇸 Instructions for hand treatment and disinfection of the ward, Algorithms of action in a case of suspicion of the patient with COVID infection, Instructions for self-protection and equipment protection in critical care unit, OP theater , and emergency department

🇮🇹 Universal safety precautions for all patints, except for protective aprons (only goggles and surgical masks, and gloves). N95 (FFP2) masks, aprons and visors in case of COVID.

🇮🇹 Use of protections (Masks FFP3 – disposable coverall – shade – 2 pairs of gloves). Different ways for suspected Covid- Patients from others

🇮🇹 Head cap, gowns, surgical masks, FFP2 and 3 masks, face shield, shoes cover

🇺🇸 We have N95 masks of varied size and style, which we have been fit tested on. If the fit test fails, we have canister masks available. We place surgical masks on all patients with ILI or COVID-19 S/S. We have surgical gowns, eye protection, shoe covers, Tyvec level B suits, and knee high boot covers; as the situation requires.

🇮🇪 Development of Policies, Procedures and Clinical practice guidelines; Full PPE with various response to clinical need and availability of the equipment which can include goggles/safety shields, masks (FFP2/3 or surgical), gowns or aprons, gloves, clinical waste bags, hand sanitisers

🇳🇱 The ambulance callcentre gives us a notification for COVID19-suspicion and we have a national protocol. If we think that the patient will be positive, we use a FFP2-mask, gloves, safety clothing and glasses against aerosoles.

🇸🇮 For actual needs as required as the governmental institutions on the patient 0 day; Tyvek, nitrile gloves, sealing glasses (= eyes mask as skiing models), face visor,  FFP3 masks, IIR masks. All the equipment was disposable as “remaining’s form” the Ebola outbrake. After the 1^st week added simple protective coats (non woven material for uniform protection) and head coverages – intended for the crew member that is not need to be in close contact with patient. After the 4^th week gas mask (3 pcs) intended for “heavy duty” transport

Who runs the covid test in the preclinical setting?

🇫🇷 no testing in the hospital, all the patients with SaO2 low, viral syndrom, fever, cough, shortness of breath, loss of taste or smell, are considered as COVID positiv and admitted in the department wich is excluvisly covid

🇷🇸 As I know, so far it is not possible to run COVID test in the preclinical settings. Patients who are not hospitalized should address to the general practitioner or epidemiologist in the Institute for the public health. All patients testing are performed by Institute for the public health in towns around country and National laboratory in Belgrade. As I write this lines, on the TV there is “Breaking news” in all towns in coming two days there will be possibility to test all suspicion COVID cases in ambulatory circumstances.

🇮🇹 Actually a mess… our service cannot handle it, so it’s delegated to GPs, who delegate it to Public health services, who often do not test you unless you are in a pre-mortem experience.

🇮🇹 Usually the Physician, but it should run also by RNs

🇮🇹 The public health department

🇺🇸 COVID-19 testing is being run by the local public health authority: Austin Public Health. To receive a test, the patient has to have a positive pre-test screening through our Medical Operations Center phone assessment. Tests are scheduled, and conducted in a drive-thru process with full contact precautions in place.

🇮🇪 Initially the testing was and still is in the main ran by the National Ambulance Service (Practitioners) in conjunction with the National Health, Protection and Surveillance. It has now been increased due to level of demand that includes community nursing and defence forces

🇳🇱 At the moment no one, mostly it will be testing in the hospital.

🇸🇮 Physician on the local health center. The biggest city health center is the “entry point” for covid 19 for the whole region – disposed by the ministry of health.

What are the biggest challenges in your field of work right now?

🇫🇷 How to deal with the numbers of patients in need of ICU. We are facing up to 15 intubations per day, with most of the time patients at the 8th-10th day of the disease, who are just deeply hypoxic, with GCS 15, a bit polypneic and a chest X ray with a marked bilateral interstitial syndrome. Most of the patients eligible for ICU are under 75 years old.

We have only three ED rooms in the department, usually we are intubating between 1 or 2 patients a day. Our two ICU are overcrowded (before the attack we had 35 ICU beds, now 55 beds), we are transferring up to 12 patients a day to others hospitals, in France, but also in Luxemburg, Germany and Switzerland by helicopters, or with the help of a medical Airbus of the French air force (6 intubated patients per flight). As soon as a bed is free it is used for a patient waiting for it in the A/E dpt or in the Op theater awaking room which is a sort of pre ICU unit. Since one week a tent military hospital has been built on one parking of the hospital offering 30 more ICU beds. Today a train has transferred in the west of the country 20 intubated patients of the Alsace. Patients are staying at least 2 weeks in ICU, the crisis has started 20 days ago here, and the rate of admission in ICU is still increasing. We are making a very strict triage to know which patient is going to ICU and which will have a supportive not intensive treatment as an end of life project. The rate of death in the dpt and in the emergency hospitalization dpt (15 beds) is very high (6 to 8 a day).

There is so much patients under sedation and curare in ICU, that there are days where the stock in curare or sedatives drugs are at zero.

The other big challenge is psychological. There is the fear of being ill. Most of the staff has been sick, they are most of the time young people, and up to now, none of us has been severely sick. But the pressure is huge, you have to be very careful especially when you are taking care of the airways, avoiding any nebulization process.

There is also the quantity of work, the number of patients severely ill and the huge numbers of patients dying in our dpt. The quantity of emotion and stress for the staff is huge, and has never been so high and for a so long time. Nobody is smiling or doing smart jokes like it was before. When you decide to intubate a patient, you tell him you will send him off to sleep, that he will wake up in another hospital. Then you leave him 5 to 10 minutes alone in the ED room, in order to let him to phone his beloved, with his cellphone, to say them goodbye. We know, as well as the patient, that a lot of these patients will never wake-up. For the staff, the aftermath of the crisis could be even worse than the crisis itself. When the pressure will go down and when the staff will think about what they have been through, post-traumatic stress will be an issue.

🇷🇸 To identify ill people or people which were in contact with ill. Many of people do not respect the isolation as well as many of people which were in contact with ill do not respect quarantine. Not to get infection. Not to contaminate (infect) people in my surrounding.

🇮🇹 Safety: global lack of PPEs and training about NBC.

🇮🇹 Change the usual organization in short time and grow up the level of attention in emergency care

🇮🇹 The need of time to correct donning during emergencies, lot of time wasted to do that but you have to be safe

🇺🇸 The public participating in the pre-arrival screening questions, being fully truthful with COVID-19 screening, and we have starting to experience decreasing supply chain availability of PPE

🇮🇪 Meeting the demands as they increase while maintaining normal service delivery with daily dynamic changes.

🇳🇱 Do we have enough safety precautions and do we have enough ambulances to take care of all the patients?

🇸🇮 Dealing with personnel. Feel that lot of colleagues are quite nervous and not sure about their own security. It is sown by the overprotection in use for every covid suspect patient. My personal opinion is that beside maybe a lack of knowledge the main reason is a lot of excessive media coverage with an exaggerated emphasis on the number of deaths, infected and the general danger of that actual epidemic.

What are the two things you wish you could tell your younger self half a year ago? 

🇫🇷 The crisis was difficult to imagine, it is a bit like the 11 September, before it wasn’t thinkable that a plane could be used by terrorist against buildings, today it is a „normal“ possibility. Before this crisis a world deadly pandemic virus was just seen in horror movies, but now it will be part of the sanitary risk we could have to deal with once again or every year.

🇷🇸 COVID is not happening to somebody else (as I thought so), start to think on taking precaution measures

🇮🇹 First: DO NOT EAT THAT KEBAB.  Second: study and train on nbc, and try to convince your superiors that those (chinese news) are not only rumors.

🇮🇹 Nothing, in Emergency Field it is normal to have a level of preparation before the crisis. The point is that nobody could think about of this kind of disaster and in so few time.

🇮🇹 a) make another trip abroad, because you’ll have to work a lot; b) visit your family (parents and grandparents) since you’ll not be able to see them for a while…

🇺🇸 Pull your money out of the stock market. Build up a small supply of non-perishable household supplies.

🇮🇪 Don’t underestimate the potential of things happening. Don’t fail to prepare

🇳🇱 Be prepared and don’t think too easy about it.

🇸🇮 I rarely plan a lot usually if planned will not be realized There is always something that will goes wrong.

What are you taking away from the current crisis?

🇫🇷 We must see what happens in other countries (China, Italy, Spain, France) in order to anticipate the difficulties, we will be facing and in order to avoid to make the same „mistakes“ as the others did. The virus goes very quickly, when the wave starts it becomes very rapidly very big, and the virus is very violent, patient a getting off very quickly, in some hours, some don’t have the time to reach hospital. The capacity of resilience, of endurance, and the devotion of the hospital staff are amazing. Nurses, porters, doctors who were previously working in this hospital are spontaneously coming back, just to help the staff.

🇷🇸 Nobody is safe. We should better prepare our self for novel type of infective diseases which are our future

🇮🇹 Training is as important as having the right equipment. Despite the efforts, volunteer EMTs are never good as professional EMTs s at all.

🇮🇹 The motivation is the most important thing in medical field, because during the crisis you find in your original motivation the necessary resilience. You re-discover why you wish became a nurse, PhD or an Emergency Technician. The second thing is preparation. Not only professional and training related but, overall, mental preparation.

🇮🇹 See and have a good time with the people you love, appreciate good time outside, go somewhere sightseeing new places, just to do that

🇺🇸 We are not good at doing the right thing because it is the right thing, social distancing. The public is easily panicked. Politicians will make everything partisan. We have not been using PPE properly up until this point to begin with, and this has created a false sense of security in our PPE stocking levels. Some of the adjustments we have made to response protocols need to become standard, and not a situational adjustment.

🇮🇪 The individual resilience of every practitioner no matter what their scope of practice and the potential need of support that they will require and deserve once we come through this difficult time. How will we develop, implement and prepare for the next time? Will this become more frequent? Is this a new normal?

🇳🇱 Use allways your FFP2-mask at patients with fever and cough.

🇸🇮 No not believe anyone, especially not to the government and politicians.