By : Alberto Palacios
Jefe del Departamento de Inmunología y Reumatología del Hospital de los Angeles Pedregal en CDMX

09 June, 2020

"A story of what is currently happening at the hospitals. “You live from day to day, like a cloistered family that subsists by carrying out common tasks under the only purpose of saving lives”."

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It is not dawn yet and Roberto collapses exhausted. He tears off his double glove protection and with his free hand he carves his eyebrows to drive away his yearning to sleep. Away from the flickering of the monitors, he takes a bitter sip of his cold coffee and starts preparing the documents to hand over his watch.  

Twenty-seven patients with various ventilation requirements and different vasopressors are no small matter, although the force of habit helps. His eleven nurses and four residents stopped talking several hours ago; they no longer have the energy to exchange impressions.   

Sonia, the most experienced one, simply checks that PPI parameters and the volume are not arbitrarily altered. Two nights ago, they lost three young patients because someone adjusted the ventilators to the theoretical criteria of normality. With this infection everything is new and the peripheric resistance, as well as the wedge pressures tend to be very variable, especially in the elderly.  

Outside, Elena and Mauro, nurses on call, have taken off their masks and N95s to mitigate their headache after four hours and a half of continuous use without being able to freshen up or breathe at ease. -it’s a pain-, she says as she goes out, aware that no one is listening and that she will have to gear up again as soon as she is called for.  

As a good boss, Roberto provides space for catharsis and heads over to the doctor’s lounge to wash off the sweat and to have a bite. At midnight he reprimanded two rookie assistants that had a panic attack and for a moment elevated the tension that usually keeps his team at bay. The hysterical tide distracted him for over fifteen precious minutes. It is the last time that he will allow upstarts on his watch; the gravity of the situation does not have room for improvisations.     

He had just taken a bite out of his tasteless sandwich when Daniela, the highest ranked resident, bursts in warning him that the “UTI 22” has gone into heart arrest. The code blue routine was set in motion. Atropine, defibrillator on sequence, oxygen pressure at its peak, and bicarbonate to neutralize the acidosis. Nothing was working. After twelve long minutes, the rescue team gives up. They withdraw the catheters, the foley catheter, splints, aspirator, and the endotracheal cannula on a well-known ritual, and they review the corpse’s data to inform the family at dawn. No one expresses any emotion or sign of annoyance; it is just one more death, a skirmish loss in this endless war.   

On both sides of the cubicle where the corpse is being cleaned and throughout the whole room there are many criteria for poor prognosis: age, diabetes, kidney failure, EPOC. None of the hospitalized patients have improved in the last week, despite using steroids and the exhaustion of repeated doses of Tocilizumab. The issue with convalescent plasma is that, although it is reluctantly adopted by intensivists, it has stabilized four cases and it is important to point out that as a heroic measure it was quite innocuous. The team is under unusual stress, it does not compare to anything they have experienced before. in the few moments of solace that are allowed, the sotto voce conversations are quite predictable.  

- Were you able to go shopping this afternoon? They said that they ran out of milk and that they are going to start to ration the gasoline. 

- And your children? Are they still at your mother in law’s, right?

- My husband does shifts at the ER; you know how that is now. Our shifts never coincide…

- What will you do when this is over? If it’s ever over…

Sometimes Luisa, another nurse, stays still without any reason, as if she was trying to decipher far away sounds or as if she wanted to hear an inner voice that urges her not to give in, to overcome the invincible, to understand the ineffable. Those who pass by her avoid pulling her out of that sudden somnambulism. Her colleagues fear that she may break, fall into pieces, like the ephemeral existences that they have to jealously tend to and watch them vanish despite their cares. Most of them work tirelessly, absorbed, adjusting monitors, washing and changing the patients, giving applying medications and recording every change with accuracy. Few of them pray or privately cross themselves, fearing that their devotion could be interpreted as a rejection of the demon that the infected carry within.  

They live day by day, as a cloistered family that subsists based on the compliance of their common labors under the sole purpose of recovering lives. An alienated family that is recognized by the first names written down on large letters on the front of their perennial disposable gowns. An army in functions that admits to its trenches time and time again those fragile bodies, anonymous characters that have exhausted their vital resources and like objects, depend on machines and pharmacological supplies.   

All at once, wrapped in their high security gowns, wearing face masks or goggles and communicating through the filters that separate them from that deadly cloud, present at all times and in every corner. 

Unaware of the suffering, from which she is already fed up with, the person in charge of the shift counts the available amine, epinephrine, and electrolyte vials, before taking of hew gown and gloves to call the store and request urgent replacements. 

As an army of zombies, as the clock strikes seven, they move on and finish their duties for each of their critical patients. Calibrate devices, check drips, make sure that the recollection bags are quantified and that the notes on each chart reflect each adjustment and progress, for better or worse. 

Soon everyone will appear, haggard and exhausted, around the table (now enlarged as a protective measure) to listen to the daily report and the incidents that must be prioritized. In the course of a week, they have lost seven colleagues that were infected and were sent home. It sounds logical at first, but who would prevent their families from getting infected? As if this were not enough, the uncertainty weighs in the atmosphere, condensing the climate of anxiety. 

Margot, the youngest resident has the responsibility of providing the opinion of the shift. She does it with a soft voice, to the point that she has to repeat herself several times because she cannot be heart at the head offices. It is not a detailed report, this will be done by each nurse regarding their three patients; it is more of an overview of the five deaths and the condition of the newly admitted patients on the Unit.  

The doctor in charge of the morning shift arrives with his usual entourage. He is a man with a unibrow that had to shave off his beard against his will. Without further protocols, he interrupts from time to time to ask for details. It is known that he likes to blame those who make technical mistakes, an insidious way of teaching the younger ones. When he speaks, everyone turns at the same time, except for Regina, a third-year resident, that does not hide her contempt for his authoritarianism. She wears several earrings on both earlobes, a shaved and dyed head, in contrast with the appearance of her colleagues. In this sense, she has demonstrated her rebellious spiring in various occasions, but she is, without a doubt the most competent, and after losing two family members in this epidemic, it is preferable to leave her alone rather than to deal with her temper. It’s part of the solidarity that we owe one another, her peers often confess, to excuse her a bit and acknowledge her even more.     

The breviary scarcely lasts three quarters of an hour, while the nurses deliver their corresponding critical patients. It seems that during this lapse time stops and only two alarms go off requiring immediate correction. In intermediate therapy they await six more patients with pneumonia that may require intubation at any moment. So, Roberto knows, as he says goodbye, that the next battle is just starting. 

Little by Little, the night shift team is replaced by a new army, perhaps more refreshed, but similar in position. No one complains, they immerse themselves in their constant work under the same demands, and they communicate the minimum indispensable information to continue procuring those who by chance of fortune will make up the day.  

PD. Thirty-six hours after writing this note, Luisa Valenti, specialist nurse and single mother, tried to take her own life with an overdose of opioids. Fortunately, her eleven-year-old daughter Elisabetta, was staying with some friends. She was providentially saved by a neighbor who went to ask for oil and, when she did not answer she was alarmed and asked the concierge for help. They found her next to her bed, unconscious, drooling, drenched in vomit, with myotic and unresponsive pupils but still with a breath of life.  

*Onomatopoeia for the acronyms for “Intensive Care Unit” 

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