Editorial
More than just internists
Más que internistas
A. Zapatero Gaviria
, J. Marco Martínez
Corresponding author
Directores Médicos Hospital de Ifema, Madrid, Spain
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Zapatero Gaviria, J. Marco Martínez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Zapatero Gaviria" "email" => array:1 [ 0 => "antonio.zapatero@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Marco Martínez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Directores Médicos Hospital de Ifema, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Más que internistas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There have been many of us. This is our first thought. When we arrived at what would later be named the Hospital de IFEMA, what was just a little while ago the headquarters of ARCOmadrid, it was the first days of this tragic spring and there was everything still to be done. Internists had been those in charge of caring for patients infected with COVID-19 at the start of the epidemic in the country's hospitals; it was soon evident that that it wasn’t going to be enough.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Urgent care physicians, geriatricians, gastroenterologists, cardiologists, pulmonologists: all quickly enlisted in the army of medical specialists needed to attend to the wave of patients who disembarked at the emergency departments of hospitals everywhere and overwhelmed these facilities, coming to occupy every last inch of available space that had been fitted out as hospital wards.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The battalion grew with pediatricians, hematologists, oncologists. Surrounded by a team of surgeons, rehabilitation physicians, endocrinologists—physicians from all over the hospital collaborate on ordering tests, writing discharge summaries, processes with other hospitals, what have you. Chimerical teams, capable of completing any mission, that distribute the work in the mornings and whose workday never ends. Everyone together.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We found pavilions 5, 7, and 9 practically empty. That first day, beds and nursing stations were set up in pavilion 5, which was going to be provisional, and the first 40 patients arrived late that afternoon.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aspects regarding care can be outlined. Admissions performed two functions: administration, with identification and filing of information, and triage. For the latter, we established four levels of severity:</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group 1.</span> Intensive Care Unit (ICU) patients (they must meet at least one criterion):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">∘</span><p id="par0035" class="elsevierStylePara elsevierViewall">O<span class="elsevierStyleInf">2</span> saturation <92–93% with a mask-reservoir.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">∘</span><p id="par0040" class="elsevierStylePara elsevierViewall">Respiratory rate >28 bpm.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">∘</span><p id="par0045" class="elsevierStylePara elsevierViewall">Hemodynamic instability.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">∘</span><p id="par0050" class="elsevierStylePara elsevierViewall">Abnormal level of consciousness without any other explanation.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group 2.</span> Meets poor prognosis criteria (they must meet at least one):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">∘</span><p id="par0060" class="elsevierStylePara elsevierViewall">Bilateral interstitial infiltrates.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">∘</span><p id="par0065" class="elsevierStylePara elsevierViewall">Respiratory failure upon arrival to the emergency department.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">∘</span><p id="par0070" class="elsevierStylePara elsevierViewall">D-dimer >1500 ng/mL.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">∘</span><p id="par0075" class="elsevierStylePara elsevierViewall">Cardiopulmonary comorbidity.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group 3.</span> Does not meet short-term poor prognosis criteria.</p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Group 4.</span> Patients with limitations for experimental treatment:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">∘</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients with end-stage organ disease (advanced chronic heart failure, severe chronic obstructive pulmonary disease, liver cirrhosis, severe chronic kidney disease).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">∘</span><p id="par0095" class="elsevierStylePara elsevierViewall">Patients with Clinical Frailty Scale (CFS) ≥6.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">∘</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patients with severe dementia.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">∘</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients with terminal cancer.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">∘</span><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with any disease and a life expectancy of less than one year.</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">On the fourth day of operation, the computer system was able to be extended to all clinical units (there were up to 25 with 50 beds each). The electronic medical record was configured in questionnaires to facilitate patient care in a scenario with a highly heterogeneous group of physicians with varied training. Questionnaires were created for admission, ward rounds, and discharge. The different treatment regimens were also protocolized.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Work was organized into two shifts—morning and afternoon—with discharges on two of the seven days of the week. At night, two physicians from the Emergency Medical Service of the Community of Madrid (SUMMA, for its initials in Spanish), two from the Municipal Emergency and Rescue Assistance Service (SAMUR, for its initials in Spanish), and two hospital physicians from our staff divide the work in the two pavilions.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The final facility comprises two connected pavilions with 550 and 736 beds and an ICU which can hold 16 patients, for a total of 1300 beds. The facility also has two thoracic radiology rooms, five portable radiology units, five portable ultrasound devices, a CT scanner, five portable automated blood gas and electrolyte analyzers, and the possibility of performing lab tests with a pre-analytical counter in each pavilion and samples being sent every two hours during the morning shift. Urgent tests are able to be performed at any time via a shuttle to a large hospital, which provides us with everything for this service.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Other areas set up in the pavilion include two large work rooms for medical personnel, a panel-enclosed room with four spaces where severe patients can be accompanied by their families, and a space dedicated to triage and admission.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Information collected upon admission included:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">∘</span><p id="par0140" class="elsevierStylePara elsevierViewall">Name</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">∘</span><p id="par0145" class="elsevierStylePara elsevierViewall">Hospital of origin</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">∘</span><p id="par0150" class="elsevierStylePara elsevierViewall">Date of birth</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">∘</span><p id="par0155" class="elsevierStylePara elsevierViewall">Description of the pneumonia</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">∘</span><p id="par0160" class="elsevierStylePara elsevierViewall">SARS CoV-2 PCR (result)</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">∘</span><p id="par0165" class="elsevierStylePara elsevierViewall">Vital signs in the Emergency Department of the hospital of origin (respiratory rate, oxygen saturation, temperature, heart rate, level of consciousness, blood pressure) and upon arrival to the center</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">∘</span><p id="par0170" class="elsevierStylePara elsevierViewall">Days since onset of symptoms</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">∘</span><p id="par0175" class="elsevierStylePara elsevierViewall">Significant comorbidity</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">∘</span><p id="par0180" class="elsevierStylePara elsevierViewall">Emergency Department blood test: leukocytes, lymphocytes, CRP, D-dimer, PCT (if available), lactate, creatinine, LDH</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">∘</span><p id="par0185" class="elsevierStylePara elsevierViewall">Clinical frailty scale (CFS)</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">∘</span><p id="par0190" class="elsevierStylePara elsevierViewall">Triage classification: group 1, 2, 3, or 4</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">∘</span><p id="par0195" class="elsevierStylePara elsevierViewall">For patients in groups 1 or 2, an ECG is performed and the QT interval is calculated</p></li></ul></p><p id="par0200" class="elsevierStylePara elsevierViewall">In regard to treatment, the medical team itself has been discussing and modifying it daily based on the literature made available everyday online. Later, it is updated in the medical record protocols so it can be implemented by all medical personnel involved.</p><p id="par0205" class="elsevierStylePara elsevierViewall">In addition, from the beginning, an information service was created for family members. It is staffed by physicians who have successfully passed the resident physician examination (MIR, for its initials in Spanish) and operates through access to the comments on progress on the electronic medical records. The content is succinct, but recent. The mean number of cases attended to daily is 600. They are connected with psychological care in the event it is requested by the attending physician or nurse or by the person informing the family members.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The center also has a hospital pharmacy that dispenses to the different clinical units in the morning and as needed, in addition to a logistics unit with a massive storage area that manages orders and receives donations. IFEMA makes something fundamental available at all of its facilities: security, sanitation, and personnel.</p><p id="par0215" class="elsevierStylePara elsevierViewall">During the hospital's set-up, it was necessary to create all the procures on the fly as each need arose (discharge, <span class="elsevierStyleItalic">exitus</span>, pharmacy orders, blood test orders); over 20 procedures that were made available in the electronic medical record. The list of details that had to be organized, made available, and foreseen so that everything works is infinite. A structure that was not designed to be a hospital; that had to be set up in record time; that filled up in the blink of an eye, first with workers and then with patients. For some, it was a miracle. For others, it was a result that we believed in more and more with each passing day.</p><p id="par0220" class="elsevierStylePara elsevierViewall">This was the key: Turning to all types of professionals, not just internists. Primary care physicians, medical specialists, pediatricians, and surgical specialists joined the project. We established teams made up of a hospital physician, who led it, surrounded by four primary care physicians to a ratio of 50 patients, which was the capacity of our nursing stations. Nights were initially covered by SUMMA physicians until hospital physicians also joined in, and it worked.</p><p id="par0225" class="elsevierStylePara elsevierViewall">In total, we had 392 physicians available, of which 260 were from primary care, 81 from hospitals, 24 from SUMMA, two from SAMUR, and 25 recently-licensed physicians who served as informants. We also had 436 nurses (353 from primary care), 357 clinical aides, and 228 porters. Likewise, radiology and laboratory technicians were hired. In record time, a hospital pharmacy was set up that was connected to the electronic medical record for electronic prescriptions and stock management.</p><p id="par0230" class="elsevierStylePara elsevierViewall">These teams were also joined by surgeons, who helped write discharge summaries, and specialist physicians from all areas: oncologists, pediatricians, cardiologists, pulmonologists, and geriatricians, who all showed incredible bravery. As stated above, an electronic medical record was created and it was decided to work with questionnaires as much as possible in order to facilitate the work. Treatments were protocolized in the prescriptions tool, as were the blood tests that had to be ordered. This methodology undoubtedly facilitated the incorporation of physicians from all over with different work routines.</p><p id="par0235" class="elsevierStylePara elsevierViewall">In 15 days, we had received more than 2500 admissions and had discharged more than 1500.</p><p id="par0240" class="elsevierStylePara elsevierViewall">This hasn’t been the work of internists, nor infectious disease physicians, nor virologists, nor epidemiologists, nor many other “whateverologists.” What we want to underline here—and this is the reason behind this editorial—is the importance of physicians in general, as professionals with no distinctions between categories, specializations, or origin, in the fight and sure victory against this cursed pandemic that we have to live through. This includes, of course, the rest of the professional staff and those from different care units who have fought alongside us to launch and sustain this project.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zapatero Gaviria A, Marco Martínez J. Más que internistas. 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