From the liver ICU to the COVID ICU: The story of a transformation

In December 2019, an outbreak of an unknown disease caused by a novel coronavirus, SARS-CoV-2, occurred in Wuhan, China. Despite the fact that experts, epidemiologists and infectious disease specialists initially estimated that its infectivity and lethality were lower than the influenza virus, this outbreak has now reached pandemic levels and has affected almost five million people, causing the death of over 320,000 individuals. Spain has been affected with particular virulence, with Madrid and Catalonia being the regions with the most accumulated cases. Because of the tsunami caused by the COVID-19 pandemic, the Spanish health service has had to greatly expand itself, requiring much reinforcement to stop it bursting at the seams. In this exceptional context, several super-specialised critical care units had to become COVID-19 units in a matter of a few days. One of these was the Liver ICU at Hospital Clínic in Barcelona, the hospital’s first critical care unit inaugurated 49 years ago and dedicated primarily to abdominal, mainly liver, disease. In the following article I describe in first person the most noteworthy accomplishments of the transformation which, unsurprisingly, has had both negative and positive aspects. This crisis has brought with it unique experiences, and it has also brought out values and intrinsic characteristics of the healthcare profession which often go unnoticed. I have to highlight three of these characteristics: courage, humanity and teamwork.

For exactly eight weeks, the Liver ICU experienced the greatest transformation in its almost half century of history. From 14 March to 8 May 2020 we lived through 56 intense days of providing patient care. These were long days dealing with a highly contagious disease with an unknown pathogenesis and no established treatment. Unfortunately, from very early on, we had the added challenge of limitations both in the quantity and quality of personal protective equipment (PPE). In spite of everything, we were able to make up for our lack of knowledge and resources with courage, intensity, professionalism, camaraderie and, I would like to repeat, humanity, which meant that we soon managed to convince ourselves that as a team we could beat COVID.

The first two weeks were probably the most difficult. We went from having 12 beds (four of them intermediate care) to having 14 beds, all intensive, with the resulting work overload well supported thanks to the efforts of the hepatology and gastroenterology departments. As we were among the first to deal with COVID, our early patients were among the most serious, probably because a lack of knowledge about the disease’s symptoms meant they were at a more advanced stage when they consulted. As a result, most required immediate intubation and long periods of prone ventilation. In the early days, when the therapeutic protocols were not well defined, non-invasive mechanical ventilation and the use of high-flow nasal cannula therapy were advised against because of the high risk of infection for healthcare personnel. However, weeks later we learned that a good percentage of these patients responded to these non-invasive strategies, which meant a decrease in the number of patients requiring orotracheal intubation. We also found that, with the appropriate protection measures, the risk of infection for healthcare personnel was minimal. Around the same time, as the people responsible for our ICU, the hepatologists and gastroenterologists took a crash course in pulmonary ultrasound and learned that there were aspects of the mechanical ventilation in these patients which differed from classic distress.

In a context of changing treatment protocols, with little scientific basis, we focused our efforts on two aspects that we felt were key to improving the prognosis of our patients: 1) “Fight” at the hospital level for each treatment with remdesivir, a priori the most effective antiviral against SARS-CoV-2; and 2) Promote research on this disease. We actively participated in national registries and international genetic studies, and launched a multicentre clinical trial in record time to assess the clinical impact of plasma exchange on mortality in patients with COVID-19 pneumonia. Both strategies provided us with more knowledge and therapeutic weapons, essential tools in the battle we were waging against the enemy, SARS-CoV-2.

I would like to highlight as an essential element in the course of our personal war against the virus, the full conviction of the entire team that, if we maximised protection protocols, we would minimise the risk of transmission. Almost obsessively then, but absolutely necessary, during the early days of the pandemic the correct placement and removal of the PPE was supervised, special care was taken at times of rest breaks to prevent us from lowering our guard and make sure we maintained the mandatory distancing between members of staff, and surface cleaning in common areas was intensified. All this, added to the epidemiological surveillance that the hospital provided us, which consisted of nasopharyngeal swabs to detect SARS-CoV-2 by PCR every nine days, helped us minimise transmission within the team. In fact the surveillance strategy went beyond the walls of the hospital, providing peace of mind in the family environments, as we were able to confirm periodically that the healthcare professionals were not “taking the virus home”.

There is no doubt that the great support provided by other specialist areas contributed to making our work easier. Day after day we discussed aspects of patient management with other specialities such as infectious diseases and radiology, debating uncertainties, reasoning out therapeutic approaches and, ultimately, strengthening our ability to respond to COVID-19.

Lastly, I would like to highlight the tremendous work done by the nursing staff and healthcare assistants. From the very start they acted professionally, demonstrating great commitment and empathy, all of this despite being the most exposed group in terms of contact time with infected patients. Added to the phone calls the medical team made every morning to inform the relatives about the medical aspects and how the patient was progressing, were the nursing staff’s evening calls and video calls. These “extra” phone calls, reporting less technical, but more human aspects, brought the patient closer to their families and helped alleviate the pain of their absence. We have to remember that all this was necessary because during the pandemic family visits were not allowed. The human side of the medicine practised in these two months in our ICU was evident in the applause that accompanied each discharge and, unfortunately, also in the tears shed when we lost a patient after the team had fought for them for weeks.

To sum up, the Liver ICU managed to adapt, live with and fight against COVID-19. We tried, and I would venture to say managed successfully, to practise the best medicine possible, which involved both medical and human aspects. The tireless fight against COVID-19 has been possible thanks to a tremendous team of healthcare professionals who worked together against an invisible, but surmountable enemy. Our experiences in these last two months have left an indelible mark on the memory of each and every one of us and are now another chapter in the history of a Liver ICU which, if necessary, would be prepared to deal with the challenge of a new outbreak, although we obviously hope that will not come about. The competent authorities should take note of the enormous professionalism shown by all the country’s healthcare personnel and work to avoid repeating the major management errors made before and during this crisis, which have cost the lives of more than 27,000 Spaniards and exposed a good part of its healthcare personnel to extreme situations.

Acknowledgements

Abad, Begoña

Abarcas, Antonia

Aliberch L, Anna Maria

Almarante, Alejandrina

Andrade, Jear Antonio

Ansede, Mjose

Araujo, Isis

Arco, M. Carmen

Ayllon, Victoria

Aziz, Fatima

Baiges, Ana

Bassegoda, Octavi

Blaya, Sandra

Bruna, M. Carmen

Caballol, Berta

Cabello, Anna

Caceres, M. del Sagrario

Cañadas, Esther

Carnicer Silvia

Casal, Rosa Maria

Cervigon, Mireia

Chamorro, Vanessa

Costa, Montserrat

Cuervo, Luis

Diaz, Cecilia

Diaz, Juan Carlos

Donaire, Alicia

Echeverria, Guillermo

Egea, M. Jose

Fresno, Laura

Garcia, Marta

Garcia, Nuria

Giraldez, Josefa

Gonçalves, Alessandra

Gonzalez, Rosalba

Gratacos, Jordi

Graupera, Isabel

Guerra, Ana Maria

Hernandez, Virginia

Hernandez-Tejero, Maria

Hervas, Alicia

Jimenez, Caridad

Jimeno, Elena

Juanola, Adria

Jung, Gerhard

Llach, Joan

Lopez, David

Lopez, Sara

Lopez, Olga

Loren, Isabel

Lorenzo, Laura

Mañas, Rosario

Martinez, David

Mendez, Freisa Elizabeth

Monterde, Albert

Monton, Africa

Moral, Marta

Moreira, Leticia

Mourelo, M. Carmen

Muñoz, Ana

Nieto, Susana

Olivas, Pol

Ortega, Carmen

Ortiz, Oswaldo

Pocurull, Ana

Pose, Elisa

Pulido, Enriqueta Maria

Requejo, Isabel Maria

Reverter, Enric

Reyes, Marta

Risco, Nuria

Rodriguez, Foix

Rodriguez, Sergio

Roig, Susana

Ruiz, Pablo

Saenz, Alba

Sabater, Paqui

Salo, Swago

Santiago, Ruth

Sanz, Miquel

Sastre, Lidia

Serrano, Montserrat

Sese, Pilar

Sola, Elsa

Suñe, Margarita

Tipula A, Maria Elizabeth

Tiscar, Miriam

Toapanta, David

Turon, Fanny

Valda, Erika

Valdivieso, Miriam Andrea

Vazquez, Gloria Angelica

Villanueva, Araceli

Zannini, Martina

Zapata, Cynthia Patricia

Zapatero, Juliana

Zurutuza, Idoia.