Intensive care nurse Bärbel Breimann puts on her protective clothing and enters the coronavirus intensive care unit of Münster University Hospital, where ten of twelve beds are now occupied. It is the middle of November in Germany, with winter not yet here, and for Breimann the situation is already just as bad as it was in April, when the first coronavirus wave reached its peak.

"We are working right at the limit of our capacity. It will not take much for the whole system to quickly collapse," she says. Breimann is one of those healthcare employees who were described as "system-relevant" key workers at the start of the pandemic. But the 47-year-old was irreplaceable long before that. She has worked in the intensive care unit since 1998 and has just celebrated 25 years at the University Hospital in Münster.

Mood worse than during the first wave

The intensive care nurse has already been through a lot — but the current crisis, the second coronavirus wave, has taken on a new dimension for her. "All of us in the ward are reaching our limit. It is taking an emotional and physical toll. And of course, it all begs the question: What is still to come for Germany?"

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In contrast to the first wave, an improvement of the situation seems very far away because of the many months of cold temperatures that lie ahead. But the mood is also different. The mood at the intensive care unit in Münster is pretty much a microcosm of German society: increasingly tense and frustrated.

"In the spring we all pulled together and that led to an incredible amount of positive energy. But that energy is missing now," says Bärbel Breimann. "And there is the fear that we won't be able to maintain the current standards. The staff are all on a knife-edge and damage limitation is the order of the day."

One intensive care nurse for two patients

Something else has also changed: now there is an increasing number of young people in intensive care units, some young dads in their early 30s who had no previous illnesses. Breimann and her teams can still just about keep to the golden rule of intensive care: one specialist should only care for a maximum of two patients.

But to turn a patient over into the prone position, three nurses are needed, and some patients require individual care. More and more, staff are absent due to illness or because of compulsory quarantining.

Bärbel Breimann is not the kind of person who complains about the working conditions in her job. She gives 100% to her role. "I work in my dream job: I have new experiences every day, lots of flexibility, a multi-skilled team, and level hierarchies. But would I recommend it to my daughter? I would tell her to have a long hard think about it."

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Nurses and beds constantly in motion

Bärbel Breimann's boss is Thomas van den Hooven, director of nursing at University Hospital Münster. An alternative job title would be master of stopping up gaps and dealing with deficiency.

"We have had a significant increase in COVID-19 patients over the weekend so we are in the process of reallocating our nursing staff," van den Hooven explains.

The crisis has made people creative — so it is not only the 3,000 nursing staff that the hospital that van den Hooven reallocates every day, but also the beds themselves. The goal is to try to ease things up for the nurses: a Herculean task.

Desperately seeking intensive care staff

As if that is not enough, van den Hooven is also kept busy picking up the phone to attempt to sweet talk former staff members who have given up nursing to work elsewhere.

"If they come back, we give them more training," he says. "Of course, they cannot replace the specialists on a 1:1 basis, but they are an enormous help."

Van den Hooven also doesn't hesitate to step in himself when there is a need. After all, he worked as a nurse for 15 years. 

"Of course, it is mainly symbolic — to show that the captain is also on board the ship," says the nursing director. "But I can still turn a patient over or hand out the medication."

Van den Hooven took over the job in Münster three years ago and the coronavirus pandemic is the biggest challenge he has yet faced, giving him unrelenting stress, 24 hours a day, seven days a week. He has never seen Germany deal with anything like this.

So he can only shake his head when asked about the demonstrations in Leipzig against coronavirus restrictions. "I am someone with a lot of understanding," he says. "But that just stuns me."

Peak expected in mid-December

The question remains about what Germany should do at the end of November, when the "lockdown light" will officially end. Should Germany reopen everything, as many are demanding? Van den Hooven pulls a face.

"We will already have a significant increase in intensive care patients by Christmas. Then we won't only lack intensive care staff, but also doctors in general," he points out.

Before van den Hooven rushes to his next appointment, he has one piece of advice for Health Minister Jens Spahn: "Hospitals need clear confirmation that COVID-19 patients have absolute priority, and knee or hip operations have to be postponed,"he pleads.

Available intensive care beds

While Thomas van den Hooven has an overview of the intensive care unit at Münster University Hospital, Christian Karagiannidis has an overview of all intensive care units in Germany. Germany can thank the head of the pulmonary intensive care unit at the Cologne-Merheim hospital for the management of the intensive care unit register — which is an enormously important component in the fight against coronavirus.

If a patient urgently needs to be ventilated and the intensive care beds at the nearest hospital are occupied, the intensive care register shows which hospitals in Germany have how much capacity.

"We at the Germany Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) had already built this when the first swine flu epidemic broke out," recalls Karagiannidis. "Then we let it fall to the wayside a little. The Robert Koch Institute [Germany's disease prevention agency] asked us to reopen the intensive care register with a traffic light system during the coronavirus pandemic."

Red means no capacity; amber means limited and green means there are free beds in the 1,300 acute care hospitals. At the moment, the situation is manageable: Over 3,000 beds are occupied and more than 8,000 are free. But the Cologne-based physician is facing a challenge: Germany has already broken the record of capacity set in mid-April.

"We are now at amber in terms of intensive care capacity — but the times when we were relaxed are in the past," he says.

Missing nurses

Worries for the future are related to the fact that Germany is missing between 3,500 and 4,000 care workers for intensive care units. Germany may be able to conjure a fully-functioning intensive care bed out of a hat — but there is no magic that can produce more staff.

The reasons for this are clear: Comparatively small income for a high level of responsibility; shift and weekend work and little societal recognition. Even before the pandemic, Health Minister Spahn was desperately trying to recruit nursing staff from abroad.

The results of the latest DIVI survey among intensive care workers will not calm Spahn: 97% do not think there will be enough staff to deal with a second wave, almost half are less motivated than they were in the spring and 93% are afraid that working conditions will deteriorate in the months to come.

Possible solution: Fewer hospitals

"The mood is visibly changing in the clinics," Karagiannidis concludes. "And we have to develop a strategy now so that 20% of the nursing staff don't leave in the summer. Because then we really will have the problem that hospitals will no longer be able to undertake any action."

If the physician had his way, mid-2021 — when the pandemic may be under control — would also be a good time to consider a sea change for the healthcare system. He believes that wide-reaching and consistent closures of hospitals may serve a solution.

"No country in the world can afford so many hospitals with so many hospital beds," he says. "We will have to make major cuts. And when we do this, the hospital staff will become available once more."

This article was translated from German.