We, the lucky ones, who are not diagnosed as being infected with the coronavirus, can only imagine what life can be like at the Coronavirus Care Center in Pécs where doctors and nurses work 10-12 hours a day. It is unfortunately impossible to see and experience their heroic fight up close, but between the lines it is perhaps an indication of how much endurance and strength it takes. Dr. Zoltán Péterfi, associate professor and head of division at the Clinical Center 1st Department of Internal Medicine, has been at the forefront of the case even before the establishment of the center, when only wards were set aside for patients at the Rákóczi Street institution, and he is currently managing the work as an infectious disease and professional manager. With his presence and endurance, he sets an example for his colleagues who draw the most strength from him and from each other, from their cooperation.
Written by Rita Schweier (The interview was conducted on 6 April 2020.)
-There has been a lot of talk about the symptoms of the virus, but less about what the patients have to go through after arriving at the Rákóczi Street building.
-Patients who have a respiratory infection and a fever too, meaning that they are suspected of being infected with the coronavirus, come to the medical truck set up by the Rákóczi Street building. Here they are pre-screened based on a checklist to determine if the infection is suspected based on the symptoms. If this seems to be justified, the next step is to decide whether they can be kept in their homes under epidemiological surveillance. We are reluctant to use the word quarantine because it is ordered by the authorities. If the patient can be isolated at home, they can go home after taking samples from them, or if they cannot, they will be admitted to the center. If they are unable to travel on foot or by their own means of transport and the National Ambulance Service brings them to us, then bypassing the medical truck, they will immediately be taken to the emergency care triage department where they will be questioned and examined based on the checklist already mentioned. They are then taken either to the department or to the emergency room.
-Let's imagine that you are my guide in the center; how many rooms are there and what happens in them?
-The structure of the Coronavirus Care Center (KEK) is as follows: emergency patient care facility, infectious disease department and intensive therapy unit. I would note that the design of the KEK, the construction of the hatch systems, the designation of the various patient pathways and the establishment of certain rules are the results of real teamwork and the effective support of the Clinical Center and the University of Pécs.
The emergency care facility operates on the ground floor of building “T” with two exam rooms. There is a small lobby where patients can wait who were referred here from the medical truck, as well as those brought in by the National Ambulance Service. From here, they get to the department, which operates on four floors and the intensive department is located on the fifth floor of Building “C”. The latter was set up on the site of the old intensive care unit of the former County Hospital. At the department, there are approx. 25 beds on every floor, there are 14 on the fourth floor, so we can accommodate a total of 93 patients. The first three floors function as a standard internal medicine-infectious disease department, on the fourth floor we have the opportunity to monitor the patients, it has become a sub-intensive care facility. If their condition worsens, we can transfer them to the intensive care unit with the help of the intensive care colleagues, where we have 10 beds. Patients with severe coronavirus and those suspected of coronavirus who also need to be put on a ventilator are located here. If the latter group is confirmed not being infected with the coronavirus, they are transferred to the so-called “clean” intensive care unit. The intensive professional background is provided by the Department of Anaesthesiology and Intensive Therapy, the specialists and residents there work here as well. Volunteers, doctors and specialists delegated by various departments and clinics work at the infectious disease department.
The different patient pathways and staff pathways do not intersect. In places where infected or potentially infected patients are transported, the medical personnel do not go there and there is no transport of food, medicine or clean clothing. The clean and infected areas are thus completely separated.
There is a lobby at the department - this is the yellow zone - where you can see a nurse station as well as a room for nurses and doctors. On the first floor we have two medical rooms where on duty staff members can rest. From here we enter the patient care area through a hatch door. The patient spends only a few seconds in this yellow zone until they are transferred to the so-called red zone, which is already inside the hatch door. The wards open from this corridor and the patients cannot leave them. The wards themselves are called the hot zone, containing those who are only suspicious, as well as those who have already been confirmed to be infected. The nurses work in three to four-hour shifts among them in the red zone. Inside the hatch door, colleagues are in full protective equipment: they wear overalls, goggles, a mask and rubber gloves as well. Patients are also examined, cared for, medicated and given food here.
In case the patient’s test results are negative, another sample may be taken after 48 hours in accordance with the previous procedure. Today, the new procedure allows patients to return home with one negative result, or, in the case of other types of symptoms, to be referred to the appropriate specific departments. Repeated sampling after 48 hours is performed when the suspicion of coronavirus infection cannot be clearly ruled out clinically. Coronavirus-positive patients who cannot be isolated in their homes will remain at our department until they are able to present the three negative samples required for their recovery.
-A practical question: what kind of things should the patient put together, i.e. what can they take with them to the center?
-They can bring to the center their personal items they may need during the care: toiletries, pyjamas, change of clothes, books, mobile phones, laptops. When they leave, they can take these out in a double plastic bag and quarantine them for 14 days. The mobile phone can be disinfected.
-In Baranya county, on 6 April we know of 23 patients infected with the coronavirus according to official data. Can you tell me how many are currently in the department?
-Only some of them, most of them are quarantined at home with mild symptoms. The good news is that we were now able to let a patient go home who has recovered. The number of suspicious patients is fluctuating, there are days when many patients are admitted. Fortunately, we have only had to isolate a few patients permanently so far, so bed occupancy is not maximized either.
-How many professionals are working at the center currently?
-There are 12 doctors at the ECU (Emergency Care Unit), 46 residents and specialists at the infectious disease department, and 22 doctors at the intensive care unit. As it is not possible to work for more than four hours in protective equipment, a change must be provided during the eight-hour shift. The psychological strain is also bigger than at a traditional internal medicine department, on the one hand because of the fear of getting infected, and on the other hand because of whether we have put on and used the protective equipment properly. It requires maximum concentration to prevent making mistakes even accidentally. In addition, we also encounter aggressive patients: the elderly who become difficult to treat due to fever, former drug addicts, or those who cannot tolerate confinement.
There are five professionals on each floor, namely five for 25 beds. Among them there is a manager who directs external-internal communication at the nurse station, and the others take turns in the red zone. After the shift, they relax in the yellow zone or prepare things for those working in the red zone. At each level, two doctors are on duty, a specialist and a resident are on call 24 hours a day. In the sub-intensive care unit, due to the increased workload, there are three people present, a 24-hour on-call internal medicine doctor and a resident, and an internal medicine resident in a 12-hour shift. As infectious disease specialists, there are three of us who treat the coronavirus patients and monitor their care on each floor. Since the opening of the center, we provide the department with professional background for ten hours a day, then we are on standby duty by taking turns and answer questions in connection with the coronavirus 24/7. In addition, my job is to coordinate outbound requests and actions, and send the evening reports, the latter usually taking place between 7 and 9 p.m.
-So, this is a state of continuous standby.
-Yes, we can relax for up to a few hours.
-The tasks to be solved are also to recruit professionals and expand the number of places, seeing the situation in Europe and also knowing – based on the government information on 4 April - that every eighth infected person is a healthcare worker.
-We are constantly planning ahead. We are watching when there will be an outbreak in the number of diseases in Hungary, which happened in almost all countries of the world. There is also a 40-bed and soon a 63-bed care facility in preparation and ready to use, and the training of the staff is in progress in parallel with further recruitment. Doctors, healthcare workers and volunteers are also on standby to join the work. I see medical and nursing backgrounds ensured in the future, there are only a few of us, infectious disease specialists. We have only one colleague who has come back from a long-term sick leave and has just started working today, with her there will be four of us. We also have infectious disease specialist colleagues who are not university employees. One of them, a retired colleague, undertook consultations and teaching, and a contract employee works at the traditional infectious disease department in addition to teaching.
-It is good to know that there are people to count on.
-That is right, and for that we are grateful, especially for the clinics from where a large number of doctors, healthcare workers, and residents have come to our aid. I do not want to single out any of them because we are thankful for all the clinics for providing us with doctors and healthcare workers. We talk a lot and hope that in Baranya there will not be such a mass disease as in New York or Italy, and thus the health care system will not find itself in an impossible situation.
-Do you have the opportunity and a little time to keep in touch with infectious disease specialists in other parts of the country or in Europe and to consult on key professional issues?
-We have very little time for this, but we occasionally share information with each other. We have a very good relationship with the virologists who work in an international network and constantly keep each other informed and us too, as well as with the chief pharmacist who helps us a lot in purchasing medicines. In addition, we also receive information from colleagues outside the profession.
-We know that there is no clear cure for this infection yet. Still, what treatment can patients with severe conditions receive?
-In Hungary, chloroquine and hydroxychloroquine are available for patients with severe conditions or requiring intensive care, and unfortunately, we were not able to purchase other drugs under trial, such as Remdesivir, which was developed against the Ebola. We asked for permission to purchase it for one of our patients, which we got from the Hungarian authorities, but the company could not provide Remdesivir for us. The only exceptions are pregnant women and those under 18 years of age. Older patients, therefore, who are at greater risk, unfortunately cannot access it. Other therapeutic options are still being tested, including the serum of already recovered patients so that patients with severe conditions may receive it. There are several medical literatures on their effectiveness, and there are also discussions on immunoglobulin products previously administered to severe, septic, immunodeficient patients.
-When the professional coordination of this center arose, did you have to convince yourself that you would make the right decision if you undertook it?
-No. My answer is definite because we have already started treating coronavirus patients in the infectious disease department, and simultaneously with the first mass diseases in China, we have set aside a few wards for this purpose. Later, during the enlargement, the whole department was dealing with patients who were suspicious or tested positive. I felt total responsibility, as did my infectious disease specialist colleagues. It has never occurred to us even for a moment that someone else should be doing this. That does not mean we were not and are not afraid of whether we will contract the disease, whether we do our job well, or whether we misdiagnose cases. These dilemmas constantly preoccupy us, but we are sure to be there for the patients until the end of the epidemic.
-As a leader, as a person, do you have a sentence or two in this distressed situation with which you can give strength to your colleagues?
-In the morning meetings with my colleagues, we always tell each other what we did well, we encourage new colleagues that they will get used to the work too, and I dispel their fears about the infection. I emphasize that we are safer here than outside, whether in malls or anywhere else, because we have protective equipment here and if we use them properly, we will be fine. I think these sentences are convincing to them. What I believe in is standing our ground without complaint and demand, which affects others as well. If colleagues see us working for the patients by putting everything aside, they will join us, and this is what is happening. The number of volunteer doctors and healthcare workers who have joined us is relatively high. We work together in a way that many of us did not even see or know each other before, we did not know about each other’s weaknesses and strengths. I am proud that we have managed to get through the last three weeks with little conflict and I see that everyone has a need for thinking together, a willingness to help.