Olmos Martínez JM

Internal Medicine Service. Marqués de Valdecilla-IDIVAL University Hospital. University of Cantabria. Santander

In January 2020, when a group of researchers from the Chinese province of Wuhan published the outbreak caused by a novel corona virus, few of us imagined the storm that was looming[1]. The experience of epidemic outbreaks due to emerging viral infections that have occurred worldwide in the past twenty years should have warned us that something like this could happen[2-4]. But even the very serious situation of the Ebola virus outbreak in West Africa in 2014 did not alert us, until just a few tragic cases spread across borders, set off alarm bells in Europe[5]. But it seems more incomprehensible that, with the appearance of new viruses of zoonotic origin, such as SARS-CoV-1, MERS, avian influenza viruses (H5N1 and H7N9), or the 2009-H1N1 influenza virus that caused the first pandemic of the XXI century, in the year 2020 we were still ignoring the impending dangers[6].
Just three days after its description, the new agent causing SARS reached Thailand and later the rest of the world. Thus, it was evident that, with globalization, geographical barriers to prevent the spread of biological agents had also collapsed. Two months later the infection broke out in the Italian region of Lombardy, but this did not alarm us either. When this tsunami finally reached Spain, the infection was already difficult to contain. As with natural phenomena, the impact was not felt the same in all regions of our country.
In Cantabria, perhaps due to climate, but also its geo-economic and social characteristics, the impact was not as violent as in other regions. In any case, more than 400 patients were admitted to Cantabrian hospitals in just two weeks, affected by a syndrome hitherto unknown, even by the most veteran doctors.
The Marqués de Valdecilla University Hospital (MVUH) had designed several containment lines, as barriers to a disaster that was already very close at that time. A plant (equipped with 24 beds) and later another one were enabled to treat these patients. The care of these patients fell on the Departments of Pneumology, Infectious Diseases and Internal Medicine (IMS).
As of mid-March 2020, there were more than 40 patients with SARS-CoV-2 infection admitted to ICU beds. In addition, over the next 7-10 days, the more than 100 non-COVID patients who were admitted to our usual wards at that time were discharged or transferred, in order to be able to use those beds for care. of patients admitted with a confirmed or suspected diagnosis of COVID-19. Initially, the beds on the three Internal Medicine floors were occupied, but a few days later it became necessary to relocate the patients from the floors of other services, to convert them into “COVID floors”. Therefore, in the course of a few days, the IMS was completely transformed into a “COVID Service”, serving patients who occupied 100% of the available beds on 5 floors of our Hospital (around 200 beds).
All this effort was carried out with the invaluable collaboration of the Admissions Service and all the MVUH nursing staff, which allowed these changes to be made with sufficient agility and efficiency.
In moments of crisis, it is when the seams of an institution come into sharper focus, and just then, our hospital’s best asset came out, its human capital. Our IMS, integrated into the new COVID structure, could not assume the enormous burden of care that was arriving, also taking into account that in the first weeks several doctors in our department were infected with SARS-CoV-2 and some of them required hospitalization. hospitable. Then, doctors from other services joined our wards to collaborate in the care of these patients.
It should also be remembered that, during this health emergency, the resident doctors assumed a leading role in containing this avalanche, amply demonstrating the excellent training received and their commendable professionalism. The most novice residents formed pairs with the staff doctors, facilitating the work and mutual security. Not forgetting the nursing staff who showed admirable professionalism and dedication.
We attend dramatic situations from the medical and human point of view. The loneliness of the patients and the impossibility of being surrounded by their relatives in the most difficult moments was one of the most difficult circumstances to bear for the patients, but also for the professionals who cared for them. Therefore, the satisfactory evolution and especially the medical discharge was lived with cheers, and these happy moments helped to mitigate individual tragedies.
Another aspect of care, which is currently of special interest, is the toll that, in terms of morbidity and mortality, patients affected by other diseases had to pay due to the pandemic caused by this new coronavirus.The lower frequency of hospital attendance stimulated by the advice of the health authorities, as well as the fear of contagion, the suspension of face-to-face consultations, the delay in diagnostic tests, the blocking of Primary Care or even the modification of perfectly validated protocols in other disorders –in relation to the risk of transmission–, they had collateral effects that we should assess and, as far as possible, improve.
Attention was also restructured in the External Consultations area, reducing face-to-face consultations as much as possible, without canceling the highest priority. The telephone consultations were kept open and once the outbreak was controlled, the usual assistance activity was resumed.
The reviews were mostly carried out remotely, through telephone consultations. The days before, the administrative office of the consultation, contacted patients to inform them that the consultation would be carried out by phone, unless there was some circumstance that did not make it advisable. In this way, during the months of March and April 2020, approximately 50% of the first consultations (all face-to-face) that are usually carried out in our service and more than 70% of the revisions (the majority not face-to-face) were carried out.
Another area that had to be reinforced was continuous care (medical shifts), which were expanded. In addition, the care of patients admitted to our plants was maintained during weekends and holidays, thanks to the fact that a significant part of the professionals who usually cared for these patients came to work in the morning.
This meant an extra effort for the doctors and nursing staff, who were forced to spend many hours in the hospital, with little physical or emotional rest.
The IMS teaching plan also had to be modified during the epidemic outbreak, prioritizing safety over training objectives. Thus, the practices of the Medicine students had to be suspended, although other non-delayed activities, such as theoretical classes or evaluations, continued in a non-face-to-face way.
The MIR (Spanish graduate medical) training was also altered, so that teaching aims had to be modified, prioritizing care of the patients who were arriving and designing new goals in relation to the care of the patient with COVID-19. However, the MIR group also felt that this was a historic opportunity to be part of the health response to a challenge of enormous magnitude.
Finally, continuing face-to-face training was suspended, which was an opportunity to develop other non-face-to-face training modalities, such as online sessions through different platforms (Zoom, Teams) or online seminars (webinars) that various scientific societies, such as the Spanish Society of Internal Medicine (SEMI), the Spanish Society for Bone and Mineral Metabolism Research (SEIOMM) and official organizations organized expressly and in which some members of our service participated.
Another noteworthy aspect was the role played by the SMI in research during the COVID-19[7-12] challenge. In this sense, our department led a study on the role of vitamin D in SARS-CoV-2 disease, which had significant scientific and media coverage, and in which we found a high prevalence of vitamin D deficiency in our patients hospitalized for COVID-19[12].
But in this environment of global improvement, some things could also have been done better. The COVID-19 infection in our department left the highest cumulative incidence of SARS-CoV-2 infection cases in the MVUH, with a severe case of bilateral pneumonia, which fortunately resolved after several days of admission and uncertainty. Once again, the slow response to a global threat with the virtual absence of a structural infection prevention plan for healthcare personnel, the late distribution of personal protective equipment (PPE) that arrived by the dropper, the error in Initial Public Health strategy on the restrictive application of diagnostic tests –contrary to WHO recommendations– and surely also a lack of risk perception in the first moments of our own health group, participated in this intolerable number of infected colleagues.
In conclusion, in these lines I have tried to describe the events and sensations that the ICU of our hospital experienced during the first wave of the pandemic. Later other waves have come (we are currently overcoming the 5th), the restrictions, the curfew, mass vaccination, the goodbye to the mandatory mask on the streets and other contradictory messages, but that is another story.

Conflict of interest: The author declares that he has no conflicts of interest.

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