Covid-19 is still very much present. For a few weeks now the focus shifted a bit from the present: we are looking forward and wondering what will happen next. We take the time to read through the pages written during the more intense weeks of the emergency. Many described their experience in improvised blogs, photographic galleries or in various social media posts: they talked about their view from the window, their neighbour playing the trumpet on the balcony at a set time, the long supermarket queues and the half-empty shelves inside stores. They also talked about the tragedies they personally went through. This is the case of Michela Chiarlo, clinician at the San Giovanni Bosco Hospital in Turin.
“You can say anything you want, no matter what, and nobody can judge you,” wrote Amelia Nierenberg in her “Quarantine diaries” that were published on the New York Times. Did you also feel that sense of “freedom” where you could express yourself in any way you wanted?
I should start by saying that I have been writing for years but when I started working I have been posting much less on my blog, not so much for time restrictions, but more for fear of breaching the confidentiality of patients. I applied this criterion to any story, especially pictures, that I shared. When the Covid-19 emergency started I felt I had so many things building up inside me that I resumed writing as a form of self-help. When I went home I felt the need to release everything I had inside and to discuss with colleagues, but that is not all: it was also about letting everyone on the outside know what was happening. In fact during this period we perceived a sort of increased sense of freedom, almost a suspension of the rules, also regarding pictures: it was the patients that felt the need to show themselves to one another.
During this period we perceived a sort of increased sense of freedom, almost a suspension of the rules.
Different people talked about the experience with their relatives and the quarantine at home. As health workers, did you need to respect the “distance” between you and your family for fear of infecting them? Did this make you feel lonelier?
Every health professional had to reflect on this issue, whether to keep the distance or not from relatives, unless being in a relationship with another health worker- in that case both are already exposed to the hospital life. What to do with the children, the grandparents, and in my case, what to do with my partner? The unthinkable. Staying distant indefinitely or perhaps seeing them again with the risk of causing a chain of infections?
I lived this situation with anxiety, not too well, but accepting the risk despite feeling a bit guilty. When he then got a temperature I really thought I infected him with coronavirus, even though I was never sick. In the end it turned out he had something else but those were not easy days. On the other hand, I was already used to seeing my partner very little, meeting him briefly in the mornings at the end of my shift while he was heading to work or the other way around. We decided to continue living together as normal and it was beautiful to find him smart working when I got home from work and to experience the spaces and a closeness we did not have before.
When, in the future, we will try to describe life during coronavirus, first person accounts like yours will be precious. It is an emergency experienced on a swing between distance and proximity. Mary Laura Philpott talked about the quarantine experienced with her daughter, an account also published on the New York Times: a temporary solidarity, different, tragic and intense, that united physicians and nurses to the hospital patients. Many doctors and nurses experienced, and still are experiencing, an unprecedented closeness with the patients… Will the relationship with the patients hospitalised in this emergency really be “temporary”? We talk a lot about the “necessary distance” between the sick person and the professional: is the safe distance really necessary?
It was certainly an unprecedented situation for us. Of course, it was a very different experience for doctors and nurses alike; that usually get to know a lot about their patients’ personal life given the close contact they normally have with them. There were much less doctors than hospitalised patients and the doctors had a tendency to seek a greater distance from patients to protect them more. However, in certain circumstances being the only person that the patient can have contact with, although dressed like an astronaut, leads you to do things that you would not think of doing otherwise and it makes the patient ask you something that they would not have asked of you in other situations.
We have received phone calls from recovered patients who let us know how they were doing but it was still a situation where the illness was ongoing. I do not know how preferable it would be to continue that kind of relationship because the doctor-patient relationship is always somewhat unbalanced, so much so that as doctors we hesitate to even interact with people we know. There can be an understandable temporary closeness followed by a detachment, after all that used to happen even before Covid.
Being the only person that the patient can have contact with leads you to do things that you would never think of doing and it makes the patient ask you something that they would never have asked of you.
Four scientific associations recently drafted recommendations to improve the communication with the family members of patients who are unable to communicate. How useful are these documents and how distant are guidelines like these from everyday life at the hospital?
Generally I would say that they are helpful. We have much yet to learn around communication, especially because we were never taught it and it is one of those things that is left very much to the practice. In university you never get taught how to communicate with the relatives. Everyone has strengths and weaknesses thus can experience difficult moments when communicating with patients and their relatives. Therefore it is helpful to have a reference document, especially when the communication is taking place remotely. The applicability of the recommendations always depends on the context, the time and the space in which the communication takes places. “Prepare yourself for the conversation and look for a quiet space”, interruptions complicate things, whether the communication is happening in-person or on the phone. Finding a place that is not noisy is objectively difficult, also because a quiet room in a “Covid area” simply does not exist. In emergency medicine it is a bit easier but we only had a single space to rest, with a table to eat, a space to phone the relatives or to hand deliveries. We are then faced with the reality of things, but forgoing the provision of guidelines just because things are different in reality would be wrong. The presence of these documents empathises the relevance of the themes they discuss, communication in this case: for example I think about the significance of introducing oneself when speaking on the phone, of knowing well the name of the patient, and so on. Clearly the type of person we have to interact with is also an important factor; some people are particularly difficult to deal with.
There can be an understandable temporary closeness followed by a detachment.
The last question belongs to Federica Zama Cavicchi, a colleague from the San Giovanni Bosco Hospital in Turin. “Now that calm is back in the sea, what will remain of this storm?”
I hope good things will remain. More collaboration between colleagues, more respect and less fighting over know-hows. The collaboration was excellent during the context we had to go through. I don’t expect that the same climate of friendship will persist but I do hope that an increased communication between colleagues and the predisposition to learn new things will remain. I think that what we will take away as physicians is the awareness of how important nurses are; they all had to execute different tasks and did so with great competence and passion.
I hope good things will remain. More collaboration between colleagues, more respect and less fighting over know-hows.
Riccardo is 50 years old. He’s a bit overweight, like most of our hospitalised patients. He has been showing symptoms for a week but he worsened very suddenly. We gave him an oxygen helmet straight away but as soon as we disconnect that he really struggles to breathe. He is young, healthy and we all know he deserves a better option than the helmet. We need to intubate him and bring him to the ICU. He is restless. He would like to drink, he would like to take the helmet off and talk with his wife. We explain that that is not possible. Each of those things would compromise the delicate intubation procedure and significantly reduce his chances of survival.
We explain what we are about to do and he is really terrified, inside his noisy helmet, as four little blue men, whose eyes he can barely see above the plastic mask, are shouting at him that his breathing deteriorated too much and it is necessary to put him to sleep, insert a tube in his throat and connect him to a respirator so that his lungs have a chance to heal. He asks whether it is really necessary. Yes, it is. He asks whether we will let his wife know. Yes, we will. Given I have the least important role among the group of professionals- the anaesthetist getting ready for the procedure and the nurses preparing the drugs- I give Riccardo my hand to hold. While he crashes it he asks me the question we all dread: “What are my chances of waking up?”
I give him the only possible answer, which I know is definitively a lie, but I hope it is what he needs in this moment: “There are good chances”. Then I feel really guilty and I add: “We do it because it is what gives patients the best chances of recovery”. Among the various unwritten hospital rules there is one about never being too optimistic. Never say you had a “quiet” night before your shift is over, never promise that “everything will be fine”. A rainbow drawing hanging from a balcony will not be enough for the prophecy to self-fulfil. Riccardo died less than twenty-four hours after that “How are my chances of waking up?” that will always weigh on my heart, receiving in answer my useless reassurance.
The paragraphs in italic are sections from a story published in the “Embracing with a look” book that Michela contributed to.