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Year : 2020  |  Volume : 64  |  Issue : 14  |  Page : 120-124  

Tough times and Miles to go before we sleep- Corona warriors

1 Department of Anaesthesiology, All India Institute of Medical Science, Rishikesh, Uttarakhand, India
2 Department of Anaesthesiology and Critical Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
3 Department of Anaesthesiology and In Charge Pain Management Centre, Pt BDS PGIMS, Rohtak, Haryana, India
4 Department of Anaesthesiology and Critical Care, Narmada Trauma Centre, Bhopal, Madhya Pradesh, India
5 Department of Anaesthesiology, Pt BDS PGIMS, Rohtak, Haryana, India

Date of Submission11-May-2020
Date of Decision13-May-2020
Date of Acceptance14-May-2020
Date of Web Publication23-May-2020

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesiology, All India Institute of Medical Science, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_565_20

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The world has changed due to COVID-19 pandemic. Global spread of COVID-19 has overwhelmed all health systems and has incurred widespread social and economic disruption. The authorities are struggling to ramp up the healthcare systems to overcome it. Anaesthesiologists are facing long duty hours, have fear of bringing disease home to their families, being companion to critically ill patients on long term life support, being on front line of this pandemic crisis, may take toll on all aspects of health of corona warriors- physical, mental, social as well as the emotional.At this juncture, we must pause and ask this question to ourselves, “Buried under stress, are we okay?”

Keywords: Anaesthesiologists, corona virus, corona warriors, COVID-19, front line warriors, front line workers, stress

How to cite this article:
Gupta B, Bajwa SJ, Malhotra N, Mehdiratta L, Kakkar K. Tough times and Miles to go before we sleep- Corona warriors. Indian J Anaesth 2020;64, Suppl S2:120-4

How to cite this URL:
Gupta B, Bajwa SJ, Malhotra N, Mehdiratta L, Kakkar K. Tough times and Miles to go before we sleep- Corona warriors. Indian J Anaesth [serial online] 2020 [cited 2020 Oct 28];64, Suppl S2:120-4. Available from: https://www.ijaweb.org/text.asp?2020/64/14/120/284920

   Introduction Top

The inherent nature of the subject of anaesthesiology and its training makes the anaesthesiologists 'physicians with nerves of steel'. Anaesthesiologists are always at the frontline across the globe, in face of disasters, epidemics, emergencies and natural calamities. Anaesthesiologists form core component of the team to manage the COVID-19 pandemic too. It is especially important to note that anaesthesiologists and perioperative care providers are at maximum risk of acquiring infection themselves as they provide airway management and respiratory care to patients with COVID-19. Despite the fact that anaesthesia has become very safe over the last decades, it still remains a stressful medical profession to practice.

   Front Liners from Old to Young Top

The head and senior most professors in the department of anaesthesiology bear the maximum brunt of stress. They oversee the development of designated health-infrastructure to handle a surge of COVID-19 cases. They also have to create special schedules and rosters of their team of doctors and other staff with the goal so as not to have a shortage of doctors, including faculties, residents and interns at any point of time as well as ensure that everyone gets adequate rest period in between. They are responsible for acquisition of more ventilators, video-laryngoscopes, more and more Personal Protective Equipment (PPE) in a race against time and against global shortage. They have to ensure rational use of these precious resources as well. Senior doctors not only have to stay updated, but also proactive in their duties. Most of them fall in an elderly age bracket where they may have co-morbidities like diabetes, hypertension, chronic obstructive pulmonary disease, cardio-vascular disease, dementia etc. thus making them a lot more susceptible to SARS-CoV-2 than others.[1],[2] To take lead in a pandemic creates a situation of burnout in these elderly anaesthesiologists affecting their health in a profound manner.

The doctors in the middle of the hierarchy, senior-resident doctors, registrars, assistants and associates are equally sharing the responsibilities. They keep track of World Health Organisation (WHO) or Centers for Disease Control and Prevention (CDC) or Indian health ministry guidelines for management of COVID-19. Soon enough, the guidelines change and they have to unlearn the previous guidelines and adapt to the newer ones while simultaneously training juniors, creating a never ending cycle of learning, unlearning and relearning. They have to get used to the idea of a newer era of telemedicine and remote management of patients, while ensuring safety of patients, of themselves as well as that of the staff members. Therefore, this group of anaesthesiologists is learning the new ways to work.

The youngest, the most junior anaesthesiology resident doctors are also overwhelmed with the sudden surge of patients complaining of respiratory distress. They are always on their toes, donning and doffing suffocating Personal Protective Equipment's (PPE), managing aerosol generating procedures like intubation, suctioning, extubation, cardio-pulmonary resuscitation etc. They have thesis or protocols to write and exams to prepare for too. Due to suspension of classes to prevent crowding, they have to rely on online resources.

   Performance of Duty-The Priority Top

Apart from the usual occupational hazards of anaesthesia, pregnant and lactating anaesthesiologists have other challenges to deal in this hour. While pregnant women are more susceptible to viral infections like influenza, their susceptibility to SARS-CoV is unclear.[3] A pregnant doctor does have a fear of 'the unknown' especially when the pregnancy is high risk, precious and with associated co-morbidities.[3] Many working lactating mothers are stressed and take extra precautions before coming in closes contact or breast feeding their baby. Studies have shown how this could lead to separation anxiety related complications in babies and toddlers.[4]

Single parents working in COVID-infected areas have their issues too. The fear, that they may become asymptomatic carriers and transmit Corona virus to either their elderly parents or to their young kids. Many hospitals have made separate designated corona wards, critical care units where health care worker is posted for fixed days as per hospital protocol, followed by a period of quarantine/isolation. As the number of healthcare workers infected is on the rise, a doctor who gets infected is isolated in quarantine, while their kid or elderly parent, who were dependent on them, are forced to fend for themselves.

   Challenges Far Too Many Top

Front line warriors are not only facing a daunting task of handling and treating patients, but are also struggling to keep their own worries and emotional stress at bay. To add an insult to their mental health is the stigma that they have to face from the society. Some landlords have asked them to vacate their homes due to the irrational fear of getting infected. In the hospital too, anaesthesiologists are not immune to the wrath of the public. Manhandling, verbal and physical assaults, arson and also medico-legal suits may become common over the coming few months. Every nation has strict laws and legislations for violence against medical personnel, but these are yet to be fully implemented. The anti-social behaviour against doctors is never going to stop until strict measures are enforced upon by the government. Not just COVID-19, we anticipate an epidemic of patients who have been waiting due to being home bound during the lock down – the cancer patients, chronic kidney disease, heart patients etc. The work load will be magnified and consequently the number of adverse events may increase.

   Battling for a Better Tomorrow Top

Hence, the pandemic has created stressful atmosphere for all anaesthesiologists, no matter what age, gender, work-place or years of experience. Stress is a necessary evil to successfully accomplish an activity with the best possible performance, but after a critical point, any further arousal leads to a paradoxical decline in his or her performance.

Challenges have become more commonplace in the current COVID-19 pandemic and an anaesthesiologist's balance between his professional, family and social life are being tested to the core. Nobody can predict how long this battle would last. The clinicians have to be trained physically and psychologically to endure this long standing battle against a pandemic.

The need of the hour therefore is to utilize this crisis as an opportunity to grow as an individual, and as a professional, but at the same time, we must try to counter the negative effect of this pandemic on our health, for which here are some suggestions for an anaesthesiologist.

   Anaesthesiologists Are Vital in in the Battle Against Covid Top

Recognize the stress

Erratic work schedule, night shifts and long hours in the operation theatres and intensive care unit is a norm for anaesthesiologist these days. Chronic fatigue, moodiness, trouble concentrating, fatigue, sleep deprivation, excessive worry, aggressive behaviour, impaired vigilance, loss of appetite, mood swings, behavioural changes and poor work performance often are signs of stress. A female anaesthesiologist may have irregular menstrual cycle, abortions, premature labour, Intra Uterine Growth Retardation and other gynaecological or obstetric issues due to excessive stress. Chronic wakefulness can lead to impairment of concentration, poor vigilance, short term memory, reduced retention capacity, impaired motor skills and clinical judgement. It has been seen that 24 hours without sleep undermines the ability to perform certain cognitive tasks to the same degree as much as having a blood alcohol level of 100 mg.dL−1.[5] A stressed person is likely to indulge in drug or alcohol abuse. All these factors may lead to poor inter-personal relationships and a deterioration of mental health. Chronic stress leads to health disorders like backache, fatigue, headache, irritable bowel disorder, anxiety etc.[6] Co-morbidities including diabetes, hypertension or chronic respiratory diseases make one more vulnerable to corona-related complications.[7] Acknowledge stress before it is gets out of control.

Minimize the stress

Managing your mental health and psychosocial well-being during this time is as important as managing your physical health. Work hard, but allow yourself time for recovery. Take breaks whenever essential. There must be no shame in choosing to rest when you feel overwhelmed or concerned about your ability to care for your family or patients, as much as you could before the pandemic. Ask for help whenever needed. Limit working to less than 12 hours at a stretch. Various studies have shown that planned naps can improve alertness and performance. A National Aeronautics and Space Administration field study showed that with a 40 minute nap, there were a 34% increase in measured performance and 54% improvement in physiologic alertness as compared to the no nap condition[8] and concluded that maximum duty at a stretch should not be more than 12 hours. Maintain a healthy diet, and include food items such as yogurt, whole grains, green leafy vegetables, green tea, nuts which help quell feeling of anxiety.

We must work in teams, rather than solo, and learn to delegate responsibilities. Good communication skills are essential in our personal and professional lives- the skill or ability to stand up for one's rights without violating the rights of others, also called as assertiveness, must be perfected by every anaesthesiologist. Talk to family, friends, teammates, seniors and supervisors about anything that bothers you. Turn to your colleagues, your manager or other trusted persons for social support, as your colleagues may be going through similar experiences as you are. Realization of inner self potential and inculcating a sense of optimism is the need of hour.[9] You must realize that working all the time doesn't amount to being the 'most productive'. The pregnant, single mothers, lactating ladies can be posted in non-COVID areas or utilized in teaching or training junior resident doctors as a part of continuous professional development and medical education. Parents who are forced to live separately from their kids should help their children find creative ways to express feelings of fear or sadness, as every child has a different way to express emotions and cope. If possible, staying connected with loved ones, through digital methods is one way to maintain contact. Ensure that during this period of separation, the child is in regular contact with parents by means of video calls etc. A proper support system, the 'mentor system' at workplace should be devised. Attention should be paid towards improvement of workplace conditions by making sure that there is adequate and continuous supply of personal protective equipment and ensure that anaesthetic equipment like video-laryngoscopes and intubation boxes are also available to manage COVID patients.

A hazard allowance for all and a health insurance should be provided by the employer in case one falls sick during this pandemic. Medico-legal protection by the hospital authorities and proper assistance in legal matters will also help minimize stress. The Indian Union Cabinet approved the promulgation of the Ordinance to make amendments in the Epidemic Diseases Act, 1897 to make acts of violence against healthcare workers cognizable and non-bailable offences. It also provides compensation for injury to healthcare workers and for damage or loss incurred to their property during this pandemic.[10] All these steps could go a long way in minimizing stress levels in doctors.

Handle the inevitable stress

Stress is inevitable at times, but keep a positive attitude. Create a menu of personal self-care activities that you enjoy and religiously pursue them such as spending time with friends and family, exercising, gardening, listening to music, cooking or reading a book or may be write in your own journal. Learn relaxation techniques and guided meditation to handle anxiety. Spend time with nature. Take perspective of stressful situation, and question yourself, how important will it be in the long run? Is it really worth getting upset over?

Avoid use of alcohol, caffeine or other drugs and stay well hydrated to mitigate stress. Get adequate sleep every day. Getting regular physical activity is another positive lifestyle modification to help combat fatigue and anxiety. Family time is very important too, spend time with those you enjoy. Health care workers suffering from health ailments such as hypertension, diabetes, chronic respiratory ailment or mental disorders should continue taking regular medications and sudden discontinuation of drugs be avoided. Use effective stress reducing techniques such as mindfulness, yoga, deep breathing exercises and guided imagery meditation, they are an excellent way of combating anxiety and achieve deep mental and physical relaxation. Stress management workshops should be conducted at regular intervals. All these steps will go a long way in making the workplace of anaesthesiologists stress-free.

We suggest minimising watching, listening or reading news related to COVID-19 that cause anxiety or distress, seek information only from trusted sources, follow ISA advisories provided from time to time and take practical approach to prepare your plans to protect yourself and your loved ones.[11],[12],[13] Indulge in facts and avoid rumours. Sudden and near-constant stream of corona related news can cause anyone to feel worried.

   Collaboration of Indian Society of Anaesthesiologists (ISA) Top

Support of Indian Society of Anaesthesiologists (ISA), in coordination with its state and city branches, is also crucial to meet the higher need for training and technical resources. ISA has committed to provide healthy and safe environment to all anaesthesiologists as COVID-19 patients continue to increase. ISA has already issued advisories,[11],[12] to ensure safety of patients and the anaesthesiologists during the “Corona Virus Disease 2019” in India. Anaesthesiologists should lead by example and be victorious in long fight against COVID-19 by maintaining social distancing, hand sanitization, using face masks or N 95 masks.[11],[12],[13] ISA is regularly reviewing recommendations from CDC and WHO to keep readers updated. ISA has already advised all its members to wear N95 mask, cap, face shield, gloves and impervious gown during all surgical procedures. ISA is doing everything to reduce the stress of members and supplying them with tools and knowledge to do their duties safely and effectively. ISA has ear marked substantial amount from the ISA constitutional provision of Grant-in-Aid to ISA city and state branches all over the country to make available PPE, face shields and masks for ISA members. Motto of ISA is to relieve stress and strengthen the morale of all corona warriors, they should remember they are not alone, but have a huge support of ISA. Though it is a long battle, we are sure TEAM ISA will serve our beloved nation India and emerge victorious.

Accept the things you cannot change. As the famous saying goes “what does not kill us makes us stronger”, try to look the situation as opportunity for personal growth.

To conclude, anaesthesiologists in particular have a vast skill set that makes them extremely valuable in emergency intubation, intensive care management and cardiopulmonary resuscitation, but the most valuable procedures they perform puts them in the most danger, especially in pandemic like this. Therefore, we must acknowledge our expertise during this COVID 19 crisis, it will be a folly to sacrifice ourselves as 'collateral damage'. We must ask ourselves if we are okay and learn to take care.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Liu K, Chen Y, Lin R, Han K. Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. J Infect 2020;S0163-4453(20)30116-X. doi: 10.1016/j.jinf.2020.03.005.  Back to cited text no. 1
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Zhao X, Jiang Y, Zhao Y, Xi H, Liu C, Qu F,et al. Analysis of the susceptibility to COVID-19 in pregnancy and recommendations on potential drug screening. Eur J Clin Microbiol Infect Dis 2020;23:1-12. doi: 10.1007/s10096-020-03897-6.  Back to cited text no. 3
Howard K, Martin A, Berlin LJ, Brooks-Gunn J. Early mother-child separation, parenting, and child well-being in Early Head Start families. Attach Hum Dev 2011;13:5-26.  Back to cited text no. 4
Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57:649-55.  Back to cited text no. 5
Kakkar B, Gupta A, Jain R. Stress amongst Anaesthesiologists-an illusion or reality? Inter J Curr Res 2017;9:44995-7.  Back to cited text no. 6
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM,et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A nationwide analysis. EurRespir J 2020;55:2000547. doi: 10.1183/13993003.00547-2020.  Back to cited text no. 7
Rosekind MR, Smith RM, Miller DL, Co EL, Gregory KB, Webbon LL, et al. Alertness management: Strategic naps in operational settings. J Sleep Res 1995;4:62-6.  Back to cited text no. 8
Bajwa SJ, Kaur J. Risk and safety concerns in anesthesiology practice: The present perspective. Anesth Essays Res 2012;6:14-20.  Back to cited text no. 9
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Press Information Bureau, Government of India Ministry of Health and Family Welfare. Promulgation of an Ordinance to amend the Epidemic Diseases Act, 1897 in the light of the pandemic situation of COVID-19; 22-April-2020 22:14 IST. Available from: https://pib.gov.in/PressReleseDetail.aspx?PRID=1617327. [Last accessed on 2020 May 10].  Back to cited text no. 10
Malhotra N, Bajwa SJ, Joshi M, Mehdiratta L, Trikha A. COVID operation theatre- advisory and position statement of Indian society of anaesthesiologists (ISA national). Indian J Anaesth 2020;64:355-62.  Back to cited text no. 11
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