The times they went through last year were not easy. Accustomed to working in adversity, the truth is that the great focus of salvation was in Intensive Care Medicine, in the hands of few people. Day and night, hour after hour, days in a row in an uninterrupted and long year, it was desperate. The scenario is not exaggerated if we give it the following perspective. Do you know where patients go, from the central area to the south of the country, when their local hospitals can no longer treat them? They go to Santa Maria Hospital. And do you know who usually ends up in Intensive Care? The most serious cases of all. Now imagine living every day in this limit where everything either works out or simply doesn't, where the time of action can be decisive. Luck is not one of the parts of the equation.
The Intensive Medicine Unit of the Northern Lisbon University Hospital Centre was the first Hospital Service to receive critically ill Covid patients. It was also the place where, on 17 March 2020, the first infected patient nationwide died. This was the Service that received a profile of patients hitherto unknown, a Service just for Covid patients whose stay lasted much longer than usual (a minimum average of 15 days). These were the teams that went to work without being sure what SARS-CoV-02 was and what collateral damage it might cause. Think if you would still want to volunteer in this Service. About 150 people asked to help this Service. All of them without the right to the vaccine, all of them students of the Integrated Master Degree in Medicine and admirers of the perseverance of a group of doctors and professors, including Nuno Gabino.
The room where we meet beeps regularly, as if we were in one of the control towers where vital signs are monitored to keep us closer to life, or death. It commands respect, but in the same room that beeps to warn of the reality of permanent life on the razor’s edge, there is a board personalized by the Intensive Care Medicine teams, with one of the famous images of Banksy (British street artist) portraying a bunch of brave hearts who push any superhero to the side.
In the most acute phase of the pandemic, the Intensive Care Service took care of 80 patients simultaneously, doubling its usual capacity. While it is true that at specific times they received reinforcement from other medical and nursing teams, it was also true that the usual team had to ensure the management of patients. The routines, at the highest peaks, also changed. If one day the schedule was only daytime, the next day the emergency took long hours. Leave days, when possible, took place after the shifts. Soon after, the cycle repeated itself, with no holidays, no weekends, no special days, And given the impossibility of long breaks, the motto is clear in Nuno Gaibino's voice, "Turning our backs was never the hallmark of this Hospital, let alone this team". Despite the huge solidarity movements on the part of their peers, doctors from other services, they knew that patients recovered faster the more they maintained stability in the resident teams.
I already knew him well from the various initiatives in which he was involved with our students and also because he was mentioned so many times. In a brief visit to the Students Support Office, our opportunity to communicate finally came up. The last characteristic I was given of him, even when I got to know him, couldn't be more precise. "Nuno said he would be here in 5 minutes, but he must have stopped in all the rooms he came across, because he knows half the world." That was precisely what happened.
Nuno Gaibino always had two major goals in his life: to be a doctor or a pilot. He applied for the Air Force and passed all the tests. However, he was barred by an unavoidable condition, poor sight. He knew that the chances of never passing the tests were high, but he didn't want not to fulfil one of his big dreams. This was followed by another equally important choice, Medicine. He applied in 2005. None were successful, he also failed to enter Medicine. He assumed he would go across the road to study Pharmaceutical Sciences, but he never lost sight of what he was truly going to achieve.
Stubborn and with a good sense of humour, he says that every time he spoke to his mother on the phone and she asked him how life was going, Nuno always said what urged him not to fall asleep, "I'm no good, because I'm on the wrong side of the road and I spend all day listening to planes flying over me". He tells me that that year he learned that the commitment we put into things is what makes us attain our goals. He knew that there were things that would always be unavoidable, like having a good sight, but others were as simple as crossing the road, it depended only on the will. He sat new exams, applied for his great choice, FMUL, but also abroad.
He is from Vendas Novas, in Alentejo, and lived there until he was 18 years old. He only returned to do an internship in year 6.
He graduated from the Faculty of Medicine in 2012. This was followed by the common year in Santa Maria. He learned early to feel part of FMUL. All it takes is to remember his six intense years at the Faculty.
He was President of the AEFML for over a year. Then something changed his whole life, meeting Inês, now his wife. For 5 years he followed the activities of the AEFML. He was also President of the ANEM (National Association of Medical Students) and served in the Senate and General Council of the Rector’s Office. From those times he fondly recalls the summer months, which he chose to spend in Santa Maria, especially July and August, when things at the Hospital were quieter and many teams were on holiday. During those times, he came to know everything and everyone from the -2 to the 8th floor; calling each person on the electricity team by their name, or knowing everything about the shipyards, or to show up to solve flooding in the photocopying room. A true son of the Faculty ever since he joined it, nevertheless he did all possible internships outside the CAML, in order to get to know various realities and only then know what to choose. It is no longer surprising to anyone to say that Nuno Gaibino wanted to return home, to the Hospital and to his Faculty.
In 2019 he completed his first specialty, Internal Medicine. Since then, he has been part of the Intensive Care medical team, the second specialization he decided to take, which will be completed in January next year. He has been a medical operator of the emergency medical resuscitation vehicle (VEMR) in Santa Maria since 2017, and he is also an INEM trainer in the area of resuscitation and in the training of VMER operators.
After five years as an Anatomy Junior Assistant, in 2013 he became an Assistant at the Faculty. This year will be his last, since next year he will move to the Intensive Medicine University Clinic.
It is in the Intensive Care Medicine that we focus now and talk about.
Just before the chaos of the pandemic, Nuno Gaibino decided that he couldn't visit his entire family in Alentejo, parents, brother and grandmother in the near future. With Inês, Nuno's wife and also an Intensive Care doctor at another Hospital, the same thing happened. It was as if they abandoned their own, to take care of a much larger universe. They knew they were just protecting everyone they loved, as much as possible. Another factor increased the pressure of the moment, Nuno and Inês were going to be parents for the first time. There was now one more element to protect, this one. However, it was very close, so close that the only way to take care of it was to take Inês away from a risky work group and away from Covid patients. In November 2020, they became infected. Inês and the baby did well, but Nuno, despite not having gone to the hospital because he had no respiratory failure. However, he had persistent fever, extreme tiredness and cough, as well as very intense myalgias for 12 days. Both recovered, Nuno returned to his team, with the same eagerness as always. Of the 16 doctors that make up this team, only 5 were infected. These doctors were also joined by 120 nurses. But if we think that the Service doubled to accommodate 80 patients, can you imagine the superhuman wear of these teams?
If it weren’t for the dramatic situation in the NHS, the expression that Nuno Gaibino would use from his friend and nurse Carmen Garcia would be amusing, "if we are going to find more beds for the patients, we always have IKEA". But what really matters is knowing, "when will the NHS hire more people"? And what about the NHS human resources after a pandemic? How were these teams themselves taken care of throughout the process?
The immediate answers tell us that, for now, they continue to care, talking about their patients vividly, showing their passion that explain why they did not give in to fatigue.
Have you heard about Afonso Cruz' case?
Afonso Cruz was one of the first Covid patients to be admitted to hospital. He arrived in Santa Maria directly from Ponta Delgado and connected to the ECMO. The medical team and a group of volunteer students accompanied Afonso in extreme hypoxemia. A short time later he woke up, was extubated (when the ventilator was removed), the rehabilitation process started, so that the extracorporeal circulation process could be put into practice. Two weeks later, Afonso left walking with only a litre of oxygen, having met the healing criteria for SARS-CoV-02 and needing only to undergo the rehabilitation process through physiotherapy. Nuno described Afonso's clinical condition, with exact days about all the procedures, in great detail, as if he said goodbye to Afonso just yesterday.
"We wake up in the morning hoping for more cases like Afonso's to happen, because those who work in Intensive Care Medicine know that the disease burden is enormous. They usually arrive here when one of the diseases worsened or is hypercritical, which puts almost all of them at risk. Those who get here have some organ failure and in Covid cases with very residual amounts of oxygen and in need of support, ventilation, or ECMO". Intensive Care Medicine is usually the service that has the most patients on ECMO. Even though we know that a large percentage of patients who come here have one of the highest mortality rates, albeit with a tendency to drop, they still have very serious diseases. The good news is that an increasing number have survived, but there are always disappointing situations, when we cannot change someone's natural course.
He believes that human beings follow a natural and logical sequence of life, and disease is also part of this process. Although they do not receive children, young victims of polytrauma, road accidents, cases with very serious illnesses come to them. Faced with a patient’s failure, these teams feel that it is also their own failure. They alter small parameters of the natural course, which can allow it to be stopped, but nature will always follow its path later. He explains that it is not the specialty that removes the sensitivity towards the others, there is no button that turns off when one leaves the room. It is the great victories in the face of life that make them come back, every day, with the same eagerness to start from scratch.
It is precisely this attitude that he passes on to his students. He feels that his mission is to anchor his people, to teach them also to know how to anchor others, in this case sick people. There were many students who had one to two weeks to visit patients, to keep them company and encourage their recovery. The week the internship ended, they returned. When the sick were transferred to the ward, the students continued to visit them, and even when these patients left the ward and moved to "clean areas", these groups kept the visiting ritual. Every day they call or text, wanting patient feedback.
But it's not just the younger ones who have a close connection with the patients. Nuno Gaibino refers with some paternalism that the "patients always belong to the teams that take care of them", and this is not an exaggeration. Exactly a year ago, one of the most seriously ill patients that Nuno Gaibino looked after left intensive care. Pedro Silva, just over 50 years old, ended up spending almost 3 months in his service. After several weeks without being able to breathe on his own and always dependent on a ventilator, he was demoralized at his new way of being, to the point of rejecting treatment and food. Nuno Gaibino knew he had to find something that would make him closer to that patient. He found that they supported the same football team, so Nuno decided that he would talk to his patient about Benfica every day. The conversation continued from there, the breathing improved slightly, and the look too.
Benfica was going to play in the League Cup final and doctor Gaibino discovered that his team could also be an ally of Medicine. He then agreed that on the day of the Cup final, that patient could no longer be hospitalized and would have to be able to breathe on his own, so that they could go and watch the match, live, together. Pedro Silva has already left the Hospital and what's missing is the live match that hasn't happened yet due to the pandemic.
How does an Intensivist deal with the idea that “there is a natural order in life”?
Nuno Gaibino: Some patients have conditions that are simply incompatible with life and then we have to make decisions. For example, making use of futile organ support is totally against our deontological principles. Fortunately, most of the time we are able to offer prospects for treatment and so many other cures and that's what makes us get up every day. Intensive Care Medicine, despite the high failure rate, is also the positive version of the story, like Afonso's. If we hadn't implemented a technique on Afonso, he would have died. Yet, we managed to return him to his parents, his siblings, his dog and his island. And then we changed the order of things.
Can you measure the impact on students coming to volunteer with Covid patients?
Nuno Gaibino: They knew that the NHS was collapsing, in a situation that we didn't even know if we were going to overcome. Yet these students wanted to come and have their say, they immediately said "we are here" when we called them. They realized that, even though they weren't doctors yet, they could help provide care, some health care and even differentiated care. A patient who has been hospitalized for several weeks, without seeing a family, needs a certain type of care that this group can provide and knows how to do it. They played a very important role: making calls to family members, refocusing patients who had been asleep and who were still feeling confused. They tried to keep patients awake and calm through their physical presence, which is the true non-pharmacological treatment.
Isn't it more psychologically violent for a patient to be awake when he can't move and realizes he's connected to the ECMO?
Nuno Gaibino: For patients it is always better to be awake, in every way. Do you know why? Even if only to understand their own evolutionary process; then their collaboration is fundamental for us. While they are asleep, they do not collaborate and their stimuli are essential to speed up recovery.
Let me emphasise the psychological part, regarding the teams. I know you are used to severity peaks. But not such a long peak and with a new profile of patients. How are these Intensive teams doing? Or is it too early to predict the consequences of all this on you?
Nuno Gaibino: Some things have changed. We went through several stages throughout the pandemic. The human reaction was the first of all. We had to deal with fear and prepare for the clash, and this had direct implications on our lives. Some sent their children to their grandparents, to the countryside, they spent months without seeing them. We didn't know if we were all going to get sick and to what extent we were going to get sick. Managing the team's anxiety was very difficult and involved a reconstruction and the arrival of new people that formed teams that were not usual for us. Then we had to reposition ourselves to expand the service. We were used to seeing patients at all the Hospital's Services, but not expanding our own Service. We reached 8 Units, of course with the support of other colleagues.
The team was tired, despite the quieter periods and we went through three very different periods. The first wave had few cases, but the ones we received were in fact in very bad condition. It was in the summer that most of us managed to take a few days of holidays. But there were persons who couldn’t because in September/October the cases came back again. The most complex time to manage was the January period. The situation mirrored the expression "hot bed syndrome". We managed to treat a patient, or unfortunately ended up losing him and right afterwards we had 10 candidates for that bed. The phone that received the requests rang day and night... We talked to other hospitals, managing phone calls and adjusting places. From the point of view of teams, I usually say that physical fatigue is the one that can be overcome best. We work hard while we're here, but what about psychological fatigue? Right now we have had the same routine for a year. We were defeated because we didn't always achieve the goals we intended, because there are patients who don't get better, we saw many young people seriously ill. I had high competition athletes in the ECMO, they were under 30! Despite the resilience, dealing with the tremendous disease, seeing sequelae in our patients, places a great psychological burden on us.
In the worst of times Nuno Gaibino says that not a single doctor gave up on being at his place firmly. Often close to collapse, they knew that if they broke, they would make those who needed them even more fragile.
Firmly convinced of the importance of students in hospital life, several people spoke of Nuno Gaibino as a force of nature and a source of inspiration. He himself prefers to see in his students the revelation of what humanity is best at, the sense of humanism towards others. He managed to convey to them that after overcoming their initial fears, there were countless people in need of help, perhaps just a companion. Believing that we must improve human skills, especially now that we live in a world of technology, he finds it mandatory to exercise deconstruction and adjustment of our best attributes. Perhaps this spirit justifies that almost every week a former intensive care patient goes to see his treatment group again, visiting Santa Maria just out of nostalgia of what they once experienced together.
“Our mission is to help others and when we don't know what to do, we instinctively want to help those in need. There is no other way to live!”
On the finalist ribbon, at the end of his year 6, his mother wrote "never forget your home, you know you can return to it". The truth is that today his home is the one in Lisbon, the big house with grey walls, small gardens, thousands of people walking around, where some learn while others teach them, where there are deaths and so much is born.
Nuno set aside a good deal of time in his morning to meet me, while peeking at the phone because at any moment he could have news from his wife Inês. He is ready to go out and take Inês to the Hospital for the birth of the baby girl about to be born. He said
"This is the project I decided on, I can't live without it anymore!"
It wasn't right on that day, but a few days later Maria do Carmo was born, the result of a solid life story between Inês and Nuno.
Welcome baby Carmo.
Thank you Nuno and your entire team.
Joana Sousa
Editorial Team