‘We Feel Fear, But We Feel We Can Help People’: Brazilian Intensive Care Doctors Prepare For Coronavirus Peak

“I’ve been an intensive care doctor for many years and been through a lot of stress,” says Dr. Ciro Leite Mendes, “but nothing like I’ve been through in the last 20 days.” Mendes, ex-president of the Brazilian Association of Intensive Medicine, is one of the many professionals hard at work on the frontline of the effort to combat the effects of COVID-19. He speaks candidly about how hard it has been so far, but he is under no illusions; he knows the worst is yet to come.

As the coronavirus pandemic spreads through Brazil, intensive care units across the nation are preparing themselves for a peak of cases – and, therefore, of deaths – that in many areas is still some way off.

As of April 9, the country had confirmed 18,176 cases of the coronavirus and 958 deaths, with the largest concentration in the southeastern states of São Paulo and Rio de Janeiro. So far, 23 states have issued social isolation orders, though the president, Jair Bolsonaro, has been widely criticized for encouraging people to disregard the lockdown to continue working.

With advice from professionals across the world who have already seen the virus at its most destructive, Brazil’s doctors at least have a lead to follow when dealing with the most severe cases. But the worry that the country’s healthcare system may be overwhelmed remains powerfully present.

Dr. Mendes works as the chief medic in the intensive care unit at the Federal University Hospital of Paraíba, a relatively small state in the far northeast of the country, and explains that, “As Brazil is very heterogeneous, the situation [with regards to the virus] is still very heterogeneous. The capitals of some states, like São Paulo, the Federal District, Amazonas and Ceará, have been badly hit. Others have not been affected so intensely.”

Whilst São Paulo, as of April 9, had 7,480 confirmed cases of coronavirus and 496 deaths, in Paraíba there had been 79 cases and 11 deaths, making it one of the least badly hit of Brazil’s 27 federative units. “But,” Dr. Mendes says, “we are expecting the pandemic to disseminate, and we think there may not be enough resources, especially human resources, because of the contagion among medical professionals. A big proportion will end up getting ill and having to self-isolate.”

In Maranhão, another state in the northeast, the situation is similar, as Dr. Rodrigo Palacio, an intensive care specialist who works the capital São Luis, explains: “We are around three to four weeks behind São Paulo [in the number of cases], but we are starting to see a worrying rise.”

Dr. Palacio believes that the real number of coronavirus cases in Maranhão, Brazil’s poorest state in terms of per capita income, is considerably higher than that officially reported. As of April 9, the authorities had confirmed 293 cases and 16 deaths, but owing to the lack of kits, only patients in at-risk groups and those with more severe symptoms are currently being tested. “We can see that from the number of admissions, the number of cases [in Maranhão] must be higher,” Palacio says.

Maranhão has declared a “state of public calamity,” which will oblige private hospitals like the one Palacio works in to take patients from public hospitals when they reach capacity. And all hospitals, public and private, are putting extra beds in place to deal with the rush of patients.

Even so, he is concerned about the entire system’s ability to cope. “For now, we have enough [resources], but our fear is that the structure starts to collapse. It’s not just the beds, you need the equipment and the professionals, who will get infected. We need protective equipment, medicine, ventilators, and we’re worried they won’t get to Brazil.”

“This week, cargoes of mechanical ventilators were taken by the United States”, he adds, referring to a story that appeared in the Folha de S.Paulo newspaper last week. The article suggested that a shipment of 600 ventilators that was destined for Brazil had been detained in Miami after the U.S. government had offered more money to the Chinese suppliers. The U.S. ambassador to Brazil, Todd Chapman, has since denied the accusation.

Whatever did happen to that particular shipment, the reality on the ground is that protective equipment and ventilators could soon become scarce. “We are having to re-sterilize and reuse mask, which is absurd, but it’s the only option we have,” says Mendes.

The stress that comes with this new challenge is also difficult to endure. Dr. Filipe Amado, a colleague of Palacio in Maranhão, works all day in a specific COVID-19 ward that their hospital has set up in a newly completed building. At night, he returns to a flat he has temporarily moved into with another colleague. “Three weeks ago, I left my house,” he says. “I don’t see my parents or my fiancée anymore. My dad has a serious health problem [so I stay away to protect him].”

For Mendes in Paraíba, the strain is similar; “My wife, who is an infectologist, and I haven’t seen our grandchildren for almost a month. It’s painful, but it’s necessary.”

“Working with COVID-19 patients in intensive care is one of the worst experiences that someone working in healthcare could have,” Mendes continues. “Stress is inherent to what we do, taking quick decisions, worrying about other people. Now you have the added stress of being inhumanly overworked and being scared about your own physical integrity.”

All three doctors also speak of the added physical burden that comes from dealing with such severe cases whilst wearing the hugely uncomfortable PPE.

“The symptoms that the patients present are extremely severe and make high technical and physical demands on the doctors,” Palacio explains. The sickest patients need to be placed face down on the bed and turning them without displacing the tubes of the ventilator or catheters is difficult for the whole team of nurses and doctors, demanding a high level of concentration, care and physical effort.

For Amado, though, there is comfort to be found in contact with other medical professionals online. “Twitter is fantastic,” he says, “It’s a way of sharing experiences and our anguishes.” And it is not just reassurance that colleagues in distant lands can provide; acquaintances in Italy, Belgium and Thailand have been in touch with advice. “They told us about their experiences so that we avoid their mistakes and copy the things they did well. It gives you a security and tranquility. You think, ‘I’m doing something that has already worked on the other side of the world.’”

However difficult the task at hand, all three professionals finish by reiterating their commitment in this time of crisis. “It is my duty. It’s what we were trained for,” says Amado.

Mendes agrees; “The time has arrived to show why we graduated in medicine, why we graduated in nursing or physiotherapy.”

“We feel fear,” Palacio concludes, “but we feel that we can help people by working on the front line. It’s our mission.”