In March, Moscow City Hall asked the capital’s hospitals to assess how many coronavirus patients they could accommodate. They were given five days to plan the reconstruction and construction of the necessary partitions. Thousands of people were sent home from the hospitals for further treatment, leaving only the most seriously ill.
The rebuilt clinics are accepting almost no new non-coronavirus patients – ambulances are being diverted to other hospitals. To separate the contaminated zone from the clean zone, new walls have been built in the hospitals, says Vitaly Gusarov, chief physician of the medical center for patients suspected of having coronavirus infection at the NMCX named after Pirogov.
Sanitary gateways have been installed, as well as airlocks where workers change clothes before entering the red zone, and airlocks where they return from the zone. When hospitals are restructured, a lot of effort goes into logistics: which elevators will sick patients take, where will convalescents go, how will nurses move around the building, how will medical waste be removed from the red zone.
Now, even bed linen has to be sent to the laundry in a different way: all linen from the Covid department is disinfected, and only then can it be taken to the laundry.
Neurologists, cardiologists, therapists, surgeons and traumatologists went to work in the coronavirus ward of the Pirogov center, according to its chief physician. “We were all engaged in providing high-level assistance,” the intensive care physician of this hospital, head of the Department of Anesthesiology-Resuscitation № 1, Boris Teplykh, wrote on Facebook.
“Somewhere there were remarks that using us is like hammering nails with a microscope. But seeing the storm in the following days, no one had any doubt that it was time for the ‘siege battalions’. The female neurologists cried, put on hazmat suits, and entered the red zone. According to Gusarov, however, his colleague exaggerated the medics’ emotions. “All employees in the red zone from the first day were aware of their responsibility and were ready for hard work, true heroes,” he says.
But not all healthcare workers are emotionally prepared to work with Covid-19. The Pirogov Center reports a shortage of nurses and sanitarians. Nurses refuse for fear of infecting their loved ones, some have difficult family situations and cannot leave their families while working at the hospital, and many older workers are at risk because of their age.
Doctors who have agreed to treat coronavirus patients, but do not have the necessary specialization, work in departments where the patients are not the most severe. For them, non-infectious disease specialists, the hospital is developing step-by-step instructions.
According to Gusarov, these instructions are composed of recommendations from the Ministry of Health, the city authorities, the WHO, the Association of Anesthesiologists and Rheumatologists, and other sources. Works in the Red Zone and is the head doctor of the hospital of the Pirogov Center.
The first week we opened, the ICU was full within a day and there was a shortage of hands. And I have such a specialty. There was a need to do tracheotomies and put people on mechanical ventilation, so we went to help the guys. “Have you, as chief physician, ever done it?” I used to come to the ICU regularly to make rounds and discuss difficult cases. But to have to step up as a resuscitation physician and provide emergency help because of an influx of patients – no, that hadn’t happened before. This was the first time we had been in such a situation, and it was acute.
Before entering the red zone, where people infected with the coronavirus are located, everyone puts on a special protective suit. It is disposable. Underneath, they wear a disposable cotton suit, similar to what surgeons wear, a cap, disposable socks, crocs and shoe covers. “We take everything off, leave watches, keys, cell phones. Household items are not allowed in the zone. Sometimes people leave a small cross pendant, but I wouldn’t recommend wearing anything,” says Alexander Levchuk, former chief surgeon of the Navy fleet, who has been working at the Pirogov Center for 14 years.
Levchuk is a surgical consultant, oncologist, professor, Doctor of Medical Sciences and Honored Doctor of the Russian Federation. This is the fourth quarantine in the 61-year-old surgeon’s career. The first three were in military units during outbreaks of dysentery, malaria, and cholera. At the center, he is responsible for sorting the patients brought in by ambulance.
After four hours of working with patients, the suit needs to be changed. We explain quickly, simply, and clearly what happened, why it matters, and what will happen next. Episodes End of story. Podcast advertising. About 30 people work in the sanitary sluice at the 15th O.M. Filatov Infectious Diseases Hospital, helping doctors change their clothes. “Before all this started, we used to pick a volunteer from the team and put him or her in protective gear about twenty times to remember how to put on a respirator, for example,” says chief physician Valery Vechorko. In the red zone, nothing is allowed to come off or go on, including respirators and goggles. “It’s hot in the gear, you want water, it’s hard to see. You can’t go to the bathroom, you can’t eat or drink. Just in case, we have adult diapers here, some people already use them. But if you wear them under the suit, it gets even hotter, you get skin problems and diaper rash,” says the head doctor of the Pirogov Center.
Doctors wear two pairs of gloves and a third pair over them to examine the patient. The third pair is discarded immediately, while the first two pairs remain on the hands. “As a surgeon, I can say that tactile sensitivity decreases. It is difficult to examine. But the sound quality is good – the suits are not made of rubberized fabric as they were in the 80s. It was very difficult to work in those suits,” says Levchuk.
So the training on the equipment took place in the Pirogov center. In defense, it is impossible to listen to the patient’s breathing and wheezing – the stethoscope cannot be used together with the protective equipment. It is necessary to rely on the respiratory rate, fever and oxygen saturation levels, says Gusarov. “In general, it is about three times more difficult to assess a patient in the defense and red zone than in a regular hospital,” he explains.
In the ICU and the sorting department, shifts last four hours, while on the wards they last six. At the end of the shift, some people in hazmat suits faint, but they get up and keep working. “And this is not a delicate creature, but, for example, our senior nurse, who can beat any man in terms of strength and health,” says chief physician Gusarov. He tells the story of a nurse who, the day before, due to exhaustion, tore off her breathing mask in the red zone, but finished her shift without leaving the patients. “These are the kind of people you want to kneel before,” the doctor adds. “I love this job, I am ready to do anything,” says Levchuk, who works in the reception room of the Pirogov Center. “I’m actually a military surgeon, but now I sort patients. If necessary, I will go and carry stretchers.”
“If all sanitary and epidemiological norms are followed from the beginning to the end, it is difficult to get infected,” says Levchuk. But usually, in his opinion, doctors get sick who remember the rules for the first two weeks, and then a period of self-confidence comes, and that’s when mistakes are made – they carelessly put on a suit or a mask, or violate the rule of changing gloves three times”. Hospital workers are tested for coronavirus once a week. Almost all of the doctors have isolated themselves from their families. Gusarov has rented an apartment, while most of the other doctors from his center are staying in a hotel opposite Pirogovka – the hospital is paying for them. Valery Vechorko, chief physician of the City Clinical Hospital No. 15, explains that there are two cafes for doctors in the hospital: one with palm trees in place of the old swimming pool, “like in Turkey in a five-star resort,” and the second, called “Zvezda,” in two army tents on the street.
What do doctors do with patients in the red zone? If a person is in a satisfactory condition, he only needs observation, antipyretics and plenty of fluids. Such patients are often unhappy. “They complain that they are not being treated. And intravenous drips are not administered,” – smiles Gusarov. But the main task of being in the hospital is not to miss deterioration. The clinical picture can be fleeting, says surgeon Levchuk: a patient can get worse in two to three hours and may need mechanical ventilation. Patients in critical condition receive antiviral drugs and drugs to reduce damage to internal organs. “We are trying tocilizumab, which blocks human interleukin-6. This anti-inflammatory mediator is produced by our immune system to damage virus-infected cells and the tissues of the organs it has invaded. The lungs and heart suffer the most. “The immune response to the coronavirus is too strong and leads to complications,” says Gusarov. “So the widespread desire for strong immunity at the moment is not very appropriate,” he sighs. “There is a feeling that everything depends on the strength of the immune response to the virus. The stronger it is, the worse the disease progresses. The drug we are looking at blocks this strong immune response. But there is no evidence base, and for now we are in the dark. All personnel at the Pirogov prevention center take an antimalarial immunosuppressant. As for the ultraviolet lamps that Russians are now buying for their homes, doctors are skeptical: the latest data on ultraviolet rays have shown that standard air purifiers do not affect the virus. The head physician of Hospital No. 15, who worked in the Chernobyl disaster zone after graduating from medical school, says that back then doctors had a better understanding of what they were dealing with. “There was a prominent factor, and then there was a clearly worked-out support for that factor. And here, with this disaster, it came down like a ton of bricks. We saw what happened in China, Italy, Spain, but no one fully understands what this thing is. It is very mutable. “Many don’t understand the most important thing – this pathogen is constantly mutating,” agrees Levchuk, a former military doctor. – It is becoming more and more complex. This is not the coronavirus that was described in 2005 or in 2015. This is a virus that evolves maliciously, causing pneumonia that ends in death.” In most hospitals, coronavirus is detected based on the results of a computed tomography (CT) scan, without waiting for test results – their sensitivity is not perfect, says Valery Vechorko, chief physician of GB No. 15. “The patient came to us, we performed a CT scan, and it is immediately obvious how the lung tissue has changed – it looks like frosted glass. These foci are visible to the naked eye. Even with a negative covidate test, we treat the patient as if they have it,” he explains. The CT scanner is disinfected after each patient – the nurse cleans the machine with chlorine antiseptics and sprays the room with a special sprayer. In the red zone of the hospital No. 15 there are three machines. In the zone of the Pyrogov Center there is one. The workload on it is enormous, but “it still works”. It is not possible to stock up on large quantities at the moment, because foreign manufacturers are working for hospitals in their own countries during the pandemic, and there is no serial production of tomographs in Russia at the moment, says Gusrarov. Patients between the ages of 25 and 90 are on mechanical ventilation in hospitals. “One of our young patients is a boy with cerebral palsy. But according to the experience of our colleagues, with whom we are in constant contact, there are many young people on mechanical ventilation with severe forms and without concomitant diseases,” says Gusarov. Or people with obesity and diabetes,” adds Levchuk. These diseases significantly worsen the condition. Diabetes does not allow for adequate treatment of the patient – there are many complications in the lungs and kidneys, says the doctor. According to the doctors, the patients are those who came into contact with a sick person at work or in the family, traveled somewhere or visited someone, or met an asymptomatic carrier in a shop. In the center of Pirogov, a couple is being treated who visited a relative carrier of Covid-19 while in self-isolation. Now the husband is on a respirator, and the wife is in a room one floor above. A person who is breathing with the help of a ventilator cannot speak. If they have an endotracheal tube inserted through their mouth, they will most likely not be able to tolerate it quietly and will be sedated. Such patients are pharmacologically sedated and unconscious. “The rule is that a patient must be calm, either on his own or under the influence of sedatives,” explains the Deputy Chief Physician of Hospital No. 15, Borislav Silaev. If a tracheostomy tube is inserted into a patient’s throat below the vocal cords to help them breathe, and the patient tolerates it well, they may be kept conscious. In this case, they communicate with doctors through their lips, gestures, and nods. They can say “yes” or “no” and even write. Such patients can even eat in the usual way. Others are fed by having a nutritional mixture pumped directly into their stomach through a tube, or, if their condition is severe, they receive mixtures administered directly into a vein, Silayev explains. Mechanically ventilated patients have their teeth cleaned, their bodies washed, and their bedclothes changed regularly. Sometimes all of this happens several times a day – and it all depends on the efforts of the nursing staff. When care is compromised, the risk of bacterial complications increases. When they are added to viral pneumonia, the chances of recovery are greatly reduced. It is easier for coronavirus patients to breathe while lying on their stomachs. “In hospitals, this is a standard procedure – when the oxygen level in the lungs falls below acceptable limits, we turn the patient onto their stomach,” Silaev says. “They can stay in this position for up to eight hours. But you need hands to turn them, and the paramedic does not have enough strength to turn healthy people.” Lucky people get by with an oxygen mask and do not need to be put on a respirator. But if a patient has a tracheostomy, the treatment on a ventilator is prolonged for 2-3 weeks, according to Dr. Levchuk.
Because then we have to teach the patient to breathe on his own again, and this is not easy either – every day the ventilator’s working time decreases, the patient is temporarily disconnected from it and trains to breathe on his own. It is a difficult process,” explains the surgeon.
Are you afraid? Doctors are supposed to give you hope, but you are walking in the dark. As we understood from the words of the doctors, a person can lie in a normal state for 10 days, and then – boom, and on a respirator. – Well, first of all, we don’t tell them about the possibility of a sharp deterioration,” says the head doctor of the Pirogov Center, Gusarov. “We encourage them, tell them that everything will be fine, explain which catheter will be placed where and why each tube is necessary. We urge them to hold on and listen to the medical staff.
By the beginning of the second week, both intensive care units at the Pirogov Center were full, and patients began to be transferred to operating rooms. There are a total of 33 ICU beds and 33 ventilators here, but doctors cannot open all of them yet: there is a shortage of anesthesiologists and nurses, and they are still being recruited. At the large Filatov Hospital, there are enough hands for the time being; five new resuscitators recently arrived. “Today I have no problems with the medical staff, but I don’t know what will happen tomorrow, I can’t say. One thing I can say – it won’t end tomorrow,” says Vechorko.
The number of patients at Hospital 15 has doubled. They usually receive 150 people a day, but last week they received 300 a day. Most of these are people with moderate to severe conditions or those with respiratory failure. – How long will all this take? “Based on the data we are seeing, and considering that we have 1,500 patients with viral pneumonia, this is just the beginning of the peak,” says Vechorko. – There are currently 8,000 patients on Covid-19 in Moscow. That’s not 30 or 50. Is that a lot? Why is everything, as they say in the city hall, already bursting at the seams? – We ask the head physician of the Pirogov Center.
Well, you understand that patients with other diseases haven’t disappeared anywhere. That is an additional eight thousand people who need emergency medical care and personnel who are working in conditions that are fundamentally new to them. That is almost the limit. If the flow increases, we will not be able to cope with it, – Gusarov replies.
What will it look like? – Italian scenario. Intubation on the floor. Choosing between young and elderly patients for transfer to the ICU. Inability to properly examine everyone on admission: that is, they arrive and lie down, and if the condition worsens – grab them and run to the ventilator. How do they decide, young or old? Are there protocols for such a decision? From the standpoint of medical ethics, such protocols do not and cannot exist, we are obligated to help everyone. – And then what? Well, how do they make decisions during combat when there is a large influx of casualties? They sort them according to their condition. Lightly wounded people help themselves. The moderately injured are a group that receives special attention to save and heal them. Severely injured people are left alone.
Former military doctor Levchuk, who works in the sorting center at the Pirogovskiy Center, says that every third patient of hers is sure that he does not have a coronavirus infection: “People underestimate the situation very much. And when they realize that something is wrong with them, they keep silent. His colleague Gusarov recalls the panic in the eyes of coronavirus deniers when they arrive at the hospital with symptoms of acute respiratory viral infection (ARVI) and encounter seriously ill patients. “You understand, it is more acute here. They may have denied it all yesterday, but what use is that?” he sighs. “I would like to ask the deniers to stay at home. And if you have to go out for urgent matters, for example to walk your dog – do not interact with anyone, talk to your dog. If this is not done, the health care system will suffocate. We will not be able to provide medical care to all those who need it if the flow continues to increase because of deniers and quarantine violators. And then, Gusarov says, people have to be prepared to be intubated by a traumatologist or a pathologist. And it may be the last procedure in their lives, he adds.