From the Developing EM Archives: Dr. Ana Paula Freitas, Brazil, 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 September 5, 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. Ana Paula Freitas discusses the state of the EM field in Brazil, in relation to residency development and COVID-19.

Mark Newcombe: Hello Developing EMers! Today, we're catching up with the wonderful Dr. Ana Paula Freitas: from Porto Alegre in Brazil. Ana Paula is a leading light in emergency medicine in Brazil and was critical to that country, recognizing the specialty of emergency medicine in 2015. She's helped us out at DevelopingEM for many years and in Cartagena in Colombia, she presented on how a specialty, our specialty is progressing in Brazil, and there'll be some links in the notes that are accompanying this video. So you can watch that as well. Ana Paula, It's lovely to see you. How are you doing in this very strange world that we now live in?

Ana Paula Freitas: I'm fine. Thank you. It's great to catch up with you and to talk to everyone. And, you know, I think it, we are going through a stressful phase in time, but this kind of meeting and association and talk helps a lot for us and others as well. So it's great to talk to you.

Mark Newcombe: It's always great to talk to you and it helps us at this end as well to hear how our friends and colleagues are going from around the world. Maybe just for our viewers and listeners who don't know your background, can you just remind us where you're working and what your roles are within the departments that you're working in?

Ana Paula Freitas: Yeah, well, I'm I've been working in emergency medicine for more than 15 years now. I'm one of the first emergency medicine trained physician in my country, actually in my city where the specialty began 20 years ago. And I'm now working as a residency coordinator for this first residency program here in Porto Alegre, which is in the south of Brazil. And I'm also a part of the association of emergency medicine, the Brazilian association, emergency medicine directory. So I'm the first secretary there. And we are working since 2015, which was when our specialty has been recognized officially. In our country, we have been working a lot with all the new programs and, and the board certification and accompanying all the physicians that are already working in emergency departments. And that really need our help in sort of like getting their certifications and also they are continuing their education.

So this is one of the main things that our association is doing is trying to guarantee that everyone that worked in emergency departments in our country get well-trained get material for training and also are stimulated to take the board exam so that they are certified as nurses and physicians. And this is one of the ways that we're going to make our specialty grow even more in our country. It will take a long time for us to have residency trained physicians working in emergency departments. So those two main ways of having specialists in our area is, you know, our goal for the next few years in our society.

Mark Newcombe: Brilliant. And look, we met a couple of your younger colleagues at DevelopingEM 2020, Juliana and Daniel. And if there are any example of the product of these training systems, it's going to be a good future for emergency medicine in Brazil. And you'll have to say hello for us to then when we all last caught up the pandemic adjustment announced, and we were leaving Colombia quite uncertain as to what the future held. What's been your experience of this last four months since we saw each other.

Ana Paula Freitas: Well, I came back, I remember coming back few days after Italy had closed the borders for the rest of the world. That was something that I wasn't, I never thought I would see. So we weren't sure how this was going to developing or, you know, what was going to happen in our country from there. But we knew that because Brazil already had many problems with the healthcare system. And because of that, we were really afraid that things would be even worse than it was in Europe. Right? Then, you know, this is our fear because Brazil was so big and we are now politically in a really strange situation. And, and things are not really well organized in our Brazilian capital Brasilia, right? The government was struggling with many issues and having difficulties in many areas trying to approve or change laws that when the pandemic happened in beginning of March and starting to arrive in the Americas it was hard to have one unique organized response for the whole country.

So what the ministry of how they did. And I think that was a Saturday that was really good, was organized the distribution of money for all the states. And so like delegate and give the states the opportunity to organize themselves with within their own characteristic or characteristics because socially and culturally and economically, we are so different north of Brazil is one reality south of Brazil is another. So all of that was organized in March and where I live since the beginning of March, we have been working with epidemiological studies and testing individuals to have a notion of how fast the virus, the virus is spreading in our state. We have organized within the region of the state, how the commerce, the shopping and other businesses that are not critical are going to work depending on how many ICU beds we have available, how fast the virus is spreading and how many, you know, deaths we're having new cases we have each day.

And this strategy seems to be working very well because we have been seeing more and more cases, but really slowly right now, I guess we're starting to get a peak and, and starting to get where Sao Paolo and Rio got a month go, right. And maybe not with the same organization. And that could be one of the reasons that things didn't go so well. And also north of Brazil that we know lots of money where, you know, going somewhere else, not where they were supposed to go and things didn't go well at all. So this is the reality. This was the reality. Then we knew this was suppose this was going to happen. We knew that maybe things are going to be different depending on the state. And this is exactly what we're seeing. So I mean, I, my expectations were that things were going to be even worse now than they are my state. So I'm glad we had the time to prepare ourselves. So I'm really glad.

Mark Newcombe: It's really good to hear that because I guess the media reports about Brazil, but Brazil is 10 countries in one, in many ways, as you say. And so we were all very intensely worried about your situation, but it sounds like at least where you are, that it's a different situation to Rio and it's different to Salvador, different to Manaus. You've had a bit of extra time to get ready.

Ana Paula Freitas: Yeah, well, everything that you got, yeah. Everything that you got of information about our country is real. Yes. And it's a big part of the country, right? It's a shame, but it is, you know, our main cities where most of the Brazilian populations live, the ablation live is Sao Paolo, Rio, Salvador, Fortaleza, Manaus was specifically, but it's where the virus hits first and harder where we had more, most of the deaths. I mean, Sao Paolo is by far where most of the debts are came from and happened. But if you see per thousand or per a hundred thousand people, well, some power was about 40 per thousand. And you have Manaus where you have much less, the number is less of people. You know, that the city is, it's not as popular as Sao Paolo, but you had twice the number of deaths per a hundred thousand people.

So it really it's, it depends on how well stricter is the healthcare system within the state really. But yes, maybe what you saw people dying. I mean, Manaus was so horrible about half a month or one and a half months ago. So sad what happened there so sad. And it was real. That was for then that's Brazil, Brazilian jungle, that's inside the Amazon forest. So but that's completely different reality than where I live. So you get there, you get that kind of thing inside the same country. And you talked about Juliana and Daniel. Now Juliana is working now into big emergency departments in some Paolo. And Daniel is a resident in Rio and they both were in the middle of it about one and a half months ago. And they saw everything that happened. They were out, we were always talking physicians in Brazil, know each other because we're so new.

We are, we have, you know, we, we can, we chat in, you know, WhatsApp groups and it's, it's easier to communicate the communication flows really well. And they were always reporting what they are seeing. In their emergency departments and things got really bad for some time now where you have less cases and things are smooth, you know, not so hard. They got their peak has already gone, but it was sad. The situation in Rio was so sad. So many people died and they arrived in the problem with these big cities with so much distances and few hospitals with their shared care is that this people take too long to get to the emergency department. So they arrive very ill and it takes a long time for them to be able to get an ICU bed once. Well, once it happened, once the system was overloaded.

So the, the mortality was, I guess, bigger because of that. And this is what I hope doesn't happen here. I'm so, you know, I mean, all the residents in the North of Brazil are overwhelmed. They are the amount of work they're having is amazing. It's it's too much. And now my residents here in Porto Alegre are feeling that as well, because we work with education more than with assistance, but they are the ones there every day of the week, you know, lots of shifts in two different hospitals. And so they are suffering a lot in the emotional part of them. They are starting to see how it grows so quickly from one shift to the other, the number of cases are exponentially growing. And so that makes everyone anxious. So the feeling you have, it's safe if chipped, it really gets to, you know, everyone's tense, everyone's worried. Yeah. So they are feeling that more than

Mark Newcombe: There has been a period, I guess, in most countries where you've sort of been waiting for this wave of patients to arrive. And then it suddenly does, has that occurred in Porto Alegre yet?

Ana Paula Freitas: It's we are in the middle of it, right. It's occurring. So we went from, in the private hospital, we went from about 20 cases a day in one week to 80 cases a day in the next one. Right. So it's more than double the number of cases. And, and so like, we, we had to organize ourselves really quickly within, from one day to the other, like, what are we having the calm we had one day, the other day, everything came everyone together exactly. As it is described to happen everywhere. Right? The, the the positive point, I guess, is that because we knew it beforehand, we were always expecting that moment to arrive. We were always expecting the moment one day, it's going to happen here. One day, it's going to be with us. So when it arrived, well, now it's the time. If we have the plans, everything is, you know, once we have 80 cases, , this is how we're going to work.

You know, this is plan a plan B plan C, and this is happening everywhere. Not only in the private businesses where I work the most at the assistance, right, but in the public hospitals as well. So we already had in our city, the two main hospitals there were going to get COVID cases. And all the pre hospital system was organized to take everyone from everywhere else and send them to those emergency departments. And those ICU's, there are now about 90% full, right? So this is why we have, we have like our government in the whole state, but mainly, and in our city has a flag-- a color for flags, depending on the number of ICU beds that are occupied in the number of cases we're seeing each day. And so they go from, you know, blue, green, yellow, orange, red, and black, black being locked down completely.

And we are now in red flag in our city, but this is because of the number of cases daily, you know, the growth, the rate of growing and the number of ICU that are being occupied, because we know once the patient's there, they're going to be there for about 30 days, right. This is about the average time one COVID patients, patient occupied, occupied one bed. So it makes us worry if we are getting short of ICU beds, how are we going to, if they do have plan, plan plans already being made with other hospitals on how to get more ICU beds, but there's a physical limit on how to do that. So this is how we are, right.

Mark Newcombe: I guess you're in a bit of a unique position in that you're managing a workforce who is in this very stressful circumstance. What have you seen with your staff? Are they managing themselves and are they adjusting to what is a very anxiety provoking workspace?

Ana Paula Freitas: That's a very good question, Mark. Very good question. Because I'd like to address that question in different, in two different points of view or two different ways. One is as a staff in an emergency physician, inside a hospital with my group of people that work with me what we see is the load of stress going up. But at the same time, even if not perfectly done the manager of the hospital and our chiefs of departments and nurses and doctors that run above us, the hospital, they are always there. I mean, I can always look around and see one of them inside the emergency department taking care of the flow and how are we going to manage? If we have five beds, we have about 30 beds in the emergency department, all the plans are there, it's all closed. And once we start, you know, we should have five beds in one area, then you start moving around and then you have to separate the COVID cases or the suspect, the suspicious patients from the others.

So even with all the stress load we have, this is one of the things that makes it easier. You know, being able to go face to face with your chief it's it makes things easier. He's there, you know, our chief of the medical staff, the chief of the medical staff and the nurses, the chief of the nurses. So everyone, we are really stressed, but they are there with us. So we know we're not alone. So this is one of the things, and this is true, not only for the private business, but the public costs, at least the ones I work the same, you know, they're not physically there most of the time, but they are. We're able to communicate with them. And they are always sending us feedback and telling us what's the next step to do and all that. And the other thing that I think is really tricky for me, because I'm a residency coordinator, I have to think about, you know, the health of my students, of my residents.

And this is one of the things that is really tricky because now we're having more and more cases and some of our residents are falling ill. I have, from my 18 has residents, I already have five with COVID and I know more will come because they all, you know, they were together in most of the shifts. And, you know, you know, it's, it's gonna grow, this number. And we were just talking about that in this meeting is how are we going to manage? Is it time to take them out of the emergency department or maybe spread instead of five residents having two and then, you know, rotating the more slowly so that they don't catch the disease all together. And this is really tricky because they don't want to leave, right? You want to be there. And they, what they say. And, and I think they're right is that this is the moment that the emergency medicine is more important.

And because we are in a country where this specialty is really new, everywhere, and this is not only in portal, like, you know, that Porto Alegre is the first city in Brazil to have emergency physicians, to have emergency medicine being taught as a specialty. And it's been a long time we've been doing that, but in the rest of our country, it's really need you. We only have one, maybe two graduation groups working as emergency physicians. And what we are seeing throughout the country is the specialty is being valued. A lot, the governors are listening to the specialists. So this time, what we see is of growth of our importance inside, you know, our, amongst our colleagues. So our society are writing the guidelines for how to prepare how the prehospital care is going to deal, should deal with the pandemic how the emergency departments should deal with the pandemic, how to use PPE's, what to expect, and, you know, sort of like, this is really important for us to be inserted inside this discussion as a specialty.

Yeah. So it, it is really hard for us to decide what is the best path to take in regard to taking care of health of our, for our residents. So what we are doing is we are having more meetings to talk about what their feelings are. We are trying to exchange experiences within the departments and other programs, see how they're managing and how they're sorting their problems as well. So I think bottom line and what we're getting out of it is positive things. We're growing as a group, as a specialty, you know it is stressful, but I think we're doing okay in one of the things that I also would like to point out since we're talking about, and we were talking about politics and all that. But we, as a people, as Brazilians, Brazilian doctors, or Brazilian healthcare workers, this is for all of us, we are used to work under stress.

We are used to work with low resources. This is our daily visit basis. We are always short of ICU beds. We are always short of antibiotics. We are always short of ventilators. This is, this is our day to day. This is why so many people died north of the country. I think you've heard in Manaus, right? It was chaotic. It was a war zone. It was sad, really sad. And we had some of our former residents go to, went to Manaus to help because they felt the necessity to be there and try to organize or try to help organize the system and the things they talk. And they tell us about what they saw. You cannot imagine it's the same country as the place we work. You know, it's, it's a mess. The money goes to the government of the state and it disappears. It doesn't go to, it's supposed to the system is already very badly organized people don't get to the healthcare facility easily.

It's normal. The distances between the cities and the villages are so big and so hard to get, and you have to go through the river and, you know, in horrible streets or roads between the forest, the jungle or something is so different from our reality. And it's the same country, but that's our daily business in here in the public health system is the same thing. We don't have enough ventilators. We don't have enough ICU beds. So we are already working under stress every day, every shift, because we closed before the rest of the country. And maybe because of that, we were able to organize ourselves. And we opened more than a hundred ICU beds, specially for COVID patients. We hired more professionals to work in our ICU. We are now training other physicians that are not intensive care physicians and not emergency medicine trained to work in the ICU that we are opening because we don't have enough personnel.

We don't have enough intensive care physicians. And while we, we won't even talk about emergency medicine, because even though we are the local in Brazil, where we have more emergency physicians, it's still not enough to cover all shifts everywhere. So it's really hard in terms of human resources, but we had time to organize ourselves. We got about two months to sort of try and organize our, our system. And the same thing happened in smaller towns. We had problems. We have problems. Some places are not well-equipped and didn't organize as well as they should. But most of all, in our state, south Brazil, I think we did what we could with the system, the broken system we have while we do it, we did the best we could. There's. This didn't happen in the rest of Brazil, where we saw more people dying and the stories and the cases it's really sad when you see money going and being spent on things that are not important and politicians doing stupid things. Yeah. Really stupid things. It's hard.

Mark Newcombe: How do you keep people positive at a time like this as a leader? You know, when there doesn't seem to be any end in sight?,

Ana Paula Freitas: I think it's about this small things you do every day. You know, first of all, you have to be an example as responsible as a responsible physician, responsible for your staff. Because when you arrive in shift, you are the leader of that group of people that are working with you, the nurses and technicians and other specialty colleagues that are together with you, and maybe no, don't really know how to deal with the stressful situation you're in. And so I try to set a model, a role model myself. So whenever I get into a shift, I remind myself that for me to keep the environment positive and calm, I have to be calm and I have to be assertive in what I'm saying and what I'm doing, and I'm playing what I'm planning. And as a teacher, that's most of the time that I'm there is I try to, whenever we're we have meetings, I give them time to express what their feelings, what they are feeling.

So if we have, we, we kept the scientific meetings going throughout the pandemic. Okay. We do that online every week. And one of the things that I we chose to do is we, we, we used to have one day, one afternoon with all the scientific meeting happening at the same day. So it was one meeting, but now we're doing it every day, a little bit so that they can get together with us and they can pause and stop what they're doing to meet. Even if it's through a camera, they are together even virtually, but they are together with us, the teachers, the models, the people that can help them, and they get the opportunity to talk. And we talk about other things, not only COVID. Yeah. So we talk about, you know, funny cases and, and we interpret you know, AKGs and, and talk to neurologists and to cardiologists and just in the things that you used to do before all this mess.

And so they, they, they keep the excitement going about learning emergency medicine. It's not only COVID and we are, we are avoiding, avoiding the COVID thing because it gets overwhelming. Everyone is, is reading and studying COVID all the time, the teachers, the students. So when we get together for a scientific meeting, we talk about everything, everything apart from COVID. And then once every 10 to 15 days, we sort of like gather all the things that are new and as a discussion with everyone, not only the residents organized, you know what we know that's new. Well, this is a really important paper that came out. Did you read, have you got any questions about it? Yes. No. Okay. That's it. Let's talk about something else. I think that makes the load of stress go down a bit, and it helps people to organize their feelings as well. If they have the opportunity to talk about them and all my residents that are ill, all of them, they get text messages from me every day, you know, I'm, I'm, they, you know, I think they don't even want to talk to me, but how are you, how are you doing? Are you safe? Are you with someone? Or are you alone? Do you need anything? I can go there. I can take you anything or, you know, because they, they feel a part of a big group. It makes it easier to cope as well.

Mark Newcombe: Yeah. Well, we knew you were an amazing leader, but you know, those sorts of strategies are very inspiring. And I think that our listeners will take a lot from that. Anna, Paula, thank you. I mean, it's interesting. I've chatted with a few people around the world now and ideology and this disease don't make sense-- it's very obvious, but people are, as you say, in an under-reported fashion, finding solutions locally, helping one another collaborating, and it sounds like that is happening in your shops that you work in.

Ana Paula Freitas: But as you said, you said it really well. You understood what I was trying to say within our micro-environments. We end up finding the solutions. I mean, if, if the solution doesn't come from the government, we're used to that. Yeah. Let's make the best we can with what we have or what we're given. And this is one of the things that I'm sure we're going to get out of this pandemic because our country is not well organized in terms of healthcare system. And because we are always struggling with deficiencies, I think we, we will end up working better together because we used to do that. We will end up managing our problems in a creative way or ways that may work out and maybe help more people with less money or less political help or government help. This is what I get the feeling. This is what I end up seeing. It's our everyday, since forever, it's always been like that. So we're used to law resources and managing with what we have.

Mark Newcombe: Have you had to make decisions about rationalizing treatment as well?

Ana Paula Freitas: Not yet. Not here. Not yet. We do have, we have had a short shortage in neuro muscular block. K yes, yep. Blockers. Yes. And some antibiotics as well. But that was it's it's international. I mean, depending it depends on how many countries need need or how, you know. So we did have shortages. I know some places in Brazil, I mean, for performing an intubation or intubate a patient, they sort of like have almost no drug at all. You know, no sedative, nothing for analgesia. And we have some places in our country and a lot of places actually that have shortages of many drugs that are really, you know, the base of our specialty that gets to you, you have to be inventive, but Brazilians are inventive. So they are finding a way. And, and we are sharing these experiences all the time, online with webinars and live meetings throughout the country.

We do that a lot in Brazil, the emergency physicians with intensive care physicians as well. We discussed those inventive solutions as well as legal solutions and stuff that we can do locally to get our politicians, to, you know, do what they're supposed to do. You know, the, the load of stress that we were talking before, this is one of the things that we also talk about how to not let it get to you. And it's most of the times it's not irresponsibility to, so those kinds of problems where you have to help, but it's not up to you if there's no drug or no ventilators, I mean, what can you do? We didn't get to the point where you have to choose, who's going to be intubated or not, or who's going to the ICU, at least where I live yet. I know Sao Paolo in Rio went through a really tough phase and, and difficulty, but they didn't get to send anyone home to be, you know, proning at home.

I mean, I, I read about those things happening in New York and in other places in Europe, and this didn't happen. I don't know if it didn't happen because we have no idea how to do that. You know, monitor patients in their homes, you know, in a favela. But I didn't hear a lot about that kind of study strategy. We did get sort of short resources many times, but now for example, those drugs that we didn't have last week are now arriving. And when we don't have it, we, well, we get the note from our manager manager saying what the option is like, we don't have this and this antibiotic, but we have reorganized the protocol. And now this is how we're going to do it. Right? So this helps a lot because it takes a load out of you and, you know, they should just run is doing like that.

And it's easier. Not the same thing as you know, smaller hospitals. Yeah. The difficulty is harder, but because of dependent, dynamic, even those places where the protocols were not well established, where the staff didn't talk amongst themselves are now having to sit down and organize themselves. And this is the good that's going to come out of it. It's going to be hard while it is, if you're not used to that. And it's the first time, and it's throughout a pandemic while it's going to be hard, but you are going to learn. And I think the emergency departments are going to get out at the end of it. If it's going to be an ad, they hope so. But at the end, they are going to be better emergency departments than they were.

Mark Newcombe: And we talked about some of the bizarre positives that you've drawn from this horrible experience. Do you think there are certain things that you've learnt that will be able to be used later once this thing does get under control?

Ana Paula Freitas: Most of the things that I told you that we as a group learned are also my personal points of view. So I think I have learned how to be self conscious of how much damage I can do to a patient in terms of contamination. I know this is not something I used to be aware. I mean, you do know, but now you really are aware, you know, how much you have to take care, not to get contaminated and how much you can contaminate other people. Yeah. also pay it's so good to work with nurses that know what they're doing, and they are so good in organizing the flow of patients and thinking about how they're going to, you know, change the places where we work to make it actually work. Now, it seems so much more important what I do every day, as I said to my colleagues and the staff and to my students, I mean, I'm growing so much, I'm learning so much exchanging experiences with them and trying to figure out ways to solve problems as a group, not alone, but as a group. And this is, this is amazing. I think this is going to stay with me afterwards. You know, I'm not, I'm not going to forget what I've learned, what I've been through and the emotions that came with all this mess that we're going through.

Mark Newcombe: Well, Ana Paula one of the reasons we wanted to talk to you was that sometimes you say inspiring things and you haven't disappointed today. And it's been really wonderful to catch up with you, especially given that we were worried about our friends in Brazil and we're, glad to say that you know, maintaining positivity in very trying circumstances. And we really, really appreciate you spending just a little bit of time with us to tell us how things are going. And I am sure that our listeners will draw a great deal from what some of the things that you've been saying. So thank you very much. We will try and catch up soon to see how things are getting better.

Ana Paula Freitas: Hopefully getting better, not worse. Yes. It's been a pleasure.

Mark Newcombe: Thanks, Ana Paula and we'll chat soon.

Ana Paula Freitas: Yes. Take care. Okay. Bye bye. Bye. Bye. Bye.