Dr. Andrea Alfonso is an anesthesiologist at a private hospital in Milan, Italy's second-most populous city. Each day, he drives to work on near-empty streets in a country grappling with at least 69,000 COVID-19 cases and more than 6,800 deaths.
The work conditions are physically exhausting, Alfonso said. It takes 10 minutes to suit up with all the protective gear, gloves, face masks and more once he's at the hospital. And every six hours — because shifts can last eight or even 12 hours — everything needs to be removed and changed, only to start the suiting-up process all over again.
There's no drinking or eating while wearing the gear. There's no break, no "down time" — just a ceaseless flow of patients with the respiratory disease, not to mention those who come in for other emergency issues.
The donning and doffing of gear and the being on your feet all day aren't the hardest part of the job, Alfonso said. What's hardest is feeling helpless against an invisible, seemingly never-ending force.
"As a doctor, it's frustrating to see people dying," Alfonso said. "There's no way to do more than we are doing now. That's the problem."
Doctors from around the world are facing similar issues: lots of patients, long hours and frustration. And there's concern that it could lead to some serious mental health concerns, even post-traumatic stress disorder, or PTSD.
"I expect it'll have quite a lot of psychological impact on people, not only doctors but nurses and everyone else who works within [the critical care] team," said Dr. Laura Hawryluck, the critical care response team lead at Toronto Western Hospital.
Asked if Alfonso expected to see PTSD in doctors in Italy, he replied, "100 per cent. The answer is yes."
His response wasn't surprising.
A new study published this week in the journal JAMA Network examined the health effects of the COVID-19 outbreak in China on front-line workers. It found that front-line workers who were involved in the diagnosis, treatment and care of patients with the disease had a higher risk of symptoms of depression, anxiety, insomnia and distress.
Hawryluck was on the front line during the SARS outbreak in Toronto. She said she saw the toll it took not only on patients in quarantine — a subject on which she wrote a study — but also on those in the medical field. Some, she said, chose to leave the field altogether.
"We have seen that some people they leave our fields and feel that this is no longer an area of practice that they want to be in," she said. "Other people may say, 'You know what? We got through it, and I feel that this has made me stronger in terms of how I work and how I work with my team.'"
Alfonso has considered leaving the profession during these difficult times.
"It's quite complex to explain in simple words," he said. "But apart from that feeling that you can't do enough for people, there's also added fear [for] your friends and relatives."
Life or death decisions
Doctors from Italy have shared stories about having to make the agonizing decision between who lives and who dies, due to a shortage of ventilators needed to keep people breathing.
It's these choices that can deeply affect doctors, Hawryluck said, even though they're trained to make those difficult decisions.
But those who work in intensive care units have a very strong bond, she said. It's that bond that can sometimes help them deal with such difficult situations.
"Our bonds are so strong because we've lived through these moments together, and we're going to live through them again in the future. And we all know that," she said.
But there are also colleagues in different fields they can depend on, such as counsellors, psychologists and psychiatrists.
'I got angry'
As cities, provinces, states and entire countries issue lockdown orders, what is particularly frustrating, Alfonso said, is the stubbornness or selfishness displayed by people who violate the orders.
"I woke up in the morning, left my house, and I took my car and drove to the hospital. And I started looking around me.… And I see people jogging or doing silly things they shouldn't do," he said. "And I got angry because I'm [putting] my life on the line — for these idiots."
And it's this behaviour, he said, that is making the fight against the virus so difficult.
"We are facing a very unknown enemy. This is a big problem, but if you add to this people's behaviour, then, forgive me, we're f--ked."
All of this, Alfonso said, can be very demotivating, almost soul-sucking. But he has a job to do, and he will do it, despite the personal cost.
"I've never been so stressed as I am now," he said.
Hawryluck said the doctors and others in the field are going to be pushed to the limit.
"We've got a longer journey to go — getting through this particular pandemic," Hawryluck said. "I think this is going to hit the medical community quite hard."