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Adversity is the mother of adaptation

Lucrecia M. Burgos MD.

Staff Cardiologist, Heart Failure, Pulmonary Hypertension and Transplant Department.

Fellowship in Cardiovascular Ultrasound.

Cardiovascular Institute of Buenos Aires, Argentina.

WHF Emerging Leader 2019.

 

“A few months ago, I was diagnosed with a neurological disease that stopped me from adequately moving and feeling the right side of my body. This had a great impact on me, not only because I did not expect it, but also because I am right-handed and very active.”

 

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A few months ago, I was diagnosed with a neurological disease that stopped me from adequately moving and feeling the right side of my body. This had a great impact on me, not only because I did not expect it, but also because I am right-handed and very active.

 

Medication and a lot of rehabilitation helped me gradually improve until I only had a mild sensory and motor sequel. I was able to return to work at the Cardiovascular Institute of Buenos Aires, which was what I wanted the most, but from my home, using the telemedicine resources and teleconsultations available at the hospital. I started working in an adapted healthcare setting, mainly in the critical care unit treating patients in cardiogenic shock, advanced heart failure or ventricular assistance, and heart transplantation. I also had to adapt to cardiovascular ultrasound methods, since I am learning to do ultrasounds with both hands in my fellowship.

 

Telemedicine is now a task that I know very well and an invaluable resource at this stage. I believe it is absolutely necessary to continue caring for and monitoring our patients with heart failure and heart transplantation, especially after hospital discharge. The early post-discharge period immediately following hospitalization is known as the ‘vulnerable phase’ and carries a particularly high risk of poor clinical outcome.

 

We have remote access to the digital medical history of each patient. Prior to the teleconsultation, the studies are sent to us by email. At discharge, we ask them to record daily weight, blood pressure, and heart rate. We have our medical consultations by video call and many times family members ask to be added remotely to help their older relatives. In the case of the patient not being a friend of technology, we simply call them at home. It is important we continue communicating with our patients and identify those individuals that require an on-site medical evaluation or to attend the emergency department. Most patients are worried about COVID-19, but they need to continue taking care of their heart health and not ignore symptoms of heart failure or myocardial infarction.

 

We are able to continue attending remotely the hospital’s academic meetings, the inpatient discussion sessions and Friday’s heart transplant meetings with our multidisciplinary team where we evaluate and follow-up the heart transplant patients. During this pandemic, I am trying to collaborate from home by making updates of recent relevant science relating to cardiovascular disease and COVID-19 in WHF’s The Heart in Time of COVID-19 blog, because there is little yet known about the potential cardiac complications which may occur following COVID-19 infection. And we hope this knowledge will be shared and together we can learn how to prevent and treat this disease.

 

I am also in charge of one of the most important tasks, that I also enjoy the most too, which is continuing the academic training of cardiology residents. They are working tirelessly on a daily basis, and we must not forget that they are still in their training stage. We must help them to achieve the expected knowledge and skills. In order to do that, we use interactive video classes, daily clinical cases and different types of new articles. We also use educational material from organizations such as the European Society of Cardiology, the Argentine Society of Cardiology and the ACC.20/WCC Congress.

 

Due to the coronavirus 2019 pandemic, we are all going through a difficult time with uncertainty and fear, but I learned many things in adversity. Many people say necessity is the mother of invention. In our case, adversity is the mother of adaptation.

Coronavirus pandemic and me, my family and my country

Ferdous Hakim MD.

National Consultant – Evidence and Information for programme.

World Health Organization Bangladesh.

WHF Emerging Leader 2018.

 

“I have been working from home for almost a month, which has been a challenge for me. I have not faced the circumstance of working remotely for a long time. Finding the right place, at the proper time and proper attitude, was difficult especially with three children at home and schools closed.”

 

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I have been working from home for almost a month, which has been a challenge for me. I have not faced the circumstance of working remotely for a long time. Finding the right place, at the proper time and proper attitude, was difficult especially with three children at home and schools closed. I have a lovely wife and two daughters. My younger brother and his wife have a son. We live together with our mother in a house in Dhaka, the capital of Bangladesh. My wife is an obstetrician and a gynecologist working in a tertiary private hospital in Dhaka. My brother is also a specialist in general intensive care in a tertiary private hospital. Unlike me, they don’t have the privilege of working from home. Because I’ve worked as a resident of cardiology in several tertiary private hospitals in the city, I know the risk they are taking to manage patients and put the bread on the table for the family.

 

Bangladesh has a good health service infrastructure extending from the tertiary hospitals in divisional cities right to the sub-districts and the villages as the community clinics. However, it is clogged by many problems that are a consequence of corruption and inefficiency in systems, organizations, and individuals. As a result, the expensive private sector is the one that provides health services at a relatively higher cost, paid by the people as an out-of-pocket expense. Authorities don’t have enough regulatory mechanisms in place that can ensure proper health care by the private sector, let alone its own.

 

Since the beginning of the COVID-19 situation, when it became a public health hazard and moved from epidemic to pandemic – the Bangladesh health sector (specifically some policymakers and technocrats) was confident enough that the virus would not affect us. The system boasted its good preparedness repeatedly as the cases remain at ‘zero’. Then expatriate Bangladeshis started coming back from China, Italy and other countries. Authorities handled the quarantine situation well at the beginning, but soon measures became ineffective due to ‘quarantined’ people wandering in many directions. Despite repeated guidelines from world health organizations and other countries affected badly with COVID-19, Bangladesh has not taken the situation with the required seriousness.

 

Though the World Health Organization (WHO) has been repeatedly pushing countries for contact tracing and maximum testing, Bangladesh has been conservative on this approach. The Institute of Epidemiology, Disease Control and Research (IEDCR) were entrusted to do the testing because they have a biosafety level 3 laboratory. However, they did not test the most referred suspected cases and were very slow to respond. As a result, we lost the opportunity to label the cases when the numbers were low. Suspected patients referred from different hospitals were not tested on various grounds, such as lack of contact with people from abroad (China, Italy, etc.) at a time when community transmission was evident. As the diagnosis was confirmed centrally by only one laboratory, other laboratories who volunteered to undertake this task were left sitting idle. Additionally, the diagnosed patients (confirmed or suspected) were directed to 4/5 hospitals in Dhaka.

 

Despite repeated warnings from professional people in official channels, mass media and social media, the national health system followed a very dangerous conservative approach. People were diagnosed based on symptoms pertaining to the respiratory system, even when this is also the normal flu season for Bangladesh and Dhaka is one of the most polluted cities in the world. Private hospitals started referring the suspected patients to the IEDCR and the enlisted hospitals. Under the circumstances and due to lack of diagnosis, a cascade of wrong, untimely and inadequate decisions collapsed the health service.

 

There was a dangerous confusion among the health ministry and government on the need for Personal Protective Equipment (PPE). Currently, authorities are collecting PPE for government setups, but private hospitals are lacking it, and the disposal of PPE is still an unsolved issue. Physicians stopped their private services in their chambers where most of the out-door services were provided. Now we are getting news of people dying out of symptoms of the respiratory system. Non-COVID-19 patients suffering from acute and chronic disorders are left at home to suffer as private hospitals are not serving them if they have any symptoms of COVID-19 infection. People have also become afraid to visit hospitals. As a result, hospitals in the capital have become almost empty.

 

Among other preventive measures, a lockdown is proven to be a very effective measure for slowing down the coronavirus infection, but Bangladesh failed to enforce this as an absolute measure. The government declared general holidays until April 25 but people are still moving around openly and secretly. The daily earners are out on the streets to earn their daily expenses. The kitchen markets are still swarming with sellers and buyers. Authorities failed to stop ‘prayer in congregation’ initially, although this was eventually imposed – better late than never.

 

We should have taken the issue seriously since the moment WHO declared the pandemic. We could have decentralized the testing services to eight administrative divisions of Bangladesh weeks ago. We could have had valid data to help determine decisions at the policy level. We could have prepared hospitals and staff. We could have taken a proactive approach to provide health care for both non-COVID-19 and COVID-19 patients, as well as protect healthcare workers, globally recognized as the front-line fighters.

 

Prices of commodities are rising due to the greed of businessmen and supply shortages. As the lockdown extends from week to week and might escalate from month to month, the threat of losing your job goes up. I live in constant risk of contamination from the virus as two family members are working at a hospital without wearing appropriate PPE. My elderly mother and three children are too with me. The fear of losing financial capacity and my near and dear ones, and the uncertainty of a global economic recession, famine and the risk of war challenges the solace too often as the days go by in this pandemic.

 

 

Disclaimer

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

 

 

Focusing on healing both the body and the spirit

Eduardo Chuquiure-Valenzuela MD. MSc.

Cardiologist, National Institute of Cardiology, Mexico City.

WHF Emerging Leader 2019.

 

“Since social isolation was imposed, I have received hundreds of calls and messages from patients, friends and family with similar concerns. Everyone is worried and stressed about future uncertainty. Some people believe they have symptoms of COVID-19 without any evidence and others ask about the risk of being patients with heart disease.”

 

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With the maelstrom of the pandemic advance, we can all identify a family member, associate, or a friend who has been affected in some way. As a cardiologist, I can share my experience with both cardiovascular patients and colleagues.

 

Since social isolation was imposed, I have received hundreds of calls and messages from patients, friends and family with similar concerns. Everyone is worried and stressed about future uncertainty. Some people believe they have symptoms of COVID-19 without any evidence and others ask about the risk of being patients with heart disease. There are also those who already had some degree of dyspnea or edema and who now link these symptoms to this new disease, and finally, the ones that really start with clinical data that require medical attention.

 

I believe that in this current complex situation, the cardiologist’s duty is to focus on healing both the body and the spirit by listening to their anxieties and fears. And to try to guide them in a positive way, being a voice of encouragement. It is also important to provide support through explaining and “deciphering” all the medical terminology to which they have access and that confuses or misinforms them. Nowadays, there is much news circulating, some of them false, which can be potentially harmful and only help to disorient.

 

Among colleagues we share concern, fear, and burnout about the disease’s progression. However, we have faith in the improvement of the ill and we rejoice when hospital discharge is achieved.

Emergency cardiac care in the time of COVID-19

Shirley Ingram

Advanced Nurse Practitioner (ANP) Cardiology.

Tallaght University Hospital, Dublin, Ireland.

 

“Once a heart attack is ruled out, patients are electronically referred to me and I telephone them. I now assess the patient over the phone instead of face-to-face. I take their health history, risk profile, medications and perform risk stratification, all by a conversation.”

 

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Before COVID-19, if a patient came to the emergency department with chest pain they would be assessed by an ANP/CNS. Once a heart attack was ruled out, the patient was discharged and invited to the nurse-led chest pain clinic to follow up for potential heart disease and a diagnostic test. The nurse-led chest pain service is a pioneering service at Tallaght University Hospital, Dublin that has been really successful in admission avoidance and diagnosing coronary heart disease.

 

Ireland has managed the pandemic very well and hospitals haven’t been overwhelmed, but we did see a huge reduction in the number of patients coming to hospital with chest pain. We’ve tackled this issue with social media and patient presentations to the ED with chest pain are rising, but now in the era of social distancing, there are no face-to-face clinics and very limited access to diagnostics for follow up.

 

Now, once a heart attack is ruled out, patients are electronically referred to me and I telephone them. I now assess the patient over the phone instead of face-to-face. I take their health history, risk profile, medications and perform risk stratification, all by a conversation. I decide if the diagnostic investigation is warranted or discharge to primary care. Capacity for diagnostic testing has been an issue, but it’s becoming more available now with COVID-19 precautions in place. I then follow up after the test telephoning the patient with the results.

 

Setting this tele-service up has meant a number of major changes. In particular, we had to enhance the nurse prescribing policy so that I can prescribe ‘virtually’. This means I can continue to operate autonomously. Prior to the pandemic, there were four nurses (2ANP/2CNS) in the chest pain service but redeployment to critical care areas means it’s currently just me! However, I work in close collaboration with consultant cardiologist Dr. David Moore, emergency department Consultant Dr Aileen Mc Cabe and ED colleagues, physiologists and my amazing administration colleagues. Running services virtually is a totally different logistic and relies hugely on administration support, often overlooked.

 

Patients really appreciate the phone call and the follow-up, they find it reassuring. Although the process is more time-consuming than the face-to-face service it’s vital for the safe discharge of the patient with non-ACS chest pain from ED.

 

Picture: Shirley is in the centre, Dr Aileen McCab (ED) to the left, Dr Mohammad Tariq to the right.

 

 

Uncertainty feelings are predominant

Andrea Fernandes das Neves, MD.

Gynecologist and Obstetrician, Hospital Geral José Macamo

Maputo, Mozambique

WHF Emerging Leader 2019.

 

“As a clinician working in a busy public hospital, we had to quickly adapt, even though there was no way we could be close to the security measures needed for the situation that we have been seeing in other countries.”

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It took a while for Africa to start experiencing COVID-19 cases. In Mozambique, we got our first case on 22 March. This has now slowly progressed but because of our fragile health system, the country immediately declared the state of emergency in April, and we are still going through it.

 

As a clinician working in a busy public hospital, we had to quickly adapt, even though we knew that there was no way we could be close to the security measures needed for the situation that we have been seeing in other countries the previous months.

 

Two weeks have passed since the emergency state began, and we have closed most of our elective activities and changed our setups to implement the security measures. Our waiting rooms are now outside - fortunately, the good weather allows them to be -, consults are being delayed and family visits have been canceled. Emergencies are still going as usual, and in a country like Mozambique, with a fertility rate of around 5,2, our maternity rooms are busy as always. As much as we would like to leave an appropriate distance with our patients, this is not always possible. Tents have been placed outside most hospitals so that suspected patients don’t need to come inside.

 

You can sense a mix of feelings amongst the medical class. On one side, we are terrified of the experiences we’ve seen from other parts of the world: countries that have more resources than ours are finding their resources insufficient. We’ve started this pandemic having a total of 32 ventilators in our country, so you might imagine how we were picturing the situation. Fortunately, these numbers have now grown thanks to donations.

 

Despite knowing it was a matter of time, things have been spreading slowly, and almost two months after our first case we have less than 100 cases and no deaths. This might be due to not enough testing, which all the services are working to increase… but at the same time, there is not an elevation of COVID-suspected cases coming to the emergency rooms, not even an increase of admissions or even an increase of unexplained deaths.

 

This has given place to a second feeling, one of anxiety and stress. There are no cases needing ventilation, nor exhaustion of our scarce UCI resources. Are things about to get worse? When? For how long do we wait to be sure? How can we, as doctors, advise people when things are going out of the expectations? How do we keep people complacent with the appropriate measures and behaviors? Personally, and because I visit the hospital every day, I have been distant from my family for almost 2 months. My only companions are my colleagues and my fiancée. My master’s class is now online, as well as any training course for the situation.

 

It has been lonely, but somehow we are trying to remain positive and believe that maybe somehow things won’t get as worse as predicted. Our focus remains on asking people to obey emergency measures. Masks are a must; there has been washing hand devices installed almost everywhere, and social distancing is now a reality.

 

Unfortunately, it is virtually impossible to get to a state of isolation as we have seen in other countries. It is not only that people might not understand completely the gravity of the situation, but more like a survival instinct. Between an invisible enemy and getting just enough money for the food of that day, for you and your five kids, what would a person choose? Would you risk losing your job when only half of the population is employed? Our emergency state includes a little mobility and a lot of personal conscience in trying to do our best to keep surviving and not making things worse.

The role of a cardiac nurse in the COVID-19 pandemic

Rita Akiki

Heart Failure Nurse and Educator.

Aboujaoudé Hospital, Jal el dib, Lebanon.

 

“In Lebanon, we have very low capacity in intensive care units and low availability of mechanical ventilation, a health care system that is based on patient payment out of pocket and no national programme for CVD patients. All these challenges have been amplified by COVID-19.”

 

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In Lebanon, we have very low capacity in intensive care units and low availability of mechanical ventilation, a health care system that is based on patient payment out of pocket and no national programme for CVD patients. All these challenges have been amplified by COVID-19.

 

Here at the heart failure clinic in Aboujaoudé Hospital, our challenge has been to keep our patients safe during the COVID-19 pandemic. Cardiac nurses from all departments have collaborated with physicians and other professionals to identify the most vulnerable heart failure patients. We sent them WhatsApp messages twice a week to educate them on wearing face masks, self-isolating and taking their medication. Many of our patients were anxious about the effect of their medication on COVID-19 but we were able to reassure them and make sure they didn’t have the wrong information about side effects. We also made sure we were available for them to talk about other concerns, such as their mental wellbeing and issues to do with medicine supply.

 

At the same time, we established a phone helpline to provide support to caregivers of heart failure patients. We are now preparing for people to go back to work in Lebanon. It’s not simple and must be done in a safe way, so we are focusing on educating our patients on workplace segregation.