A health system at the limit in the second wave of COVID-19 cannot follow up the patients with sequelae of the first wave

Julián Sotoca, 55, spent 40 days in the ICU this spring due to COVID-19, half in an induced coma: "I was very critical, twice on the verge of multi-organ failure. My family was warned that they could have a very bad news in no time. " Fortunately, he has just received his medical discharge (he was still on leave, although he left the hospital on May 14) and he is going to return to his job. He lost 17 kilos and all mobility, but he has recovered it after a rehabilitation in which his son, a physical education monitor, has helped him to a large extent. He assures that he does not suffer major sequelae beyond a pressure ulcer after 25 days with practically no change in position and a tone somewhat lower than normal: "I am not 100%, but I am 90%," he says. He had a follow-up appointment to check his condition at the Severo Ochoa Hospital at the beginning of September, but the last week of August they called him to cancel the tests he had planned (chest plate, spirometry and analytics) and the consultation. "They told me that with the outbreaks they are lacking means and that they can only attend emergencies, that they will notify me by phone or by letter for a new appointment," he explains.

Anosmia, pulmonary fibrosis, heart injuries: the sequelae of COVID-19 are the least visible face of the pandemic

Anosmia, pulmonary fibrosis, heart injuries: the consequences of COVID-19 are the least visible face of the pandemic

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In that hospital, Internal Medicine consultations for posthospitalizations have gone from ten a day to twenty a week since the beginning of September. "It is something hasty because there were still enough patients to review and now new ones will come, but it is true that the number of hospitalized patients does not allow us to pay as much attention to the consultations. that department, Patricia Moreira.

There are 9,752 hospitalized for COVID in Spain as of September 14, 3,095 in Madrid (that is, one in every five beds). The problems of lack of medical resources in most of the autonomous communities (such as they insistently denounce Primary Care professionals, now charged with tracking tasks), adds what some experts say is a second wave of coronavirus, or at least a significant rebound. There were 54,995 diagnosed in seven days as of this past Monday, compared to 1,737 in the same period three months ago.

And the complications and sequelae of the COVID disease suffered by some patients are joining these growing cases. The vast majority of those who pass this coronavirus infection overcome it without sequelae, but according to different studies, there are between 5 and 10% of those affected who suffer secondary effects to the disease itself, especially those who have suffered a severe COVID-19. In total, in Spain there are already more than 600,000 confirmed cases since the pandemic broke out in March, according to the Ministry of Health, which would yield a total of between 30,000 and 60,000 patients suffering from more or less disabling sequelae. Among other, have been described anosmia (loss of smell), pulmonary fibrosis, thrombosis, heart damage and muscle weakness. "They are pneumonia that take a long time to resolve, in some people up to three months, and their X-rays continue to see images of lung involvement," emphasizes Dr. Moreira.

Mood disorders are also highlighted as sequelae of this disease, "perhaps not related to the disease itself, but to the fears and anguish that it entails and that cause anxiety, depression and insomnia. Many patients demand psychological and psychiatric attention from us," he stresses. .

Neurological sequelae

"Probably the most complex problem is to attribute to what extent the symptoms are a consequence of the virus itself and not a consequence of having a serious illness. Because every patient who has a very serious illness is always more predisposed to have confusional pictures, to have weakness for having been in bed for many days, being a little disoriented, etc. ", stresses for his part the neurologist of the Hospital Clínico Universitario de Valladolid David García Azorín, member of the international area of ​​the Spanish Neurology Society (SEN).

According to the registry of neurological diseases related to COVID that Spanish neurologists have sent to the SEN these months, there have been 77 different manifestations of the disease, many times combinations of ailments. Some symptoms related to the immune response, such as headache, loss of smell, muscle pain, appear more frequently in people with a strong immune system, with greater responsiveness, that is, especially young people. Other symptoms such as encephalopathy, stroke, or seizures (much less frequent) occur more in older patients.

In any case, according to García Azorín "from a neurological point of view, in the very long term it is unlikely that anything will happen", despite the fact that more than half of those affected by COVID have neurological symptoms during the disease. A month after the virus has passed, the SEN estimates that between 10 and 20% of patients may persist with these problems, but afterwards the percentage decreases: "Once the symptoms have been resolved, generally the patient can be reasonably calm, because it would be unexpected and atypical to have them again ", ditch.

The neurologist emphasizes that his hospital is also canceling or rescheduling consultations due to situations such as loss of colleagues or redeployment of staff due to the increase in COVID cases and that schedules are being planned month by month, which entails a certain difficulty for follow-up of cases.

The persistent COVID collectives

Among those who do suffer sequelae, there are patients who suffer them months after having passed COVID. In Spain they have decided to group themselves territorially (in Catalonia they were the first, and later they did so in Madrid, the Valencian Community, the Basque Country and Andalusia) under the name "Affected by persistent COVID-19". There are about 1,500 registered in the different groups. "After having a first meeting together, we realized that we had a common denominator: we had all started to report symptoms of COVID-19 since the end of February and the beginning of March, which, far from having disappeared in two weeks, were still manifesting in a constant or cyclical way limiting us enormously ", they affirm. In certain cases, a PCR test could not be done at the time of the disease (there was very little availability in the first months) and now the serological tests do not detect the presence of antibodies. However, they came to suffer from symptoms of the disease that have become chronic or complicated with new ones months later.

This is the case of Beatriz, 40 years old. "In my case, my illness began with an irritating cough that lasted 10 days until the night of March 15 I began with tenths of fever and burning in my chest. That night I called the coronavirus information phone and after several calls finally An operator told me that if I did not drown, I should wait the next day to speak with my health center. " There they prescribed paracetamol and isolation. "That was the beginning of my hell, a never-ending quest of symptoms that lasted or went and came back cyclically: cough, diarrhea, nausea, tiredness, sore throat, burning chest, skin rash, persistent low-grade fever", Aftermaths that in several cases still continue, despite which he returned to work in August.

It is similar to what the Basque veterinarian Sonia Bilbao, 43, relates. "In addition to being a health worker, I am a mountaineer, I was used to pain and exertion. But now I have a feeling of fatigue since I get up. The little I do takes its toll. Since last March she has suffered from low-grade fever, phlegm, drowning, diarrhea, headaches ... A third example of this persistent COVID is the one described by Angeles, 30, a nurse in Valencia. Explain how at the end of March he was with a positive patient without the necessary EPIS. "They told me to watch me and after four days I started with a low-grade fever, sore throat, fatigue and discomfort. They did a total of three PCR and two serologies and everything came out negative." At present, she suffers from a low-grade fever (37.5–37.6) several times a day and a fatigue and malaise that prevent her from leading her normal life. "The specialist clearly told me that he does not know what is wrong with me and that he does not know if I am going to evolve for the better or worse, but that he has already done all the tests that he had to do and that I can only wait to see if it passes It is a desperate situation not to have a clear diagnosis, "he says.

Since last July, these groups collaborate with the Spanish Society of General and Family Physicians (SEMG). They have started a research project, with patient follow-up for at least two years, to obtain clear scientific evidence about what happens to those affected by persistent COVID-19. Its vice president and head of research, Pilar Rodríguez, emphasizes that these are people who are not in a life-threatening condition, but suffer paralyzing pathologies that are very harmful to their quality of life. Regarding the fact that in certain cases his tests are negative, he affirms that it could be possible that the current equipment does not detect certain forms of the virus, and recalls that sometimes they are trying to determine positive with stool samples instead of the respiratory and blood due to unexplained results in the last two before certain clinical pictures.

"They are patients who are 80% women, with a mean age of 44 years, and a severity of symptoms that can be placed at 5 on a scale of 0 to 10. Their sequelae are not related to the severity during the surgery itself. disease ", highlights this family doctor from Lugo.

And as in all the cases consulted for this article, he highlights the difficulties in the follow-up of some cases that present a high demand for care: "The health system is at the limit: we have been overworked for many months, but also the protocols do not include what follow-up should have patients with sequelae of COVID, "he says. A situation that could worsen in the coming months if the pandemic flares up in the autumn.


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