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Dr Ricard Ferrer (Barcelona, 52), president of the Spanish Society of Intensive and Critical Medicine and Coronary Units, has been dealing with the coronavirus on the front line for eight months. From his trenches, the intensive care unit (ICU) of the Vall d’Hebron hospital in Barcelona, Ferrer has treated hundreds of critically ill covid-19 patients. The head of this service, which became the largest in Spain in the first wave with 200 enabled beds, warns that the intensive care units are shaking again. The scenario that is outlined for November reminds him “too much” of what he experienced in the spring.
Question. Intensive care units are at 25% occupied with covid-19 patients, according to the Ministry of Health. What does it mean?
Reply. Of those admitted to the ICU, 75% are non-covid and 25% are covid. What you need to understand is that these patients weren’t there last year. If 25% is now covid, it means that we have 25% of our beds dedicated to a disease that we did not have last year. This additional activity is superior to what we have installed structurally.
P. What does this imply?
R. We need to expand the ICU, have more well-equipped beds and more professionals. And we must try, if the entry of covid patients is not interrupted, stop that of non-covid patients. Discontinue some scheduled surgeries, transplants that are not a life-threatening emergency. Now and for the next few months, an ICU bed will be a very valuable asset, and patients with covid, any serious illness and any catastrophe that could occur, such as a multi-fatal accident, will compete for this bed.
P. The director of the Alarm and Emergency Center, Fernando Simón, said on Monday that at the end of November the situation in the intensive care units will be “very complicated”.
R. I think exactly the same. The transmission carries an inertia, such an important impulse, that the effect of the measures taken is not seen for another two weeks. With intensive care units, this inertia extends beyond two weeks. If we now take a decisive measure, for three weeks the patients would continue to enter intensive care significantly. For this reason, with the inertia that this entails, I say that in November a UCI bed will be a very precious resource and for that bed there will be a very tough competition.
P. Can anything be done to prevent it or are we already doomed to collapse?
R. There are many areas of the country that will experience a very difficult November. They will open new ICU beds every day, looking for professionals so that they can care for these patients and deciding which activity to stop doing, not only to stop non-covid patients from entering, but also to see which professionals exclude an activity do another one.
P. Are there any differences between the patients you see now versus those in the first wave?
R. The patients were younger, although it is now reversing and looks more like the first wave. The growth rate is slower and the ICU course is faster. But unfortunately the situation that arises for the month of November reminds me too much of the first wave.
P. Why do patients spend less time in intensive care?
R. We know the disease better, the treatments we give now have scientific evidence behind them. We stopped giving drugs that probably had no effect and caused problems. And we have improved patient care with knowledge.
P. Is ICU survival now even higher?
R. So far, yes, but we must keep in mind that if we reach a collapse situation, the death rate will increase again. The mortality of these patients depends not only on the treatments, but on the fact that we have sufficient technical means and skills to assist you. And if they stack up, they can’t be as busy as when you have all the time in the world and the ability to do it.
P. The threat in the first wave was to have enough respirators and beds. What is the big challenge now?
R. Be able to serve all critically ill patients, whether they are covid or non-covid. During the first wave, the non-covid pathology disappeared because many activities we are now trying to maintain have been stopped. In addition, total confinement has reduced many acute transport-related illnesses, but now the level of car traffic and accidents at work is very similar to what we would have had in other years.
P. Are you worried about the staff shortage?
R. If this continues to increase, the staff will certainly be absent. It is very difficult to find experienced ICU nurses. The intensivists on the market have already been recruited and, logically, the training of these professionals is not generated overnight. There will be no more professionals, so the only option will be to stop doing some activities and incorporate these professionals, who are not intensivists, into a multidisciplinary unit to help us manage this increase in cases.
P. Are you afraid of infections in intensive care?
R. Quarantine management makes staff availability very difficult. That’s a percentage of people who can’t come to work and need to be replaced. There are hospitals that every two or three weeks perform PCR on staff in critical areas and I believe this is a measure that we should extend to all hospitals.
P. Has the population normalized these ICU figures and the risk of collapse?
R. Yes. We have been talking about these problems for many months and, in a sense, it is normalizing. Like the smoker, when he sees on the tobacco package that smoking kills, the image no longer affects him. Basically we are failing, we have let the virus circulate freely. It is a collective failure: we have not been able to find a way to prevent this very important circulation of the virus.
P. What do people need to know to become aware?
R. We are absolutely committed to serving all critically ill patients, covid and non-covid, who come to the hospital. But we can get where we can, and if the circulation of the community doesn’t stop and the cases don’t stop coming to the hospital, the time will come when we won’t be able to assist everyone. It is important to be responsible and to try to reverse this situation.
Coronavirus information
– Here you can follow the latest hour on the evolution of the pandemic
– This is how the coronavirus curve evolves around the world
– Download the tracking application for Spain
– Search engine: the situation of the municipalities
– Guide to action against the disease
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