From the Developing EM Archives: Dr. Carla Rey Navarro, Chile, September 2020
The following interview is presented in collaboration with DevelopingEM: A Conference with a Conscience. The interview was recorded last year, and published on July 12, 2020. The original publication can be seen on the DevelopingEM blog here. For an unedited transcription of the dialogue, please scroll below the video.
In the interview, Dr. Carla Rey Navarro offers insight to the transition toward retrieval medicine, , and more from Chile.
Mark Newcombe: Hi, Developing EM'ers! Today, we're catching up with Dr. Carla Rey Navarro from Chile. Carla an emergency physician working in the capital, Santiago. She works in emergency departments, but also in the field of retrieval medicine, both clinically and at a coordination level. She spent some time observing our prehospital and retrieval medicine operations here in new South Wales in Australia. And she attended our DevelopingEM conference in Cartagena as part of our Twitter feed management team Carla, it's really lovely to see you again, how you're doing at the moment.
Carla Rey Navarro: Hi Mark. I'm doing pretty well now today, resting at home, but with a lot of work with all that is going on, here in Chile. It's nice to see you again.
Mark Newcombe: It's nice to see you too. It's good to hear that your at home relaxing. I imagine you don't get much time to relax these days, but maybe for our viewers and listeners, can you just expand on my brief description of where you're working and what your current roles are?
Carla Rey Navarro: Okay. Actually, I'm just, I've been there for about six years. I, I started working in the control center. So there you have to decide as we don't have much ambulances, you have to decide which one is going to go out and which ones can pace can wait. So you have to talk to the people and explain them that I dunno abdominal pain, for example, it's important for them, but you don't need an ambulance for that instead there's the, patients that you really need to get the ambulance fast to them. So you have to decide that. And then I am also starting to work in, in the ambulance itself, like about two years, I'm working continuously into that, the only ambulance with other
Mark Newcombe: Amazing, it's good to get that background. I guess just to fill in out our listeners, Chile has one of the DevelopingEM have come from Chile and, you know, look at they've helped us out with our conferences. And Carla has been part of that team. So four months ago, we were in Colombia, enjoying ourselves at developingEM 2020, and then the pandemic was declared and we all went our separate ways and back to work places that were the same, but at the same time, very different. Can you tell us what has the situation been like in Santiago and Chile over the last few months? It's been quite challenging by the sound of it.
Carla Rey Navarro: Yeah. At first, when I had to come back to Chile, I was spending some time in Columbia traveling around and then I had to come back early because of all that is going on. I didn't believe in that. I believe that all was an duration about our petitions and authorities. But when the first cases you can began, I saw, okay, this is not going good. We have a lot of patients. And sometimes it just exploded because some very mild patients arrive to the emergency department because they were scared. So at some point we have 200% extra patients, all the units have to convert, have to hire more doctors. And we have to make changes in every way in the hospital. Some beds has to be transforming to ICU beds. So we have a place which would the patients, some pediatric units have to be changed into adults ones. And then we have, we begin with a retrieval of the patients first from one emergency department to an ICU from another hospital. It's like the normal things we do. But then at the point we didn't have any beds to move the patients in Santiago. So the public and the private ones were used. They were the same, the point. And then the government asks us to move patients from Santiago to others, other parts of the country. So that's when we say, okay, this is not going good at the shift. I have to intubate seven patients one after another. So it's been a chaos, but I think that we're getting a little bit down. We still have a lot of beds used, not ICU but our units transform, but we now have some, some spaces to put our patients in, not leave them in the emergency department for so many days.
Mark Newcombe: Right. Okay. And so it sounds like that that wave of patients really overwhelmed a lot of the bigger hospitals and their critical care capacity was exceeded in really the first weeks that the pandemic hit Chile. With your experience in retrieval medicine, I guess that meant that this system had to do something about that. And you had to stop moving patients really around the country. How was that organized and what sort of services did you have to do that before the pandemic were there services that moved patients in that same way beforehand?
Carla Rey Navarro: During the winter, especially with the kids, we've moved patients to other cities it's kind of normal, but it's just by ground. I don't know the next CT one hour, maybe two hours. So we knew that this was coming everyone on first was saying, okay, we have to, we will have to move patients out of Santiago. But then when the at the coordination level with the air force was in conversation with us telling us, we need to move patients about a hundred kilometers was, like, wow, this is bad because it means that Santiago is all used. We don't have more beds on Santiago is the biggest city in Chile. So if Santiago has no beds, what w what will come next? So we started doing this, eh, we had a little experience a couple of years early because of the earth quakes that Chile has, there are some people that have done a lot of transferring airplanes, but it's not something that we have experienced. So in the first ones we just knew we have to do, but also they give us the isolation chambers. We had a couple that were booked during the Ebola epidemic, because we needed to be prepared. If that, if that arrives to too late, we didn't use them. So they were stuck in somewhere full of dirt, and we have to clean them and rub them all over. But we started doing that and we have to learn how to use them. So it's a problem because when the patient is inside the isolation chamber, you just lose the patients. You cannot do anything. So we learn that we need to move very stable patients. We had luck too, we can choose, but you also don't want to move a patient. That is, that is new to waning. So you have to decide very carefully, which one. And also you have to decide because if the patient had, I dunno, some kind of dysrhythmia, you cannot do anything in the plane and with isolation chamber. So the patient has to stay in Santiago, you have to just pick very careful the patients, and you have to make the teams. So, so everyone can do it with this. We choose the in the morning. And after that, we go and see them. And lots of times we have to say, this patient don't go because they were sick or they were having some trouble. Some of them were unstable. So everyday we were prepared for, for patients. And at the end of the day, we usually move three, right. Or if we can choose another one, we decided at the moment to pick another one.
Mark Newcombe: That's really interesting. The way that you had to adjust the selection of patients, I guess in retrieval medicine, we are used to moving the sickest patient from a small place that is struggling to manage them to a big place where they can get better services. But this is almost a reverse of that. You had to pick the patient who was sick, but not so sick that they had a problem whilst you were transporting them. So it's a, it's a, it's a very different, well that the pandemic has brought to even retrieval medicine. Were you still moving patients who were formally ventilated or were they on noninvasive ventilation? What sort of patients where the bulk of those air medical transfers?
Carla Rey Navarro: Oh, they were all intubated. Yeah. They were all ventilated. We decided that we have to move, transfer them, wait, four infusions, two sedations, one blockade. And also base [unknown], usually in our adrenaline, because at some points, maybe they don't need it, but if they need it, we cannot start it at the moment because they were in an isolation chamber. So we just put a low, the lowest dose possible to start them transfer. we decided that all of the patients were going with those four infusions. If the patient is going with another one, like a fifth or six, that the base doesn't work
Mark Newcombe: Okay.
Carla Rey Navarro: Because you have the isolation chamber, you also have the ventilator, the oxygen, the, the, the infusion pumps. So you need a lot of hands to do all of this. And we were just three in every team. So more it's impossible. So one thing we did have were a lot of patients, if this one doesn't work, we have three more nurses, similar condition that can go.
Mark Newcombe: Right. Okay. And it sounds like we were chatting about this a few weeks ago, that you were moving patients mainly by road ambulance, but also, and this is something that was quite new for July. You were moving an increased number of patients by rotary wing, by helicopter, and also by large military aircraft. How many patients in those larger aircraft were you moving at once?
Carla Rey Navarro: Those aircrafts were prepared to move six patients. Right. But we do like four because it goes with the and also with doctors from the air force. So we inside the plane, we work. And also if something happens like a innovation is unstable, or we have to, in any way, open the isolation chambers, they are the ones that have to say that we help, but they are the ones in charge of the patients over the plane. So we cannot move six patients because of a space and personnel that will be too much. There are like 10 and, 10 air force equipment.
Mark Newcombe: And so it sounds like you were drawing people into the world of retrieval medicine who maybe hadn't done that sort of work before. Where were your teams coming from?
Carla Rey Navarro: Well, the ones from the air force are used to that. So they are a prepared team. And we start doing with the doctors and our nurses and respiratory therapists, but every day, so there was not enough personnel. We were calling some doctors from other parts from ICU or emergency departments that don't do retrieval medicine. So they're starting doing that. Also some nurses from the hospitals, we usually go. So it's interesting because all the pre-hospital medicine is not something that everyone knows. And now we have a lot of people that is doing this and learning how to do this. And I think it's an opportunity to have more people interesting in developing this.
Mark Newcombe: I imagine that creating a system like this in the middle of a pandemic was challenging. And how did you maintain the safety and the quality of care during these transports with teams who were really learning how to do these things?
Carla Rey Navarro: Well, there was a nurse in charge of the site and decide how the teams are going to be. So he, he decided to build a very old one, a paramedic or a nurse with a new doctor or vice versa. So they're go people with experience and some of them who don't have much experience, but they can compliment each other. So the ones that are older are teaching the new ones. And also we have a, at the first ones, we have some problems. It's not good to say, but it's the reality is the patients who are not very well today, then they started to waking up. So then with experience we learned that we have to put some sedation levels that we are not used to, but also the aircraft that we go, the, one of the military forces, it's like a tracking there, so it moves a lot. It sounds horrible. And the patients are not comfortable with that also in the isolation chamber. So we'd have to do a lot of sedation, a lot neuromuscular blockade locate to them. So that's the way we learned that we can have some safe retrievals,
Mark Newcombe: Right? That's, it's really amazing developing this system in the middle of a crisis. And it's really hard to imagine that there were many other services around the world that would have quite the same experience as you guys in moving critically unwell COVID patients. What do you think are the most important things that you've learnt about moving these types of sick patients in the last few months?
Carla Rey Navarro: Oh, the first one is the preparation. You have to have a good team. Also. It's not the people you are that you use to work everyday because I got my paramedic. I've got my driver. Now I have to work with some other people that I don't use, usually work with them. So we have to speak all of the same language so we can understand also you're in the plane. You don't hear anything also with all the protection equipment. So you have to know what the other one is thinking. So we can work and not be able to hear, to move our mouth because you have a 95 mask. And also having the checklist because the first patients were moved, we didn't use the checklist and we always forget something. And when we started doing the checklist first were something mentally that we say, okay, let's have a minute. We have this, this, this, this, okay. We can move. And then it was written and we started taking everything less. I think for example, it was a good thing to learn that checklists helps. And that couple of minutes you take, it's necessary.
Mark Newcombe: It's incredibly interesting hearing your experiences, but I guess the, it must be also incredibly tiring and fatiguing without much of an end in sight. How do you keep yourself motivated and refreshed when it's when it's like this for months on end?
Carla Rey Navarro: Okay. Well, it's very exhausting because when you work, the patients will have the Tyvek suit, also all the plastic and the N 95 mask. And when you move, this is like about 10 to 12 hours with all these clothes. So you don't eat, you don't drink, you don't go to the bathroom. So at first we started preparing the day before, eh, having a lot of sleep, drinking, water, and eating well. During the day we care about the food, eating some small things. And after the transfer, you get so tired. So in our free times, you need to do something extra. If not, you will become crazy. In my case, I started doing online lessons of Pilates. So that keeps me motivated. And also it serves me because I'm getting some strength and they kind of have, can move over ventilators and things, but everyone is looking for something to do. Other have learned to cook, or some other friends are learning how to play music the things that we always wanted to do. But for some reason we never did. So that's, I think the, a good way to keep us motivated. And also I think that is good because some, you work with friends, so you cannot go out and meet your friends, but at least you can be with them at the work. So have a chat with them also helps. And when someone is feeling low, the other ones can lift him up.
Mark Newcombe: Right. Okay. So it sounds like that you know, our listeners could take some of those strategies to their own much more settled workplaces. And it's been really interesting hearing how you've achieved unbelievable change in the system. What do you think the future holds for your own workplace and for Chilean emergency medicine? And it's hard to imagine that there are positives that the pandemic has brought, but do you think that there are some positives for the systems within Chile as a result?
Carla Rey Navarro: Yeah, absolutely. As doctors, we will, we're a lot of time asking for more resources for the emergency departments on the critical patients. We didn't get them. And during this four month, we ha we triplicated our ICU capacity, right? So I hope that this new beds and new personnel will stay. Also, a lot of doctors are now interested in the retrieval medicine, and now the people understand what we are doing because of course, moving all these patients generally tell the public important. So the TV was there and the news, they were showing us what we were doing. So people now understand what we are doing. And also the emergency departments, most of them are run by surgeons, in Chile, and now they realize the importance of the emergency doctors running an emergency department. So I think that will be a, definitely a with the opportunity to emergency medicine, to grow up in this country.
Mark Newcombe: Right. Excellent. And I understand from our last conversation that your own work in the emergency departments has been pretty tiring. You mentioned that on your last shift, you did seven RSIs in the, in the course of a shift, which I don't think I've done my whole career. So that's sort of one and a half patients that you were putting on to ventilators. That must be an unbelievable experience. Were you able to draw some of the experience you'd had from retrieval medicine and bring it across to your emergency department?
Carla Rey Navarro: Yeah, especially the teamwork, because we were having a lot of new nurses and paramedics. Sometimes we did have very sick patients, a couple of young ones that, so you have to be like the leader of the team and have an emotional contention of them. Sometimes we don't do that in the emergency department, but as we had new teams, we have to work with them. Also, a lot of them didn't know how to do some things that, because they were new. So some things I usually ask the doctors don't do like manage the infusion bombs or the arterial lines that are more for the nurses. I know them because of my work into the retrieval medicine. So I help them. And also they helped me doing some things. The respiratory therapist help us with the ventilators. And then I learned from them and then I just passed my experience to others. So I think that's a good mixture of things.
Mark Newcombe: Excellent. That's really interesting to hear how, I guess we're all taking some positives from this very strange time in our lives, but it got a little bit stranger for you as well, because within a few days of you telling me about intubating seven patients, you weren't feeling so well yourself. Do you feel comfortable talking about what happened next?
Carla Rey Navarro: Yeah, sure. I did have this lesson and I was feeling a lot of of... Okay, this lesson was terrible. And then the next day I had that fever. So I said, Hmm, I don't think it's the lesson. Something else is going on in here. So I went to do my test and I got positive for COVID.
Mark Newcombe: Wow.
Carla Rey Navarro: Yeah. The first day that I was at home, a little fever, not feeling that bad, but on the fifth day I started having trouble breathing. So I went to the doctor and I was the saturating and I had to be hospitalized for a couple of days. Oh, wow. I got a pneumonia.
Mark Newcombe: Wow. Okay. And so you were in hospital, I guess from a practitioner's point of view, what would you put people into hospital beds all the time? But this would have been a very strange experience without being able to see your family being isolated. What was it actually like being in a hospital like that?
Carla Rey Navarro: It was terrible. I went to the hospital that I know a lot of peoples that work there. And sometimes you just need some gum from your friends and they couldn't give me that some friends go to visit me all protected, but I couldn't have them or not even touch them. So that was hard. I would talk with my family by phone, but it's not the same because when you are seeing you on your family to be with you. Yeah. So it gives you another perspective on how to treat your patients because sometimes you're tired, it's 4:00 AM in the morning. You just wants to sleep and the patient needs, I don't know whether and you say, okay, okay. And you don't, you forget about him. And then you realize when you're on the other side, that that glass of water means everything to them because they really need them. And sometimes to just feel alone. So I think will make me change how I treat my patients because I've been there when they're where they are.
Mark Newcombe: So you've got an absolutely unique perspective now on what's happening with the whole world. And we're very glad to see you up and about and looking fit and well again, how are you feeling now?
Carla Rey Navarro: I'm feeling good. I'm not a hundred percent, I'm about 90%. Cause I still get a little bit tired doing some, some things, but I'm doing well, but I'm out of the planes for a couple of weeks just to be sure. I'm okay. Yeah. I just returned to work last week on Friday. So after 24 hour shifts, I was very tired. It's not like the same before that I could continue doing my life. I, the next day I slept all day.
Mark Newcombe: Yes. Right. Okay. Oh, well, it's been a very unusual time for all of us, but especially for you and we it's been really awesome catching up with you. I'm glad you're doing better now in very trying circumstances in Santiago, it sounds like where a way away from being at the end of this thing we might try and catch up in the next 12 months to see how things are progressing. Do you think you would be able to do that for us?
Carla Rey Navarro: Yes. For sure. I think I will have a lot of news for you also think that the summer will be getting a lot better. We will definitely be in touch and talking and I will keep you telling all the things that we are doing.
Mark Newcombe: Awesome. Well, muchas gracias, Amiga, thank you for your time and good luck. And I hope that you're back in fighting fit and back to normal very shortly. We really appreciate your time and it's been absolutely fascinating to hear about how things are going in Santiago.
Carla Rey Navarro: Yeah, for sure. Thank you for this opportunity. It's great. I've never speak so much in English for other people, but it's good. Let's keep in touch. Okay. Thanks, bye.
