“We have a very good epidemiological investigation”: the head doctor of the hospital in Kommunarka - on the situation with coronavirus in Russia and the world

- What is the situation today in general in the country and in Moscow in particular?

- In Moscow, the situation is very open in terms of information. The headquarters Telegram channel (the channel of the Moscow operational headquarters on the situation with the coronavirus. - RT ) uploads daily reports with real facts.

The situation is tense, because the trend that I see is starting to grow slowly. I mean the average age of the patients. Earlier we, doctors, watched young children who returned from Italy.

We understood that their age explained the absence of severe patients (according to reports, coronavirus is most dangerous for the older generation. - RT ). There were only a few patients who ended up in the intensive care unit. While we are doing without mechanical ventilation (mechanical ventilation apparatus), but now we see that elderly patients appear, and here we must be on guard.

- How many elderly patients are there in the hospital?

- There are six people. One of them is in the intensive care unit.

- None of them on mechanical ventilation?

- None of them on mechanical ventilation. This is the Rubicon that I would not want to cross.

- When we talk about elderly patients, does this mean that we confirm, and officially, that the virus is in the general population, and these people became infected here in Russia?

- Working out these people, at the moment we understand that they all had contact with the arrivals or arrived on their own. Honestly, to the parents whom I call daily, I visit them at least once a week, I half-jokingly say: "See you in September."

- That is, you predict that it will all end in September?

- I look at what is happening in the world. There are several scenarios. If we follow the Chinese scenario, I hope that this will all end in May-June. But if we follow the Italian scenario, September will be considered a good story.

- Why? We don’t think that in Italy everything will end in May too? Here the weather improves - and it’s all over. We don’t think that Italy generally reacted especially hysterically to this, unlike Germany, for example?

- I would agree with you if we did not have a daily exchange of information through professional chats. For example, our Russian-speaking colleague from Italy sounded the alarm for 10 days when we were just starting to turn around in Russia (with measures against coronavirus. - RT ). She found my phone, called: “Denis Nikolaevich, but we have complete trouble. The north is on fire, our planned operating rooms have been closed for a week, they have been turned into intensive care units. I work in the San Rafaelo hospital on a regular basis, but at the same time I go out to other hospitals twice a week as an assistant. Because there are not enough resources. ”

- Why did this happen in Italy, but not in Germany? Why are statistics different?

- It will be more appropriate to compare Germany with Italy in two weeks. Now again lead from the fields: the German government placed an order with one of the manufacturers. I mean the company Dräger, which produces anesthetic and respiratory equipment. In Germany, there is no such situation as in Italy, but nonetheless ...

- That is, ventilators?

- Yes. We made an order for ten thousand ventilation devices, and now all plants will work only on the domestic market. I think that the German government makes such investments for a reason. Therefore, it will be possible to talk about the German scenario different from the Italian way in two weeks.

- We see how, say, in the same Italy or China, the epidemic developed exponentially. Do we understand that here, in Russia, the exhibitor will also begin?

- Honestly, so far the situation is not developing exponentially. Draconian measures in terms of developing contacts (diseased. - RT ), isolation and so on, which were taken in Moscow, allow this exhibitor to restrain.

- So we have a good epidemiological investigation?

- We have a very good epidemiological investigation. Probably, the Moscow headquarters does not tell much out of modesty. But, being involved, I understand how it works: how many people are involved in epidemiological investigations ... Nine people in our hospital only work around the clock in the epigroup.

The protocol, which is in our hospital and in Moscow, has no age limits. If we suspect pneumonia, including viral-bacterial, we scan all such patients at the entrance. And this procedure worked out to automaticity.

• Hospital building in Kommunarka at the address: st. Sosensky Stan, d. 8, p. 12, where patients with suspected coronavirus are placed
• AGN "Moscow"

Regarding the patient who died here at Kommunark, everyone said: “How did you do the analysis in 40 minutes?” No, just at the time of intubation (insertion of the endotracheal tube into the trachea in order to ensure airway patency) the smear itself is taken. All these manipulations are performed immediately upon admission.

- What is the clinical picture of the disease?

- Fever, dry cough. For those patients who were ultimately COVID-positive with us, it is always a high fever, but it can drop.

- By her own?

- By her own. Or against the background of a single dose of paracetamol. We observe, but do not treat, despite the fact that they are COVID-positive. A severe form is a combination of fever, cough, shortness of breath. And a very alarming sign is a decrease in oxygen tension in arterial blood. This is because a very large volume of lung tissue is included in the viral lesion, and it ceases to fulfill its main function - the transfer of oxygen from the outside to the blood. This causes compensatory shortness of breath.

“However, there are devices ...”

- They are. For example, ECMO (used in the outbreak of swine flu), but it did not bring any serious victories. There is the point: blood is taken, then it is passed through a special oxygenator filter. Instead of lungs, it saturates the blood with oxygen, and it returns to the body. But the experience of our Italian colleagues and Chinese doctors suggests that less aggressive methods, such as transferring a patient to artificial lung ventilation using certain modes, can be effective.

There are simpler ways to help - turning the patient on his stomach from a lying position on his back. Now this is one reliable technique to improve oxygenation and survive a critical situation. Thus, we avoid the use of ECMO - a very heavy aggressive technology.

With our first patient, which we transferred from intensive care, we performed this maneuver and achieved a good effect, while also avoiding tracheal intubation.

- So, the majority of patients with confirmed COVID are people in whom it passes by itself against the background of a single dose of paracetamol, right?

- Yes.

- Because they are young?

- Yes, they also complain.

• At the Sheremetyevo airport, sanitary control in connection with the coronavirus was strengthened
• AGN "Moscow"

- But the patient, 44 years old, who really was connected to a ventilator, got to you.

- No, there was no mechanical ventilation, he was with oxygen, in a position on his stomach. For nine days the patient was in the intensive care unit, around the clock with the constant presence of doctors and nurses.

- 44 years is not a risk group. Why?

- Because no one has canceled the concept of heterogeneity. Remember the saying: whoever is destined to drown will not burn. Each patient has a predisposition to some kind of ailment ... Someone tolerates a temperature of 37.5 without noticing at all, and someone cannot get up and go to work. It’s the same with the virus. Yes, in general, in the population - it's okay. But, if we recall the Chinese charts, the age of 30-40 years, still 0.1-0.2%, in my opinion, is.

- That is, he turned out to be the first patient from this 0.1%?

- I think yes.

- 44 years old. But a smoker. Accordingly, he, of course, has a defeat ...

- Yes, the background. Premorbide (a condition contributing to the development of the disease) is such.

“How did you treat him?”

- We started with antimicrobial therapy, an antibiotic protected by aminopenicillin. Because community-acquired pneumonia in 46% of cases is caused by streptococcus pneumonia. We did not see any improvement in the patient. Against this background, we changed antibiotic therapy. At this moment, academician Alexander Chuchalin (one of the largest pulmonologists of the Russian Federation, academician of the Russian Academy of Sciences. - RT ) arrived at the hospital. And in parallel, we received confirmation from the patient COVID and already prescribed combination antiretroviral therapy.

- This is the main question of all people. Why is coronavirus treated with Kaletra (an antiretroviral drug used to treat HIV / AIDS)?

- It's all about the accumulated foreign experience, primarily Chinese. When the pandemic began, the treatment was chaotic. Someone was treated with neuroamidase blockers, someone with antiretroviral drugs. And they saw that in the group of patients who were treated with Kaletra, there was no conflict of interest with other drugs.

We discussed this, of course, with our Moscow virologists and infectious disease specialists. Why did Kaletra enter the protocol for us, for Russia, for our clinic? Because the specific volume of patient studies conducted at Kaletra turned out to be higher. In this situation, few people argue precisely from the point of view of pharmacology, pharmacodynamics, pharmacogenetics. But more still they are repelled from the experimental path. And we appoint “Kaletra” not just like that, but discussing with patients, conducting a medical consultation.

- By the way, the first question of my colleagues yesterday: “And how did the doctors generally buy Kaletra?” This is an improper use, from the point of view of the legislation of the Russian Federation.

- Why? We got "Kaletra" from the 2nd infectious diseases hospital in Moscow. The focus of the media and society should be on the other.

In our country, there is such a story with COVID that older people do not die from the coronavirus, but with the coronavirus. You also need to talk about how important it is to avoid contact with your elderly parents, while ensuring proper care for them. About how important it is to wash hands, ventilate the premises ... Instead, they are looking for some catch.

- In Moscow on the 19th the first patient died. She was 79 years old. She had a suspected COVID , second degree diabetes, coronary heart disease. Chronic heart failure, even urolithiasis. What did she die from?

- Let us wait for the autopsy results. There was a consultation regarding this situation, including a team from the Moscow ECMO Center, which is located in the 62nd hospital. The woman was an elderly patient, and the deterioration came from a heart rhythm disturbance. Not with a progressive decrease in oxygen in the blood, which we could not cope with, namely, with a violation of the heart rhythm ... Chronic heart failure decompensated against the background of arrhythmia. What specific contribution COVID made here is a debatable issue. But I think that elderly patients, no matter where they are, in Russia or Italy, die from decompensation of chronic heart failure due to temperature and infection.

- Is it possible to say that a large number of elderly people at the same time can begin to get into intensive care. Are we afraid of this?

- In Russia this is not so. I constantly repeat the word “bye,” because no one knows what will happen tomorrow — the day after tomorrow. The Moscow healthcare system is already taking overmeasures and has bought mechanical ventilation devices.

- How many ventilation machines do we have in Moscow now?

- We have about five thousand units working for all city hospitals. This includes anesthesia machines. If you turn off the narcotic drug, in essence it will represent the same mechanical ventilation apparatus.

- Well, after all, people also need to be operated on.

- In this situation, as a rule, multidisciplinary hospitals, if we follow the bad, Italian scenario, leave only emergency operating devices. Relatively speaking, a person with cholecystitis (inflammation of the gallbladder. - RT ), who needs to be operated on, or with a hernia, can wait.

- Do you think the Moscow health care system is ready?

“Ready, yes.”

“Are we ready for a real exponent when we have 2.5 thousand confirmed cases per day?”

- First of all, it is possible to re-profile hospitals.

- What hospitals are ready for this?

- We have fully prepared for this the 52nd hospital, where the ECMO Center is located. The 68th hospital, which has already been redeveloped, is ready. The experience of our hospital in Kommunark suggests that re-profiling can take about 10 hours. Although a lot depends on the number of patients. We had an almost empty hospital, and therefore it was easier.

But the most important thing is that the behavioral medical model has already been worked out, there is a team, there is a headquarters, there are trained multidisciplinary teams that have been trained. There is an understanding of how to act. What is very important to me, there is a team of young volunteer children who are ready to help. Some of them went through our department, this is a separate pride.

- Your department is the department of anesthesiology ...

- And resuscitation FDPO (Faculty of Continuing Professional Education) 2nd Honey (RNIMU named after N.I. Pirogov. - RT ). Department of Academician Mikhail Gelfand, of whom I am a student. These are the values ​​that have been instilled in us, and now we are broadcasting them ... This team can come to any hospital, turn around, start training. Those scripts, protocols that were developed by us in Kommunarka as a starting treatment are simply brought and given to colleagues from other hospitals.

“You are entering the Moscow operations headquarters.” But how do you, as a physician, work with the Moscow authorities?

- I work very comfortably. Because they hear me as a doctor 24 hours a day. And if I feel that I do not have enough resources, I can call my boss at any time. I mean the head of the Moscow Department of Health. And most importantly, the solution of issues is accompanied by the absolute support of the team of chief physicians.

- I often hear that the headquarters are led by people who are not related to health and medicine. Are there experts besides you?

- Of course. The fact that the vice-mayor is in headquarters who oversees our work (we are talking about Moscow Deputy Mayor Anastasia Rakova. - RT ) is an absolutely professional manager who relies on the opinion of experts and makes the right decisions. The headquarters opens hospitals and conducts epidemiological investigations.

- Why is a separate infectious diseases hospital being built here, nearby, on the Kaluga highway?

- Because there is always a "plan B". And in this "plan B" it is better to overtake than to repeat the Italian script.

- There are two points of view on the fight against coronavirus: Italian and English. Italian is that it is necessary to quarantine everyone and thus stop the spread of the virus. And the English one is to quarantine only the elderly, and all the rest should develop population immunity.

- My main complaint to the English scenario is that older people do not always, unfortunately, can bring a bag of food and toilet paper, set up Skype and more. Some of them are bedridden patients, patients with poor rehabilitation potential, after a stroke. They need appropriate care. The English script does not answer the question of what to do with it.

Another point is whether there will be a second outbreak of coronavirus in the next 3-4 months? Therefore, we cannot now say whether the acquired immunity to COVID exists and whether it will appear. Therefore, from my point of view, the Italian way is more humane and reasonable.

• An employee of the laboratory FBUZ "Center for Hygiene and Epidemiology in St. Petersburg" is testing samples for coronavirus.
• © Alexey Danichev / RIA Novosti

- That is, you propose to close Moscow, metro, transport?

- At a certain stage, the price of the issue can be very high. Looking at what is happening in Italy, I believe that such measures can be taken, and, by the way, cancel car sharing.

“I can't imagine it.” During the war, the subway worked. And you suggest to close because of COVID .

- You can recall the war, but you can - "Spanish".

- But we do not have such mortality as from the Spanish.

- For now, yes.

“Do you think she will be?”

- I always come from the worst case scenario.

- Good. Why did the Wuhan epidemic stop?

- I can’t answer for sure. I think because there were also very strict quarantine measures there.

- But at the same time, none of the largest cities in China was closed.

- I explain this with timely measures.So now in Moscow (as part of an epidemiological investigation) the first, second and third contact groups are being tracked. The calm situation today in other cities with a population of over one million people: Yekaterinburg, Novosibirsk, Irkutsk.

“Maybe no one pays attention to these old people who die at home?”

- This is the null hypothesis, it must be confirmed. And I’m talking about closing Moscow as a possible option.

- What do we recommend people do now?

- Three things. Do not panic. Follow the instructions published by the official medical authorities and take care of the elderly.

- And the last question. Suppose I start tickling. Can I take a coronavirus test?

- A high-risk group needs a coronavirus test. If you have a sore throat, temperature, you need to insulate yourself. If you are in constant contact with people, then it makes no sense to take it. You went down the subway, met someone, talked ... What to do? Pass a new analysis?

- That is, it is not just not necessary, but also harmful?

- Suppose you are a young man, and as a result, the coronavirus was confirmed, but it is asymptomatic. What to do? Isolate.