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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" => "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.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.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.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.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:Group 1. Intensive Care Unit (ICU) patients (they must meet at least one criterion):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">∘O2 saturation <92–93% with a mask-reservoir.</li><li class="elsevierStyleListItem" id="lsti0010">∘Respiratory rate >28 bpm.</li><li class="elsevierStyleListItem" id="lsti0015">∘Hemodynamic instability.</li><li class="elsevierStyleListItem" id="lsti0020">∘Abnormal level of consciousness without any other explanation.</li></ul>Group 2. Meets poor prognosis criteria (they must meet at least one):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">∘Bilateral interstitial infiltrates.</li><li class="elsevierStyleListItem" id="lsti0030">∘Respiratory failure upon arrival to the emergency department.</li><li class="elsevierStyleListItem" id="lsti0035">∘D-dimer >1500 ng/mL.</li><li class="elsevierStyleListItem" id="lsti0040">∘Cardiopulmonary comorbidity.</li></ul>Group 3. Does not meet short-term poor prognosis criteria.Group 4. Patients with limitations for experimental treatment:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045">∘Patients with end-stage organ disease (advanced chronic heart failure, severe chronic obstructive pulmonary disease, liver cirrhosis, severe chronic kidney disease).</li><li class="elsevierStyleListItem" id="lsti0050">∘Patients with Clinical Frailty Scale (CFS) ≥6.</li><li class="elsevierStyleListItem" id="lsti0055">∘Patients with severe dementia.</li><li class="elsevierStyleListItem" id="lsti0060">∘Patients with terminal cancer.</li><li class="elsevierStyleListItem" id="lsti0065">∘Patients with any disease and a life expectancy of less than one year.</li></ul>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.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.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.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.Information collected upon admission included:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070">∘Name</li><li class="elsevierStyleListItem" id="lsti0075">∘Hospital of origin</li><li class="elsevierStyleListItem" id="lsti0080">∘Date of birth</li><li class="elsevierStyleListItem" id="lsti0085">∘Description of the pneumonia</li><li class="elsevierStyleListItem" id="lsti0090">∘SARS CoV-2 PCR (result)</li><li class="elsevierStyleListItem" id="lsti0095">∘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</li><li class="elsevierStyleListItem" id="lsti0100">∘Days since onset of symptoms</li><li class="elsevierStyleListItem" id="lsti0105">∘Significant comorbidity</li><li class="elsevierStyleListItem" id="lsti0110">∘Emergency Department blood test: leukocytes, lymphocytes, CRP, D-dimer, PCT (if available), lactate, creatinine, LDH</li><li class="elsevierStyleListItem" id="lsti0115">∘Clinical frailty scale (CFS)</li><li class="elsevierStyleListItem" id="lsti0120">∘Triage classification: group 1, 2, 3, or 4</li><li class="elsevierStyleListItem" id="lsti0125">∘For patients in groups 1 or 2, an ECG is performed and the QT interval is calculated</li></ul>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.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.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.During the hospital's set-up, it was necessary to create all the procures on the fly as each need arose (discharge, exitus, 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.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.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.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.In 15 days, we had received more than 2500 admissions and had discharged more than 1500.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." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Zapatero Gaviria A, Marco Martínez J. Más que internistas. Rev Clin Esp. 2020;220:350–351." ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000022000000006/v2_202102250828/S2254887420300539/v2_202102250828/en/main.assets" "Apartado" => array:4 [ "identificador" => "72714" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000022000000006/v2_202102250828/S2254887420300539/v2_202102250828/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887420300539?idApp=WRCEE"]

Revista Clínica Española (English Edition)

ISSN: 2254-8874

Revista Clínica Española published its first issue in 1940 and is the body of expression of the Spanish Society of Internal Medicine (SEMI).
The journal fully endorses the goals of updating knowledge and facilitating the acquisition of key developments in internal medicine applied to clinical practice. Revista Clínica Española is subject to a thorough double blind review of the received articles written in Spanish or English. Ten issues are published each year, including mostly originals, reviews and consensus documents.

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0.7

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0.162

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0.211

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