Juan José Ríos, the medical director of La Paz hospital, walks briskly through its labyrinthine corridors. “It’s been hard, but you have to keep your spirits up,” he says. “Every day, it’s as if three planes had crashed. We’ve had 800 patients and more than 250 waiting to be admitted into the emergency ward.”
Ríos walks by an area generally filled with people waiting for their appointments with various doctors. The place is deserted. Another area normally used for doctor’s appointments is now being used for testing staff members who could be infected. They sit and wait with drawn faces and a constant dry cough that is recognizable and highly contagious.
The pandemic has turned Spain’s best-rated hospital and an icon of the country’s public health service into an immense machine dedicated to Covid-19. There were plans to deal with the disease, but reality intervened. The first patient to be diagnosed with the virus at Carlos III, which is part of the La Paz hospital complex, was a 24-year-old male admitted on February 25. It seems like a century ago. Today, almost 90% of the hospital complex is dedicated to the coronavirus. As its manager, Rafael Pérez Santamarina, says, “La Paz is a hospital at war.”
Entire departments have been transformed; redundant areas have been turned into intensive care units (ICUs): the on-call system has become the shift system and they have laid out meters and meters of oxygen tubing as its use has increased seven-fold. Crisis meetings are held every morning and new decisions taken on a daily basis. And specialties are no longer as relevant as they once were, with doctors signing up from more than 30 departments. “There’s been a revolution,” says Ríos as he makes his way to the surgery block to show us wards that have been converted into ICUs.
The corridor is narrow and cluttered with tables for medicines and medical instruments. There’s an area dedicated to waste materials that needs to be given a wide berth. A lot of people are on the move, some carrying bags, others looking intent. The bustle is overwhelming. Several nurses are disinfecting the ICU exit. They scrub the floor and spray themselves with a pink liquid called Virkon that is present everywhere here: it is a potent virucide that they sprinkle like water on their gloved hands, their suits, masks and shoes.
This virus has put around 750 healthcare workers out of action, approximately 10% of the workforce. Behind the nurses are beds on which a dozen patients lie inert, surrounded by cables and tubes connected to ventilators, their lives hanging by a thread. You can hear the beeping of their devices. Suddenly someone shouts, “There’s a [cardiorespiratory] arrest!” A healthcare worker rushes down the corridor and enters the ICU. Seven people gather around the patient. The panic lasts several seconds.
“They have just saved that person’s life,” says Ríos, moments later. “With this disease, people start out with few symptoms. But after seven to 10 days, they develop pneumonia that can be very severe and causes respiratory failure.”
Ríos then takes us along more corridors until we get to a wing of operating theaters also converted into an ICU. As with army units in war movies, each ICU has its own approach. This one is run by an anesthesiologist from the children’s wing of the hospital, Luis Castro, who explains, “We are a bit saturated. In each operating room there are three patients with ventilators normally designed to run for just a few hours during surgery.”
They have 11 critically ill patients here with severe bilateral pneumonia. Several are upside down. “It’s a position that helps the patients – the pronation,” says Ríos. “That’s how you get more oxygen to poorly ventilated areas of the lungs.” Another anesthesiologist shows us a diving mask that is being tested on patients. A team has been working on adapting it. “Everyone here contributes something,” he says.
There’s no time to delve deeper: Ríos is already heading to another corner of the hospital. “We’ve converted 20-odd floors,” he says as he goes. “And they’re all full of people with pneumonia.” En route, we pass through a room where the surgical instruments are being stored. Close by, a nurse rummages through boxes of medicines while outside there is a cloud of fog that comes from the immense oxygen tanks. “The consumption is tremendous,” says Ríos. These are the lungs of La Paz, working at full capacity.
Soon we are in the original ICU, the one that existed before the pandemic. Eva Flores, a 49-year-old intensive care physician, looks exhausted as she stands at the entrance to a roomful of people on ventilators. A pregnant patient has just died. “How are we doing?” she asks rhetorically. “Badly. There are a lot of problems with beds; we’re assessing about 50 patients a day.”
“We have a lot of work. But it seems we’ve got passed the peak," adds Juan Carlos Figueira, 53, head of the intensive medicine department. "This week, we’ve noticed an improvement in the ER.” His glass-walled office overlooks the ICU. While he’s talking, a patient goes into cardiorespiratory arrest. “We’re hoping that what is happening in the ER will be a sustained trend,” he goes on. “And that it will be reflected among the critically ill patients. La Paz has made a huge effort. We now have 149 beds for the critically ill.” Below, they manage to revive the patient and a nurse leaves the room, clearly distressed.
The microbiology department analyzes between 500 and 600 samples a day, although there have been spikes of 770. These samples are kept behind a door with a sign that reads: “Warning. Biological hazard.” Julio García, who is in charge here, calls it “the machine room.” He has good news. “There have been times when all the samples coming from the emergency ward were positive,” he says. But today, April 1, there are around 40% fewer samples testing positive than there were 10 days ago.
The crisis meeting starts first thing in the morning in a conference room. The heads of the various departments sit down, leaving empty seats between them. Everyone is in a gown and mask. The medical director opens the session and they go over the figures: 822 admissions, 63 beds free, 12 spaces in the ICUs. They comment on the difficulties they’re having receiving equipment due to problems at customs. They assess the possibility of opening and transforming a new area. The head of the emergency ward is asked how things are going. “We’re doing well.” There’s laughter. “We’re still on a downward trend in terms the number of patients,” explains Ríos. “It’s the first morning we have had good news.”
The head of microbiology adds that the percentage of positive diagnosis continues to drop. The intensive care specialist Manuel Quintana, who coordinates the 120 volunteer doctors coming from different departments, closes the session. And everyone returns to their posts.
Shortly afterwards, Ríos takes us in the elevator to the pulmonology department on the 12th floor. This floor, he explains, is the precursor to the intensive care unit, the place where patients receive lesser degrees of support for their battered lungs, such as double pressure masks. “We try to keep them here as long as possible to put off the moment when they go to the ICU,” explains the pulmonologist Ana Santiago.
In the hallway, various healthcare workers push a machine used to take chest X-rays. In the wards, you see patients on different types of ventilation. Those who have the strength for it look at their cell phones. Others shrink behind their masks.
On the floor above is the internal medicine department. In the supervisor’s room, Cristina Marcelo, a resident doctor, has just recovered from Covid-19. She returned to work two days ago after almost 20 days off and was confronted with a barely recognizable, interdisciplinary set-up in which specific areas of expertise are no longer relevant. A colleague sits down close by to deal with paperwork. “Death certificates,” he says. Two patients have died in the last five minutes. “Due to the pneumonia, oxygen levels get so low that the body stops living.”
Outside, rooms are open on either side of the corridor. In one, an old woman is sitting with her back to us on the edge of the bed. Her hair is white and disheveled. She blows her nose and replaces her mask. Her figure is silhouetted against a large window overlooking the mountains north of Madrid. It is a bright day. “Here, you can see the loneliness of the sick,” observes Ríos. “They don’t have their relatives. It is difficult for them to be here in their final moments.”
Francisco Arnalich, head of the internal medicine department, has his office on this floor. Between him and his pulmonology colleague, they coordinate 14 floors dedicated to the coronavirus. With his window open, Arnalich describes the whistling sound made by the tiny air sacs in the lungs called alveoli once they have been hardened by the inflammation. “Whoever said this was a flu was wrong,” says Arnalich. “This disease commands respect.”
Patients, he explains, are treated with oxygen therapy; with antibiotics; with an anti-inflammatory called hydroxychloroquine, which is used against malaria and lupus. Sometimes they are given a biological agent – a monoclonal antibody. And an experimental antiviral treatment called remdesivir is also being tried. Between 2 pm and 3 pm, the patients’ families are called and given updates. “Sometimes they are allowed to come,” he says, adding by that stage in the day the health workers are starting to get tired.
“We will hold out, we will survive,” says a sign on the ground floor. Ríos passes it on his way to the last ward he wants to show us. Here, another ICU was set up in the space of four days. Set apart from the other ICUs, they have named it Perejil, after a rocky islet off the coast of Morocco that belongs to Spain. A handful of doctors crowd in front of computers here. Behind them is a window and, behind that, are beds filled with the critically ill. One of them is not responding to intubation, so they prepare to perform a tracheotomy. A nurse leans on the glass and watches the operation, in case she is called upon to do it herself at some point. “This is a hard place to be,” she says. Her name is Marta Martínez. She is 28 years old and the red mark on her face from the protective eyegear accentuates the tiredness in her eyes. Behind her, another health worker is putting on protective clothing.
For many in the hospital, one day is indistinguishable from the next. José Ramón Arribas, head of the infectious disease section of internal medicine and coordinator of the high-level isolation unit, doesn’t know if it’s Wednesday or Thursday; April 2 or April 4. What he does know is that it’s day 37 of the epidemic. He saw the first patient to test positive in Madrid and has only had one day off since.
“This virus is capable of destroying the health system,” he says. “It is highly contagious, unpredictable regarding who is going to come out of it better or worse, and capable of infecting healthcare personnel in a way we have never seen before. From a biological point of view, it can produce a systemic reaction: at first it is viral, but in the second week the organism can go haywire. A cytokine storm occurs, which makes the body go into overdrive to stop it, attacking the lungs, the heart and the clotting system. And that’s why a significant number of patients end up in the ICU.”
Having also belonged to an experienced Ebola team, Arribas adds, “Looking back, all other crises seem banal. This is like HIV, but in fast motion. Nothing will ever be the same after this.”
Soon after, there is a change of shift for the internal medical team. The doctors explain who will be in charge of which floor. Then they update those coming on duty. Elena Trigo, a specialist in tropical diseases and imported pathology, complains that the support team that arrives from other departments barely lasts a week; no sooner have they been trained than they disappear and it’s time to start over, forcing those left behind to double their shifts. The people in charge shrug and say they’ll come back to it. Meanwhile, Fernando de la Calle, a specialist in infectious diseases, invites us to visit him on his floor.
In spite of everything, De la Calle has not lost his sense of humor. He has “opened” so many new areas dedicated to Covid-19 that he jokes, “Along with the Queen, I am the person who has cut the most ribbons this year.” We are given special footwear to put on before entering. The corridor is long and in one of the rooms Roberto Casado, 59, can be seen behind his door, preparing to go home. “I’m excited,” he says, coughing from time to time behind a mask and maintaining a safe distance. He himself is a nurse at Carlos III where he helped to treat the nursing assistant Teresa Romero, one of the few Ebola cases in Spain back in 2014.
Casado was also among those treating the first patients with coronavirus. But he’s not sure if he caught Covid at the hospital. “My wife started with the symptoms first, and three days later, my daughter and I got them. But while they got better, I started to nosedive,” he says. It didn’t seem serious until he realized he could barely speak; that he was suffocating. “And I’ve run marathons," he says. “I thought I wasn’t vulnerable because I was fit. But at times I felt like I might not make it. Because I wasn’t able to breathe. You don’t appreciate the simplicity of air going in and out of your lungs until you lose it.”
Casado has spent the last seven days in the hospital, during which time he was medicated with one of the new experimental treatments. He’s been off oxygen for three days and, after having a fever for 12 consecutive days, has been free of it for two. He hasn’t had a test to confirm he is negative, but as soon as patients stop showing symptoms, they are sent home armed with hygiene and isolation measures. “It’s a treacherous virus,” he says.
“But it’s not Terminator,” adds De la Calle, who walks us out and sprays the soles of our shoes with the pink virucide.
Around 9 am, a session of mindfulness run by the hospital’s psychiatric team begins in an area next to the emergency ward. The doctors are told to get into a comfortable position and close their eyes to connect to “the stillness within the storm.” A small bell sounds ting, then a voice says, “I observe my mind and bring it back.” Ting. “I notice how my breath goes in and out, something so precious, thanking the body for doing this.”
The session is brief. The doctors return to the fray. “We do it to train the mind in stress management and so make fewer mistakes,” explains Beatriz Rodriguez Vega, head of psychiatry at La Paz. “It’s about surfing the wave in the middle of the storm.”
Until a few days ago, the emergency ward was one of the hospital’s hot spots. The influx was relentless, with nearly 500 patients a day and more than 250 pending admission. “There was no end to it,” says medical supervisor Charbel Maroun. “We felt helpless. We knew that no matter what we did, many would die.”
Facilities had to be expanded. A waiting room in the form of a tent was set up outside. The old gym became a “mini Ifema,” alluding to Madrid’s convention center, which has been converted into a field hospital. In the meantime, doctors were taking sick – 63% of the medical team.
Today, the emergencies section is a complex of wards, cubicles and recovery rooms. Maroun and the coordinator Rosario Torres explain the transformation as we walk down corridors. All around us, the hospital is being scrubbed. Tapes on the floor distinguish areas that are clean from those that are dirty. There are a lot of patients in the rooms, but there is also some space. A few days ago, you could hardly move in these corridors.
In one of the waiting rooms for Covid-positive patients is Alejandro Merino, 63. His mother died yesterday of the virus. His father is in a critical condition at 12 de Octubre hospital. When he himself started to notice symptoms, his sister, a Samur ambulance worker, told him to go to the ER and he showed up in the small hours of the morning. “Doctors and nurses are heroes,” he says.
Beside him is Laura Fernández, 21, whose symptoms, including a fever, cough and vomiting, started some time ago. She has an oxygen tank next to her, which she has been hooked up to all night. Now it seems she doesn’t need it. If she can manage without oxygen, she’ll be sent home. She appears to smile behind her mask when she says she is a third-year nursing student. A passing healthcare worker observes, “If you were in your fourth year, you’d be working already.”
At 23, Laura García isn’t much older. She has been nursing for a year and is standing just outside a cubicle while one of her colleagues wearing protective gear walks around between the patients inside. Hours pass like this. Referring to the past few weeks, García says, “It was chaotic with patients. I got dressed at the entrance [of the hospital] and I couldn’t even get in due to the number of people there. There was no one seeing to them. You had the feeling that you couldn’t do your job properly. It was frustrating.”
As they are frequently moving between clean and dirty areas, her team has been the most affected by Covid in La Paz, with 235 colleagues falling ill.
Rosario Torres, the coordinator, takes us to the gym, which has been converted into a field hospital. “It has been essential,” she says. By the end of March, they had 90 patients. On the day of our visit, April 3, there were fewer than 40. Torres says she hasn’t seen her children, who are four and six, for weeks. They have gone to stay with their grandparents outside the capital. A woman buzzes around us, checking items off a list. She is the head of Pediatric Ophthalmology. “Here I am in another new role!” she says. “I’m organizing the ambulances.”
The intensive care specialist, Manuel Quintana, who coordinates the support teams, explains, “The idea is that there are no more specialties. We are all doctors. Period. That’s the definition of an emergency.” Then he adds, “It’s been two weeks and it seems like we’ve been here forever.” Also working as an emergency coordinator, he confesses that after his shift in the ICU the other day, he had his first ever nightmare. “I was carrying a suitcase, which was very heavy, and suddenly I opened it and there was a dead man inside, one that I had actually seen.”
Quintana admits that making decisions in a ward of 40 critically ill patients means you start having “reasonable doubts” about what you are doing. Then he sums up the situation with a line from a song by Quique González – They can’t beat us, but they came close yesterday.In mid-March, at the height of the crisis, Quintana convinced an R-0 team – R-0 being the basic reproduction number by which the intensity of infection is calculated – to go to the research wing of La Paz every day. They sit in pairs on computers and punch out clinical summaries for a database. “It’s our Silicon Valley,” says Quintana. You hear them singing, ‘Lower right lung.’ Then ‘Cardiac? Systolic?’ Joining this team is a Spanish epidemiologist from Columbia University who has returned home to lend a hand. “With data, we will be better prepared to take the next steps,” says Quintana.
A jack-of-all-trades, like so many doctors just now, Quintana is also coordinating another R-0 team who are working in a converted-hotel hospital near La Paz, at the foot of the Kio Towers. A four-star establishment, it is now a surreal space such as you might find in a science fiction movie. The lobby has been laminated. Health workers, several of them fourth-year student nurses, move around the ground floor.
The hotel has 120 stable patients and 45 professionals who have come from all over Spain as well as abroad to lend a hand. The carpets in the corridors have been covered with easy-clean material. The conference rooms have been converted into warehouses for protective clothing. And in each bedroom, the fake flowers, net curtains and anything else that is difficult to disinfect, have disappeared. Patients are provided with clean towels and a thermometer. One of the best rooms – a corner room with a view – is being used for the nursing control desk. Medicines are kept on the shelf above each bed. Sitting by a mirror, three very young healthcare workers say, “We are eager to help.”
It’s Friday, April 3, at approximately 6 pm and the medical students have taken the decision to discharge several patients. The first to leave is Valentín Macarro, 80, who steps out of the elevator into the lobby and starts to cry as he expresses a desire to see his grandson. He has been in the hospital for 17 days. He goes out onto the street and blows a kiss in the air.
The second, Felipe Andrés, 67, has been in the hospital for almost a month. “We have a health service we don’t even deserve,” he says. The third, Francisco Javier Jiménez, 86, is picked up by his daughter Aurora, who has already picked up her mother at Ramón y Cajal hospital. “I don’t believe it!” she says as the elevator opens and her father steps into the reception area. Her voice breaks with emotion. “Daddy, we’re going home!” she says. They want to hug, but they can’t. They elbow each other instead. The healthcare providers clap. Father and daughter raise a hand in a gesture of gratitude. Then they leave the hotel and reach the sidewalk with tears in their eyes.
English version by Heather Galloway.