{"id":47060,"date":"2020-03-31T21:25:03","date_gmt":"2020-03-31T20:25:03","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=47060"},"modified":"2020-03-31T21:29:00","modified_gmt":"2020-03-31T20:29:00","slug":"on-the-front-lines-of-the-response-to-covid-19-in-spain-a-nation-under-a-state-of-emergency","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/03\/31\/on-the-front-lines-of-the-response-to-covid-19-in-spain-a-nation-under-a-state-of-emergency\/","title":{"rendered":"On the front lines of the response to covid-19 in Spain: a nation under a state of emergency"},"content":{"rendered":"<p><span style=\"font-weight: 400\">I work as a paediatrician in a primary care centre in Madrid. It is the area in Spain that has been hardest-hit by the covid-19 pandemic. <\/span><a href=\"https:\/\/www.bmj.com\/content\/368\/bmj.m1090?utm_source=twitter&amp;utm_medium=social&amp;utm_term=hootsuite&amp;utm_content=sme&amp;utm_campaign=usage\"><span style=\"font-weight: 400\">Spain<\/span><\/a><span style=\"font-weight: 400\"> is currently the second worst affected country in Europe after <\/span><a href=\"https:\/\/www.bmj.com\/content\/368\/bmj.m1065\"><span style=\"font-weight: 400\">Italy<\/span><\/a><span style=\"font-weight: 400\">. Following the Spanish cabinet&#8217;s decision to declare a state of emergency on 14 March, the entire country remains in lockdown.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The number of diagnosed cases, deaths with coronavirus, and patients that are now in or have required admission to the intensive care unit (ICU) at some point are still escalating at a high rate. On the 31 <\/span><a href=\"https:\/\/www.mscbs.gob.es\/profesionales\/saludPublica\/ccayes\/alertasActual\/nCov-China\/documentos\/Actualizacion_61_COVID-19.pdf\"><span style=\"font-weight: 400\">March<\/span><\/a><span style=\"font-weight: 400\">\u00a02020 they numbered 94,417, 8,189, and 5,607, respectively. One third <\/span><span style=\"font-weight: 400\">of the ICU admissions and almost half of the deaths have<\/span><span style=\"font-weight: 400\"> occurred in the Community of Madrid, the metropolitan area of the nation\u00b4s capital (population: 6,6 million). Catalonia (population: 7,5 million) follows with 20% of the total cases.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Nevertheless, under detection remains a problem given the many asymptomatic cases and our shortage of diagnostic tests. Since at least mid-March, and <\/span><a href=\"https:\/\/www.mscbs.gob.es\/profesionales\/saludPublica\/ccayes\/alertasActual\/nCov-China\/documentos\/Procedimiento_COVID_19.pdf\"><span style=\"font-weight: 400\">following our Ministry of Health protocols<\/span><\/a><span style=\"font-weight: 400\">, we have been testing only those with acute respiratory infection admitted in hospitals or expecting admission, and essential personnel, such as healthcare workers.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Our healthcare facilities are being pushed to the brink of collapse in the most affected areas. There is <\/span><a href=\"https:\/\/www.thelancet.com\/journals\/lanpub\/article\/PIIS2468-2667(20)30060-8\/fulltext\"><span style=\"font-weight: 400\">a concerning lack of personal protection equipment for healthcare workers and rates of exhaustion<\/span><\/a><span style=\"font-weight: 400\"> are high. <\/span><a href=\"https:\/\/www.nytimes.com\/video\/world\/europe\/100000007051789\/coronavirus-ppe-shortage-health-care-workers.html\"><span style=\"font-weight: 400\">Over 12,000 nurses, doctors, and other healthcare workers have already been infected (12,7% of the total of diagnosed cases)<\/span><\/a><span style=\"font-weight: 400\">. Many remain on sick leave or quarantined and many are probably undiagnosed, which is further exacerbating the situation. <\/span><a href=\"https:\/\/www.diariovasco.com\/sociedad\/salud\/fallece-enfermera-osakidetza-20200319130145-nt.html\"><span style=\"font-weight: 400\">A 52 year old nurse was the first one to die<\/span><\/a><span style=\"font-weight: 400\">. It happened in <\/span><a href=\"https:\/\/www.journalofhospitalinfection.com\/article\/S0195-6701(20)30101-8\/fulltext\"><span style=\"font-weight: 400\">China<\/span><\/a><span style=\"font-weight: 400\">, it\u00b4s happening in <\/span><a href=\"https:\/\/portale.fnomceo.it\/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19\/#.XniIZejzDgw.facebook\"><span style=\"font-weight: 400\">Italy<\/span><\/a><span style=\"font-weight: 400\">, and it will happen elsewhere.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The issue is not only that <\/span><a href=\"https:\/\/english.elpais.com\/society\/2020-03-22\/spanish-hospital-workers-on-frontline-of-coronavirus-crisis-this-is-the-war-of-our-generation.html\"><span style=\"font-weight: 400\">large hospitals in the hardest-hit areas are overwhelmed and many patients are not receiving proper care<\/span><\/a><span style=\"font-weight: 400\">, but that regular healthcare is being affected the consequences of which we will only be able to account once this whole crisis is over.<\/span><\/p>\n<p><span style=\"font-weight: 400\">In Madrid, thanks to the collaboration between national, regional and local authorities, the whole regional healthcare system is <\/span><a href=\"https:\/\/www.vice.com\/en_us\/article\/k7e5ba\/spain-just-opened-a-massive-coronavirus-field-hospital-in-a-convention-center\"><span style=\"font-weight: 400\">undergoing a massive scale emergency reconfiguration<\/span><\/a><span style=\"font-weight: 400\">. It\u00b4s worth noting that <\/span><a href=\"https:\/\/www.bmj.com\/content\/346\/bmj.f2363\"><span style=\"font-weight: 400\">Spanish public healthcare has suffered important austerity \u201creforms\u201d<\/span><\/a><span style=\"font-weight: 400\"> following the 2008 financial crisis. Madrid has been particularly affected by <\/span><a href=\"https:\/\/blogs.bmj.com\/bmj\/2013\/03\/28\/aser-garcia-rada-protests-against-the-privatisation-of-healthcare-in-spain\/\"><span style=\"font-weight: 400\">budgetary cuts and privatization policies<\/span><\/a><span style=\"font-weight: 400\"> implemented by conservative Governments that, although <\/span><a href=\"https:\/\/www.bmj.com\/content\/348\/bmj.g1240.long\"><span style=\"font-weight: 400\">strongly contested by health workers<\/span><\/a><span style=\"font-weight: 400\">, may now be taking a toll.<\/span><\/p>\n<p><span style=\"font-weight: 400\">There currently a lack of protective equipment among staff in residential care homes. They come in and out regularly and thus can transmit the disease unintentionally. S<\/span><span style=\"font-weight: 400\">ome of those premises\u00a0have become very dangerous for the most vulnerable populations.<\/span><span style=\"font-weight: 400\"> In some of them the Military Emergencies Unit (UME) has found <\/span><a href=\"https:\/\/english.elpais.com\/society\/2020-03-24\/spanish-prosecutors-launch-investigation-after-bodies-found-inside-senior-homes.html\"><span style=\"font-weight: 400\">death bodies left abandoned<\/span><\/a><span style=\"font-weight: 400\">. Some staff <\/span><a href=\"https:\/\/cadenaser.com\/emisora\/2020\/03\/24\/radio_madrid\/1585038148_148391.html\"><span style=\"font-weight: 400\">report wearing robes made from plastic bags and self-made masks<\/span><\/a><span style=\"font-weight: 400\">.<\/span><\/p>\n<p><span style=\"font-weight: 400\">If you still have the common misperception that covid-19 is just \u201clike flu\u201d, consider also that in Madrid <\/span><a href=\"https:\/\/www.elespanol.com\/espana\/madrid\/20200323\/madrid-convierte-palacio-hielo-morgue-fallecidos-coronavirus-emergencia-cadaveres-funeraria\/476953156_0.html\"><span style=\"font-weight: 400\">a large skating rink has just been set as a temporary new morgue<\/span><\/a><span style=\"font-weight: 400\">, given current overwhelming situation of our local funerary services.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The limited availability of ventilators and intensive care beds and the dramatic consequences it&#8217;s involving for some of our largest hospitals means that the large amount of patients with mild symptoms goes unnoticed. They remain at home thanks to the <\/span><a href=\"http:\/\/sano-y-salvo.blogspot.com\/2020\/03\/la-importancia-de-poseer-un-activo-como.html\"><span style=\"font-weight: 400\">ongoing telephone follow-up we are undertaking from the public primary care network<\/span><\/a><span style=\"font-weight: 400\">, where all scheduled appointments have been cancelled. This policy aims to prevent people from leaving their homes and hospitals to collapse.<\/span><\/p>\n<p><span style=\"font-weight: 400\">At a time of widespread community transmission and lack of diagnostic tests, we are considering all new cases of people presenting with acute respiratory infection such as cough, fever, or difficulty breathing, including children, as a <\/span><a href=\"https:\/\/www.mscbs.gob.es\/profesionales\/saludPublica\/ccayes\/alertasActual\/nCov-China\/documentos\/Procedimiento_COVID_19.pdf\"><span style=\"font-weight: 400\">\u201cpossible covid-19 case.\u201d<\/span><\/a><span style=\"font-weight: 400\">\u00a0Therefore, we take all possible precautions if people with any such symptoms seek attention, and we try to make all possible diagnosis throug<\/span><span style=\"font-weight: 400\">h phone calls to <\/span><span style=\"font-weight: 400\">our primary health centre. <\/span><span style=\"font-weight: 400\">This means that what two months ago could be considered \u201ca cold\u201d, is now considered a \u201cpossible covid-19 case.\u201d<\/span><span style=\"font-weight: 400\">\u00a0<\/span><a href=\"https:\/\/www.mscbs.gob.es\/profesionales\/saludPublica\/ccayes\/alertasActual\/nCov-China\/telefonos.htm\"><span style=\"font-weight: 400\">Covid-19 specific hotlines<\/span><\/a><span style=\"font-weight: 400\"> have been established in most regions countrywide.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Even without confirmation\u2014which is usually the case\u2014we quarantine all patients with mild symptoms at home, we do home visits if their condition worsens, and do regular follow-up calls until they remain symptom-free for two weeks\u2014<\/span><a href=\"https:\/\/www.thesun.co.uk\/news\/11185025\/coronavirus-patients-contagious-two-weeks-symptoms-disappear\/\"><span style=\"font-weight: 400\">the period it is consider patients may remain contagious although clinically fully recovered<\/span><\/a><span style=\"font-weight: 400\">. Advice on how to conduct r<\/span><span style=\"font-weight: 400\">emote assessments can be found in recent literature. [<\/span><span style=\"font-weight: 400\">1]<\/span><\/p>\n<p><span style=\"font-weight: 400\">Widespread community transmission <\/span><a href=\"https:\/\/coronavirus.jhu.edu\/map.html\"><span style=\"font-weight: 400\">probably applies now worldwide<\/span><\/a><span style=\"font-weight: 400\">, particularly in urban areas. If in some countries the number of diagnosis remains strikingly low, this may be due to an incapacity of healthcare systems to test, a lack of transparency, or both. Consider this policy to prevent health workers from contagion if you lack enough diagnostic tests and make\u00a0<\/span><a href=\"https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(20)30644-9\/fulltext\"><span style=\"font-weight: 400\">all efforts to provide them with proper protective equipment<\/span><\/a><span style=\"font-weight: 400\">.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Physical distancing, hygiene, and staying at home seems the only way to flatten this widespread outbreak and allow healthcare systems to cope with it. From Madrid, let me tell you\u2014prepare for it, prepare right away. We keep on.<\/span><\/p>\n<p><em><b style=\"font-size: 1rem\">Aser Garc\u00eda Rada <\/b><a style=\"font-size: 1rem\" href=\"https:\/\/twitter.com\/AserGRada\"><b>@AserGRada<\/b><\/a> <span style=\"font-weight: 400\">is a paediatrician and MD, PhD who works at a primary care center in Madrid. He is also an actor and a freelance journalist.<\/span><\/em><\/p>\n<p><b>References:<\/b><\/p>\n<ol>\n<li style=\"font-weight: 400\"><span style=\"font-weight: 400\">Greenhalgh T, Koh GC,\u00a0 Car J. Covid-19: a remote assessment in primary care.\u00a0 BMJ 2020;368:m1182. Available at: <\/span><a href=\"https:\/\/www.bmj.com\/content\/368\/bmj.m1182\"><span style=\"font-weight: 400\">https:\/\/www.bmj.com\/content\/368\/bmj.m1182<\/span><\/a><\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I work as a paediatrician in a primary care centre in Madrid. It is the area in Spain that has been hardest-hit by the covid-19 pandemic. Spain is currently the [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/03\/31\/on-the-front-lines-of-the-response-to-covid-19-in-spain-a-nation-under-a-state-of-emergency\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":47061,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[263],"tags":[],"class_list":["post-47060","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-global-health"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>On the front lines of the response to covid-19 in Spain: a nation under a state of emergency - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/03\/31\/on-the-front-lines-of-the-response-to-covid-19-in-spain-a-nation-under-a-state-of-emergency\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"On the front lines of the response to covid-19 in Spain: a nation under a state of emergency - The BMJ\" \/>\n<meta property=\"og:description\" content=\"I work as a paediatrician in a primary care centre in Madrid. 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