A report from the battle zone – Post of an Italian doctor fighting COVID-19

The following message was shared in an EM docs group, granting the right to repost it. Everyone should read it: I think that this message not only displays how dramatic the situation is, but also provides VERY useful tips on how to manage and treat patients. 

A MUST read!

Posted Message:
I reached out to a friend in Italy and my perspective on the situation has definitely changed to “concerned”!  Every year a group of the top medical students from Italy are given the opportunity to come to the US for a cadaver lab for 2 weeks during the summer.   I volunteered to allow those interested in EM to shadow me during my shifts.  One of the students is facebook friends with me.  2 days ago I messaged him.  

He is a 3rd year anesthesia / critical care fellow in Milan. Here is a string of his messages over past 2 days:

“Hi doctor!! I thought you just forgot about me!.  I am very happy for this message. I am an Anesthesiologist resident (in Italy we have Anesthesiology and Intensive Care Unit Residency Program in 5 years, I am attending the third year). Actually, I do really spend most of my time in ER and “critical care units” that are the hospital wards we converted in “covid wards” to better treat this patients. I am writing from Milan, which is, actually, the most affected city in Italy. To be honest, situation is dramatic. We had to create 4 new intensive care units to treat intubated patients, all patients in “critical care units” are on Cpap from 8 to 12 hours a day and their p/f is never more than 120. Our biggest trouble is that we are now noticing that even 40 or less yrs old men are developing very bad pneumonia. Best satisfactions come from prone positioning cpap, prone positioning mechanical ventilation (even 18 hrs a day) and mechanical ventilation itself.

My personal impression is that mechanical ventilation is essential in this kind of patient. Most of the time, typical patients arrives in ER with mild dyspnoea, cough and fever (even 39°C or more). Even if spo2 is 90% you can easily find PaO2 of 50 or less and end stage compensation is near so they can easily need rapid intubation or they’ll die in acute respiratory distress

These are very interesting questions. Until now we were testing all patients who arrived in Emergency department with respiratory failure. First problem is that this patients have no symptoms until they become really sick. Now we are in a very difficult situation. 80-85% of critical patients are men, over 30 yrs old, no linkage to smoke/vaping or other comorbidities. Now we have a lot of troubles in taking care of new cases. Our “911 service” cannot take care of all respiratory patients, they are dying in their house with no care. Our triage rules are to treat in icu only “young” people (less than 60 yrs old) with ‘light’ comorbidities. Active cancer patients are the most challenging choices to do. I believe 3-6% of mortality can be real. One one hand you have to consider that a lot of asymptomatic/paucisymptomatic patients are not tested for Sars-cov swab,so mortality could be less than 3-6%. On the other hand, a lot of mild flu/pneumonia in elderly patients are not tested “after death” so there are a lot of ignored covid patients. Maybe they would have died even for a common bacterial pneumonia, we cannot know. Other problem, all the intubated patient don’t improve “fastly”. ICUs are full of ventilated 40yrs old patients and they don’t improve… If you want I can’t try to translate our covid “vademecum” to better explain the situation… When you’ll be in Italy, obviously, let me know!

I don’t know what is the difference, maybe it is a mutated strain. Today we have had 600 death in respiratory failure CoViD patients. Italy is in quarantine, everyone must to stay at home, no-one can move from home except to buy food and social fundamental works as hospitals and food markets. Anyway, here healthcare workers don’t take any prophylactic medication, but -in my little experience- people taking ACE inhibitors and ARBs have worse outcome. In our hospital we have obtained your Giapreza (angiotensin II) to give to our patients and it seems that giapreza improves outcome and vital signs (just 50 cases anyway). Our therapeutic plan for patients includes chloroquine, tocilizumab, antiretrovirals, anakinra and no steroids at all. Please, be safe. When we have to stay nearby a CoViD patient we always wear a single-use cap, a single-use coat, shoe-covers, double gloves and goggles or face shield with a N100 mask. Despite all these, my first anesthesiologist tutor is now intubated and mechanically ventilated in ICU (36 years old female). BE SAFE, you and your family, paucisymptomatic people are everywhere. Avoid crowded places, wash frequently hands, neck and face. We thought it would be “nothing more than common flu” and now all italian ICUs are full of CoViD patients…Please, feel free to ask for anything.

Edited 2020-04-04 03:04