A Catalonian family doctor in COVID-19 – How much can you give before it’s too much? A crisis of PPE

DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.

Date of interview: 17th March 2020

Number of confirmed cases at time of interview: 11209

Number of deaths at time of interview: 501

Population: 46.6 million people

Today, I am speaking to Dr Miriam Rey who lives in Barcelona with her husband and toddler. Miriam is also someone I know from the European Young family doctor network, VdGM, and is someone I deeply respect. We first met at the pre-conference in Copenhagen where she really opened my eyes on the importance of touch during patient consultation. Being British/Japanese, I like my personal space but Miriam taught me that there is a level of humanity that can be conveyed through physical contact. I wish it was in better times that we could chat but I really wanted to know how Spain was coping under the new changes.

Spanish international borders were closed on the 16th to try to stem the spread of COVID-19. Spain is also currently in the midst of a quarantine lock-down and I ask her how that is going because it is on the cards for the British next. Barcelona, where Miriam lives, is the second hardest hit after Madrid. People are supposed to be indoors except to get food, medicines or to seek medical attention and the government has drafted in the military to enforce this. If caught outside without a relevant excuse or papers, they are able to fine you 1500 to 600,000 euros. She says that people are going a little crazy already because of this quarantine and is a little worried about how people will cope if this gets extended. There are queues outside the supermarkets because there is a ‘one-in-one-out’ system to minimise shoppers inside and people are stockpiling thermometers and alcohol sanitiser (like in the U.K). She says that everyone is panicked but yet they attempt to carry on with their daily lives despite the quarantine, like smoking in the street or walking their dogs. I find this behavioural psychology interesting because it’s the same in the UK. Everyone talks about COVID-19 all day, get panicked and then go out for dinner despite being told to minimise non-essential contact. Perhaps we find it difficult to accept this infringement on our personal liberties compared to our East Asian colleagues. This is corroborated by another Spanish friend, who lives in Ibiza, who is aware of up to 50 private jets that flew to the island this week from across Europe, including Germany, Milan, Holland, Madrid and Spain. It sounds like there are some people who are really not understanding the situation and have more money than sense.

A sign outside a shop stating the one-metre apart rule
The train on Miriam’s commute

Those who are worried about having COVID-19 in Barcelona used to call the emergency number 112 in order to be triaged. Unfortunately, this meant that this number was jammed a lot of the time which meant reduced access to all the emergency services including ambulances and firefighters so now this has been separated. Much like Germany, Spain has a decentralised health system, with 16 regions that have their own rules and regulations, which has similarly posed issues on delivering a top-down protocol. Five days ago, the Ministry of Health took back temporary control (along with temporary centralisation of the train services and military) in order to speed up the process and to introduce the harsher rules of self-isolation. We’ve talked on my medical anthropology Masters about the interaction between conspiracy theories and medicine and I wonder whether these authoritarian methods of surveillance and control in times of emergency will open the doors to a more totalitarian governing system. Who knows?

Currently, the family doctors in Spain are working with only simple surgical masks of which they are rationed one per day. If there is a patient who looks like they could have COVID-19, a special box with Personal Protection Kit (with FFP2 mask, eye protection and apron) is opened and only with the permission of the senior clinician. In Spain, family doctors also run the emergency department so Miriam is exposed to many respiratory conditions, all with the potential of being COVID-19. The morale amongst Spanish healthcare staff appears to be low and this has been exacerbated by the recent rule to stop testing healthcare staff (we suspect due to a lack of tests although this is hard to prove). Miriam reminds me that their health system has been chronically understaffed (much much more that the NHS) and a doctor can earn only between 1100 and 2000 euros a month for ALL the work that they do. I remember that there were strikes at a similar time to our 2015 UK junior doctors’ strikes in Spain and I know that there was a lot of discontent in their workforce in the recent past. This is a link to an article about the Spanish healthcare system by a UK trainee who had been on a VdGM conference exchange to Madrid.

Miriam and her colleagues in their PPE

In Spain, once qualified, doctors are expected to do residency before becoming a bona fide specialist. Final year residents (Spanish equivalents of specialty trainees) are expected to step up to Completion of Training (CCT) level for the foreseeable future through this crisis and have been told that they would not receive the appropriate pay rise. And bizarrely, final year medical students will be expected to work at post-CCT specialist doctor level which technically means that a final year resident would be taking orders from someone fresh out of medical school!! I’m not sure if this makes logical sense. In the UK, there is talk about later-year medical students being asked to step up as health care assistants (HCA) or physician associates (PA) but, in Britain’s accountability culture, I doubt they would be allowed to work as doctors. Miriam and I both feel sympathy for these Spanish medical students who will be stepping up having bypassed the training scheme. We both laugh as we reminisce over the first time we both did night shifts as junior doctors. I was teaching Miriam the phrase “rabbit in headlights” as she teaches me the Spanish equivalent “octopus in the garage” – either way, I cannot imagine what it must feel like for a newly-qualified to be put on the front-line like that.

Although medicine always has been and always will be a vocational job where we have signed up to help other people, Miriam questions how much you can give before it becomes too much. Now that she feels that doctors’ and nurses’ lives are at risk and that she is potentially compromising the health and safety of her friends and family, she thinks that this is the limit. She feels that the message that they are receiving as front-line staff is that everyone has rights but doctors don’t. I can feel Miriam’s desperation where she feels stuck between wanting to look after her patients but not feeling adequately equipped to do so – like being sent into war with only a stick to defend herself. She feels that there might be radical changes after the virus is controlled, perhaps even a strike. COVID-19 seems to have really taken the Spanish workforce to the brink.

We talk also about how the community is coming together. In Edinburgh, a local shop had created COVID-19 packs for the elderly which included a toilet roll pack, paracetamol and hand wash. In Miriam’s block of flats, there are posters in the elevators for offers of help to elderly, vulnerable or less mobile members. Spanish university students, who now have no university classes, are offering childcare services whilst schools are closed for parents who need to work. ‘Care-mongering’, an initiative that started in Canada, is trending across the world and groups are setting up on Facebook to help the vulnerable. After we finish talking, Miriam sends me this video (see below – sorry, I don’t know how to rotate it) and she tells me that there is a round of applause every evening at 8pm in Barcelona to thank all the emergency services. I got really emotional when I watched it and Miriam told me that she had cried too.

I thank Miriam for the time to be interviewed and I wish all my Spanish colleagues strength through these adverse times. I look forward to the day we can share una cerveza without any worries again x

Miriam tells me that there is a round of applause at 8pm every evening to thank all the emergency staff – I felt quite emotional watching this.

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