Covid: a year in the life
As Europe faces its third wave of corona virus infections and hospitals are once again under the threat of being overwhelmed, is the long awaited vaccination programme going to provide the relief that we’ve been waiting for or will gaps in vaccine distribution between member states make matters and tensions worse? Emergency medicine doctors Giulia Roveri and Michiel van Veelen discuss their experiences over the past year and provide expert insight on these matters and more.
Last year in the midst of the first wave of the corona virus pandemic I met with Dr Michiel van Veelen, one of the researchers at our Institute for Emergency mountain medicine to talk about his experience of working in the hospital of Bolzano and how his background in emergency medicine enabled him to work with the local health authority. A year later, alongside research partner and fellow doctor Giulia Roveri we get together for an online catch up to check in, realign and discuss the latest developments. Giulia is working out of an ICU in Milan and Michiel in the Covid unit in a hospital in Holland – thank goodness for Teams at times like this!
What's the past year been like for you both?
Michiel: Caring for Covid patients, has made up the bulk of the work. It’s changed since the first wave, back then there was a lot of uncertainty and stress, and quite a bit of anxiety. No one knew what was going to happen, which then really diminished over summer. And now obviously, the numbers are back again. So, the workload is there. It's not one big peak as it was in the first wave but crowding of patients continues and so does the hard work. Luckily, I think the anxiety has lessened. The care has become routine. The illness in itself is not overly complex.
Giulia: I agree with Michiel. I think the first wave last year in March was completely different from November’s. Last year, we were completely shocked, when we saw the first cases, we couldn't believe our eyes. It was so bad; we couldn't understand what was going on. Patients were dying immediately, and we couldn’t do and didn't know anything. That was very challenging because in the end it's our job. There was a lot of anxiety. By November, it was completely different, we knew what was going on, the organisation and staff protocol ran smoother which made a massive difference. Dealing with PPE was a part of the stress at the beginning too – we weren’t used to wearing it or to not going to the toilet, not drinking water or eating. But now, I feel comfortable in it. Another huge difference is that now, we know what is going on, and that means that people don't stay at home for days or weeks before coming into the hospital. in March, patients were staying home for weeks, and only coming in the hospital when they were almost dying. Now, we know that as soon as we treat them, the better it is for them. The patients I had tonight, had symptoms on Wednesday, last Wednesday, so it was less than a week – big difference. Michiel: Yeah. I think another difference also is that that people who now come in with symptoms already know that they are Covid positive-because of the testing and general knowledge of the situation. They’ve had symptoms for a couple of days which may have been minor, but they know what to look out for and they have been warned. Compared to the first wave, now we just have to decide if they actually need to be admitted, rather than having to diagnose whether they have Covid. Another major difference has been that the routine addition of dexamethasone in patients that require oxygen and that’s made a huge impact. That and, earlier presentations at the hospital result in a better outcome and a shorter length of stay as well as less aggressive intubations.
And of course, last year there were no vaccinations. You’ve both been vaccinated - when, where?
Giulia: Fourth of January.
Michiel: Eighth of January. I had to travel a 1000km for it. I got word that the hospital I work got their delivery. So I jumped in the car and drove there, because I was very eager to get it. And then when the second dose was ready. I was back here in Bolzano and got a heads up from the hospital here that approximately on the day that I should've driven back, there was a no show. I had about an hour to get there. The vaccine had already been allocated up for another doctor and basically would’ve been thrown away. I was really lucky I didn’t have to travel another 1000km.
Have vaccine will travel – is a vaccination passport the future?
Michiel: For now, it doesn’t have any legal status. So if I travel, I need a PCR. The certificate’s not the problem – it’s basically a record of you having had the vaccine. Every airline or country will have to state what they can do with it and that's difficult. Obviously, from the perspective of a country like Italy, there's a lot of requests to get the vaccine in order to start up tourism again. I understand the urge for it but it's a very delicate subject. What could be realistic proposal could be to create is some sort of proof that it is highly unlikely that you have COVID at the moment, whether that is because you have a complete immunisation or a valid, negative PCR. I think in this maybe you cannot discriminate. This could be a solution to keep facilities accessible to everyone. Also, if you have not been able to get vaccine yet, even if you want to.
Giulia: When I got the vaccine, they told me that I would have it on my health card but actually haven’t checked it yet, here in Italy we have a record of the vaccines we had as kids on our health cards.
So it might not be unheard of that maybe in one or two months, we'll say, "Let's just skip the second vaccine," but we cannot say right now. We don't know. We have to find out.
I've actually heard of people who have had coronavirus twice. Surely once you've had the virus, you should have the antibodies. Is it necessary to vaccinate people who have had the virus already?
Giulia: In how many months?
Once in March and once in November
Giulia: It’s possible, but still very uncommon, what they are trying to investigate now, which is quite complex is whether a true COVID infection would be as worthy to your immune system as one vaccine shot for instance. In these instances, you could still say that person might need one shot instead of two. This is all pretty new because obviously the pharmaceutical companies say, "We tested it with two and we know that that works. So, if you're going to do something else, we don't really know what effect it will have." We know now from databases from UK and Ireland and Scotland that for a lot of people who have only been vaccinated once, including elderly people, that it's very, very rare for these people to be admitted to the hospital. So it might not be unheard of that maybe in one or two months, we'll say, "Let's just skip the second vaccine," but we cannot say right now. We don't know. We have to find out.
What about if you have the antibodies but haven’t had the vaccine?
Michiel: I would still definitely take it. Maybe you shouldn’t be prioritised. This is also being discussed - if people have antibodies, maybe they should be last in line. But if that for instance would be me, I would still very much want to have access to a vaccine. Just for extra security, I think the point is that we don't really know how long your own antibodies can help you. I think maybe a general remark about COVID, and vaccines is that anyone who claims that they know exactly what's going to happen, that's bullshit. I think that's the common conclusion. Because we really are getting new things every day and every week, and we have to adjust our opinions. So yeah, people with very strong opinions, I think it would be wise to distrust them.
Giulia: A lot of the information which is difficult to interpret is about and efficacy and difference between the vaccines. The difference where it really counts, when it comes to people being admitted or dying from COVID for now, shows there’s actually been no evidence to suggest a difference between vaccines. This is an important message that gets drowned by the different percentages, and the efficacy against getting the virus, which is maybe not so important, especially not on a public health scale.
Because we really are getting new things every day and every week, and we have to adjust our opinions. So yeah, people with very strong opinions, I think it would be wise to distrust them.
You two haven’t stopped. How have you been taking care of yourselves and your mental health over the past year?
Giulia: I think this is a very important topic and again, I find a huge difference between March and let's say November or now. One of the main problems, at least in Italy is that we don’t have so many doctors. We’ve all been working for 70 hours a week for months. I didn't get any days off in Christmas, or in August. And now it's March, and that's too much. It's just going to work and coming back and going to work again. That's it. Before COVID, for example, we had two intensive care units, eight beds for each. In November, we opened two new intensive care units, so we had four of them. And yet, we still had the same number of doctors. At the end of February and beginning of March last year, it was very hard because people were dying - completely alone. They couldn't see their family and one of the reasons was because there wasn’t enough PPE. They couldn't even call their children or loved ones. Now, we’ve got tablets and we’re using WhatsApp to do video calls. Using this technology makes it completely different. Humanizing the experience is such an important thing we can do. Now we are also trying also to let the family come to the patients. Of course, they have to sign that they will take responsibility if they contract COVID. They put PPE on, and they come in, it makes a huge difference for the patient, of course and also for the family which in turn make it a lot less stressful for us. Sometimes in the intensive care unit, we have patients who stay for three months. Imagine not seeing your family for three months.
Michiel: Between the first and the second wave there are huge differences in terms of emotional taxation, because now at least you know what's happening and what you can do. So, the uncertainty is not there anymore, but now it's more like the physical fatigue of the ongoing work. Month after month - it never seems to end. And of course, you have a lot of confronting conversations - usually in Emergency or ICU every patient that gets admitted in has some other illnesses that make them basically not very likely to survive. Sometimes this is a discussion that has to be held with people when they are not that sick yet - but one that should be discussed prior. This is also a bit of a cultural difference between northern European countries and southern ones. In Holland its quite an openly discussed with the patient, and the patient's relatives initially at an early stage. You need to align perspectives. For that you really have to be present. To be there for someone at that moment, 100% and that’s also a challenge if you also have busy dept to run at the same time. Sometimes these are the demanding patients even though technically it's less complex medically.
I worry that all the vaccination effort in the Global North won’t make a difference if only half of the world is vaccinated. What are you hearing from Botswana Michiel?
Michiel: The countries that paid the most got all the vaccines obviously. It’s unaffordable at the moment for a lot of countries to buy vaccines. The COVAX initiatives where they try to buy up and distribute vaccines, are great initiatives but are still woefully small in number. What is interesting and perhaps I shouldn't be shocked, is the vaccine skepticism that exists in Europe, also exists in exactly the same way in places like Botswana - people are very hesitant to get vaccinated by a vaccine that comes from the west. Everyone is from the west is telling them to do it to keep the mutations in check - there's two sides to it. It’s a sad realisation that in the developing countries will probably be the vaccinated with vaccines produced in Russia or China and not European or American ones as we keep all those for ourselves.
Giulia: I think it's a huge topic, and I agree with Michiel. One thing to consider is that COVID usually affects people that are overweight or elderly and of course these are two symptoms of richer countries, let's say even though this could help it somehow, it's definitely not a reason not to promote the vaccine.
Humanizing the experience is such an important thing we can do.
Will there need to be new vaccines every year, do you think?
Michiel: Highly likely. In many ways, I think a vaccine will be the answer, there might be modifications but it's also quite likely that even the vaccines we have now will have some efficacy in the foreseeable future. But that does not mean that they might not be adapted. The other out is herd immunity through natural infection. We are also moving in that direction. Herd immunity is the product of vaccinations and natural infections. And the quicker we can catch up with the natural infections the faster this will come about. In the UK maybe already month ago, let's say the number of people being vaccinated, overtook the number of proven cases. So, this is now starting to happen in most European countries, it's around this point. Herd immunity through infection is not really a plan. It's just something that's happening in the background. Getting that effect through vaccinations is much better and quicker, saves a lot of lives.
Giulia: And it’s safer of course.
How long until we can go back to normal?
Giulia: It will depend on how fast we vaccinate everyone.
Michiel: It depends on what you define as normal If we could, for instance, have a summer like last summer-I would settle for that.
Giulia: Yeah, me too.
About the Interviewed
Michiel van Veelen is currently working as a researcher at the Eurac Research Institute of Emergency Mountain Medicine where he is investigating medical possibilities and applications of drones, about once a month he commutes from Bolzano to the Netherlands where he is employed as a medical doctor in the Emergency Department. He previously worked as a HEMS & Aeromedical Retrieval Physician for Okavango Air Rescuein Maun, Botswana where he was also a lecturer in Emergency Medicine in Gaborone, Botswana.
About the Interviewed
Giulia Roveri is a medical doctor, resident in Critical Care Medicine, currently working at an ICU in Milan; she is also a specialist in the field of Emergency Mountain Medicine. Her paths crossed with Michiel's while she was researching the medical possibilities and applications of drones - comparing drone assisted mountain rescue versus mountain rescues without drones on times delivery of medical equipment. They have also been working together on the effect of wearing personal protective equipment on CPR quality in times of the COVID-19 pandemic.
Novel technologies in Mountain Rescue
The Drone Assisted Mountain Rescue project was presented at the GLOMOS conference last year. The project, undertaken at the Bletterbach canyon aims to compare the time scales of rescue teams assisted with a drone versus current conventional rescue operations. Randomised control trials designed with standardised scenarios at different locations and with different teams isolated the following specific timepoints; time to localisation, time to arrival of medical equipment on site (dropped with a parachute in cases using drones), time to telemedicine contact (radio dropped as well) and time to first human contact. While performing the scenarios, stress levels of the rescue team members, victims and bystanders were monitored using continuous heart rate variability measurements and standardised questionnaires.