MUNI graduate: Spanish hospitals were like a warzone

As an anaesthesiologist, Fagulha primarily provides care to patients undergoing operations. However, during the coronavirus crisis in Spain, the department of anaesthesiology and resuscitation where he has been working for more than seven years was converted into a unit handling the most critical COVID-19 cases. In the Catalonia region, where Luis works at University Hospital Arnau de Vilanova, located about one hour outside of Barcelona, more than 6,000 people have fallen victim to the disease, out of 27,000 in all of Spain.

Three months ago, Spain was hit hard by the coronavirus. For quite some time Spain was the second most heavily affected country. What do you recall about the start of the crisis?
I recall how my colleagues and I were following the situation in China with a great deal of concern. But we all said it was far away. When it spread to Italy in February, most people were still saying that it was far away, but I was already afraid that it would soon arrive in Spain. In early March, the number of cases began to rise steeply in Spain.

At that time, I ventilated an intensive-care patient, who we later found out was infected with the coronavirus. It was one of the first patients in our hospital. Unfortunately, I was infected by this patient. At the time, Spanish hospitals seriously lacked protective equipment; we weren’t ready for the coronavirus.

So, you were ill, too?
Yes. The first week I was in bed with a fever. I had a cough and breathing problems. I lost my sense of smell and taste. The next week was better, but I had to stay home in quarantine. The worst thing was the feeling that I can’t help my colleagues and patients in need. That was when things were beginning to escalate rapidly.

When I returned to work in the second half of March, it was crazy. We put in many 24-hour shifts, then went home to eat and sleep before going back to work. In the hospital, we usually have about 30 beds for critical cases. During the coronavirus crisis, we had to expand this section to 45 beds. But that was far from being sufficient. Hospitals were overflowing. Unfortunately, we had to send 80-year-olds and older patients home. We didn’t have ventilators for them. It was horrible. And this was happening all over Spain.

The situation has calmed down a bit now. The strict measures in place are slowly being eased up. Our department too is going back to normal, and Spanish people can, for example, go to restaurants and cafes, although they still wear face masks.

Do you anticipate a second wave?
We are worried about it, but we hope it won’t be as big. The current measures have been well designed, but unfortunately, they were implemented far too late. That contributed to Spain’s high death toll.

So, Spain was asleep at the wheel?
Unfortunately, yes. It took a horribly long time before politicians decided to act. They were constantly considering the economic impacts, and the government and the opposition took different routes, which slowed down the implementation of necessary measures even more. But health must always be the primary consideration. So, a state of emergency was declared in Spain when there were already 100 dead. But, for example, Czechia and Portugal declared a state of emergency before the first death.

Moreover, hospitals were the epicentre of the pandemic. No one knew about the presence of the virus for some time, so people came in for ordinary check-ups and operations and got infected. And so many, many doctors and nurses were infected due to a lack of protective equipment.

At the start of the pandemic, people had the feeling that the coronavirus isn’t that dangerous. Would you agree with that?
It was that attitude that was the biggest problem. People talked about the coronavirus as if it were the flu. But when you have the flu, you have a fever, you experience the symptoms, and you stay home. But with the coronavirus, it is reported that 80 to 90 per cent of people don’t have any symptoms and therefore don’t know that they are a source of infection. Some people still can’t wrap their heads around it.

The infection and mortality rates of the coronavirus are much higher than those of the flu. People didn’t know about is infectiousness and high mortality and didn’t expect it. They simply didn’t believe it. Perhaps we have learned our lesson for the future.

In mid-March, when the first cases began to show up, the Czech government ordered all people to wear face masks in public. Do you think this is an effective measure?
I followed the situation in Czechia pretty closely. I studied there at Masaryk University in Brno, and it was the best six years of my life. Ordering people to wear masks in public was wonderful. Wearing masks definitely helps, especially in a situation where people don’t even know if they are infected. The virus doesn’t spread further if there is sufficient testing and people practice social distancing and wear masks.

Czechia handled the situation wonderfully. I am really proud. The overall strategy of declaring a state of emergency before the first death, the immediate closing of borders, schools, shops, and restaurants – it definitely had a major impact on slowing down the spread of the virus. Also, mass testing, smart quarantine, and immediate contact tracing of the infected and rapid isolation are the right way. It is always better to establish strict measures right from the beginning. It is easy to return things to the way they were. It also influences the overall duration of the lockdown. In Spain, there was too much hesitation, and things could no longer be stopped.

As a doctor, you have now had to deal with the gravest of cases. Did you want to be a doctor when you were little?
It was always my dream. My dad was a radiologist. As a boy, I liked to visit him at work and talk with patients. After secondary school, I applied for medical school, but I was one point short of acceptance because I also played football at the time. So, I began to study biology, and in my fifth year of study, I came to Czechia to spend an entire year as an Erasmus student at Masaryk University. I fell in love with Brno right away. It was a wonderful year. The university captivated me – a great campus, new computer labs, and a big library. I had never seen anything like that before.

So, during your Erasmus programme, you decided to apply for medical school again?
Yes. I spoke with several international students, and they recommended Masaryk University. So, I spent the final month of my Erasmus programme studying and getting ready for the entrance exam. I am really glad I had this opportunity. Even though the programme was hard, it prepared me well for the situation I have currently been experiencing on a daily basis. Moreover, it was great that there was a good balance between studying, practical workshops, time spent in the hospital, and free time, which is not something usual at medical schools. I also met so many international students. Now they are doctors working all over the world. We are still in contact today.

What does your normal workday look like?
In the morning, the previous shift gives us a report about the last 24 hours and then we take over care for the patients. In our department there are at least three doctors and about 11 nurses every day, so we have one nurse per patient, who provides constant care.

Our department gets the most serious cases. COVID-19 progresses like this: between the third and fifth days, people have a fever, a cough, and other symptoms. Around the seventh to ninth day they have breathing problems, and the first pathological findings show up in lung x-rays. A small percentage of these cases is critical.

What do you provide to patients?
Patients who are admitted to our hospital need to breathe highly concentrated oxygen. They are given medicine, most often anti-inflammatories, antivirals, or malaria drugs. If that doesn’t help, we have to intubate the patients and put them on a ventilator. They are usually on them for 14 to 20 days, but there have been cases where it was more than 50 days. Restoring the lungs is a lengthy process.

During the day, patients on ventilators undergo various tests, including blood tests. Every patient has a monitor on which we can always keep an eye on their vital signs. Based on this data, we then adjust the ventilator. Our goal is to ventilate patients as best we can. The data, for example, tell us whether a patient needs more or less oxygen. We also monitor whether a patient is reacting to medication, and if needed, we decrease or increase the dosages of medicine or we change medicines.

It is very difficult to work to be all day on your feet in suits and protective equipment in which you can’t drink or go to the toilet. But the most difficult thing was that our patients were dying and their loved ones couldn’t be with them during their final moments. Family members couldn’t even go to their funeral. This kind of situation is horrible for everyone – patients, families, and doctors.

That must have been a nightmare.
It certainly was. At the height of the pandemic, it was like a warzone in the hospital. It was heartbreaking to see so many people dying. But it wasn’t only old and sick people, not by a long shot. We even had a 32-year-old patient, who was completely healthy, die. I knew that the coronavirus would come to Europe sooner or later, but I didn’t expect such a large wave. It is a gigantic catastrophe for humanity.

How did you manage to go on working in such an atmosphere?
At a certain point, I stopped looking at the death toll, and I just said to myself that I need to go on. You can’t go to work thinking about how many people have already died. You can’t admit it. Otherwise, you will lose energy. You need to be optimistic and tell yourself that today I will save someone. And carry on and on. Maybe this is why we have had relatively good outcomes. Our mortality rate was below 9 per cent, below the countrywide average.

Is it all over for you now?
Those difficult weeks are already over, thankfully. As a doctor, I thank everyone who stayed home. It saved many lives. And I thank all my colleagues – our doctors, nurses, receptionists, and attendants. And I hope that the entire world will learn from what happened in Italy, Spain, and the USA. People have to see chaos to learn a lesson. Next time, we will already be prepared. Next time, people will no longer be suspicious of government regulations. They won’t ignore the data only because they don’t want to change their habits. But now, unfortunately, we have to change our mindsets until a vaccine or treatment appears. We have to get used to the fact that this is the way it is going to be. We can’t let the virus win again. We can’t forget about what happened and about those who died needlessly.