At 6 a.m. on a Monday morning, the start of the early shift, there are 19 extremely ill patients in the COVID-19 intensive care ward of the Leipzig University Hospital. And one dead body.
The man died a few hours ago in room B1115 and the corpse is lying on a bed, shrouded in a black plastic body bag. It will stay there for another two hours, in a room with two other patients. They are still alive, but have been put into artificial comas, sedated with benzodiazepines and opiates. Artificial lungs are supplying their blood with oxygen while dialysis machines have taken over the function of their kidneys.
At around 8 a.m., the morticians arrive and take away the body. There is no room set aside for mourning, no candles, no last moments of togetherness. That’s what it’s like to die in the coronavirus intensive care unit, where deaths are mounting as the fourth wave breaks over the country.
A total of 55 nurses work at Station IOI-C, and 12 of them are on duty on this Monday morning, along with an assistant who brings material into the room, picks up blood samples and returns with the results. With 18 patients already in the ward, it has actually reached full capacity, but new ones keep coming.
At mid-week, the seven-day incidence in the city of Leipzig was at 438.5 per 100,000 residents, and as high as 1,064.3 in the surrounding area. And finally, it is becoming clear to everyone that Germany is facing a catastrophic corona winter.
"We are certain that the fourth wave is going to be a nightmare," says Sylvia Köppen, head nurse at the Interdisciplinary Surgical Intensive Care Unit (IOI).
"It's all good." Intensive care nurse Andreas KnauthFoto: Sven Döring / DER SPIEGEL
"We are certain that the fourth wave is going to be a nightmare,” says Sylvia Köppen, head nurse at the Interdisciplinary Surgical Intensive Care Unit (IOI).
"It’s going to be a catastrophe," says Andreas Knauth, a nurse specialized in intensive care and anesthesiology.
"It just going to be terrible," says Anke Schrötter, also a specialist, who has been working in health care for 18 years.
DER SPIEGEL spent three days with her and her colleagues in a station that has already reached its limits. It is a place where the fear of what lies ahead in the coming months is at least as great as their incomprehension for a society that is simply carrying on as if the coronavirus were history.
Monday morning, 6:15 a.m., 19 patients in the station
"One thing we have learned is that COVID is an asshole," says Knauth, just beginning his third early shift in a row. He has two more ahead of him. The rings under his eyes tell you all you need to know about his work schedule: four late shifts, then a day off, five early shifts, two late, two early. And any time he doesn’t have off is full of stress. "You can have the perfect patient for seven hours, with all the values stable and everything going well. And then COVID will just rip him away."
Like all the nurses here, Knauth is in high demand. When he moved to Leipzig in 2018 with his family, he was able to choose which hospital he wanted to work in – and decided on the university hospital. When his patients are stable, he says: "It’s all good." In his next three early shifts, he will have sole responsibility for two patients in room B1113, both of whom are in artificial comas.
In the bed up front is a 47-year-old woman who weighs 100 kilograms (220 pounds), suffers from diabetes and chose not to get vaccinated. "It hits the obese first," says Knauth. In the next bed lies a 37-year-old who is just half her weight and fully vaccinated, but he had a lung transplant. To prevent the body from rejecting transplanted lungs, the immune system must be suppressed by way of medication, which led to the man’s severe case of COVID.
A black crust stretches across the man’s breast, a condition called necrosis – essentially dead tissue stemming from decubitus. Decubitus, commonly called bedsores, is a sign that the patient has been incorrectly positioned and is often an indication of poor care. But here, in the war against the virus, decubitus is but the collateral damage of survival. The patient has to lie on his stomach so that his lungs can be sufficiently ventilated. But if he lies on his stomach, his breast suffers.
"COVID takes the satisfaction out of nursing," says Knauth, saying that caregiving at a COVID intensive care ward has very little to do with the training he received. The primary goal here, he says, is not that of reestablishing health, rather it is a desperate battle aimed at somehow keeping the patient alive. In other words, it’s better to survive with an ugly scar on the thorax than it is to die beautiful. Knauth has a term for it: "survival pragmatism.”
A nurse carries the belongings of a deceased patient out of the ward.Foto: Sven Döring / DER SPIEGEL
The people that Knauth is helping to survive are all hooked up to ventilators. A thick tube with air leads into the mouth, joined by two smaller ones. One of them is used to pump air into a balloon so that the thick tube doesn’t slip out. The other is for the extraction of secretions. A tube going in through the nose leads to the stomach and provides the patient with nourishment. The dialysis catheter is attached to the neck, while the central venous catheter is in the groin. Then there is the urinary catheter and additional entry points in the arms. The patient is sedated with midazolam, a benzodiazepine and with sufentanil, the strongest opioid approved for use in Germany.
Caring for two patients in such a condition requires eight hours of hard work and extremely high levels of concentration. Mistakes can be deadly. Knauth must keep a close eye on a dizzying number of different drugs along with four machines. He has to keep track of blood levels, air pressure and saturation levels. He must correctly interpret the endless columns of numbers on the various screens and react appropriately. "It is exhausting over time," he says. "You can never relax." There is a constant chorus of peeps and rings. If there is just a quiet chirping, then "it’s all good." But when the sounds become shrill and loud, then things get hectic. Everything is monitored, but nothing is really under control.
Three years of training are required to become a specialized nurse, with an additional two years necessary to become an intensive care nurse. And it takes two more years, says Knauth, before you’re really confident about what you are doing.
His female patient has a fever of 39.8 degrees Celsius (103.6 degrees Fahrenheit) and her skin is cold to the touch. She manages 13 breaths per minute, with the help of a ventilator. Should her oxygen exchange get much worse, she might need to be hooked up to an ECMO machine, which completely takes over the function of the lungs.
Knauth’s other patient on this morning is managing to take 12 breaths per minute on his own. It is his 19th day in intensive care. He’s still not getting better, but at least he’s still alive. He, too, may ultimately need the ECMO machine.
"The ECMO doesn’t cure anything, it just buys you a bit more time," says Robin Müller, also a specialist nurse. It is, he says, a common misunderstanding. ECMO stands for extracorporeal membrane oxygenation – a machine that ensures that oxygen gets into the blood and carbon dioxide is pulled out. It is the last hope for COVID patients. And its operation, says Müller, is a "delicate balancing act," because it can cause serious health problems.
In order to stave off the ECMO machine for as long as possible, patients who are in artificial comas must be regularly turned. A doctor stands at his head with four nurses surrounding the bed, two on each side. "Which direction are we turning," asks the doctor. "To us," says Köppen, the head nurse. She and her partner pull on the patient while Knauth and his partner push. The doctor follows the rotation with the patient’s head and the tubes.
"Careful with the catheter!”
As the patient is being turned, a maze of wires and tubes must also be shifted. The patient is now lying face down.
Eight interlocked arms belonging to four nurses bent over the patient lift the body 30, perhaps 40 centimeters above the mattress. Müller shoves two pillows under the patient, one in the breast area and the other just above the groin – part of the fight against bedsores.
Nurses in the intensive care ward at the Leipzig University HospitalFoto: Sven Döring / DER SPIEGEL
The perhaps most important principle in this intensive care station is "keeping the hallway clean." Contaminated protective clothing must remain in the rooms. Without exception. The nurses don their protective clothing outside the room, and then take it off inside before leaving.
On the way in, that means they must disinfect their hands, put on their gowns, put on their gloves, put on their facial protection, their FFP-2 masks and then their visors.
On the way out, they must first take off their gown then their gloves and facial protection, disinfect their hands, take off their visor, replace their FFP-2 mask, disinfect their hands again and then leave the room.
"I’m not particularly worried about contracting the virus here," says Felix Dietze, a 31-year-old nurse. He knows what he’s doing at the station, he says, and has protective equipment. "It’s a different story in the tram." He says he has been vaccinated and received his booster. If he is worried about anything, it’s that he could bring the virus home with him. His son is eight years old.
The beeping suddenly grows shriller and louder. A woman in room B1124, bed number 46, is extremely agitated and has pulled the breathing tube out of her throat. A nurse quickly dons her protective equipment and runs off.
Nurse Felix Dietze says he's afraid of bringing the virus home to his family.Foto: Sven Döring / DER SPIEGEL
Knauth learned the job from scratch. After finishing high school, he did his civil service – which used to be a mandatory alternative for those who didn’t want to join the military before both conscription and civil service in Germany were discontinued in 2011 – at a hospital and enjoyed the work. Now, Knauth says, he wouldn’t advise anybody to become a nurse.
Tuesday morning, 5:50 a.m., 22 patients in the station
The labor union Ver.di is setting up tents outside the main hospital entrance for a strike. They are demanding pay raises for nurses of 300 euros per month. "Money isn’t the problem," says Knauth, "at least not here." The situation is much worse, he says, in geriatric care. An intensive care nurse earns a gross average of around 45,000 euros per year.
Knauth says the union didn’t ask him to go out on strike. Had they done so, he adds, he would have told them that he still had to save the lives of a few anti-vaxxers.
It’s now time for the handover briefings outside the rooms, where they speak the sober jargon of their craft. "The cuff is overinflated." "Have the values been checked and sent off?" "The patient arrived yesterday during the late shift, not as bad as we had been told. Already in ventral position."
The man with the transplanted lung survived the night. "It’s all good," says Knauth.
Bed number 51 in room B1126: a 54-year-old male patient. He spent two weeks in an artificial coma, was regularly rotated from the ventral position to his side to his back. Until just two days ago, oxygen was continuously pumped into his lungs through a tube from a ventilator, an Evita V600. He was on dialysis until yesterday. Today, though, the man can speak. A nurse says that he has just claimed that the virus is an American invention and that vaccination is pointless.
"Here, on the inside, we are all preparing for the absolute worst," says head nurse Köppen, "and out on the street, people are talking about Christmas markets and plane flights." She simply can’t reconcile the two realities. It’s like they’re living in a parallel world full of suffering, labored breathing and death while outside, the party keeps on going. And politicians stand on the sidelines and do nothing.
"She's been living here for the last 18 months." Sylvia KöppenFoto: Sven Döring / DER SPIEGEL
In her early shifts, Köppen takes care of two patients. After that, she puts together the shift schedule, orders supplies, and takes care of some administrative work. Her colleagues say: "She has been living here for the last 18 months.” Köppen has the sharp facial features of a person under permanent stress. When she steps outside for a cigarette once or twice during her early shift, she wears a hoodie reading: "Mother nurse. Shocked by nothing."
Köppen no longer believes in such things as rationality, understanding and education. She says a television crew was at the hospital to film the suffering. After it was broadcast, she says, she was asked where she found all the extras to play the patients. She has seen family members of patients in intensive care expressing doubts that COVID is really dangerous. One COVID patient told her that he didn’t get vaccinated because he can’t stand politicians. "As if the politicians would care," Köppen says.
In Köppen’s world, the greatest share of which is the intensive care station, winter is going to last a long time – likely until March or April. "We were completely overwhelmed by the second wave," she says, adding that this one is going to be far worse.
"Even if huge numbers of people were to now get vaccinated," says Köppen, "they wouldn’t be fully protected until the middle of December. And that is too late to prevent the intensive care stations in the country from being overrun. "The catastrophe can no longer be prevented."
The new arrival in room B1115 is lying sedated on his back, his arms immobilized. "A precautionary measure," says the nurse Robin Müller. He says that people who have a ventilation tube in their throats often reflexively try to pull it out. The new patient is doing relatively well compared to the other three in the room. "They are all suffering late-stage corona," says Alexander Leitner, 48, a doctor at the station. His nickname, Alei, is written on his mask.
Leitner says the coronavirus has taught him two things. The first is to recognize the most important things in life. Closeness with those he loves, spending time together, honesty with each other: All those things, he says, are more important than status or money.
Second, that society is undependable. Egotism has gained the upper hand, he says, and individual freedoms have been prioritized above all else.
Leitner walks into a room saying: "Peace, freedom and no dictatorship." It is the battle cry of the those in Germany who oppose all measures to combat the coronavirus pandemic. The doctor dives into his work, but then looks up after a bit and says: "In my next life, I’m going to be a corona truther." He pauses briefly. "I’ll print T-shirts, make my money and then retire, that’s what they do." Sarcasm can be a helpful tool in surviving the madness.
On the counter lies a sheet of paper printed with "The Story of Caspar, the Anti-Vaxxer." "The third wave had arrived with force, but he was convinced of his YouTube source: I don’t need vaccine, no, I don’t need vaccine!"
"People don’t always understand our humor," says Müller. "When things start to get bad, the joking stops." From that point of view, the worst hasn’t yet arrived. But that situation won’t last long. The Dresden University Hospital is no longer taking patients, and some will soon be sent to Leipzig. What then?
Outside, Ver.di is still demonstrating for more money to be made available for nursing. Knauth says: "A much bigger problem is the shift work." When he emerges on Monday morning from the night shift, his work schedule notes that he has Monday "off" even though he has already worked for six hours that day. And then there are the rotations: Every few days, nurses are moved from the early shift to the late shift, and then to the overnight shift. When you’re young, says Knauth, you can deal with it. But then, he says, "it gets harder, and especially once you have a family." Knauth is 37 and has two children.
Knauth believes the problem is that nurses haven’t adequately joined forces in a labor union. "The largest group of health-care workers has the smallest lobby," he says. The unions, he adds, are small and fragmented, adding that nurses have never really learned to stand up for themselves. Knauth is not a member of a union either.
In the office of Christoph Josten, the university hospital’s medical director, a small globe sits on the shelf among the medical books. He warned way back at the beginning of November of the approaching "tsunami wave."
He says that when it comes to nurses, his hospital is in relatively good shape. Rents are affordable in Leipzig, there are plenty of young people in the city and lots of training programs available. "We know that the situation is quite different elsewhere," Josten says.
"A university hospital," Josten says, "is like a giant ship, and the nurses are its engine room. If they are exhausted, you can’t do anything anymore and the ship grinds to a halt." He says the hospital’s board decided in mid-September to cut back on activities and cancel non-essential operations to give staff a bit of a break, eliminate overtime and give people a chance to go on vacation. "Our primary goal was to give our staff a chance to relax and gather their strength," Josten says. And then the fourth wave arrived.
There is an important question that doctors are unable to answer, says Josten, one to which only society can provide a response. "To what degree can we tolerate a situation in which many patients must go without treatment because a specific group is blocking vital resources?" He means the group of those who refuse to be vaccinated.
Wednesday morning, 5:45 a.m., 20 patients in the station
The Day of Repentance and Prayer, on Nov. 17 this year, is a holiday in Saxony. Three-hundred meters away from the hospital entrance is a group of 10 men, a long night of partying behind them. They are drinking and smoking, with not a mask in sight.
Inside, at the intensive care station, Anke Schrötter, 44, is furious. One of her patients in room B1129 is responsive. The man told her that he didn’t get vaccinated, saying the vaccines can’t be trusted and people also die from the flu. His wife, who works in geriatric care, also has also chosen to forego vaccination. "We provide equal care to the unvaccinated and the vaccinated," Schrötter says. But hearing such things, she says, hardens you. Now, though, Schrötter has to move on and rotate a patient. She starts putting on her protective gear.
Meeting time: Part of the intensive care team at the Leipzig University HospitalFoto: Sven Döring / DER SPIEGEL
In 2019, around 55,000 protective gowns were used at the hospital, a number that rose by 132 percent in 2020. Before corona, they used 900 FFP masks, but usage spiked by 3,444 percent in 2020. When the second wave peaked around last Christmas and then finally abated in spring, "we were certain that we wouldn’t be able to withstand a third wave," says Knauth.
In the currently building fourth wave, says head nurse Köppen, they have treated 80 patients thus far, and 54 of them have been unvaccinated. "Vaccinated patients only end up in our station if they have a serious pre-existing condition," she says.
Schrötter, a wiry woman with shoulder-length blond hair, cared for the very first coronavirus patient admitted to the hospital. That was back in March 2020, and patients were flown into Leipzig from Bergamo in northern Italy, where the pandemic first flared in Europe. The disease was completely new back then and not all that much was known about it. Fear was everywhere, there was no way to treat infections and people were generally cautious. They stayed at home and practiced social distancing.
All of the 20 patients currently being treated in the intensive care ward are infected with the coronavirus, but only 15 are there because of the virus, including a woman who contracted the virus late in her pregnancy. The child was born via Cesarean delivery. Five patients ended up in intensive care for other reasons. One of them had a stroke, an elderly woman has abdominal bleeding, there is an attempted suicide, a victim of a car accident and a man who fell down the stairs when he was drunk.
"In the second and third waves, we hardly had any accident victims," says Köppen. People were more careful and there were fewer accidents. That, too, is different this time around. And what about the medical emergencies that are unavoidable? "More COVID patients makes it extremely difficult to treat non-COVID patients," she says.
In room B1115, a man dies at 11:42 a.m. He was still responsive when he was brought in, Müller said on Monday. He was complaining and saying that he didn’t need treatment. Now, he’s dead.
"In the last wave, corona patients spent an average of 10 to 20 days in intensive care," says Köppen. Now, in this wave, the patients are younger, and they die slower. She doesn’t have precise numbers yet, she says, but she talked with colleagues in Berlin who have been dealing with the fourth wave for longer. "They say patients are spending much longer in intensive care."
After the man dies in room B1115, it gets unusually quiet at the station. The normal buzzing and beeping continues, but there are none of the alarms that so frequently crop up. "Totally unusual," says Knauth. He walks into the hallway and says: "What’s going on? Is this the calm before the storm?"
Outside, in front of the hospital entrance, a large Christmas tree has been set up. But the Christmas party has been cancelled.