Monday, June 27

Coronavirus crisis: A breathless year in ICUs | Society

An asphyxiating tense calm has settled in the intensive care unit (ICU) of the Vall d’Hebron Hospital in Barcelona. The bustle of those first days of the pandemic, removing beds and respirators from under the stones, has subsided and, like an accordion, what was the largest ICU in Spain, with 200 enabled beds, has dwindled to about 66 places. There is no more juggling for a mask or crestfallen glances hurrying through the corridors, but inside the pits, the battle for life continues. And although patients with covid have made room for patients with other pathologies, the virus continues to mark the tempos of exhausted health workers. The contagions do not stop and the beds are not emptied either: increasingly young faces, 50, 40 or 30 years old, fight in silence, alone, for weeks, a disease that does not give up in ICUs. EL PAÍS returns to the same critics unit that it visited a year ago, in the middle of the first wave of the pandemic.

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“The first wave was a tsunami of patients with a very clear peak of work. Was a sprint. But now we are in a long-distance race in which you are adding more patients. It’s like a marathon in which your legs get more and more tired ”, summarizes Ricard Ferrer, head of the Vall d’Hebron ICU and president of the Spanish Society of Intensive Medicine. Spain has been submerged for months in an intense healthcare pressure that does not stop. With more than 2,200 critically ill patients from coronavirus, one in every five ICU beds is occupied by covid patients.

The nurses at the Vall d’Hebron ICU do not stop. From here to there, they make kilometers through the corridors of the unit, entering and leaving the pits, dodging cars of priests and colleagues absorbed in medical records. The morning is calm, but there is always something to do: a treatment to adjust, an analysis to get. “It has been a year of a lot of work. At first, there was uncertainty and surprise; now we continue with the work and the feeling that we are not finished. We still don’t see the light, ”says nurse María José Sala.

In this wing of the ICU, a dozen patients with covid now live with three cardiac arrests and a couple of transplants that have been complicated. On the front window of each room, a colored sign marks whether the patient is covid, postcovid or neither. Experience is a degree and health workers now know that the risk is not the same if the infection is active or the patient has already overcome the disease and has antibodies. “We have learned to know the covid. It is not on the surfaces. The common areas do not concern us: now what is covid is the room, not the entire corridor ”, exemplifies Ferrer. In fact, health workers no longer wear the tedious individual protection covers or use diving goggles to enter the boxes of infected patients. Instead, single-use gowns, gloves, and at most a screen behind the double mask.

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The faces on the stretchers have also rejuvenated. In one of the boxes colored with the “covid” sign, a 54-year-old man faces his third day hooked on a respirator, completely sedated and oblivious to the tubes of blood drawn from him by a nurse wearing a pink flamingo cap. Across the hall, a 35-year-old is serving his first 24 hours in the ICU plugged into high-flow oxygen-blowing nasal goggles. Mass vaccination of the most vulnerable age groups has changed the profile of covid patients in the ICU: the elderly in nursing homes and those over 80 are fully immunized and those over 70 and 60 with a dose set close to 90% and 62%, respectively. According to the Ministry of Health, the average age of positives since the third wave has dropped from 42 to 40 years and that of ICU patients, from 63 to 60.

A physiotherapist cares for a 33-year-old patient admitted for COVID-19 who has been in the ICU for three months.  / Albert Garcia
A physiotherapist cares for a 33-year-old patient admitted for COVID-19 who has been in the ICU for three months. / Albert GarciaAlbert Garcia / THE COUNTRY

“The income that we have over 60 years is going down. We still have one of more than 70, but they entered before the vaccination began. The 18 to 60 age group is physiologically more resistant, they need less ICU, but those with risk factors, such as obese, hypertensive and diabetic, do have a higher risk of entering here. When this group needs intensive courses, they have very long stays because they are candidates for everything: they are very young and you have to fight for them until the end ”, points out Ferrer. That is why the occupation of ICUs has not just dropped: those who enter, although quantitatively less than a few months ago, stay longer. “Longer stays are a collateral effect of having decreased mortality. We have patients who have been there for more than 100 days ”, says the intensivist.

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From those first chaotic days in which patients arrived in floods and everything was improvised to treat that unknown ailment, there is nothing left. “The first wave was crazy. A new disease came and totally overwhelmed us. The patients were very ill and we did not know very well how to treat them or how to handle the situation because they were very tragic cases: it was not just a patient, it was the family. We felt powerless, ”recalls intensivist Elisabeth Papiol. Time and scientific evidence, however, have put order in the work dynamics and the therapeutic approach. “A year ago we gave what we thought would work, not what we knew would work. Whereupon, patients received cocktails of things. Now there is nothing that we think might work if it is not in a clinical trial. Remdesivir, for example, is an antiviral that was widely used and now we know that it does not work in critically ill patients and we are not using it, ”explains Ferrer.

The importance of physical therapy

Time in the ICU passes slowly and becomes very small. In one of the “post-covid” boxes, a 53-year-old man throws the remains to respond to the demands of the physiotherapist, who asks him to raise and lower his arms several times. He still has the tracheostomy done, but the high-flow oxygen system has already replaced the ventilator. It is a first step. The physio presses on your chest, then moves your wrists and again your arms, up and down. “Those who spend many weeks in the ICU have many sequelae. They have a lung disease that is already evident in the ICU: they have a stiff lung, a lot of muscle weakness and it is very difficult for them to tolerate the effort again. Covid patients need intensive physiotherapy from a respiratory and motor point of view. It is very important ”, points out Ferrer.

One year after that tsunami of patients that devastated the ICUs in the spring of 2020, doctors know more about the disease, the patient’s evolution and even the unforeseen events. It can be seen in the work dynamics and in the toilets themselves, who cross the corridors with a firmer step. With the bulk of the personnel already vaccinated, in addition, the fear of becoming infected is less; Despite the persistent healthcare pressure, the environment is calmer. “The situation is a little more chronic now. The hope that this will go down is there, but it has not yet come. Vaccination gives you peace of mind, but it also gives you uncertainty every time the restrictions change, the appearance of the variants… ”, admits Papiol.

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Toilets in the ICU of the Vall d'Hebron Hospital in Barcelona.
Toilets in the ICU of the Vall d’Hebron Hospital in Barcelona. MASSIMILIANO MINOCRI

What has not changed in the UCI of Vall d’Hebron is the rumor of a distant beep that comes out of the monitors from time to time. Neither the full beds nor the stories that keep the boxes indoors. In one of them, for example, a 46-year-old woman who has just given birth, struggles for life on a respirator. “In the ICU we are hardened to see serious things, but this affects everyone and you have more empathy. They are family dramas, ”insists Papiol. And that emotional burden also takes its toll on exhausted staff. “I have not had a leave for medical or psychological reasons in my service. I am even aware that they have postponed non-urgent interventions to work. But I see a lot of contention and when this relaxes, we will have to update many things that are now withheld ”, assumes Ferrer.

The worst thing is that the pandemic is not over. “The feeling here is different from that of people on the street. We have no feeling that this is over, ”says Sala. The virus continues to lurk, Ferrer agrees: “Now we have more certainties, but there are still uncertainties, such as the new variants or how the fall of the state of alarm with the ICUs so full will affect it. If the curfew ends and the restaurant opens at night, the group from 18 to 60 years old, which is the most socially active, will increase us in the ICU. We are confining it without protecting it and infection will predominate over them ”.

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