From the DevelopingEM Archives: Dr. Hector Real, Nicaragua, July 2020
The following interview is presented in collaboration with DevelopingEM: A Conference with a Conscience. The interview was recorded last year, and published on July 1, 2020. The original publication can be seen on the DevelopingEM blog here. For an unedited transcription of the dialogue, please scroll below the video.
In the interview, Dr. Hector Real describes the multifaceted challenges Nicaragua has faced preceding and during the pandemic.
Mark Newcombe: So hello, Developing EM-ers! Today we're catching up with Dr. Hector Real from Nicaragua. Hector is an emergency physician working in the capital Managua, and he's been critical pushing forward the development of our specialty emergency medicine in the country. He gave a really great presentation on the history and development of emergency medicine in Nicaragua at our conference earlier this year. And it's really great to see him today. How are you doing, Hector?
Hector Real: I'm doing great. I'm doing good right now. Thanks for asking Mark. And also, thanks for inviting me to this interview right now.
Mark Newcombe: Not a problem. It's great to see you again. Maybe for our viewers and listeners, can you just remind us which department you're working in at the moment and what your role is within that emergency?
Hector Real: Yes. Well, as I, as you mentioned, it, I'm an emergency physician and I work in a private hospital. I work in a Hospital Vivian Pellas hospital that is located in the capital city, Managua, and at this moment, eh, as emergency physician I'm working in the ICU unit in the COVID, eh, 19 area.
Mark Newcombe: Okay. So you must be seeing a lot of sick people and facing challenges every day. I guess we've got a bit of a perspective from your talk in Cartagena about what the situation was like before the pandemic, but on an average day before 2020, do you have shortages in people, in equipment in consumables that make your work life difficult?
Hector Real: Yes. Well, eh, as any other countries, there's no perfect healthcare system. Unfortunately in my country, we we've been experienced as you already know, political situations in since 2018 and it's social political situation. So a lot of healthcare workers were fired around 400 in that moment. And also we have some kind of restrictions for educational purposes for this fire health and workers. A lot of them were, were professors in universities or professors in hospital areas for residents. Also, we have, we've been having a little bit of problems with investigation parts. Eh, it's I had to mention that Nicaragua is one of the, is the, the country that has the lower incomes related to, to the other central American countries. Eh, you can compare it with Honduras, El Salvador, Costa Rica, and Nicaragua is the, is the country that has the lowest income related to healthcare workers also regarding talking about this political situation. There's another situation that, that comes eh, and it's related with some political harassment talking about in, in the healthcare system, because there are a lot of restrictions because all of this situation,
Mark Newcombe: Well, it's great to get that same set for us, Hector, I guess. The that's the setting that you came back to in March when the pandemic had just been declared during the conference. So that starting point is a difficult starting point to then deal with a new problem, which is COVID-19. How have things developed over the last three months in that regard?
Hector Real: Yes, well I need to, to make clear that, that I work in a private hospital. So fortunately for me, I have all the PPEs that I required and I need I have work in a different setting regarding the, the public health care system. But I have a lot of friends who work in the health or public health care systems. And there is a lot of restrictions that there's not enough PPEs for all of us. I mean, you need to remember that we will live in a development countries in developing countries. So we already have, we already had PPE restrictions because we don't, we don't, we didn't have enough PPE. And with this COVID-19 pandemic situation, everything's got Wars, also the ventilators. We don't have many ventilators in there around the whole country. And even with that, we don't have the it's not, it's not only about the ventilators. It's also about the, the, the people who, who are trained to, to, to manage, to, to use these, these ventilators. So it's a, it's a critical situation regarding this pandemic situation right now in Nicaragua.
Mark Newcombe: Yeah, it sounds very difficult. On the face of it, if you look at who official COVID-19 figures for Nicaragua, it doesn't seem too bad, but I remember you saying that politics and healthcare in your country are pretty difficult to separate. Are you content to discuss how you feel the situation is more accurately reflected than the official figures and what are you experiencing on the ground when it comes to the ability to test and treat cases of COVID-19?
Hector Real: Yes. I mean, first of all, talking about the WHO view that the picture that has Nicaragua, eh, you need to keep in mind that we have around the glove every, the whole home world, every country has the, the numbers and the official numbers, and you'll, you'll never will match the real numbers with the official numbers. Even you have all the willing to do it. You can't. So picture the situation in a country where the Politic's the politicians don't want to, to, to, to, to show you the real numbers are. So it's been kind of complicated last time we saw you. I mean, we were in Cartagena, Colombia, so on March 11th if, if I if I, if I remember WHO declared and then make a COVID-19 the situation. So when I went back to Nicaragua on March 12th, eh, we didn't have any official cases reported at that moment, but, eh, it was until March 18, when the first case was reported in that same day we also, we have in, in my hospital, we have another positive, eh, so in that moment, it's supposed to be two cases, but just one was official.
And obviously there was more than one, even more than two. So we've been struggling with this, eh, reality when we have the official numbers and we'll have the real numbers, and we need to deal with the fact that the healthcare authority, the, the, the health authorities, eh, they tried to, to, to keep like top secrets in that moment. And the real numbers are so talk it about the, the, the COVID tests. You know, also the government tried to centralize everything. I mean, we don't have, even today, we don't have private, even, even my hospital don't have the COVID-19 tests. So if we want to, to run the test, we need to, to send the sample, the test to, we would take the sample. We would take the, the, the, the RTPCR, and we need to send it to health help ministry lab in order today to prove to process.
And we have the, the result. So there are a lot of complications with that, because how much you can wait for how long you can wait for, for, for for our result, like three hours, four hours. So in my setting at the beginning, we need to wait until four 24 hours to 48 hours in order to have some results. And that was one of the biggest problem at the beginning in right now, because we don't have the availability to test everything who wants to be tested even in the private settings. So that's, that's a pretty difficult scenario and what we we're doing right now, it's a, we don't use, I mean, we send the test we, we ask for tests and we send it to the, to the health administer that, but also we use a lot of clinical signs and symptoms, and also other lab works like biometry 13, you know, creatinine, PCR, D-dimer and also x-rays and CT scan. And that's the way we are working right now.
Mark Newcombe: Right. So you're making a lot of presumptive diagnoses whilst waiting for a test that might not come back, that it must be difficult to work in that sort of environment. Have you seen a lot of sick patients in your institution?
Hector Real: Yes, actually, yes. In the emergency at the beginning, it wasn't until the, kind of around the fourth week, since we have the first case, when in my hospital eh, the, the emergency department where was crowded, like, I mean, we, we live in a small country and I work in a, in a private setting. So even in that, in that moment, in the, for a private hospital, we, we, we were, we were crowded in the emergency department. We didn't have enough emergency physicians to cover all the patients at the same, at the same times. In that time, there was like two emergency physicians for 30 patients, patients on ER, demanded for health, demanded for, for attention demanding some lab works, demanding tests and abandoned x-rays CT scans, a lot of DSAT people, eh, a lot of critical patients. Unfortunately, a lot of patients die in that moment on ER, eh, even even doing everything that we can, eh, they, they die because they, they, they went to the ER when they, their, their symptoms were kind of critical.
Also there was a moment that when our ICU, eh, was crowded and we need to transfer all other critical patients who went to the hospital to, to be hospitalized, we need to try to transfer them to a public hospitals because we, we, we tap, eh, we, we didn't have availability for them, unfortunately. So it's, it's kind of a stressful situation for, for the healthcare workers in the private hospital and for the patients also also, and, and relative of the patient and at worst, just in a private hospital, but in the public hospital and things were worse, mean picture that a hospital public hospital Nicaragua was a small country. We're just, eh, our population, it's around 6 million peoples is so pictured that the public hospitals are, we have four, 400 patients. So you can picture up 400 beds full of COVID-19. So, eh, things went crazy, because eh, the public hospital ran out of beds, eh, eh, a lot of people unfortunately died on on that public hospitals. And that's one of the parts the healthcare, the health and ministry, eh, hide those, those numbers, eh, telling us that turn the pool because they, they, they, they can't, they can't fool us. They can't fool the workers, they, they, they fool the citizens, tell them that they die because typically or acquire pneumonia or other related complications.
Mark Newcombe: Wow. that's, it's really interesting to hear that perspective, Hector the challenges in dealing with, you know, a lot of sick patients without resources and ability to test must be incredibly frustrating for yourself and for your colleagues, especially in the public sector. How do you manage to keep your team and yourself positive in that sort of environment, where there are so many hindrances and obstructions to the way that you would like to practice?
Hector Real: Well, and one of the things we're doing, I mean, the hospital I mean it help us with, would they cover us with all the, the, the PPEs that we need? I mean, so that's a big help in in a low resourced country. And with all these limitations of resources, that's a pretty big help. They, they, they, I mean, in, in my setting and the, the administrative part of the hospital, they were worried about our safety. So they, they spent money on that. So that, that one of the things that help us to, to cool things down for us also, it's hard to mind to keep being positive in a situation when you don't have all the resources, all the ability that you want to do. And it's kind of frustrating, but we try to talk in between between the physicians among us.
We try to talk and to discuss and, and see how we can support us, each other. Unfortunately, in my hospital a lot of my yes, a lot of colleagues tested positive for COVID-19 and, and they, they had to, to, to move from the attention to, they went to, to take rest for 21 days. And it's, it's kind of difficult to, to stay positive because you don't even, you you've been having all the equipment you want, you have the availability to use it. You, you can, even with that, you can, you can, you can have COVID 19. So it's kind of hard. It's kind of difficult. Also, we have some numbers I mean, not official numbers that are a group of people, a group of citizens eh, the social society. They, they made something that they call the observatory for COVID-19.
So they, they look for people around the whole country and try to, to, to keep tracking the numbers and compare and comparing to the, to the official numbers. So, eh, eh, thanks to them, we, we are able to have numbers talking about healthcare workers and a, well at this moment, the official numbers for just doing like, like a parenthesis the health ministry reports 100, 100, a 1,823 today around the country and 64 deaths. But this group of people, the, of the social observatory, they, they, they have different numbers. They have like 5,957 cases treating them by symptoms talking with other physicians in other private hospitals and gathering all this information. And meanwhile, the government reports 64 dead. They, they, they have a report of 116, 88 deaths. So it's a big, it's a huge reach, different of that. Also they have certain numbers about healthcare workers. They have a report for, of 614 health or workers positive with COVID-19 or suspected, highly suspected of COVID 19 with a lab works and x-rays or CT scan. And unfortunately of that 72 health workers between nurses and physicians and other healthcare workers elated to that unfortunately.
Mark Newcombe: Right. Wow. It, I guess one of the problems that we've struggled with across the globe is that we don't know when this is going to end. And when the end is in sight are things, do you think it's hard to tell, but things starting to slow down and improve a little bit in terms of the rates of infection and the number of sick patients that you're having to deal with on a daily basis?
Hector Real: Look, it's kind of complicated the situation because in my country our government didn't take any type of measures to, to, to contain this COVID-19 right. We don't have any restrictions. Eh, we can go out to the street, if we, one, we don't have quarantine. A lot of people is doing a self quarantine and a lot of physicians, we recommend to do self quaint, a quarantine for the citizens, but the, the official voice, the health ministry, eh, never, never told us that there's no official paper that, that gave us any type of recommendations to prevent COVID-19 besides washing their hands, washing our hands and using, using face mask, you know, in, eh, also we have w we've seen a problem here at this moment talking about June, eh, talking in June, thinking in June, right now on ERs, even in private hospital, in, in public hospitals, the number of patients are, are, are decreased.
The people who were, who, who go to the ER, looking for, for health attention for suspecting COVID 19, it's less than like three, four weeks ago, but, but there's a catch. There is not like the, the viruses it's contained or, or the, the, they, they, they spread of the infection, decrease the issue here is the people, eh, it's, it stays home. And they, they spend the, that this period of sickness in home, and a lot of people are dying in home. So because, because they think, eh, they, they, they think that if, if I go to the, to a public hospital and those hospitals are crowded, there's no availability. There there's no bed for me. So I'll better take care of home. I'm going to take treatment in home and see what happened. And unfortunately we're, we're, we're looking, we've been seeing this, this, this scenario, these like two, two weeks from, eh, from now, eh, that a lot of people are dying in their houses, but the emergency departments are not full, but we we've been experiencing a decrease in the number of, of attention on ERs,
Mark Newcombe: Right. And that's very sad, Hector I guess to ground the world, we're seeing that this disease and politics do not mix very well and that for whatever reason, different governments of both political persuasions when they have an agenda, then things don't work very well with this particular virus. It does sound however that perhaps things are slowly improving in terms of the disease itself. What do you think the next few months holds for your workplace and for your specialty in Nicaragua?
Hector Real: Well in the next month we are, I mean, we're expecting a new rise of number of cases to, to, to arise in a number of COVID-19 cases, again, going to ERs because, and we we've, we've seen that right now across the world. The number of cases are rising up again in all other countries. And Nicaragua is not going to be the exception. Eh, you need to keep in mind that we don't have an official quarantine. So the number of cases never decrease your, as I told you before, people stay at home. So for emergency physicians right now, it's it's a big moment because, eh, unfortunately we are not so many emergency physicians, like, because I told you before that in 2016, that the two major emergency residency programs two biggest ones were closed. So we just have private program of emergency physician emergency training.
And we have had this opportunity to, to, to work because we are the front liners and we need to put in front, but there are not enough emergency physicians in the country to, to help the citizens. So we, we are trying to, to, to gather ourself, we would do chat meetings and try to, to, to share our experience and to see develop any kind of protocol between us that in order to help the patient, eh, in try to avoid the political part, because that's one of our major problems right now. So we're working on, on that every day we were in, we keep in touch constant- constantly. Every day we were chatting. We, we, we share a, some cases in, in which we tried to keep informing each other.
Mark Newcombe: And that's amazing, Hector I suppose the, the pandemic has potentially brought some positives, small positives, perhaps. Are there things that you have learnt about emergency medicine and how the future might look from this whole bad experience? Are there positives that you've taken away from it?
Hector Real: Yes! Uh I think one of the positive things, unfortunately, I need to get this medicine is a spotlight right now in your profile, because it was kind of put aside this recent years. So right now we are on the spotlight right now, everyone knows about emergency physicians and everyone is asking for emergency health care worker when they go even to the public or private hospital. Also, eh, we we're having a great impact because, eh, even we're not so many emergency physicians right now, eh, we, we have the opportunity to express a, even in the public settings right now, the, to express our voice and intel, what are the needs on ERs around the country? So we, we are doing, we are giving our opinions to, to, in order to, to say how we are gonna to, to organize the ERs on the country right now. That's, maybe that's something that it could sound awkward to you cause, eh, maybe you related to, to your, you used to work in with, with some protocols of VR, but in Nicaragua, that's important because we we didn't have the opportunity before as emergency physicians, as we are doing this right now.
Mark Newcombe: That's awesome. I think our listeners will draw a lot of solace and positives from just the way that you're approaching a very adverse environment. Thank you very much for having the time to talk to us. I know that you've been very busy and it's really great to catch up. It's always good to chat to you. Do you think we can talk again in the next 12 months to see how things are going in Nicaragua?
Hector Real: Definitely. Definitely. We can talk, we should talk. We must talk again and compare things because I actually, I hope in 12 months from now, or I don't know when, when in the future I can I could bring you a different story to you and different story for all your viewers and how things, how bad things were and how good things are right now. And what were the changes that that, that we had in that process. I would like to do that. I hope to do that.
Mark Newcombe: Awesome. Hector, I hope we all have some good stories in the next 12 months. It's been the weirdest three months of my career. I know that so muchas gracias, hermano, and thank you very much for your time. Good luck in the next few months. And we hope to talk to you soon.
Hector Real: Thank you for, for giving me this space to, to, to share my, my experience and my opinions. And, and to give you the perspective of one of emergency physicians in, in Nicaragua, there are, there are a lot of voices that would love to have the opportunity to do it. May. Some of them are afraid of do it, of doing it because they, they, they are in, they're afraid to have any kind of problems others maybe they don't have the, the availability, eh, to work, to, to speak in a different language, in Spanish. And actually, I, I appreciate this opportunity to, to, to bring a little bit of light of what are we doing, and what's the situation in Nicaragua.
Mark Newcombe: Excellent. Thank you, Hector listeners in the line of notes to this video, we're going to have some background information on Hector's situation in emergency medicine, as well as a bit of a background on Nicaragua itself. So please do some reading and we look forward to talking to Hector in better times in the future. Muchas gracias.
Hector Real: De nada, adios!
