February 25, 2020, the day when covid entered the Clínic.

Ernest Bragulat, head of the Emergency Department at the Hospital Clínic in Barcelona, remembers that encounter with great precision. Well, like everything about him. Like everything about them. Like everything about everyone. There are unforgettable times and even more so for Spanish healthcare professionals. Of the world.

Several emergency physicians from the Clínic had moved, for a few weeks, to lend a hand in the refugee camp in the Greek town of Idomeni. There they had lived there, intensely, also without timetable and with certain desperation, the day to day life of its inhabitants.

Those were the early days of the covid-19 pandemic all over the world and, especially, at the Clinic, in Barcelona, in Catalonia, in all of Spain. It was a time when, sometimes, without malice, for God’s sake, simply out of weariness or without a better way to define the situation, among the doctors and health personnel of the place where the marrow of such a plague was being experienced, there was talk that it was “the closest thing to a refugee camp”.

And, of course, when the doctors returned from Idomeni and instructed, informed, their colleagues of what had been their task in that place, the first thing they asked them was not to return (“let’s return”, because they included themselves, of course) to make that comparison. That is a desperate situation,” said one of the travelers. “After all, we are a reference center, we can defend ourselves, we have 700 beds and more than a hundred ICUs. True, we have done what we could and knew, the covid-19 wave passed over us, but let’s not say that this looks like a refugee camp, let’s not say it, no”.

Despair, surprise, uneasiness

And they never commented on it again. There was also, of course, in those first months of despair, surprise, uneasiness, uncertainty, ignorance and bewilderment (February, March, April 2020) who used, in the morning meetings of the Crisis Cabinet and, later, in the partial appointments with each of the departments to plan the day to day, the word ‘war’. “I, fortunately, have not lived through a war, but it must be very much like this”, commented more than one doctor, more than one health worker, more than one stretcher-bearer, more than one member of the ‘white coats’ who saved our lives and lamented the pain and the deaths that covid-19 has produced, that it is producing.

(…) Those first days, those first weeks, those first months were a whirlwind. All over Spain, all over the world, at the Clínic and in all hospital centers. “There was a day, at the end of March,” recounts Dr. Toni Trilla, head of Preventive Medicine and Epidemiology and also Dean of the Faculty of Medicine at the Clínic, “that, after dozens of hours of work, on duty, tension, despair, not mine, everyone’s, I went home to sleep, if I could, six or seven hours. That night, I turned off the light on my bedside table thinking: ‘God, this cannot be happening to us! This is not true! This is not happening!’ And I verbalized it, dreaming, wishing, even intuiting that, the next day, when I woke up, I would go to the hospital and everything would be back to normal, because it was a dream. But no, vI forgot and everything got worse”.

“Things you wouldn’t believe.”

It was so bad that one of the favorite phrases of those weeks, of that chaos, of that desperation and impotence, was the legendary sentence of the film ‘Blade Runner’, the one in which one of the protagonists says: “I have seen things that you would not believe”. Those were the days, as Trilla recounts, with the wisdom of a university professor, of an expert in the field, in which the doctors and all, all the healthcare workers at the Clínic, in Barcelona, in Catalonia, in Spain, in the whole world, “…were the ones who had seen things that you would not believe.we arrived at our hospital when God commanded and we left when God wanted us to”. It was, yes, it was a living hell. In fact, they had no life. The world was confined, but they were not the rest of the world.

It was at that moment, in those complicated moments, when Dr. Trilla’s world, his soul, fell to his feet. Trilla does not feel any pain, nor does he pretend to hide the reality when he recognizes that “some colleagues (very few, yes, but there were some) who up to that moment were considered a reference point in the institution, were relegated to the background”. Trilla’s metaphor sums up the situation perfectly: “When the sea is calm, all captains seem good. The real captains are those who know how to sail in a storm”.

But what happened, Trilla wonders. “Well, other companions appeared”, says the prestigious doctor. “That tends to happen, doesn’t it, in all walks of life, in all jobs, in all companies and offices? When you think that some are going to become the leaders who will help us all bear the burden of the unknown, of the crisis, some, I repeat: very few, are inhibited or blocked by the situation. But, suddenly, that orderly you thought was modest, hardworking but discreet, almost hidden, becomes the master of the floor; that quiet and calm nurse, shoots up and dares everything and takes, not one, but 10, 100 steps forward and ends up leading the situation. Many of these healthcare professionals ended up becoming vital people in their day-to-day work areas. The pandemic has provided us with a lesson in teamwork and leadership”.

(…) Dr. Jordi Vila, head of the Microbiology service and head of the Clínic laboratory (the ‘lord of PCRs’, or almost), refuses to speak of a ‘biological bomb’ – he and, of course, all his colleagues – when asked whether AIDS, Ebola, which still swarm, and the various covid (19 was not the first, no), are a punishment and/or consequence of our way of life. “I only know one thing, if this happens 50 or 60 years ago, it would have been horrible, a debacle, a hecatomb. Covid-19 has been so damaging, so disconcerting, so unexpected, so difficult and impossible to face, to stop, to cure, that not even a terrorist group could have imagined an evil so damaging, so devastating, that would make the population suffer and frighten so much”.

(…) And it is here where, without mincing words and, above all, without wanting to become anyone’s spokesman, far from it, Dr. Vila dares to say, to criticize, to explain, to raise what very few have dared to comment. “I am sorry, or not, but someone should demand from all countries, and especially from the powerful China, a good veterinary medicine and an exhaustive veterinary control over their animals. It makes no sense what has happened and there is no doubt that this Covid-19 is the result of a great negligence”, Vila points out with conviction. The doctor affirms that, on other occasions, when a similar case has occurred, the countries involved have controlled the virus and have managed, thanks to this veterinary control and the appropriate precautionary measures, to prevent the problem from reaching the population. “China lacks this veterinary rigor, lacks controls in the markets for the sale and slaughter of animals. In that sense, the possibility of a virus spreading is much easier than in other countries of the same level”.

The doctor who treated the first case

José Muñoz, head of the International Health Service at the Clínic, was the first to see Covid-19 at the Barcelona hospital, in the person of an Italian woman, resident in Catalonia, who traveled to northern Italy, conflict zone, landing point of the pandemic, via, they say, China-Iran. That happened on February 25. From that day to this, no one has seen more Covid-19 than Muñoz. (…) Muñoz considers that, despite having made many mistakes, not only because of ignorance of the disease and its behavior, but also due to lack of resources (especially material) and the difficulty of dealing with the virus, the Spanish healthcare system has once again been exemplary in its behavior, as it has not ceased to attend, treat and fight for as many patients as possible in its hospitals.

(…) “We are still in the fight, we have not yet come out of it and, although we sense that we can already see the light at the end of the tunnel, covid-19 will remain among us”, says Muñoz. “And it is now when, from time to time, we look at each other and review the photos of the first weeks of 2020 that we have on our cell phones, when we all come to the same conclusion: it has been, it is being, two years that count as ten. In our physique, in our gray hair, in our eyes, in our heads? Especially in our heads because of the tremendous stress we suffer and the impotence of, at times, not being able to prevent the death of some (many, always too many) of our patients. Many have needed help to try to recover from this”.

Goosebumps

And it is here, as Bragulat, Trilla and Vila have done, when Muñoz, who has just arrived from Kenya and has completely stopped a research work, several, in different parts of the planet because of this pandemic, agrees to talk about two aspects of it and his first catastrophic, chaotic, goosebumps-raising, voice cracking first months and, despite having seen what he has seen that we would never believe, moisten his eyes: the lack of contact with families and responsibilitysometimes, to decide whether, in certain patients, it was worthwhile or not to continue fighting for their recovery, for their life. This is what the Ethics Committee of the Clínic and the other Catalan hospitals know as the Therapeutic Ceiling Protocol.

Needless to say, professionals often sought alternatives to the protocols and guidelines regarding the impossibility for families to say goodbye to their loved ones when it was most obvious that they were going to die. It was not easy.

They were not able to facilitate this possibility for everyone, but they do acknowledge having created small rooms, corners of the Clinic, where they could attend to the families of those who were going to die. “We are here to cure,” Trilla points out, “but also, also, to accompany and console”. “Our society, the way we have been brought up, almost forces us, we need it, to be sitting at the bedside of our loved one who is suffering”, says Bragulat.

“When you, as a physician, have to give bad news to the family, you are the first one who is broken, shattered”, Muñoz says. “And, unfortunately, during these two years and those first months we suffered that feeling too many times, many times. And your legs tremble, your voice breaks, no matter how prepared the family is. And not to do it live, face to face, face to face, is very painful, I would say almost impossible. Those things cannot be said over the phone and, unfortunately, we could not always skip that order. Why do I explain this? Because 70% of our communication, not from doctor to patient, not from doctor to relatives, not from relatives to patient, no, in everyday life, between us, is nonverbal communication. It’s your tone of voice, it’s your gestures, it’s your eyes, it’s your emotions, it’s the way you say it that you have, that you use. And that did not exist. Or it existed little, scarcely. And we will always carry that in our backpack. It hurt us a lot. Too much”.

(…) “Let’s not fool ourselves and even less so now, two years after the explosion of this horrible pandemic”, Trilla points out. “We were all surprised when this new coronavirus appeared. At the beginning, because of our referents, because of our experience, because of our mental framework, we were convinced that it could be just another coronavirus. Yes, we were on our guard, but the first mistake we made – all of us, because it had already happened in other cases – was to think that it would not come out of China, that the Chinese would contain it, would control it. Or that, if it arrived, we could act as we did with Ebola: detect the cases, control them, isolate them and that was it”. But from China it quickly jumped, they say, to Iran and suddenly emerged in northern Italy, where the impact was devastating, catastrophic, unthinkable. “It was in those moments that we realized that the virus was already here”.

(…) “The situation is so chaotic, so unknown to all of us, so unpredictable, that we can only save ourselves, save the people and move forward united, together, being tremendously supportive, supporting each other”, Trilla and Bragulat recall in unison. “The decision is to endure whatever it takes, but no one knew, in those days, what ‘whatever it takes’ meant, although we figured it out right away: as long as our body could take it, that is, until physical exhaustion, which is what happened. We’ll pay the bill sooner or later; well, we’re already paying it. All of us. But together, which is the best thing about this pandemic, that we have all come out stronger, especially the public sector that has worked side by side with private healthcare, and that has been beautiful, as well as very gratifying”.

(…) They were moments, days, weeks, of improvisation. That someone, for example, the hotel in Plaza Espanya, made itself available to the Clínic and hundreds of patients were sent there. Its walls were perforated, an oxygen tank was installed in the street and a lot of lives were saved. And not only that, no. In desperation, Trilla, Bragulat, Vila, Muñoz, all of them, decided to install copper pipes, with holes, along the corridors of the whole Clínic!!! in case there was the need to place patients in those corridors and supply them with oxygen. And not only that, no. Trilla, as dean of the Faculty of Medicine of the hospital, asked them to study (which in the end was not necessary) how many beds “or whatever” could fit in the classrooms of the faculty.

(…) Sick people who did not have covid stopped going to the hospital. They stopped having operations. They stopped visiting other specialties. All, all, all the doctors, doctors, specialists, geniuses, gurus of other services, got down to work and became soldiers of covid-19. Well, not all of them, there were a few, yes, who disappeared, those reference doctors that Trilla will never forget in his life, replaced by the new and last gladiators of the Clínic’s corridors, that appeared like mushrooms, like mushrooms, like heroes.“The pandemic has transformed our lives and has certainly shaken the healthcare family in an unimaginable and positive way”, Muñoz reflects, who dreams of being able to recover his research and analysis project on intestinal parasites in Africa as soon as possible. “It’s obvious that, if you dedicate yourself to this, it’s what you have to do, isn’t it? But, certainly, covid-19 was a tremendous reality check for all of us”.