The most critical moment of this coronavirus epidemic has arrived. While waiting for the Community of Madrid to expand the places in the Intensive Care Units by 900, the hospitals in the region, saturated with patients affected by Covid-19 at different levels of severity, have practically complete the 641 seats they had before this crisis, which is forcing them to screen the patients that come to them.
At the Severo Ochoa Hospital in Leganés, the medical association has had to issue a statement clarifying that "patients continue to be accepted at the emergency door with complete normality. The doors of our hospital are NOT closedThey do it to counteract the hundreds of messages that, on social networks or WhatsApp, alert that this and other centers are rejecting the patients that come to them. They do not reject them but the situation is overwhelmed and many of them are sent to other centers Pediatricians are already having to care for 'children' up to 30. At Hospital 12 de Octubre yesterday they had 163 people in ER, when the usual maximum is about 60.
The news from Italy that horrified us two weeks ago, like doctors being forced to choose between two patients and ruling out the oldest, already they are a reality in our hospitals. When the number of those infected with severe pneumonia increases, the 70-year-old patient without comorbidity who was admitted to the ICU yesterday and was intubated is discarded today. Many go to hospice care. Tomorrow it will happen with those 65 and the day after who knows. Is a fatal advance of what awaits the rest of Spain starting this week.
The calculations made by the Data Unit of El Confidencial based on the occupation of the ICU indicate that Spain will exceed sometime next week the 4,404 ICU places that I had before the start of this pandemic crisis. We have been hearing for days about 'flattening the curve' to avoid crossing that red line that would lead to saturating the system. Well, that line is already right under our noses.
Without the reinforcement of new places we would cross that dangerous boundary between March 24-25. This is also pointed out by other mathematical and computer models, such as the one recently developed by the Rovira i Virgili and Zaragoza universities, which also expands the capacity to almost 5,000 ICU beds and also assumes that they would all be available to Covid-19 patients. Given the growth rate of cases (202 between Thursday and Friday) even with new places this limit will be exceeded in the near future.
In our case we have taken an occupancy base of these ICU places of 60% in public hospitals and 43% in private hospitals (data from the Ministry of Health) and we have added the patients admitted by Covid-19 in critical condition in recent weeks, a number that yesterday amounted to 1,141 people. In this sense, two points must be made: the 'usual' cases could be slightly lower given that there are operations that have been postponed and because the number of traffic accidents is also expected to be lower due to mobility restrictions.
An algorithm will decide who enters
Hospitals for days they work against the clock to expand the ICUs —Mainly installing beds in spaces of the hospital itself as resuscitation services or operating rooms— and to save a little more time. Case growth rates have declined moderately since last week, but the horizon when we reach the zenith and cases begin to decline is still far away.
Meanwhile, for patient admission services there is no specific protocol for coronavirus. In his appearance on Friday, Fernando Simón said that "it is working on an algorithm to standardize the mechanisms and criteria for access to the ICU ", but the reality is much cruder than an algorithm. It is not a question of humanity but of hands and resources. The criterion 'first to arrive, first to enter' that it applies during peacetime has become obsolete.
This week the Barcelona College of Physicians has published some general recommendations for doctors to manage these 'difficult ethical decisions' that they are having to face. Admitting one income means denying another. "Priority 3 and 4 patients will tend not to be admitted to the intensive care units in case of crisis," that is, those who are terminally ill or so critical that they have few recovery options.
The same message was sent by the Spanish Society of Critical Intensive Care Medicine and Coronary Units in a contingency plan published this week: priority will be given to those patients with the highest life expectancy, regardless of age. Furthermore, they clarified that "this triage procedure has not been validated in any pandemic situation and is based only on the opinion of experts."
I know of several hospitals where the ICU is already only for Covid-19 patients
"The criteria for admission to the ICU are in themselves strict," explains Javier El Águila, a doctor specializing in epidemiology and mathematical modeling, to El Confidencial. "Outside this pandemic, not everyone who is a candidate for admission to the ICU does so, it is necessary to assess the patient's previous situation, previous quality of life, life expectancy … and it is most normal for patients to be rejected" .
The doctor insists, however, that "no doctor would ever deny that admission to a person who needed it and expected a recovery and a good quality of life afterwards. Perhaps in the most saturated hospitals that 'threshold' is being tightened, and I know of several where the ICU is only for Covid-19 ".
Madrid and the rest
The Community of Madrid is being the national equivalent to Lombardy or Hubei, a cluster of several outbreaks that have resulted in a chilling increase in cases and a chilling number of corpses.
However, and despite the isolation that Spain has been in since last week, other regions are not safe. "In fact, the highest incidence is found in La Rioja, with 157 cases per 100,000 inhabitants, while Madrid stands at 108 cases per 100,000 inhabitants, but it seems that the rate of new cases is slowing down, "Clara Prats, a computer biologist at the Pompeu Fabra University and one of the authors of a mathematical model of the growth of the Covid-19 presented yesterday and financed by the Fundació La Caixa.
Outside of Madrid, the concern in this regard is Catalonia. "The incidence is lower, 43 cases per 100,000 inhabitants but the increase in the number of cases is being very fast"says Prats.
'A priori' Catalonia is better prepared than the rest to face a wave of critical hospitalizations. However, despite its 900 intensive care places, many of them do not have respirators or equipment needed to care for a Covid-19 patient. La Rioja, for its part, announced that it will expand its 17 ICU slots to 29 after practically collapsing them with 15 coronavirus patients and a number of cases that will soon exceed half a thousand.
The situation is also pressing in Castilla-La Mancha, surely derived from the proximity of Toledo and Guadalajara with the Community of Madrid. The Henares corridor, which connects to the Alcarrian capital, is also one of the coronavirus hot spots since that first uncontrolled outbreak in Torrejón de Ardoz. With the 37 patients in the ICU they currently have, it is enough to achieve collapse.
Given the opacity of the data that Health is offering of the coronavirus – and that a large part of the autonomous communities have never published a number of places for intensive care – we can only do this worrisome moment. national estimate of the catastrophe that is to come. The director of the Center for Coordination of Health Alerts and Emergencies has insisted this Friday that in the coming days they will offer more detailed data, with which we hope to be able to offer them the situation in the rest of the autonomous communities and how far is each region of Spain from that red line.
Finally, it should not be forgotten that even if we had triple the number of ICU places like Germany (they have 29.2 per 100,000 inhabitants compared to 9.7 in Spain), much more is needed than a bed: respirators, protective equipment and above all, staff to manage patients. The one that Pedro Sánchez called "our first line of defense" is made up of specialist doctors who see emergencies without being prepared for it, others make 24-hour guards without sleep – the beds of the doctors on duty have been destined for coronavirus patients – and continually exposed to disease or nurses in endless shifts.
Gaps and conflicts are appearing between the vocation of service, one's own security and that of others
A doctor in home isolation by Covid-19, who prefers not to appear with his name and surname, expresses it this way: "Between the vocation of service, self and other people's security, Gaps and conflicts are emerging that should not occur"We are dying to be in the trenches with our colleagues, I assure you, but our sense of responsibility prevails since we are potentially contagious. The advantage is that once we get out of isolation and recover, if the immunity generated by the disease is solid – and it seems that it is, in the short term, there are no common reinfections – we will be able to more safely attend to patients. "