The Swedish Approach

Angelica and Felix are an amazing couple. They are both physicians living in Sweden and both working directly and indirectly with COVID-19. Felix is a German doctor, he is an intensivist working at Karolinska Hospital, one of the biggest hospitals in Sweden. Currently, he works mainly with patients with COVID-19 in the intensive care unit. Angelica is a Mexican scientific researcher with a medical degree. She works at the Center of Infectious Medicine at Karolinska Institute in Stockholm. Her research field is the immunology of viral infections in the central nervous system. Currently, she is also participating in a scientific project on COVID-19 research and in the building of a biobank for COVID-19 patient samples.

In the following interview we asked Felix about his experiences working in Sweden during the COVID-19 pandemic:
„I have been working at the Karolinska University Hospital in Stockholm, Sweden for about two years now. At the moment my duty is 100% intensive care medicine where the overwhelming majority of the patients is attended for severe courses of COVID-19.
At our hospital a lot has changed during the first weeks of the pandemic. Almost all elective surgery has been postponed. Normally, we only have one ICU which can take care of around 10 ventilated patients and right before the highest amount of patients arrived we augmented our capacities to four working ICUs for up to 80 patients. Our work schedule was changed completely, we were required to work more and longer shifts and to be available by phone 24/7 in our spare time. As time went by, we also developed a set of policies regarding protective equipment, patient flow and treatment and the restriction of visitors. The policies concerning the personal protection equipment and procedures for the people working in the ICUs have been quite strict from the beginning and I am not aware of nurses or doctors that have been infected in this setting. On the other hand, the rules on the wards sometimes seemed a little arbitrary, especially in regards to patients with unclear infection status and there have been various complains from health care workers.
The overall workload has of course increased quite a bit. This is especially true for ICU-nurses who oftentimes were forced to work a lot more than they usually do. Fortunately, nurses from other wards could be trained rather quickly to work at the ICU under the supervision of the specialised nurses.
Interestingly, we have noticed a significant decline in hospital admissions due to non-COVID causes, but we are unsure about the reasons. At least in part people seem to avoid the hospitals for fear of being infected with the coronavirus.
Concerning our attitudes as medical staff towards patients I have not noticed much of a difference and the relationships between colleagues have actually become much stronger in a lot of cases due to the increased time we spend together.
I have been quite stressed due to the workload, but I always took comfort in knowing that it is not going to be for more than 2-3 months. Fortunately, my girlfriend was able to take care of almost all of the household activities including the entertainment of our two kids so I could at least relax a little in my free time. She did that besides working for the Karolinska Institute from home, so I am very grateful for her sacrifice. Beyond that, our personal life was pretty much on hold during the past 3 months.
There has been a lot of communication between colleagues and at the ICU we even have the possibility to talk to trained psychologists who have been present almost every day. I personally did not feel the need for that kind of help although especially the issue of exclusion of older patients from ICU has been emotionally draining for me. There have been various directives concerning the selection of patients suitable for intensive care here in Sweden, that is to say, how we are supposed to choose those that have a decent chance of survival. In one of the documents that was applied in our hospital one of the criteria was that patients with a biological age (not the same as chronological) of over 80 years should not be accepted in intensive care because their chance of survival was seen as very low. This of course creates an ethical dilemma because it is unclear how low a chance of survival should be to be considered too low. In the end having only 5% survival in this age group would still mean a lot of saved lives if you consider the amount of people affected. On the other hand, this amount of patients would have exceeded our capacities by far.
Sweden unfortunately has a tradition of very few intensive care beds per capita and I really hope this will change in the future (although I wouldn’t exactly say I expect that to happen). During the pandemic we had a lot of nursing staff from different departments helping out at the ICU that have never worked there before and I really hope that the experience (although quite intense) will convince some of them to stay so we can expand our capacities even in the long run.
I cannot really speak for other specialyties but I think our intensive care team has learned quite a lot about how to rapidly adapt to new situations and recommendations for treatment, be it pharmacological or concerning for example mechanical ventilation. We also acquired a lot of experience in prone positioning of intubated patients which previously was quite rare at our unit.
The healthcare system in general has been able to cope with the situation quite well and in this sense does not require a lot of change. An exception seems to be the nursing homes around the country many of which apparently were not able to implement the necessary measures to isolate their inhabitants from the virus and in consequence saw a very high mortality.
Because of this and other reasons, the overall strategy of the government seems very questionable to me. Recently, even its main mastermind Anders Tegnell has voiced second thoughts in an interview. I am not sure how much I can really speak for the Swedish medical community as a whole, but I feel like in average we have been less impressed with the Swedish approach than the general population (which traditionally has a very high degree of trust in the government institutions). Some of our concerns made it to the news from time to time but they never caused any actual change in the policies around the pandemic.“

Felix and Angelica have produced a series of videos in Spanish on Youtube in which they share their insights on the pandemic. They share their opinions and expertise on the evolution and the management of the pandemic in the Nordic country. A big part of their current videos is focused on the clinical measures taken at the Karolinska Hospital related to treatment, personal protection and training of personnel, among others.
The aim is to share information that might be of help to people in Latin America and other countries where the pandemic is still in earlier stages, but that could end up in similar conditions as Asia and Europe in a short time.
They don’t think that the Swedish approach as a whole should be recommended to other countries but the adjustment or application of some of the measures can be of support for the medical staff and also to the general public.

The videos are available on their youtube channel Felix & Angie.

About particular scientific approaches on COVID-19 from the Center of Infectious Medicine and the construction of the COVID-19 biobank at Karolinska Institutet, although only availabe in swedish, you can find them here.