Written by María Paz Sartori.
There is no one in the pediatric emergency of the British Hospital on Monday afternoon. In the adult’s emergency there are few people consulting. Due to the Covid-19, youngsters and adults go to different places and also, respiratory cases were separated from those which are not. Mabel Mutarelli, Medical Manager of the Hospital Scheme - the British Hospital’s medical insurance - enters the adult’s emergency and describes the before and after. In the area for respiratory patients, the nursing team spends a very quiet afternoon. Mutarelli greets and little by little about four nurses join the conversation.
One of them says that at first there was fear, but now getting dressed and removing the protection is a routine. After it was known that one first positive case was a person who attended a massive wedding in Carrasco, the British Hospital (BH) suddenly received lot of telephone and face-to-face inquires. Many of those present at the wedding were members of the British Hospital or other private insurances for which the Hospital provides assistance.
Another nurse comments that she did two emergency swabs that resulted positive, but that she feels safe. A third nurse recalls that for prevention, and for having been in contact with the first Covid-19 patients in the country, she was in quarantine, but that she did not become ill.
A few days later, on the 13th of March, after the government confirmed that coronavirus was in Uruguay, The British Hospital began receiving the first patients. At one point, there were 12 people hospitalized at the same time in rooms for Covid-19 and six in ICU, and they feared the worst, that this was only the beginning. But in that moment the government decided to cancel the coordinated surgeries and polyclinic assistance, encouraging home or telephone consultations.
“At health level there was a black out. It is as if you were told that you could only have the “light on” in case you need something urgently. People only went to the emergency in case of having an important pain or an emergency surgery. In the country's hospital’s intensive care units were empty and entire units were closed because they had no patients and, of course, medicine areas were closed too. “Exactly the opposite happened here”, Intensivist Dr. Carlos Chicheff, coordinator of the Intensive Care Unit of the British Hospital (BH) told Búsqueda.
The Hospital prepared itself in different areas and planned a pathway for patients with Covid-19 so that they would not cross paths with other patients.
This involved an absolutely divided emergency, an exclusive access for coronavirus patients, and the second floor of the hospital being exclusively for them. What they now call “Covid floor” has 32 beds that can be quickly expanded to 40. There are 16 beds in the ICU, but the anesthesia recovery area could be used to add 12 more beds if necessary. In addition to this, in the “Covid Floor” there are four beds that have a High Flow Oxygen System, something they define as a “pre-admission” to ICU. Doctors from different specialties spent hours and hours planning every detail.
“If we had been exceeded by the number of patients, we would have added more beds, but there was no need to do it”, said Chicheff. The first cases came all at the same time, but) there were not so many.
The first admission to the intensive care unit of the British Hospital was on the 20th of March. Chicheff remembers it perfectly. He also remembers the increase in patients, the arrival of the second patient on March 25th, next patient on March 26th and so on until completing the six patients who were hospitalized at the same time requiring mechanical respiratory support. Those were very intense weeks not only for him but also for the physiotherapists who spent hours and hours working non-stop inside the rooms, for the nurses and even for the family psychological support team. Everything happened “so fast” and "we work harder than ever," said Chicheff.
There was a changed in the work dynamics. "Before this, we used to enter a room, make changes, come back after a while" and the physical therapy or nursing team would do the same with their checkups, but that had to stop being done, Chicheff said. When they entered a room, they had to put on the equipment and had to do everything at the same time, which could sometimes take them up to two hours.
“There were no bosses anymore, we were all doctors and we each had a different room to assist to. I go in, I do an ultrasound to see the lungs and heart, I see how the respirator is and the patient reaction to changes, I see if I should low or increase the adrenaline, if the pressure improves. I wait there, I can’t leave. That takes lot more work, time standing, tiredness, coming out all sweaty to have a bath, changing clothes and come back to continue working, "said Chicheff.
Although the cases in the BH were concentrated between March and April, the presence of the virus in Uruguay is low. Of the more of 600 ICU beds prepared for this pandemic in the country, so far there has only been a peak of 16 beds occupied simultaneously. According to information from the British Hospital insurance, this institution assisted, between March the 12th and June the 2nd, a total of 55 patients with Covid-19, of whom 34 were women and 21 men, all affiliated to Hospital Scheme. In addition, the hospital provided care to other patients of Covid-19 who were affiliated to other insurances. According to data from the Ministry of Public Health, between mid-March and April the 3rd the HB assisted 78 positive cases.
On the 29th of May the BH received the inquiry of what so far is the last case of Covid-19 they have had, and it had been a week since they had received any. The wave went through the British Hospital, passed and, in case another one arrives, the learning remains.
While going up the stairs towards the “Covid floor”, Mutarelli explains that it is a restricted area. They have placed a screen at the beginning of the corridor.
Inside, to enter the only occupied room. Also, in the ICU there are no longer patients with Covid. In fact, there is one who was admitted for this reason and has been connected to a breathing mask for more than 50 days, but PCR tests of the lower respiratory tract already gave a negative result. The virus is gone, the only thing remaining are the consequences of a disease that passed through the patient’s body and caused an “inflammatory storm”, explained Chicheff.
For doctors, the wave of cases was "a great challenge"
"For the first time, a new disease came into the intensive care unit for which we do not have a treatment internationally recognized by any scientific society, but merely tests with different drugs that ensure neither 100% effectiveness nor the cure of the disease," summarized. Chicheff.
Numbers from abroad indicated that, for patients in ICU with a mechanical ventilator as consequence of Covid-19, the mortality was higher than 50% and premature figures from New York spoke of 88%. In the BH they do not have enough numbers to make statistics, but of the six cases they had, two died, three are at their homes and one shows signs of slow recovery in the ICU.
Chicheff is happy and tells the details and the experience. At this advanced stage the viral load of coronavirus is no longer so important; however, what matters the most is how the sick person's immune system responds. They used the combination of two antivirals (designed and tested for HIV) and also hydroxychloroquine (originally intended for Malaria), but they quickly realized that in people who were in intensive care these drugs were not very helpful for the "hyperinflammation or inflammatory storm” in which they were.
They started doing all kinds of laboratory tests looking for signs of excessive inflammation. Corticosteroids or anticoagulants were used carefully, as appropriate. In addition, they found "another peculiarity", Chicheff said. These people "quickly became infected with resistant germs in many areas," he said. Due to its severity, an infection was terrible news. They furthered the analyzes as a seasoned bacteriologist, Gabriela Algorta, anticipated which bacterias were starting to grow on crops in the laboratory, even before the official results. This would allow them to start early antibiotic treatments and prevent bad outcomes.
"In this situation, getting 24 or 48 hours ahead of any infection is essential," mentioned Chicheff. In addition to this, the team managed the purchase of medications and treatments to contain the inflammation which were not available in the country and that when they arrived, they no longer had the opportunity to use, but that were available if needed. Success is not the result of just one person, and for Chicheff, doctors are joined by the effort of nurses and the role of physical therapy, which was key in the respirator removal stage.
To die alone
The deceased were two, they were 65 and 68 years old with a history of other health problems. In their case, the complication was the "unstoppable lung progression," said Chicheff. Aside from the clinical part, there is one subject that worries him and that he ensures that the team did everything they could about it: the distance. The fact of "Dying alone" was an issue that the hospital had to learn to handle, Mutarelli said.
Daily medical reports were given by phone and visits were forbidden, even in the hospitalization stages in the "Covid areas". When giving a report on long stays, “empathy with family members” is established and this is generated in several ways: through speech (voice tone), facial gestures (even with just a look) and the physical ones (which may include hugging or wave), Chicheff explained. “Out of this three, we were left with just the voice, we lost the hug, the greeting, the look, and we only had a voice behind a telephone. It was difficult and a suffering we shared”, lamented Chicheff. Even some relatives could not leave their homes, they were also positive Covid.
The BH does not rule out using video calls to give daily reports to relatives in future occasions. After a passing, relatives had a meeting with "the voice behind the phone", with the doctor who called them daily to give them the reports, a psychologist and Mutarelli. It was a “Closure” for everyone, he said.