What are the differences between this wave and the previous ones?
The Hospital is under stress because we have a lot of patients with COVID-19. In comparison with the other waves, in this sixth wave there are proportionally more patients in the hospital wards than in the intensive care units. It seems that this is due to the population’s high vaccination rate and to the Omicron variant. It appears that with Omicron, the percentage of patients with complications who need to enter the Intensive Care Units is a little lower than with the other variants. Nevertheless, we also have very seriously ill patients infected with this variant.
"In comparison with the other waves, in this sixth wave there are proportionally more patients in the hospital wards than in the intensive care units".
What does a COVID-19 ICU patient need?
An Intensive Care Unit is a place where specialized care is provided to patients who are seriously ill or at risk of becoming so. Simply put, this “seriously ill” occurs when one or more organs do not work properly: the heart, the kidneys, the lungs, etc. Patients seriously ill with COVID-19 normally need to be admitted to an ICU because their lungs are not working properly, causing severe respiratory failure. This means that the oxygen in the air is not enough to reach their entire body in sufficient quantities and therefore, we need to provide them with more oxygen artificially. Moreover, this situation means that these patients have to be more closely monitored, so that we can intervene as quickly as possible if they get worse.
When should a patient be intubated?
Intubation is a procedure that involves inserting a tube into the patient's mouth and passing it through their vocal cords until it reaches the trachea, so as to help provide the air and oxygen the patients needs. Basically, patients need to be intubated for two main reasons: either because they have a very low level of consciousness, which may lead to their tongue or the contents of their stomach obstructing their airways and causing them to choke; or because they have such severe pulmonary dysfunction that the devices we use to give them oxygen and help them to breathe when they are awake (high-flow oxygen therapy or non-invasive mechanical ventilation) are not enough to ensure the oxygen they need to eliminate carbon dioxide reaches all their tissues. This second scenario is what mainly occurs in patients with COVID-19. So, we intubate patients when we need to use invasive mechanical ventilation. However, we must bear in mind that artificial ventilation does not cure anything, it simply gives us time for the rest of the treatments to take effect.
"We must bear in mind that artificial ventilation does not cure anything".
What is day-to-day life like in a COVID-19 ICU?
We always talk about teamwork. The doctors in the ICU study the evolution of different alterations in the patients’ organs, decide what treatment to apply, monitor the patient's signs and symptoms, etc. However, the role played by nurses is fundamental. This applies to all parts of the Hospital, but it is even more important in Intensive Care Units. Nurses are the ones who are at the patient's side at all times. In an ICU, the nurse-patient ratio is lower than in a conventional hospital ward. Critically ill patients require more care and more attention, and therefore more resources. The usual ratio is 2 critical patients to 1 nurse.
How has the ICU’s work changed since the start of the pandemic?
Well, if we compare a COVID-19 ICU at the start or the pandemic to one now, at first glance it looks like not much has changed. Basically, there are patients who are more or less awake and are connected to an artificial ventilation device. However, things certainly have changed, especially in terms of the treatments we use. In March 2020, with a disease that had a very high mortality rate, we had to try many drugs: antiretrovirals, immunomodulators, etc., and gradually we consolidated the treatments that we saw worked and withdrew those that were shown not to work at all. We also learned that high-flow oxygen therapy can be very useful, whilst non-invasive mechanical ventilation is only effective in a very small group of patients.
You have been seeing patients with the same disease for two years. What has this experience been like for you?
We have gone through different phases. In the first wave, the enthusiasm and the eagerness for dealing with something new were spectacular, and this allowed us to keep going in the most critical situation.
When this improved and we experienced the different waves, fatigue began to set in. We came back down to earth and saw that this was not a sprint but a marathon, a long-distance race with the disadvantage that at times you have to run a lot. And yes, we are tired now. Moreover, the difference between the first wave and the others is that in the first wave the Hospital basically focused on just one type of patient. And from the second wave on, our aim has also been to avoid stopping our normal activity and to treat all patients with the maximum guarantees.
"We have lots of people who are not vaccinated and, when they are admitted to an ICU, they say, “if I had known, I would have got vaccinated”.
What do you think when an unvaccinated patient arrives in the ICU?
In our profession, we are faced with many situations that at first may seem contradictory: for example, we treat a person who has been drinking and has had a traffic accident due to their alcohol consumption just like any other patient, of course, but at first this might seem unfair to some people. Our job is to try to help everyone. But we should try to convince everyone to get vaccinated. We have lots of people who are not vaccinated and, when they are admitted to an ICU, they say, “if I had known, I would have got vaccinated”. Getting angry about this situation doesn’t help us. We have to educate people.
How do you deal with the death of a patient in the ICU?
The mortality rate in our Unit has been higher than before the pandemic but, unfortunately, there have always been patients who die in the ICU. It is true that, since we have had a lot more patients, we have seen many patients die in a short time. Moreover, in the first wave, above all, a lot of the patients who died did so without their family and in relative solitude. They only had us. It's something you don’t like to see happen, because I think we all have the right to die accompanied by the people we love. Luckily, we have been able to correct this, and relatives can now go in to say goodbye to their loved ones. We professionals who deal with ill people and death have to find a balance, and that is sometimes complicated: on the one hand, you have to try not to let it affect you too much: but, on the other hand, you can't stop caring. Because we all have our own story and we are all unique. The moment you stop caring about the death of a patient, you need to change jobs.
What moment do you remember from these two years of the pandemic?
Honestly, there haven’t been many happy times. I remember the last weekend of March 2020 when I was with a group of my colleagues trying to work out how we could increase the capacity of the Hospital’s critical care beds, to see how we could find more ventilators, how we could do our utmost with what we had at that time, and struggling with the fear that “tomorrow we might not have any more ventilators available”. It was a time of great emotional tension.
I also remember in particular the first patients we had to intubate during the first wave. We phoned their families and each patient asked us to “tell them I love them very much”. Being in the middle of that conversation was very moving.
I also remember the companionship we shared with the other professionals at the Hospital. It was incredible. We’ve been able to cope with a major challenge as a team. Over the course of these two years, we have learnt many things!