ISSN: 2474-3674

Monte et al. Int J Crit Care Emerg Med 2020, 6:108

DOI: 10.23937/2474-3674/1510108
Volume 6 | Issue 3
International Journal of Open Access

Critical Care and Emergency Medicine

Research Article

Covid-19 Pandemic and Health Professionals: Practical Approaches

Rebecca Renata Lapenda do Monte¹, Francisco de Assis Fernandes Tavares¹, Bruno
Barreira Cardoso¹, Alyne Barreto Mesquita de Goes¹, Thais Cristina Loyola da Silva²,
Brenda de Oliveira Silva³, Yara Saiane Marim Araujo4, Amália Cinhtia Meneses Rêgo5 Check for
updates
and Irami Araújo-Filho6*
1
Undergraduate Student of Medicine at UnP, Potiguar University, Laureate International Universities, Natal, Brazil
2
Undergraduate Student of Nursing, Federal University of Rio Grande do Norte, Natal-RN, Brazil
3
Nurse, University Center of Rio Grande do Norte, Natal-RN, Brazil
4
Undergraduate Student of Medicine, São Lucas University Center, Porto Velho-RO, Brazil
5
Ph.D in Health Science, Postgraduate Program in Biotechnology, Potiguar University/UnP, Laureate International
Universities; Teaching and Research Manager, School of Health, League Against Cancer, Natal-RN, Brazil
6
Ph.D in Health Science, Postgraduate Program in Biotechnology, Potiguar University/UnP, Laureate International
Universities; Full Professor, Department of Surgery, Federal University of Rio Grande do Norte; Full Professor, Department
of Surgery, Potiguar University, Natal-RN, Brazil

*Corresponding author: Irami Araújo-Filho, MD, Ph.D in Health Science, Postgraduate Program in Biotechnology,
Potiguar University/UnP, Laureate International Universities; Full Professor, Department of Surgery, Federal University of
Rio Grande do Norte; Full Professor, Department of Surgery, Potiguar University, Natal-RN, Brazil, Zip code: 59020-650,
Tel: +55-84-98876-0206, Fax: +55-84-3342-5079

Abstract of professionals working on the front lines in the fight against

coronavirus.
COVID-19 disease is a pandemic, with severe clinical ma-
nifestations, high lethality and which has reached at least Keywords
128 countries. In this sense, the bioprotection of health pro-
fessionals is a fundamental principle in preserving the lives COVID-19 pandemic, SARS-CoV-2 infection, COVID-19
of those who work in the direct care of patients who are pandemic, Coronavirus, Personal protective equipment,
victims of SARS-CoV-2. Each day the number of confirmed Healthcare workers
cases exceeds the most optimistic estimates, which cause
severe damage and overload in the infrastructure of health
systems. The present study addressed the main dilemmas
Introduction
and difficulties faced by health professionals in combating The respiratory infection caused by a new strain of
the pandemic. A literature review was carried out in the Em-
coronavirus not previously identified in humans, SARS-
base, Scopus, Pubmed/Medline, Web of Science, Scielo,
Cochrane Library, and Google Scholar databases, where CoV-2, has been named Coronavirus 2019 or COVID-19.
28 articles were selected after independent peer review. It appeared in December 2019 as “pneumonia of unk-
The most recent and relevant studies on the need for ef- nown cause” in the city of Wuhan, Hubei province, Chi-
fective bioprotection were included. For this reason, we put na. COVID-19 quickly spread to other regions in China
the step by step for the reader to understand and execu-
te. Besides, the indiscriminate use of personal protective and Asian countries [1,2].
equipment (PPE) was analyzed, what to do in the absence In January 2020, the World Health Organization's
of such material, and the role of the professional as a he-
alth educator in the optimization of available resources. In International Emergency Committee officially declared
conclusion, it is recommended to use PPE's with parsimony the outbreak as a "public health emergency of interna-
and telehealth as a useful device in the emergency support tional interest," and the disease has reported a pande-

Citation: Monte RRL, Tavares FAF, Cardoso BB, Goes ABM, Silva TCL, et al. (2020) Covid-19 Pandemic and
Health Professionals: Practical Approaches. Int J Crit Care Emerg Med 6:108. doi.org/10.23937/2474-
3674/1510108
Accepted: May 07, 2020: Accepted: May 26, 2020: Published: May 28, 2020
Copyright: © 2020 Monte RRL, et al. This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original author and source are credited.

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mic on March 11, 2020 [2]. The pandemic has an uncer- From the perspective obtained through arctic publi-
tain future, depending on experts' estimates, it presents shed on the subject and information based on scientific
itself in several clinical forms, from mild to severe cases, evidence, the present study aimed to analyze, describe
such as acute respiratory failure. Several other structu- and elucidate the main challenges faced by health pro-
ral problems of the public health system are added, fessionals in the face of the COVID-19 pandemic, as well
such as the Brazilian Unified Health System [2-4]. as to present and discuss on the strategies implemen-
Transmission occurs during exposure, on average, ted around the world to combat it.
1.5 m, to a person infected with COVID-19, through Methods
droplets containing the virus when the infected per-
son coughs or sneezes. Droplets can reach the mouth, The research was carried out in the Embase, Scopus,
nose, and eyes of people close by entering the lungs. Pubmed/Medline, Web of Science, Scielo, Cochrane Li-
The contribution of small particles, called aerosols or brary, and Google Scholar databases, considered “gray
droplet nuclei to transmission by proximity, is currently literature” as it does not contain peer-reviewed articles.
uncertain. However, transmission by air from person to The selected studies involved health professionals and
person over long distances is unlikely [3,4]. the pandemic of the new coronavirus (COVID-19), with
the most recent being considered. The studies were
Ferguson, et al. demonstrated that the best way to chosen by combining the following keywords: COVID-19
contain the pandemic, its transmission, and minimize pandemic, SARS-CoV-2 infection, COVID-19 pandemic,
the burden on health services is the alternative miti- Coronavirus, Personal Protective Equipment, and He-
gation policy (the combination of case isolation, home althcare Workers. All relevant studies published in the
quarantine, and social distance from the population) for year 2020, in the cohort, systematic review, meta-a-
at least three months. This measure would reduce the nalysis, case-control, cross-sectional and case series stu-
number of deaths predicted by the epidemic by more dies were included in the selection analysis. The filters
than half, and the peak demand for health services by chosen were studies carried out in humans and comple-
66% [5]. te articles. The report, review, and selection of articles
The big question is: How to balance a system that was carried out in pairs, separately and blindly, based
was already experiencing difficulties to overcome the on the reading of the title and summary of the study,
new challenges that arose with COVID-19? From this with a third reviewer in case of disagreement among
aspect, the current social reality is to discuss funda- the others. From a total of 87 pre-selected, 30 articles
mental points of daily life, such as the use of personal were included in this review.
protective equipment; provide adequate care, without Results and Discussion
fear of contamination; immediate assistance for severe
cases, and treating infected patients equally [4-6]. Analyzing the pandemic from the health system offe-
red to the population, notable countries with excellent
The COVID-19 pandemic produces ethical dilemmas
public care services have a higher capacity to deal with
for the healthcare system, managers, and healthcare
health threats. However, as Ceukelaire, et al. stated, the
equipment suppliers. Perhaps the most difficult is how
privatization of health services and the individualization
to equitably distribute scarce resources, such as ICU
of risks reduce the ability to deal with this and future
beds and mechanical respirators, as this decision can
global pandemics [3].
determine who lives and who dies. We all experience
the dizzying newness of socially distanced lives and feel Private health systems are unable to coordinate ap-
that 'things are different now' [6]. propriate collective responses, which is why the govern-
ments of the United States of America and Italy invest in
How do traditional ethical principles apply to these
new circumstances? COVID-19 reflects a recent situa- individual people's responsibilities. Thus, social distance
tion of an old problem: Ensuring fair access to health has become the cornerstone of their mitigation plans
services sparingly to ensure the law of equity. Also, it for COVID-19. In this regard, Brazil's health system is dif-
puts into question all issues of good hygiene practices ferent due to the principles of universal service. Howe-
of the population and the safety routine of health pro- ver, the distribution of resources does not guarantee
fessionals [7-9]. security [3-5].

As part of the front line in the fight against the pan- Treating patients with COVID-19 requires training,
demic, the multi-professional health team is a crucial correct use of PPE, availability of a modern ICU, and
response force. From this perspective, it is understood the presence of trained and dedicated health staff [8].
that measures are necessary to enable effective biopro- Health professionals are at high risk of falling ill while
tection since the compromised composition of health fighting the COVID-19 pandemic. Nosocomial outbreaks
teams in quantity and quality can generate a notable among these professionals are not uncommon [9-11].
economic and social impact on the country affected by In a hospital in China, about 3019 health workers
the pandemic [8-10]. were infected with COVID-19; 1716 cases confirmed by

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nucleic acid testing, and at least 6 of these professionals recognize suspected cases and demonstrate adequate
died, including the doctor who warned about the new use of PPE's [9].
coronavirus, Dr. Li Wenliang. Therefore, urgent inter-
It is essential that all institutions cancel elective pro-
ventions are recommended to protect health professio-
cedures, use telehealth when possible, limit points of
nals, such as the use of appropriate personal protective
entry and visitors, encourage patients to use hygiene
equipment to face the pandemic [9].
habits and use face masks, and screen patients for re-
Although the aggravating shortage of mechanical re- spiratory symptoms daily. Because many times, patients
spirators and Intensive Care Units (ICU) beds, the num- who seek health care for different reasons can manifest
ber of critical cases only increases, and such structures respiratory symptoms that deserve to be reviewed [15].
will not be useful unless there is an adequate workforce
Some essential points have been changing the rou-
[4,10].
tine of health professionals and are related to safe vest-
With the scarcity of health professionals in the fight ment, previously indicated routinely. Still, due to the
against the pandemic due to its increasing contamina- pandemic and generalized anxiety, it has been assuming
tion, health students, recent graduates, and residents a fundamental role in stopping the coronavirus. The cor-
are called to work on the front line. The practice can rect vestment and the respiratory etiquette bring good
be seen in several countries like the United States, Italy, results for both the health professional and the popula-
and Canada. However, placing such individuals without tion [15-17].
adequate training is a risk to public health. In this sense,
the American Heart Association (AHA) is clear that we
Health professional safety
must protect our interns and not send them to act in Health professionals are facing a higher risk of expo-
the epidemic [10]. sure, extreme workload, moral dilemmas, and a conti-
nually evolving practice environment that differs signifi-
Furthermore, the risks are not inherent only to tho-
cantly from habitual [4].
se who receive and treat infected patients, but it also
affects surgeons who, even working in a restricted field Training on personal and interpersonal protection is
of the hospital, are at the mercy of the disease, due to essential to avoid contamination of professionals, from
the possibility of dissemination during surgery, even if the step-by-step re-approach to correct hand hygiene
minimally invasive, particle aerosols, as well as by he- and the five crucial moments for cleanliness to the cor-
matogenic route [11]. rect placement and removal of PPE's [16,17].
Regarding aerosol transmission, it is worth empha- Some tertiary and secondary hospitals face a lack
sizing the necessary precaution to perform aerosol-ge- of PPE, so healthcare professionals need to improvise
nerating procedures, such as the use of a nasal cathe- using plastic (photographic film, plastic film, file bag,
ter (CN), venturi masks, non-invasive ventilation (NIV), etc.) to create a simple PPE that makes all the difference
orotracheal intubation, nebulization, among others. in the face of COVID-19 contamination [9].
The use of CN can spread particles that reach up to one In a study on which fears and anxieties afflicted the
meter. That is, procedures previously commonly perfor- professionals, continuous fear of access to appropriate
med without concern by professionals in their health personal protective equipment and exposure to CO-
services need more attention to avoid exponential con- VID-19 at work and bringing the infection to their family
tagion of the virus, causing emotional and psychological was revealed [4]. Without adequate protective gear,
stress [12,13]. some doctors in the UK are considering leaving medi-
Thus, it is evident the need to use surgical masks, so- cine as a profession [18]. In India, some intensive care
cial isolation, the negative pressure in the beds where doctors have resigned [8].
infected and hospitalized patients are. It is also worth As a reference, a hospital in Shanghai, China, provi-
emphasizing the importance of the health profession- ded adequate medical supplies to ensure the work of
als' follow-up of the protocols created for the vesting the health team under full protection, but also offered
and de-vesting, to reduce the risk of intra-hospital infec- mental well-being and psychological support, given that
tion by COVID-19 [10,12]. professional well-being promotes effective exercise and
The different epidemiological characteristics of with quality of function beyond patient safety [16].
these viruses (SARS-CoV-2 and SARS-CoV-1) probably Following the same principle, the Brazilian Ministry
occur due to other factors, such as high viral loads in of Health prepared recommendations for managers
the upper respiratory tract, as well as the spread of the about the mental health and psychosocial care of heal-
virus by asymptomatic infected people. SARS-CoV-2 re- th workers. Knowledge about the disease and training
mains viable and infectious in aerosols for hours, while in the proper use of PPE's, excellent quality commu-
it persists for several days on some surfaces [14-16]. nication, mutual encouragement and encouragement
Some necessary care measures should be discussed, as among team members, the alternation between high
well as training for health professionals, helping them to and low voltage activities, regular rest monitoring, ade-

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quate space for food, rest is essential, as well as indivi- to use the N95 mask, composed of polypropylene mi-
dual and group psychological support [19]. crofiber as a significantly more effective protection fil-
Given the above, recognizing sources of anxiety al- ter, which will remove 95% of all particles with a diame-
lows health managers and organizations to develop tar- ter greater than 0.3 µm [12,21,22].
geted approaches to address these challenges and pro- The use of other facial mask options, in the absence
vide specific support to their health workforce. For this of the N95, is recurrent, whether surgical or cotton. Al-
reason, professionals created the table called "Requests though not ideal, they can be used to minimize the risk
from health professionals to your organization during of exposure to COVID-19, as long as they are used with
the 2019 coronavirus disease pandemic" with five re- caution, removed correctly, adjusted with a facial seal,
quests: listen to me, protect me, prepare me, support and associated with appropriate hand hygiene techni-
me and take care of me [4]. ques, non-prolonged use and not reuse. For reuse, it is
necessary to confirm the mask's integrity [22,23].
Recommendations for professionals suspected of
infection For the professional who is in contact with symp-
tomatic patients with viral respiratory infections, the
The US Centers for Disease Control and Prevention mask is a central component of personal protective
considers an epidemiological risk for asymptomatic he- equipment (PPE), along with an apron, gloves, and eye
alth professionals exposure to patients diagnosed with protection. The mask in this situation is recommended
coronavirus [3]. and well recommended.
It is recommended that professionals in medium or The question that is being discussed is whether,
high-risk situations, that is, that without the use of any in this case, the mask would offer any additional pro-
PPE's or a mask/respirator, maintained prolonged close tection in the health system scenario in which the pro-
contact with a COVID-19 patient, whether or not using fessional is not in direct contact with the symptomatic
a face mask, should be suspended from work for 14 patient? [1].
days after exposure [20]. Similar behavior was adopted
in Brazil, in which isolation was recommended when in According to Klompas, et al. two scenarios are indi-
household contacts with asymptomatic persons [7]. cative for the use of a mask, even if there is no direct
contact with the suspected patient [1]:
The health professional must guarantee the afebri-
le and asymptomatic condition before presenting for • Covid-19 cases not yet recognized: The cover will
work. Therefore, if there are fever or respiratory symp- reduce the risk of contagion; however, it does not
toms consistent with COVID-19, one should immedia- protect against droplets that may enter the pa-
tely isolate oneself and notify the institutional health tient's eyes or fomites;
authority immediately, so that the necessary care can • In cases of asymptomatic or minimally sympto-
be taken [20]. matic health professionals with COVID-19: This is
In the eighth Epidemiological Bulletin of Brazil, the an important point that must be addressed. We
Ministry of Health indicated that antibodies against do not yet know about the potential for infecti-
SARS-CoV-2 should be tested for health professionals, vity.
including health professionals, as a priority when symp- The prevalence in patients with Covid-19, sympto-
tomatic. This measure allows greater precision and as- matic or not, evacuated from Wuhan during the peak
sertiveness in maintaining or returning to the health of the epidemic was only 1-3%. Assessing the behavior
service [7]. of the disease in Wuhan, it was noted the importance of
Use of masks in hospitals identifying undiagnosed infections in the spread of Co-
vid-19, recognizing that the risk of transmission in this
The universal use of masks is already a practice in population is probably less than the risk of spreading by
Hong Kong, Singapore, and other parts of Asia. Many symptomatic patients, but it exists [1,2].
American hospitals have recently adopted it. However,
there is a question as to whether it should be universally However, it is not possible to extend the use of the
indicated for all health professionals [1-3]. mask as a guarantee of protection if it is not accompa-
nied by careful hand hygiene, eye, face protection, glo-
What is known is that wearing a mask outside the ves, and apron [1,22].
health service facilities offers low protection against in-
fections since to be considered a significant exposure, There is an overuse of masks, but this act can promo-
it is necessary to stay in contact for 1.5 meters for ap- te higher transmission of Covid-19 if we do not pay at-
proximately 10 to 30 minutes [1,16-18]. tention to the implementation of fundamental infection
control measures, such as hand washing [1-3].
Added to this is the fact that cotton masks offer re-
duced protection against COVID-19. Their use is not en- Contraindicates indiscriminate use is the future lack
couraged, according to Ferioli, et al. The correct way is of masks for professionals who need it. The use of a

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mask is a reflection of population anxiety; however it possible, the patient should try to call informing that he
serves as an alert for social distance and increases peo- is looking for the service so that the PS can organize the
ple's sense of security [1,22]. best care [8,15].
According to Klomps, et al. the indication of pro- If the patient requires emergency transport, the
tocols for expanded use of masks is useful to alleviate emergency team must notify the hospital. This will al-
anxiety, above any function that may act in reducing the low prior preparation by the unit that will receive the
transmission of Covid-19 itself [1]. patient and will avoid euphoria and stress [15,24].
Lack of resources and pandemic Use of insulating vest
According to Emanuel, et al. the best recommenda- North American recommendations indicate the use
tions for managing health inputs during the Covid-19 of insulating clothing, which has not yet become a rea-
pandemic are: maximize benefits; prioritize health pro- lity in many places in Brazil. The use of insulating robes
fessionals; do not allocate on a first-come, first-served should be chosen for professionals [7-9].
basis; act according to the evidence; recognize partici-
They will perform procedures that generate aerosols
pation in research. Apply the same principles to positive
(intubation), care activities where contact with sprays
or negative Covid-19 patients [18,23,24].
or secretion droplets is expected, and events of high
The importance of prioritizing the health professio- contact with patients that offer the risk of transferring
nal ensures that he is not contaminated and is unable to pathogens to the hands and clothes. Such as dressing,
perform his role. Assisting health professionals means bathing, transfers, hygiene care, changing sheets, un-
thinking more and more about the population [18,21- derwear, or help with trips to the bathroom and wound
23]. care [10-12,15].
The availability of health system resources must be The use of the insulating garment must follow speci-
sufficient, and their use must be regulated so that no fic recommendations. After wearing the full PPE, as re-
health professional is individually responsible for whi- quired in the ICU, for example, it is not allowed to drink,
ch patients pay the most attention and which do not eat, or go to the bathroom for about 6 hours. The re-
[18,25]. moval of PPE after working hours requires training and
excellent care, so as not to become infected [4-6,8]. It
The professional and health education is necessary to discard the garments before leaving the
Inherent in health education, professionals must patient's room [14,15].
adopt an educator role, even if it does not fit their pro-
file. In this sense, it has been a challenge for some ci-
Ideal vestment
vil servants to assume this role of educator concerning The instructions from the Ministry of Health and the
well-oriented social isolation policies [13-15]. Clinical Management Protocol for the New Coronavirus
The entire multidisciplinary health team must be able (SARS-CoV-2) advise that masks type N95, N99, N100,
to guide the population, clarify doubts, and fight false PFF2 or PFF3 should be used whenever aerosol-genera-
news about the disease. Therefore, emphasis should be ting procedures are performed (intubation or tracheal
placed on a step-by-step guide for proper handwashing aspiration, non-invasive ventilation, cardiopulmonary
with soap and water, hygiene with gel alcohol, cough resuscitation, manual ventilation before intubation,
etiquette. Who is at risk, who needs to wear masks and sputum induction, nasotracheal sample collections, and
how to use them, when looking for the health unit, onli- bronchoscopy) (Table 1).
ne health care, and the importance of home quarantine Surgery center
and social distance [5,16].
In a study by Sarah L, et al. it was observed that the
It is up to these professionals to instruct patients to most appropriate and consolidated conduct among sur-
call ahead and discuss the need to reschedule the ap- geons is, primarily, to protect the health of professio-
pointment if they develop symptoms of respiratory in-
nals. Patients should be screened as needed for surgery
fection (cough, fever, and sore throat) [15].
[11].
Communication between levels of health care Thus, elective surgeries should be postponed, and
Each health professional (PS) must maintain a good the others classified according to the risk of urgency and
dialogue with the other teammates. The fear of not emergency and the probability of generating aerosols
exposing oneself exists and, to avoid or minimize it, it is during the surgical procedure. All patients undergoing
interesting to adopt some behaviors that contribute to emergency procedures are considered to be infected
the flow of activities together [15-17]. with COVID-19 until proven otherwise [17,22].
A chain of actions is essential, starting with the scre- Therefore, for safety reasons, all members of the
ening site with reduced numbers of professionals and, if operating room must wear an N-95 respirator mask and

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Table 1: Pre-defined order of vestment.

Clothing
Before entering the coronavirus patients' room After entering the insulation sector
Hand washes with alcoholic preparation, for at least 20 seconds, using Clean your hands with alcoholic preparation, for at
the technique recommended by ANVISA/Ministry of Health. least 20 seconds.
Put on the waterproof apron. Perform the lashing on the inside and the
Put on the tightly fitting gloves over the apron cuff.
back of the body.
Put on the N95/PFF2 mask, taking the strips. Place them properly, not
interlaced. Adjust the mask by the nasal clamp and perform the sealing Optimal disenfranchisement.
test.
Put on goggles or face shield.

Put on the cap.

Disparation

Insulation sector Outside the insulation sector

Remove the first glove safely with the opposite hand, touching the outside
to pull it, inverting it inside out when removing. With the ungloved hand, Clean your hands again with alcoholic preparation,
remove the other mitt, taking the uncontaminated part from the inside, for at least 20 seconds.
also reversing it for removal.
Remove the cap from the back of the head, without
touching the face, and discard it.

Remove the glasses from the sides.

Remove the mask by the strips avoiding touching the

Hand washes with alcoholic preparation, for at least 20 seconds.
front.
Untie the apron securely without sudden movements to avoid droplets. Hand hygiene with alcohol preparation, for at least 20
Remove inside out and also handle inside out to discard it with each use. seconds, using the Hand Hygiene technique.
Clean the goggles or face shield with water and soap/
Hand washes with alcoholic preparation, for at least 20 seconds.
detergent and disinfection.
Hand hygiene with alcohol preparation, for at least 20
seconds, using the Hand Hygiene technique.

be equipped with an anti-droplet suit (gown, gloves, treatments. Without contact, with efficient distribution
and goggles) [17-19]. of resources and low cost, seeking to maintain the first
In patients with positive COVID-19, unless it is an contact with patients who do not have direct assistance
emergency with a risk of death, non-operative treat- in this challenging moment of global health [8-10,25].
ment, and delayed surgery until recovery are advocated Fortunately, many Internet hospitals, such as We-
[9-11,17]. Furthermore, the cleaning team of the opera- Doctor and Haodf.com, offered free online advice on
ting room must also be equipped with droplets to avoid COVID-19 and home quarantine guidance during the
cross-contamination [11,17]. pandemic [16,23].
Technology to combat the COVID-19 pandemic These ritual treatments are known as telemedicine,
Amid the emergence of the coronavirus pandemic, in a health area that offers support to patients remotely,
the momentary absence of a specific treatment or vac- with the help of Information and Communication Te-
cine, measures such as domestic isolation, city blocking, chnologies (ICTs). Since the mid-90s, the World Health
and traffic restrictions have been implemented worl- Organization (WHO) has recognized the importance of
dwide [1-2,13]. telemedicine, especially when the distance is a critical
factor for the continuity of health care [24-26].
Besides, medical services and outpatient consulta-
tions were canceled in several hospitals during this pe- Most hospitals canceled in-person outpatient con-
riod. As a result, thousands of patients were left without sultations and converted them exclusively to telehealth
constant care, at risk of a possible worsening of their consultations. This rapid expansion of telemedicine du-
health conditions, especially those with chronic disea- ring this pandemic may imply long-term access to he-
ses [5-7]. althcare by remote means, facilitating access to health
for people living in rural communities, for example [24].
To mitigate these problems, countries like China
have adopted “Internet Hospitals”, which offer virtual In China, more than 20,000 doctors offer online me-

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dical services to 200,000 Internet users daily. The assi- critical health workforce, locally, we strongly suggest
stance involves, among other actions, guidance on me- that medical students do not get involved in no direct
dications for chronic use, home delivery of drugs, moni- patient care activity. "AAMC framed its orientation by
toring by multidisciplinary teams, and 24-hour mental pointing out that "medical students are students, not
health care [23,25-27]. employees" [26].
In Brazil, interstate telemedicine is allowed between However, students, if allowed to work in clinical fun-
patients and professionals from different states. Usual- ctions, always with the support of a superior professio-
ly, the health professional, the provider of telemedicine, nal, can assist patient care. Actions like this have been
is only allowed to attend patients where their license is seen at historical events. During the 1918 flu outbreak
active. However, with high demand, Medicaid services in Spain, medical students at the University of Pennsyl-
needed to be less rigorous [12,25]. vania cared for patients as doctors [28-30].
Unfortunately, a detailed physical evaluation of the In 1952 polio epidemic in Denmark, groups of medi-
health professional cannot perform an adequate physi- cal students were tasked with manually ventilating pa-
cal examination following all the propaedeutic methods tients. In the current pandemic, medical schools in the
(inspection, palpation, percussion, and auscultation). US, Italy, and the UK are graduating medical students
Some patients are not used to using remote technolo- from the beginning to serve as frontline doctors [3,26].
gies when consulting with a professional, so a simulated
visit is recommended so that the patient can become Students can assist in routine outpatient clinical
familiar with the chosen platform [25,26-28]. care, perform checklists on the COVID-19, offer care and
attention to the patient, as well as assist with inpatient
The health professional and the provider need to be services-all of this under the supervision of a resident or
prepared to help patients with their doubts regarding attending physician [7,13].
telemedicine: How to log in to the platform, how to
start a video call, among other questions that may arise. Besides, the presence of students from the last years
An excellent solution to avoid this type of problem is to of the course contributes to a higher number of clini-
send instructions to patients even before the simulated cians available to treat patients with the emerging virus,
visit. An appropriate location for telemedicine should reducing the overall burden of clinical staff. It is worth
be chosen, such as an office, if possible [14,25]. noting that the risks resulting from student involvement
Not all patients have devices that perform a video may be less than the risks for retired clinical volunteers,
call. So the professional can use the voice flame to com- who are more susceptible to COVID-19 complications
plete the consultation because of the social distance of due to age [26,27].
the patients. Health workers should be considered a pri- It is imperative to remember that these students are
ority in this pandemic [23-25]. future health professionals who have responsibilities
Thus, it is essential to highlight the importance of to patients and may be allowed to perform their duties
these alternative services, such as the case of telemedi- as such. In addition to the benefits for patients and the
cine, at such a delicate moment in global health. Its use health system, their participation reinforces essential
is vital today, and it will undoubtedly be indispensable values, such as altruism, care in times of crisis, and soli-
not only for COVID-19 but also for future outbreaks of darity [25-28].
infection if they occur again [29].
Other exposures to COVID-19
The student in the care against COVID-19 It is necessary to highlight other situations of poten-
A large number of contagions, the existence of em- tial transmissions, such as contact between colleagues
ployees in risk groups, and the possibility of professio- health professionals. The shift transfer, discussions of
nals carrying the virus asymptomatic raise an alert re- clinical cases, lunch or rest times, considering that most
garding the possible lack of teams for patient care. The of the time they work in confined spaces where it is not
chaotic scenario in small and large medical care centers, possible to guarantee a distance of one and a half me-
the needs of a more extensive medical staff are increa- ters [14-16].
singly discussed [20-22].
Besides, there is a risk of transmission outside the
As a result, support from students in the health field, hospital environment, since health professionals at the
preferably from the last year, has been discussed as a end of their shifts maintain contact with other indivi-
mechanism to assist in the care and enable doctors to duals such as family and friends. Therefore, it is essen-
perform more specific tasks in the care of suspected pa-
tial to keep adequate preventive measures in case of
tients or patients with coronavírus [13,14-16].
contact with co-workers, even if they are not in the pre-
The American Association of Medical Schools (AAMC) sence of patients, in addition to adopting protective me-
instructed medical schools to suspend student intern- asures outside the hospital context to obtain protection
ships. The AAMC recommended that "unless there is a for all [10,11,27].

Monte et al. Int J Crit Care Emerg Med 2020, 6:108 • Page 7 of 9 •
DOI: 10.23937/2474-3674/1510108 ISSN: 2474-3674

Prevention of "device-related pressure injury" be used to technology to use telemedicine as an indi-

spensable tool in the face of this pandemic.
Health professionals need to wear masks, glasses,
and other personal protective equipment during their Compliance with Ethical Standards
working hours, often overlapping [8-10].
Acknowledgments
Prolonged use, in addition to the physical effort of
the long workday, leads to excessive compression of the The authors thank the Ph.D. in Health Sciences and
skin. The compression, in turn, causes poor blood circu- Teaching and Research Manager at League Against Can-
lation and results in ischemia and local tissue hypoxia, cer, Profa. Dra. Amália Rêgo, for her contribution and
which cause skin diseases, characterized by pain, local relevance to the scientific discussion and supervision
redness, and tissue damage, mainly in areas with less of this research, acting as an expert consultant on the
adipose tissue, such as head, face, neck [11,28]. bibliographic survey, analysis, and scientific advice. We
also thank all the study components for their dedication
The use of hydrocolloids, foam dressings, and leaf and effort to build a scientifically validated quality stu-
hydrogel as preventive methods are significant. They dy.
can be used to change pressure points of equipment
and thus cause pressure relief in other parts, promo- Disclosure of conflict of interest
te repair of wounds under pressure, hydration wound There are no conflicts of interest to declare by any of
bed, fluid absorption, surface cooling, and pain control the authors of this study.
[29,30].
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