The coronavirus keeps Madrid hospitals in tension

The virus arrived in March and swept Madrid.

It left the health centers, the Summa 112, the emergency departments, the plants, the ICUs and all their professionals breathless.

Now, six months later and earlier than they expected, the second wave of covid has not overwhelmed them, but it is keeping them under pressure with a constant trickle that seems to have changed trend in the last week in the Emergency Room - where the influx of patients with coronavirus it has dropped by 40% - and in acute units: since the number of admitted reached its peak in the second wave, on September 24 (3,968 beds occupied), it has dropped by 10%, according to data from the Ministry of Health.

But this improvement has not yet reached the critical care units, which already function above their normal capacity: they are at 110%, according to the count of a network of community doctors.

This means that hospitals do not attend routine operations so as not to collapse the ICUs further.

The official statistics account for an occupancy of 42.6% because it takes into account all the beds that have been set up in an extraordinary way, which do not allow care of the same quality as those usually destined for critically ill patients and prevent hospitals from functioning normally.

The uncertainty and the memory of spring provokes words that emergency physicians, internists, infectious disease specialists, anesthetists and intensivists repeat: "restlessness", "tiredness", "sadness" and "fear" because of having to face a situation that led to the

many centers and all within mastodóntica restructuring since then operated as a

: beds opening and closing, opening and closing corridors, enabling spaces and moving professionals will of the coronavirus.

The doubtful "favorable evolution" defended by Madrid

In Severo Ochoa de Leganés, "the plants change from day to day," says Luis Díaz, an emergency room doctor at that center, who sees how the "red areas", those of covid, or "green" areas are more crowded. covid.

“Corridors are opened and closed daily according to the healthcare pressure we have.

We have not reached the previous collapse, but we have a bittersweet sensation, the influx to the ER has decreased but we do not know how long it will last or why, and the patient's profile has apparently changed ”, he explains.

While there were “young” patients in the summer, now more and more “older people” have returned.

And those, says Díaz, "have a more tendency to self-confinement, to be afraid to come to the hospital."

If two weeks ago they had an average of 160 patients a day, in recent days they have dropped by about 50.

Epidemiologists are watching with caution the drop in hospital admissions in Madrid, which have also been falling for 10 days: on September 23, 504 people were admitted and last Friday, 381 did so, in a continuous decline with some ups and downs.

This decrease has been parallel to that of incidence, which has also been showing improvement for a week;

the normal thing is that the fall in hospital admissions arrives between 7 and 10 days later, since it is the average time in which the symptoms are aggravated.

But epidemiology is not an exact science: there may be distortion factors, that what we are seeing are fluctuations, that the delay in notifications alters the statistics or that there is some other circumstance that escapes analysis.

Information October 2, 2020

The good news continues of the decrease in admissions to acute care beds (254 less than 3 days ago) and death in the last 24 hours (14 less)

Cases in critical beds continue to rise (29 more) pic.twitter.com/rivz1jm7Py

- COVID19 MADRID-SPM (@ covid19_m) October 3, 2020

In Severo Ochoa, the elasticity plan, the protocol that the hospitals drew up during the first wave - such as enabling gyms for covid patients, suspending surgeries or referring professionals to treat coronavirus when their specialties were paralyzed - began to work in mid-July, "And the biggest problems to enter happen when you have beds closed due to lack of staff, especially nurses, you can't open a hole if you don't have hands to cover it," says Luis Díaz.

That happened in the summer in this hospital and it happens now in others such as Infanta Sofía, in San Sebastián de los Reyes, where there is a post-anesthetic recovery unit with 12 beds but they can only open 8 because there are no staff.

This deficiency was suffered in the first wave in all Madrid centers and, when the coronavirus filled everything, almost all the professionals began to treat these patients under the direction of "covid teams" trained against the clock and captained, on all, by internists.

“Now, with less pressure, almost everything that arrives is seen by us and pulmonologists.

Patients are admitted earlier, we know better the virus and the markers to monitor and the protocols are more structured, "says José Ángel Satué, doctor of Internal Medicine at the Fuenlabrada hospital.

His center, also with the operational elasticity plan, has 73 patients in acute and 22 in the ICU for an original capacity of 12. “It is true that occupied beds are stabilized by discharges, but let's not forget that between 5% and 10% end up in the ICU or die.

And what they say that everything is fine is a trap, ”says Satué.

Double trap: non-covid patients and ICU occupancy

The trap that this professional refers to is twofold: "The more resources we allocate to the virus, the less we allocate to the rest of the patients, and we have not yet recovered from the closure of the first wave."

"Cuts kill," they say, "but mismanagement too, and the most basic thing has not been done, reinforcing Public Health and primary care so that we do not approach that precipice again."

There are professionals who have never finished leaving it: intensivists.

Those who work with the most seriously ill patients, those who spend weeks without being able to breathe on their own in intensive care units.

The other side of this trap is the accounting of areas such as operating rooms to expand the maximum capacity: Madrid, in reality, has 641 critical beds, 500 public and 141 private.

Miguel Sánchez, head of the ICU Service at the San Carlos Clinic, explains that there is also “a misunderstanding” with the numbers, because there are also serious patients with other pathologies: “In this second wave there are non-covid patients, we have tried keep them, not because they are not infected have less right to be treated.

In this second wave, there are non-covid patients, we have tried to keep them, not because they are not infected have less right to be treated

Miguel Sánchez, head of the ICU of the San Carlos Clinical Hospital

While in spring all non-urgent or emergent activity was paralyzed, now it has been tried that this does not happen, with greater or less success.

Large hospitals, such as Gregorio Marañón or La Paz, have room to maintain their activity;

others, such as the Infanta Leonor or the Infanta Sofía, have been canceling scheduled surgeries and beginning to attend to the urgent and non-postponable oncological issues.

Although these units have never finished emptying and the pressure on them increases daily, the situation is different.

“The rate of admission has been lower and that has meant that patients can enter our units earlier.

If seven a day arrived in March, now one or two arrive.

Also now we are giving many more discharges, we must take almost 700 in total, and our management is different, we have been learning ”, explains Sánchez, also coordinator of all the ICUs in Madrid and of a team to refer critical patients between hospitals according to the care pressure of the centers at all times.

Professionals have also been increasingly exhausted.

Eduardo Fernández, ICU nurse at Infanta Sofía, says that these specialists have been doubling guards since February: “I think they have lost count and that cannot be sustained over time, the Community has to understand that we cannot be living in a sustained way at the hospital.

The figures, the capacity, cannot be handled like chewing gum ”.

Demetrio Carriedo is one of those professionals.

They already have 21 patients for an original capacity of 18 beds in Getafe: “If you work tirelessly for months, expanding again to other units as we are doing;

with maximum effort… This has to be accompanied by measures being taken and people knowing what the situation is, and this is not good, even if it is not the war from before ”.

Why the new normal failed in Spain

Not everything is the number of places, Carriedo points out: “If we had 8,000 ICU beds, would there be no problem?

Yes, there would be;

For this reason, he says, "the question is where you attack, and it has to be in prevention, that the sick do not reach us."

Information about the coronavirus

- Here you can follow the last hour on the evolution of the pandemic

- This is how the coronavirus curve evolves in Spain and in each autonomy

- Download the tracking application for Spain

- Search engine: The new normal by municipalities

- Guide to action against the disease