Every weekday morning at 7 a.m. for the past few weeks, the surgical planning team at Universitair Ziekenhuis Brussel is faced with a choice: Which patients will be able to have surgery, and which won’t.
The deciding factor? Half of the intensive care unit (ICU) beds are needed for patients sick with the coronavirus.
For health care workers on the front line, Belgium’s fourth wave of the coronavirus pandemic is a “trial of survival, of mental survival,” says Dr. Jan Poelaert, head of UZ Brussel’s intensive care unit.
More than 27,400 people have died of the coronavirus in Belgium. The national Consultative Committee responsible for pandemic management on December 3 ordered schools to break up early and restricted large social gatherings after Belgian hospitals, overwhelmed with COVID-19 patients, temporarily suspended non-urgent care. On December 9, there were 827 patients with COVID in the ICU in Belgium. (On September 1, there were 193.)
At the hospital, the morning’s decision is a complicated one: The next available ICU bed can, at any time, be needed for emergencies like brain bleeds, life-threatening bacterial infections or acute heart disease. This leaves patients waiting for other urgent procedures — heart valve replacements, for example, after which they will need an ICU bed — in limbo, their doctors having to “negotiate” the urgency of their needs against that of other patients. Cancer surgeries have, for the most part, been able to continue as scheduled.
“For the patients, it’s a tremendous disaster,” Poelaert says, noting surgeries and procedures are sometimes postponed three times. “It brings a lot of misery.”
The hospital has had to do some reshuffling. Some of the operating rooms have been shut down, their nurses redeployed to the ICU. They expanded the number of adult ICU beds from 24 to 36 by converting other specialized units into ICUs.
“It’s heavy,” says Ronny Hertleer, a nurse working in the COVID ICU, of this fourth wave. The veteran nurse of 36 years cares for some of the sickest patients, whose heart and lungs are so weakened by the virus they require extracorporeal membrane oxygenation (ECMO). The machine adds oxygen and clears carbon dioxide from their blood before pumping it back to their body rewarmed, the blood cycling through plastic tubes.
His 13-hour shifts are punctuated, every two hours, by 45-minute assessments of his patients and of every medication and machine keeping them alive. Twice a shift, he turns patients who need to be flipped from their backs or their stomachs to help their lungs. “You sweat a lot,” he says.
While 76 percent of people in Belgium are fully vaccinated, approximately 75 percent of those in the COVID ICU are not. Before needing to be put on a ventilator, some of them shared with Hertleer concerns the jab would’ve affected their fertility, while others didn’t believe in the vaccine. Sometimes, they shared their regret for not getting it.
‘You cannot live on adrenaline’
Hertleer is exhausted. Faced with care backlogs from the previous three waves, the hospital has operated at full capacity for the last two summers, between waves, to catch up on postponed non-COVID care. Just as they’d mostly caught up, the fourth wave began. “You cannot live on adrenaline for 20 months,” says Dr. Marc Noppen, chief executive officer of UZ Brussel, whose main concern is the “stamina and the resilience of the co-workers.”
To help staff when they are “fed up or tired,” they brought back psychologists, psychiatrists and trauma specialists and based them in the hospital’s animal therapy center, redubbed Villa Resilience, where trained cats and dogs also provide comfort.
But Noppen is clear: It didn’t have to come to this. “We saw it coming,” he says of the fourth wave. He is critical of decisions that have arrived “too late,” referring to the December 3 measures, which include mask-wearing for children over the age of 6, early school closures for the holidays, and restrictions on indoor public events to no more than 200 people, each of them masked and seated.
“We know the drill,” Noppen says of the hospital’s procedures to scale up care for patients with COVID. But familiarity with the dominant Delta coronavirus strain may be short-lived with the arrival of the highly mutated Omicron variant. Omicron infections have continued to rise across Europe, and the European Center for Disease Prevention and Control (ECDC) warned it could supplant Delta as the dominant strain within a few months.
Researchers are studying the variant’s ability to bypass immunity provided by vaccines, with early studies showing booster shots may provide some protection. It remains unclear if modified vaccines targeting Omicron are required; If they are, the European Medicines Agency (EMA) said they could be authorized for use by next spring.
For now, the Delta strain has taken advantage of undervaccinated pockets of Belgium and of waning immunity from vaccines, says Dr. Yves Van Laethem, an infectious diseases doctor and spokesperson for Belgium’s national COVID-19 crisis center.
Vaccination rates vary by region in Belgium, from 93 percent of the total adult population vaccinated in Flanders to 71 percent of Brussels’ adult population. The booster shots rollout is ongoing across the country, with nearly 2.5 million doses given so far.
Last month, the EMA recommended the BioNTech/Pfizer vaccine be approved for children 5 to 11 years old. Health Minister Frank Vandenbroucke told reporters December 3 he had signed an agreement for the delivery of 336,000 children’s doses of the vaccine by the end of the month. These would be made available as soon as it is approved for the age group in Belgium.
Staffing strains
Earlier this month, European Commission President Ursula Von der Leyen said she personally felt it appropriate to discuss mandatory vaccinations in Europe, stressing that this was a decision for each member state. On Tuesday, thousands marched down the streets of Brussels protesting proposed legislation that would require unvaccinated health care workers in Belgium to be vaccinated by April 1 or risk losing their job. The bill will be submitted to parliament in January, says France Dammel, Vandenbroucke’s spokesperson.
Representatives from two unions which include health care workers that oppose the bill, CNE and SETCa-BBTK, say they are overwhelmingly in favor of vaccination, but that the mandate would worsen an already difficult staffing shortage across Belgium. They add that if the government’s position is that vaccination is important, it should be mandatory for everyone in Belgium. Around 10 percent of health care workers are not yet fully vaccinated in Belgium.
Staffing shortages are already behind the closure of 158 of Belgium’s 2000 ICU beds, according to Dammel. At UZ Brussel, where 98 percent of health care workers are vaccinated against the coronavirus, “if we could find 50 nurses, they could start tomorrow,” says hospital CEO Noppen, adding the situation is more dire in nursing homes and other hospitals.
This seismic wave of ICU admissions won’t be the end of the chapter. General practitioners are already bracing for possible aftershocks, worried about reliving a familiar double blow: Patients presenting to their offices later in the course of their disease in a backlogged health care system, explains Dr. Christophe Barbut, president of the college of general practitioners in the French-speaking part of Belgium.
But for now, Poelaert and the surgical planning team will continue to meet at 7 a.m., deciding before sunrise who will get the next ICU bed.
Poelaert has one word to describe his state of mind in this fourth wave: The Dutch word moedeloos, a despondency he says is worse than hopelessness.
“A fifth wave will come,” he says. “Certainly.”
This article is part of POLITICO’s premium policy service: Pro Health Care. From drug pricing, EMA, vaccines, pharma and more, our specialized journalists keep you on top of the topics driving the health care policy agenda. Email [email protected] for a complimentary trial.