AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Editorial View
Volume 59, Issue 1, Pages 1-6
Wei-Zen Sun 1.2 , James L. Reynolds 3
3690 Views


Experts worldwide have credited parts of Asia and Africa with having “turned the world upside-down”,1 demonstrating superior public health preparedness and responses to the coronavirus disease 2019 (COVID-19) pandemic. Much of this region has so far shown strikingly low infection and mortality rates relative to most of the historically-conceived “advanced” world. Taiwan has figured prominently among the Asian/Oceanian exemplars which also include Singapore, Hong Kong, South Korea, Vietnam, New Zealand, and China itself given its status as the outbreak’s epicenter.1-5 An international group of researchers joined with The BMJ in a 2020 editorial confronting leaders of the G20 wealthy economies with the question: [W]hy are you not applying successful measures from South Korea, China, Hong Kong, Taiwan, or Singapore?1; See also 6

Thus distinguished, Taiwan’s residents have been relatively spared the grief, the physical, psychological, economic suffering, and the civic disruption that the pandemic is ravaging upon much of the world as we write. They have not, however, been spared the characteristically human anxiety surrounding infectious disease. A February 2020 survey found that more than 50% of Taiwanese adults were experiencing “moderate to severe anxiety”, about one year into the pandemic, despite Taiwan’s not then having yet recorded a single related death.7

Taiwan’s Central Epidemic Command Center (CECC) announced two within-hospital contracted (nosocomial) COVID-19 cases on January 12, 2021 involving a physician and their domestic partner—a nurse working at the same hospital.8 Taiwan, a nation of 24 million people, had experienced only 837 cases at the time, including 7 deaths: tragic as they are, very small numbers by international standards.9 In addition to the first report of a doctor becoming infected, the event represented a rare indigenous infection: In 2020, Taiwan experienced a contiguous eight-month period with no domestically transmitted cases reported. As news of the event spread, public anxieties erupted.

We draw for comment here three impressions from amongst the consequents: (1) a maladaptive public fear and condemnation of healthcare workers (HCWs); (2) a tendency to reflexively assign high risk of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection from endotracheal intubation grounded on superficial conceptualizations and sparse information; and, (3) a relative ignorance of the level of expertise and care exercised by public health authorities and HCWs who perform intubation procedures, who supervise intubation teams, and who design protocols to maximize the safety of such procedures— most prominently anesthesiologists.

Medical Scapegoating

Shortly after the announcement, reports surfaced of some people characterizing others as engaging in victim-blaming and “witch-hunts” against HCWs.10,11 Scapegoating as a response to disease-related anxiety is apparently culturally universal and has occurred across recorded human history.12,13 Fear- and ignorance-driven attacks, violent as well as verbal, have represented serious problems around the world both pre- and post-COVID—much worse in some times and places than in others. Substantial work describes this problem and points to potential mitigation strategies.14-18

We are moved to defend HCWs, into whose hard work and sacrifices we possess some insight. HCWs, like everyone, must sometimes prioritize care for themselves, their friends, colleagues, and loved ones. At the same time, the public should care for its HCWs. A healthy and encouraged healthcare workforce makes a better overall contribution to the public health.

As we have previously reported, burnout in anesthesiologists is a serious problem; again, pandemic or not.19,20

While we here focus on the problematic side of the issues as we see them, we could perhaps just as remarkably have written about the gratitude, support, and love that so many in Taiwan and elsewhere have shown HCWs—including anesthesiologists—as well as other essential workers during the pandemic. In response to reports of calls for punishment of an infected physician and to public fears of becoming infected by hospital staff, Minister of Health Chen Shih-Chung, as well as other doctors and government officials properly urged the public to refrain from blaming victims and to support and encourage frontline HCWs. Minister Chen also worked to balance the public’s right to specific information with concerns over hospital staff “being labelled or discriminated against”21-23 and publicly advised the doctor “not to be too self-critical.”24 We agree.

Intubation: Dangerous When? Compared to What? The Anesthesiologist’s Role

Anesthesiologists lay claim to a major portion of the clinical territory involving airway management, including endotracheal intubations. Their expertise has been increasingly called on during the pandemic in clinical settings: as proceduralists, as leaders of intubation teams, and as founts of experience and expertise which vitally serves throughout the healthcare delivery enterprise in contexts expanded outside their traditional bailiwick: perioperative medicine in the operating room.

Thus, the current pandemic provides anesthesiologists with unique challenges and with unique opportunities.25 Given that close interaction with patients severely ill with COVID-19 as well as with a wider casemix whose SARS-CoV-2 status is unknown, anesthesiologists, with their particular expertise and experience in airway management and critical care medicine, play invaluable roles in this once-in-a-century drama. The opportunities can involve a sense of self-worth that can be activated when one confronts situations that demand the highest levels of one’s intellect, curiosity, creativity, training, professionalism, personal courage, and physical and emotional resilience. In Taiwan, many anesthesiologists, qua scientists, may enjoy a relatively luxurious and useful vantage point from which to observe as well as participate in the situation. The impact on Taiwan, so far, has been relatively merciful compared to the pressure, desperation, overload, and overwhelm suffered in much of the world that is impacted much more heavily, was much less prepared, and in many places is much poorer-resourced. Taiwanese anesthesiologists and their colleagues, therefore, may devote more brainpower to learning and sharing about managing this pandemic and future pandemics than can many of their global counterparts.

Both scientific reasoning and common-sense suggest that—as a general statement—working in proximity to the airways of patients sick with respiratory viruses presents risk of infection transmission involving medical providers. While clear data about the magnitude of this risk with respect to COVID-19 will remain unelucidated for some time, the notion that significant risk may be involved is established by evidence from studies involving intubation-related infections by respiratory viruses, such as influenza, and by two other coronavirus epidemics or outbreaks seen in recent years: severe acute respiratory syndrome (SARS-1) and Middle East respiratory syndrome (MERS).25-29 But we must also ask: Risk under what conditions and safety protocols? Risk relative to what benefits? And, Risk relative to what other risks?

Media headlines in Taiwan stressed reports that the first doctor identified as infected in the nosocomial cluster had assisted peripherally with an intubation procedure on a patient with COVID-19. Official information from Taiwan’s CECC mentioned this as a possible link in transmission while explicitly stating that it was not known—and that, in fact, the doctor had been in the same room with the patient several times in addition to the occasion of the intubation.30 The spin and emphasis in a substantial number of media, however, tended to implicate intubation as the definite, not a possible, cause, and tended to de-emphasize or, often, omit mention of the comprehensive and state-of-the-art safety protocols in place governing such potentially hazardous procedures.31,32

Anesthesiologists and their allied practitioners who perform and supervise endotracheal intubation procedures are the world’s definitive experts on understanding how to manage patient airways with maximum efficiency and minimum risk, including with respect to infection control.33,34 That intubations of patients who are or may be infected with a lethal respiratory virus must, on the face of it, pose risk to the HCWs involved and subsequently to others, is to state the obvious and requires only the most superficial level of thought.

The ability to recognize, on the other hand, that evaluating such risk should take into account several vitally relevant factors should require neither advanced education nor particular genius. There are other sides to the nosocomial cluster which we should seek to learn from, reflect upon as thoughtfully as possible, and communicate to others. We need such additional perspective and context to enable more people to make sound appraisals of the event.

The other side to jumping to a conclusion that the cluster sprang from an intubation procedure would have been to emphasize uncertainty unless and until specific evidence suggests otherwise. This requires more than, for example, “The doctor may have been infected because of an intubation procedure, but we are not certain.” Such messages can be foreseen to result in newspaper headlines conveying messages like: Intubation may have caused..., and then, almost inevitably: Doctor infected by intubation. Crafting the messaging more thoughtfully would likely have mitigated the chain of mischaracterizations that may have irrationally and maladaptively eroded confidence in HCWs and the healthcare system.

The other side to reporting sensational news would have been for more journalists to have researched the subject matter of their stories more diligently and to have reported with greater objectivity. This is not to say we expect journalists to become experts in every field they report on, nor to discourage the press from scrutinizing the functioning of government and the healthcare system in discharging their responsibilities to the public.

The other side of emphasizing the “high” risks of particular events, procedures, or vocations would have been to have recognized that we are living through a situation in which the dimensions of such risk are at present highly unsettled despite much admirable work being done to investigate it;33-40 and to have recognized that experts informed with a historical perspective may rationally marvel at how safe and effective medical treatment is today, including procedures that involve intubation.38

All of us could have collaborated better and worked harder to educate and reassure citizens and residents as well as HCWs as the event unfolded. This is not merely to lament that we have not done well, but to ask whether we can do better, and if so, how. In our own case, we have published the Taiwan Society of Anesthesiologists’ “Endotracheal intubation in patients with COVID-19 infection: Expert Panel-Based Consensus Recommendations”, which outlines a set of safety standards for healthcare providers who perform intubations.41 Further, it references comprehensive resources for professionals. With the benefit of hindsight, we could have done more to push a wider distribution of this information.

Anesthesiologists and their colleagues who perform and assist with intubation procedures in Taiwan follow cutting-edge safety protocols. In addition, a research report published just days prior to the nosocomial event found zero positive results in blood studies for SARS-CoV-2 among HCWs in a large Taiwanese tertiary hospital.42 Moreover, serological studies in HCWs in hospitals in, for example, the United States,42-44 Italy,45 and Germany46 suggested that positivity rates were not associated with what have been considered and remain widely considered high risk procedures, or even with HCWs working on COVID wards. Our investigations into this nascent niche of studies was only cursory, but multiple studies such as these have led some researchers to conclude that currently-implemented safety precautions, especially personal protective equipment precautions, appear to confer high levels of protection against patientto-HCW transmission of SARS-CoV-2 in situations where they are implemented.

Most HCWs, public health officials, etc., carry heavy workloads, whether inside or outside pandemics or public health emergencies. No one can do everything that should or could be done, and certainly no human being can do everything perfectly. The most we can ask of ourselves and each other is to do our best, to take time to reflect on priorities, to learn from potential mistakes or oversights, and—perhaps most challenging of all—to aim toward maintaining a healthy and productive work-life balance and to manage anxieties by coming together with others in trying times, which is the most effective way to combat threats and enhance well-being, individual and social. No one should be blamed or victimized for doing their best, and certainly not when we are aware of no evidence that a breach of any reasonable professional standard occurred.


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References

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