by JP Socrates
MAY 05, 2020 – The recently-concluded Universitas Fellows’ Night (UFN), held on April 24 via Zoom, was graced by the presence of no less than Dr. Cary Amiel Villanueva, one of the Project Managers of the Foundation and a Junior Associate in the Universitas Fellows Program.
A licensed physician, Dr. Amiel is currently working as an internal medicine resident at the Philippine General Hospital (PGH). The PGH, as the national university hospital, is operated and administered by the UP College of Medicine, from which Dr. Amiel obtained his bachelor of medicine under the seven-year Intarmed Program.
The UFN’s title and concept were taken from and inspired by an article authored by Dr. Amiel himself, entitled “Call to Arms: A Doctor’s Vocation in a Pandemic”. Published last April 16, 2020 on The Public Discourse, the article offers the perspective of a COVID-19 Frontliner on the difficulties brought about by the pandemic and how these have brought out the essential aspects of what it means to be a physician.
During the webinar, Dr. Amiel personally shared with the Universitas fellows and guests his experiences as a COVID-19 Frontliner at the PGH, and the insights he drew from such an experience. Using images typically associated with warfare, Dr. Amiel divided his talk into three segments named ‘Battle’, ‘Skirmish’, and ‘Duty’.
BATTLE: the local COVID-19 situation
In the first segment of his talk, Dr. Amiel provided a brief context on the local COVID-19 situation.
After the Philippine General Hospital was designated as a referral center for COVID-19 cases and suspected cases, Dr. Amiel and his fellow employees at the hospital could not but liken their situation with those of soldiers drafted into a war. But, as Dr. Amiel described, unlike the war that devastated the very same hospital during the 1945 Battle of Manila, the present war they are facing involves no gunshots and bomb explosions. Instead, there is only silence, coupled with a lot of fear.
“This hospital,” Dr. Amiel related, “is the national university hospital, and we cater to a lot of patients who need special care. Before the pandemic, the hospital would entertain thousands of patients everyday.”
On March 15, the Community Quarantine was imposed within Metro Manila, and five days later, or on March 20, the Department of Health had assigned the PGH, along with other hospitals, as a COVID-19 referral center. It was only three days after the announcement by DOH, however, that the employees of PGH were notified of such assignment. “It’s ironic,” said Dr. Amiel, “that it was our families and friends who found out about it before us.”
To minimize exposure to the virus and for easier contact-tracing in the event that some of the staff would get infected, the hospital had to minimize its staffing to one-third. Eventually, the hospital had to close its Out Patient Department, and by March 30, the PGH had become a full-blown COVID-19 referral center.
As of the date of the webinar, Dr. Amiel volunteered that the PGH had admitted about 190 patients, a number of whom were in critical condition. And of the front-liners working at the hospital, there were about 37 who tested positive. Surprisingly, Dr. Amiel shared a report saying that 13% of those infected in the Philippines are healthcare workers – a fact that the WHO itself had found to be worrisome.
In Dr. Amiel’s opinion, we are still far from the end of the battle. He then showed a screenshot from the movie Contagion (2011), whose plot revolved around a novel infection for which no cure has yet been found, eerily similar to the scenario the world is presently in. The screenshot shared by Dr. Amiel shows one of the male characters, whose wife died of enzephalitis, asking the doctor to explain what happened.
“Sometimes, in medicine, that’s just how it is, we don’t have the right answers, or we are not as sure,” shared Dr. Amiel. “And I could relate with the doctor in the film as he tried to explain to and help the surviving loved ones understand what happened to their families.”
Right now, there are still a lot of uncertainties about COVID, and experts are still trying to learn about the disease. As in the movie Contagion where a rumored cure for the disease turned out to be a hoax, there has been no shortage of fake news across different media since the time that news of the pandemic broke out. This, too, Dr. Amiel mentioned, is part of the battle.
He then quoted a Facebook status update posted by one of his former professors, who said that, as in a war, in this time of pandemic, “someone has to come up with an overall battle plan. And that plan needs to be communicated effectively.” Dr. Amiel thus stressed the importance of having information accurately and properly communicated to them, who are at the frontline of this battle, being like the “soldiers” in the “lower ranks”.
SKIRMISH: Stories from the Frontline
Dr. Amiel then proceeded to talk about the stories and experiences that he and his colleagues have had as front liners.
Because of the lockdown, a lot of businesses had to stop and a lot of operations are at a standstill – but health care workers still had to go to work. He then related how, at the start of the imposition of the Enhanced Community Quarantine (ECQ) in Luzon, the transportation system had not been adequately prepared to address the needs of the many front-liners.
He even recounted the story of a nurse in PGH who, to go to work, had to walk for about an hour from her house everyday. Fortunately, people from the government and the private sector were soon able to respond to the lack of means of transportation for the frontliners.
Separation from their families and loved ones is another sacrifice that many healthcare workers are forced to make during this time. Dr. Amiel shared a Facebook post of one of his colleagues and close friends who recently got married and had a baby. The post shows a photo of her toddler holding a picture of herself and her husband.
The family lived in a condominium unit close to PGH; but since the mother was assigned to a COVID referral center, she had to rent a separate unit in the same building where she could stay in order to keep her new-born child and her husband safe from the danger of being infected. Hence, she could not see her baby, save for quick and momentary peaks. “Doctors are well-acquainted with sacrifices,” said Dr. Amiel, “but in these extraordinary times, more is asked of us.”
While it may not be obvious to many who are not front-liners, Dr. Amiel shared that the hassle of having to wear personal protective equipment (PPE) in the performance of duty is also a sacrifice on the part of many doctors and medical staff.
He then described how a day goes for him and his colleagues: First, they would wake up before daybreak, and they would have to eat a heavy breakfast because they would not be out until past lunchtime. Afterwards, they would try to dehydrate and try not to drink a lot of water, the probability being that they won’t be able to use the restroom for the next eight to nine hours. In fact, to remedy the situation, some of the health workers would actually wear diapers inside their PPE’s.
Upon getting to the hospital, they would don their PPE’s, an activity that involves a series of processes which, in sum, take up about 15 to 20 minutes of their time. They would be wearing the same equipment for about 4-8 hours. “Some of us would take a break; but because of the time it takes to wear the PPE, many of us choose to stay in it for the whole 8 hours.” In fact, Dr. Amiel shared that at the start of the pandemic, many of them had to stay for 10 – 11 hours in full PPE – which meant no eating and no drinking.
“Everything in PPE is ‘hard mode’,” he shared. Because of the changes in temperature, the face shields tend to become foggy, thus making it hard for the health worker to see. Furthermore, the simple luxuries of being able to talk, write, text/type and turn around with ease are taken away when one is in full PPE. Doffing the PPE even takes much longer, around 15-30 minutes.
“And at the end of a long day,” Dr. Amiel noted, “you would go home alone.” But that loneliness, he pointed out, is not only experienced by the health care workers, but also by the patients, who have it even worse. No one is allowed to visit them, so they are given permission to keep their cellphones and can sometimes do video calls with their families. Some of them, according to Dr. Amiel, have not seen their relatives for weeks.
He then recounted the story of one of the patients he had examined. “I was asking him for the usual things, the symptoms, how are you doing, do you have cough, et cetera. What struck me was how, while we were just having a normal conversation, he was moved to tears. He was telling me that he’s a barangay kagawad, that he doesn’t work and has nothing to earn, he was the breadwinner and he couldn’t provide for his family.”
“The wife didn’t have work,” Dr. Amiel continued. “The daughter had a child, she’s working in a call center but they weren’t making enough, even for the child’s milk. He felt so helpless, and all I could tell him was that, this is the biggest thing you could do for your family. You’re here in the hospital, you don’t feel anything, you feel much better. But you’re here, you’re making that sacrifice, so you don’t put your family into harm’s sake.”
“It’s so easy to say that,” Dr. Amiel reflected. “But imagine if you’re in the patient’s situation.”
Another story shared by Dr. Amiel was that of an old male patient in the Intensive Care Unit, where patients are in much more critical condition. The patients in this unit, according to Dr. Amiel, are intubated in order to help them breathe. Most of them are sedated, or given medications to keep them asleep, while some of them are actually at the point of dying.
“The most that we could do for their families is to update them by messaging them on Telegram or by SMS,” he said. “And there was one time when one of the daughters of a patient who was already dying requested me, rather apologetically, to have her dad hear her voice recording.”
Dr. Amiel noted that the family already had an advance directive and understood that their father, who was already around 70 or 80, was not in good shape.
“The first voice recording was of the grandchild who said she was hoping that the grandfather would get better and come home,” told Dr. Amiel. “The second recording was what really moved me. It was the daughter […] and she was saying, ‘Tay, sorry po na hindi kami makapunta diyan. Gustuhin man namin makapunta, hindi kami pwede pumunta diyan.’ (Pa, we’re sorry we can’t visit you there. Even if we wanted to, we’re not allowed to go there.)”
At that moment, Dr. Amiel divulged that he could no longer hold back his tears; and tears then began flooding inside his PPE.
“This felt like an additional burden to me, an additional task to do,” shared Dr. Amiel. “But I think it did me even more good than the patient or the family. I was reminded of the humanity of the patient and I realized how tragic it is to die alone, how hard it is to not be with your loved ones in your final moments. They could not even receive the final sacraments, because we could not let the priests in.”
In medicine, said Dr. Amiel, there is a saying that goes, “to cure, sometimes; to relieve, often; to comfort, always.” But in these trying times, he mentions how even the duty to comfort almost becomes impossible to fulfill. “How could we comfort loved ones of a dying dad, a dying relative, a dying mother, whom they couldn’t even see? And so many of us health workers are actually left with broken spirits.” The challenges then that weigh on health workers’ shoulders are not limited to physical or logistical difficulties, but include mental and emotional strains as well.
“Yet, in spite of all the difficult circumstances,” Dr. Amiel added, “as the darkness abounds, the stories of determination and valor shine light.” He shared that he sees a silver lining amidst the cloud in the willingness of health care workers to give of themselves and to go out of their way just to treat the patients.
DUTY: the Doctor’s Vocation
Dr. Amiel then proceeded to the last part of his talk, entitled ‘Duty’, in which he talked about the doctor’s vocation.
He shared that his dream of becoming a doctor started when he was a kid. His parents are both health professionals, his mom being a nurse and his dad a surgeon. As a kid, he related how he would tag along with his dad to see patients. But more than the surgeries, Dr. Amiel mentioned that he enjoyed going to clinics and going on rounds. Seeing how his dad would talk to his patients, and in so doing would make them feel better, inspired Dr. Amiel to help others in a similar way. In 2017, he graduated, took the licensure exam, passed and took oath as a licensed physician.
He then shared an ancient oath that physicians are mandated to take, called the Oath of Hippocrates. Part of the oath reads, “into whatever homes I go, I will enter them for the benefit of the sick.” Dr. Amiel also cited a modern oath to which doctors swear, part of which reads, “I solemnly pledge to dedicate my life to the service of humanity.”
These, according to Dr. Amiel, are the commitments they made upon choosing to enter the medical profession. When they took these oaths in 2017, he and his batch mates had not expected that, three years later, they would find themselves in the situation that they are in now. “None of us had predicted that we would see a pandemic like this in our lifetime,” said Dr. Amiel.
He then quoted a statement by Edmund Pellegrino, former chairman of US President’s Council on Bioethics, who said, “[e]veryday that we practice medicine, we make an ‘act of profession’, a public promise that says we demand more of ourselves as persons than a mere occupation requires.”
Thus, Dr. Amiel emphasized that the medical profession should be seen by its practitioners not merely as a job. Rather, they should see it as a calling, a vocation. The word “vocation,” Dr. Amiel mentioned, comes from the Latin “vocare,” which means “to call.” And as medical professionals, they are to heed that call.
Dr. Amiel also recalled an encounter he had with Dr. Donald Landry during the summer seminar “Medical Ethics: A Natural Law Perspective” conducted by the Witherspoon Institute, which he attended along with two other fellows from Universitas in 2016. Dr. Landry, a professor at the Department of Medicine of Columbian University, mentioned in one of his speeches that “the vocation of a physician, at its core, is little changed in the millenia since the Oath of Hippocrates was first uttered: to give care to another person to the utmost of one’s abilities, respecting the innate dignity of that person and all the while subordinating one’s personal wants in a gift of self.”
Dr. Amiel then touched on the question, “what makes a good physician?” He enumerated the different virtues of a good physician as mentioned by Edmund Pellegrino. Of these virtues, Dr. Amiel focused on two: namely, fortitude and prudence.
As regards fortitude, Dr. Amiel cited the following passage from Aristotle’s Nicomachaean Ethics: “the courageous man, therefore, in the proper sense of the term, will be he who fearlessly confronts a noble death, or some sudden peril that threatens death; and the perils of war answer this description most fully.”
With the rising number of deaths that have been caused by COVID-19, death is becoming more a concrete reality than an abstract concept to many of us; but most especially to the front line heatlh care workers. Dr. Amiel then mentioned names of some of the many front-liners who have already passed away due to COVID-19 in the course of serving other people through their profession.
A passage from the novel The Book Thief by Markus Zusak was then quoted by Dr. Amiel, which reads: “A small fact: you are going to die. Does this worry you?” Responding to this passage, Dr. Amiel affirmed, “Yes, it does. But in the face of death, we have to be courageous, we have to be strong.”
Fortitude, however, must be accompanied by prudence.“Aside from being unafraid to die in battle, the good doctor is not supposed to be reckless,” Dr. Amiel maintained. “Prudence is the virtue that guards against foolishness and a false sense of heroism.” Thus, he illustrated by way of example, front-line health care workers need to wear their personal protective equipment before going to work, much as soldiers need to wear armor before going to war.
Prudence, according to Dr. Amiel, must also be observed in giving treatment to patients. “We have to weigh the risks and benefits, prudence tells us that.” He further mentioned that this need to be prudent in making treatment decisions is rooted in the latin phrase, ‘primum no nocere’ which means ‘first do no harm.’
Quoting Aristotle, Dr. Amiel mentioned that they are told in medical school “to do the right thing, at the right time, in the right amount, for the right purpose, with the right means.” In plain words, he said, they are called to live virtuously as doctors and health care workers.
He then ended his talk by quoting the last lines of the Hippocratic Oath which reads: “So long as I maintain this Oath faithfully, and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.”
The pandemic has posed different challenges to many of us, whatever may be our occupations and however peculiar may be our circumstances. Many of us have been put in situations that, in one way or another, prompted us to make great adjustments, definitive choices, or which simply changed the way we look at the world and our lives.
For the many front-line health care workers who have offered themselves and continue to offer themselves at the service of human lives in this pandemic, Dr. Amiel included, life will never be the same again. For one, their professional oath has taken on a deeper and more vital significance than it ever has, or, than they were ever prepared to witness in their lifetime. – universitas.ph
NOTA BENE: The views, thoughts, and opinions expressed in the text belong solely to the author, and the speakers mentioned in the article, and not necessarily to the Foundation.
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