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Long distance race against the virus

His entire hands, heart and head are dedicated to the titanic work of fighting the coronavirus. Jérôme Pugin is the chief medical officer of the intensive care service at the Geneva University Hospitals (HUG). A unit that received 50 patients with Covid-19 on Wednesday morning, 9 more than the previous day. All suffer from the same symptom: acute respiratory failure, requiring intubation for several days or even weeks.

Cases that will multiply frantically in the coming days, predicts the chief doctor, who agreed to answer our questions. The voice is tired, but the words guaranteed “straightforward”.

What is the current situation in HUG intensive care?

Jérôme Pugin: With 50 patients with Covid-19, we have already exceeded the usual intensive care capacity of 30 beds by 60%. To accommodate all these people, we had to densify the intensive care sector, but also colonize adjacent care zones. We have already almost reached the maximum capacity of these spaces. From today (Wednesday, note), we will begin to enter the operating theaters, equipped to receive these patients.

There is a lot of talk about the number of beds and respirators, as well as the staff needed to manage this crisis. What will we miss first in Geneva?

Human resources, I think. We recruited all the people who have the functions of intensivists, in particular in the anesthetists and in internal medicine. My team has more than doubled, more than 500 people are mobilized to face this challenge. And if that’s not enough, we have plans that will allow us to operate in “degraded” mode, even if I don’t like that term. Let’s say that we will operate with a prioritization of care: the staff will concentrate as much as possible on the vital gestures.

Are you afraid of arriving at a stage where, as in Italy, it will be necessary to choose who to treat in priority?

Yes. Be sure that we are doing everything to not get there, but we have to imagine this situation. At the national level, the ethics committee has issued criteria, depending on the rise of the epidemic, which will regulate the admission of patients to intensive care. We are already used to making these choices by considering the patient’s wishes or the chances of offering them a reasonable quality of life. But under current conditions, the criteria could harden.

What is the profile of the patients you receive?

Just under half of the patients have no risk factors and are fairly young. This is an important message. The current average age in intensive care is 56 years. It’s not old knowing that we usually turn around 62 years. On the other hand, it is true that world experience shows that the vast majority of deaths are linked to the elderly, often suffering from chronic diseases. We are hopeful of pulling many people out of this mess, especially among young people who are not co-morbid. At HUG, five people were able to leave intensive care after ten days of intubation.

How are the healthcare teams organized to be able to last the entire length of this crisis?

Psychologists and hypnotherapists were made available to employees so that they could debrief and talk about their concerns. We also revised the schedules and went on call for 12 hours straight for the majority of caregivers, to gain efficiency. I feel each and everyone very invested in their task. Worried of course, because we expect to take the big wave soon, but do not panic. Encouraging fact: I observe fewer absences than normal. I did not expect it, it shows the strong solidarity of the caregivers. But we must not forget that we are only at the start of this epidemic. We have to go the distance, and that also means taking rest while we still have the chance.

Are healthcare staff on your team directly affected by the virus?

That’s less than half a percent of our workforce. This is not a problem at the moment. It has been a priority to ensure that our staff work in a secure environment, without the worry of being infected.

Chloroquine has made a comeback in recent days. Is it used as a treatment at HUG?

Yes, hydroxychloroquine is used in intensive care patients. We are awaiting news of the large clinical trials which would confirm its usefulness, but in doubt we are already giving this drug. The main part of the management of these patients with very severe respiratory insufficiency remains the support of the respiratory and ventilatory function. For now, this is the best we can do.

How do you respond to the specialists who are delaying the current crisis by comparing Covid-19 to seasonal flu?

I am shocked to hear such comments. They should spend just five minutes in my department to realize how completely extraordinary we are. The volume of patients arriving at us poses an unprecedented organizational challenge. I have been doing this job for forty years, including thirty-five in intensive care. I experienced the presence of an Ebola patient, I thought it was the worst scenario I would ever know. But what we are experiencing now is unprecedented.

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