It's been a little over two months since the lives of healthcare workers at the 12 de Octubre Hospital (October 12 Hospital) in Madrid changed forever, following the arrival of their first COVID-19 patient.
“From that day onwards it has been horrific. We quickly created an area to treat the patient, but it was all a bit improvised. Nothing had been planned, we brought the patient in and everything changed,” nurse Maribel Lamas Rubiano tells SBS Spanish.
Maribel is a specialised ICU nurse. She has worked in public health for 23 years; twelve of those at the 12 de Octubre Hospital in Madrid, one of the main health centres of the Spanish capital.
She currently works in an intensive care unit that deals mostly with respiratory pathologies. Despite working in the hospital's premium treating unit for patients experiencing breathing difficulties, Maribel says staff there received no training or resources to deal with COVID-19, until an hour before the first patient was admitted.
"That same day (March 5) was when we were taught how to put on the PPE (personal protective equipment).
“They had not brought us the necessary material, nor [explained] how we had to work with it. They were teaching us how to put on the PPE just an hour before the patient was due to arrive. There was no preparation or foresight.”
Maribel says that the days following the first COVID-19 admission were "insane".
"We were receiving patients at breakneck speed, techniques and care were being done in record time, and despite the lack of foresight, critical care units were quickly set up.
“In a few days, UVIs (Intensive Surveillance Units) were set-up at incredible speed. The intensivists (critical care physicians) were scared.
"The pressure we felt in the ICUs was enormous."
The doctors were the ones with the real pressure since they had to choose which patients could survive and who would die, because there were not enough beds for everyone.
To date, there have been more than 228,000 confirmed cases of coronavirus in Spain.
The country has suffered one of the highest death rates in the world from the pandemic, with some 27,000 deaths to the time of publication.
Spain also has the highest number of infected healthcare workers in the world. All this in the context of a weakened health system, following severe cuts imposed by the government after the 2008 financial crisis.
Fear reigns in the healthcare frontline
As it became evident that Spain was about to experience an epidemic outbreak comparable to what was already being observed in Italy, healthcare workers feared the looming danger would have catastrophic consequences.
“[When news hit] I was paralyzed. My legs were trembling. That's when I was most scared, and the intensivists I think were too."
When Maribel realised the number of intensive care beds in Spain for every 100,000 inhabitants was less than in Italy, and below the European Union average, she understood that what was about to hit them was monstrous.
While the situation in her ICU was terrifying, Maribel says that her colleagues in the emergency department had it even worse. There, the lack of resources and planning meant that teams of only three nurses were looking after to up to 200 patients.
Source: Supplied
"Colleagues from the Emergency Department were saying it was hell," Maribel says. "Patients on the floors ... waiting in chairs whilst being very ill, because there were no beds.
"All the staff talked about how this was just beyond anything we could process: the anxiety, the frustration we felt, but above all, what I felt was fear and sadness."
As the days went by, the number of incoming patients grew relentlessly. The hospital converted operating rooms, treating and resuscitation rooms (URPAS and REAS), and any space available into COVID floors and improvised ICUs.
Expert intensive care staff were divided so that they could supervise other staff brought in to lend a hand, despite not being trained in critical care.
"We are working together with new, inexperienced colleagues, and others who came from other units, who are also giving everything they got," Maribel says.
“All this has greatly increased the workload, and this bug is a bitch. Seriously-ill patients experience a lot of complications and require a lot of care.”
An emergency worker wearing a face mask transports an elderly patient to an ambulance at the 12 Octubre hospital in Madrid, Spain. Source: AAP
Long-term intensive care
A lot of COVID-19 patients require many days of hospitalisation. The most serious cases usually stay in the hospital for weeks.
The lack of resources means the quality of care offered is greatly diminished, as hospitals scramble to stretch their resources to the max, to cope with arrivals.
“I have the feeling that patients have been discharged from the ICU to regular COVID floors [prematurely], before they've been well enough. In normal circumstances, we would have waited for them to improve more before letting them go,” Maribel says. The crisis has put healthcare professionals to the ultimate test.
“You can't give the patients all the attention they require for the time it takes to disinfect oneself, the time it takes to put on the suits (PPE). You can't give all that time to patients, which is a lot, and that's also frustrating.
“You have to be aware of other colleagues too, and help them. Especially those who don't know how to work in the IVU (Intense Vigilance Unit). That's also frustrating. But you have to help them because they too are giving everything they got.”
Rosa* is also a nurse at 12 de Octubre Hospital. She normally works in oncology and hematology, but since mid-March she has been working on COVID floors, caring for coronavirus positive patients.
Working in the coronavirus floors impacts greatly on your mental health, because you're treating patients who are alone, who need a lot of support, and you really can't help them.
"You come home and you turn on the television and it is more coronavirus. You cannot leave, you cannot escape, you cannot really relax. We had a life outside the hospital before, but now you leave the hospital and lock yourself up at home, and they only thing to talk about relates to the coronavirus,” Rosa laments.
Despite the challenges, both the hospital and healthcare workers have done their utmost to quickly adapt to the new challenges.
“I am very surprised to see how the hospital is functioning now. It's operating at 100 per cent, even at night. It's incredible — the sterilization services, the labs, all departments giving their all. Entering the operating rooms and seeing them converted into ICUs with the patients connected there, monitored, [it's unbelievable]," Maribel says.
General view of several beds at field hospital for COVID-19 patients set up at Ifema exhibition and convention center in Madrid before patients began to arrive. Source: AAP
Funding cuts cost patients dearly
The Spanish government's deep cuts to healthcare following the global financial crisis have haunted the country's response to the pandemic, more than ten years later.
"We lack everything in hospitals. Resources. I don't think we were really prepared, we didn't have enough beds, we didn't have enough resources, we don't have enough personal protective equipment, we don't have tests,” Rosa states angrily.
Both Rosa and Maribel consider that improvisation and lack of foresight has had a hefty cost to patients.
“We have put beds in places that are not really prepared for patients. Those rooms did not have a basic buzzer for patients to call us, there were not enough oxygen intakes for everyone, and sometimes two patients even had to share one oxygen intake between them," Rosa reveals.
“At the start [of the crisis], we had no PPE. We did not have suits, gowns, or masks. Facemasks disappeared from the hospital the first days. We even ran out of surgical masks! Everything was very limited”.
Spain, record in infections among healthcare workers
According to a report by the , Spain is the country with the highest number of infections among healthcare workers in the world.
20 percent of all coronavirus cases in Spain are healthcare workers, while in Italy, that percentage drops to 10 percent. In the United States, the infected rate among them barely reaches 3 percent and in China, it is 3.8 percent.
Both Maribel and Rosa told SBS Spanish that the hospital provided them with non-certified PPE: defective facemasks that only filtered the virus for a few minutes.
"The FFP2 masks that we were using ... are not certified. It turns out that the protection only lasted three minutes," Maribel says.
"We have been wearing those masks for a month. They are different from the ones we used to use. I don't know where these [new masks] came from. They are not the ones that we were included in our PPE sets before. This has left us completely outraged.”
According to several reports published in Spanish media, the defective masks were distributed to various hospitals in Spain. Although the faulty masks were later recalled, this was the second time that flawed masks have been reported in the country's healthcare system since the start of the pandemic.
“Now we understand why so many of our colleagues are infected. Because in the ICU, when you have to intubate patients, you need high filtration facemasks, otherwise you are not protected at all,” Maribel complains.
Despite discovering the faulty masks, at the time of these interviews, the hospital had not yet given the nurses instructions on what to do next.
“We have been using these masks for weeks, every time we have been with COVID positive patients, and nobody has told us how to carry on given the situation. They have not asked us to get tested, they have not instructed us to self-isolate; we are very unprotected," Rosa says.
SBS Spanish later received information that some hospital staff has already been tested for coronavirus. At least one nurse was found to have contracted the virus.
Despite the fact that the quality and quantity of PPE provided to staff has improved over the last weeks, Maribel and Rosa say that they still lack sanitizers and disinfectants.
"Supplies of alcoholic hydrogen to disinfect our hands is low, we lack the gloves and gowns we require," Maribel explains.
She also says that, although essential, PPE also makes the work more difficult.
The PPE is very uncomfortable and you suffer lot while wearing it. You have to wear it to understand what it feels like. I got an ear infection (otitis) from the pressure of the goggles and the mask. I was on sick leave for days, with a lot of ear pain.
The lack of PPE also impacts the quality of service that the nurses can offer patients.
"We could not do as many rounds as we wanted to, due to lack of PPE," Rosa explains.
“I would go past once, my colleague would go a second time, but we could do very few rounds. The patients were alone in the rooms, isolated, unable to communicate with us. We could not go to the rooms as much, and they did not have a buzzer, nor a way to talk to us.”
Spanish ICU nurse Maribel poses with PPE. Source: Supplied
Unable to provide comfort
For both nurses, one of the most painful experiences of the pandemic has been having to routinely witness patients dying alone.
"Despite already having spent many years of my life in this line of work, and seeing many people die, seeing them die alone has caused me terrible pain," Maribel confesses.
“I remember hearing their mobile phones ringing over and over again in their belongings bags, by their bedside. This destroyed me, imagining the anguish of whoever was on the other side of the line. Their family member could not answer because they were either intubated or dying."
However, the nurses say things have improved in the past month. Families are now being allowed to visit loved ones to say goodbye. The situation continues to be dramatic, not only for patients and their families, but also for healthcare workers who have to witness these emotional scenes most days.
“The first time I saw a family come in, they were children who came to say goodbye to their father and called him from a distance. 'Dad, dad,' they would say, 'we love you.' I cried and my supervisor comforted me. I remember her saying, 'We have yet a lot to see. We have to be strong.' She was right. We still had a lot left to see and still have a lot more to suffer,” Maribel says, fighting back tears.
Rosa says the pandemic has taught her important lessons about our own mortality and the human condition.
"The importance of human contact, physical contact, emotional support, and that we really need that as human beings. Because seeing these patients alone in the rooms, without any contact, neither with us, nor with their families ... that is very hard ... A hug is essential.”
“The first few days, the nurses gave their patients their phone numbers so that they could communicate with them. Afterward, the hospital provided us with one tablet per floor, so patients could make video calls to at least see their relatives' faces and have a chat, and in some way be able to receive the emotional support that they couldn't have when they were isolated.”
The fear of a second wave
The drop in the coronavirus infection rate in Spain has meant that healthcare workers are beginning to see the first glimpses of hope in hospitals.
"I have the feeling that the situation is improving a lot because they have closed many of the COVID floors that had been opened up," Rosa says.
"The ICUs have not yet seen this improvement, because the intensive care units will be the last to experience this. But we have noticed a decrease in the number of COVID patients admitted in the rest of the units."
Maribel has also observed similar signs in her unit. However, the possibility of a second wave terrifies her.
“There is still pressure in the ICUs, we cannot relax. Now you may get a free bed during your shift, and it stays empty for the duration of the shift. The intensivists also look a bit calmer, and they can better treat patients.
“But the thought of a rebound is terrifying because we are exhausted now. When I think about it — I don't know how we even survived. And to have to relive something like that, wow! I don't even want to think about it! Horrifying."
It is a fear that Rosa also shares.
“When I hear politicians, or people in general, saying that the restrictions are very harsh, restrictive, that they must be eased or relaxed, I think that they really speak out of ignorance. They don't belong to any healthcare team and ... they do not know what they are saying. Many of them prioritise the economy or companies over healthcare and do not realise that without health there can be no economy, and there can be no companies.”
Don't forget our sacrifice
Although Rosa appreciates the public's recognition of healthcare workers now, once the crisis is over, she hopes the sacrifices made by people like her are not forgotten.
“The first day I heard people applauding us [from their balconies] was super exciting. It cheered us up. We appreciate it because it gives us the strength to carry on. It gives me a reason, purpose to go to the hospital every day.
"But I also believe that this support needs to go beyond mere applause. Healthcare workers are often misunderstood, ignored when we defend healthcare, public health and our rights.
"Although I greatly appreciate the applause, I would appreciate it more if people didn't forget about our work, what we are doing, or forget the importance of public health.
"Defending public health is defending the health of all ... Health and public health are the foundation of society. There can be no society without health."
Maribel, who has witnessed with horror the discrimination that some health workers have experienced during the crisis in Spain, feels the pandemic has brought out our best and worst qualities as a society.
“In these situations, our human qualities are amplified. Those who are good and kind are more so, and the ones who are selfish and mean are also much more so, as well”.
Her team's support has been essential for Maribel to deal with her day-to-day.
“I have learned to value all my colleagues, managers, health workers and non-health personnel much more. We have all worked together as a team, and we often keep our spirits up with good humour ... We always laugh at situations and try to cheer each other up when we're down ... we couldn't have done it otherwise.”
One of Maribel's colleagues put up a billboard in their unit as a designated space to celebrate what is really important every day.
“We take photos of ourselves there. Every time a colleague returns after being on sick leave because of COVID, we welcome them back there… We cheer the patients when they leave, because all that helps you, it gives motivates you, and gives you positive vibes to cope with all this because if not, it would've been very hard.
"The most important thing is health. We must invest in health and education, so that we learn to be good people and that we understand that health comes first.”
Maribel in front of the staff bulletin board in ICU. Source: Supplied
The potential delay in finding an effective treatment for COVID-19 or a vaccine weighs heavily in the nurses' minds. That would mean, not just more loss of life, but that the hospital would have to continue to work at an unsustainable rate, with uncertainty lingering indefinitely.
Despite the obstacles faced, both nurses praise the responsiveness of healthcare workers in dealing with the challenges brought by the pandemic.
"Although we did not prepare despite seeing what was happening in Italy, and knowing that the bug was coming from Italy, afterwards, the work has been admirable."
SBS Spanish contacted 12 de Octubre Hospital for comment. A spokeswoman denied the lack of PPE and training in its use. In a written statement, she claimed:
"12 de Octubre Hospital has provided its professionals with personal protection equipment throughout the pandemic."
Regarding the faulty masks, she argued that "the types of masks used ... is determined based on the level of exposure of the professional to the virus", adding: "After declaring the state of emergency, the Government of Spain assumed sole command over many issues, including the purchase of material. Therefore, the masks provided to professionals are those received.”
*Not her real name.
