Inside Italy's
coronavirus hospital
Dr
Antonio Castelli shares what it is like to face Covid-19 on the front line at
the Luigi Sacco Hospital in Milan.
MAR 23, 2020
"Antonio,
what do you think?'
“What
can I say? It was a great vacation, Prague is gorgeous.”
“No,
Antonio, I mean the news.”
There
was a moment's silence, the time it took my wife to bring up the breaking news
on her cellphone about the first cases in the region of Lodi, in northern Italy.
"It's
here now, too, Antonio. We're creating an emergency task force, you need to get
back right now."
It
was 7.40am on Friday, Feb 21, when Dr Antonio Castelli, 56, head of the
resuscitation unit at the Luigi Sacco Hospital in Milan received a phone call
from Dr Giacomo Grasselli, the medical director of the intensive care unit at
the Policlinico hospital in the Lombardy capital city.
Dr
Castelli was at the wheel of his car, alongside him, his wife, who he first met
when they were medical students and who now works at the same hospital as a
heart surgeon.
The
Luigi Sacco Hospital in Milan is the point of reference for epidemiological
emergencies in northern Italy. It was the first hospital to have been fully
converted to deal with the coronavirus, which causes the respiratory disease
Covid-19.
On
their way back from Prague, Dr Castelli and his wife had planned to stop off
for a couple of days in the Austrian Alps. But Dr Castelli's foot never left
the accelerator, he headed straight for the Brenner Pass, arriving at his ward
in Milan by 2pm.
He
found it deserted, not a soul in sight, and he immediately realised that years
of drills, simulations and studies had now become a reality. This was no movie.
The time has come to shave off his beard, the beard he had been cultivating for
30 years.
"When
I entered my resuscitation unit, it was empty, totally abandoned, no patients,
just the chaos left behind from a quick getaway. So I went to the infectious
diseases unit, the one run by Professor Massimo Galli, where we had simulated
how we would deal with the Ebola crisis five years ago,” he said.
“It
was a hive of activity there; in the time it had taken me to get from the
Brenner Pass to Milan, they had managed to evacuate the entire ward, install
four beds in a biocontainment unit to treat those with highly infectious
diseases, and to fill them with the first patients from Codogno, the center of
the outbreak in the Lombardy region,” he added.
One
of them - only 42 years-old- was the person dubbed “patient two”, who was
linked to “patient one”.
He
said: “Everything seemed to have snowballed at an unprecedented pace. By the
following Monday, Feb 24, the number of beds needed in intensive care had
increased to 11.”
As
soon as he turned his phone on at the end of his night-shift, he received a
call from Dr Grasselli, asking him to go to the Lodi hospital to see what
support they might need in the face of the dramatic escalation of coronavirus
cases.
Dr
Castelli jumped in his car without a second thought, no stretch of the
imagination could bring him to picture what he would find there.
“The least
serious case seemed to be a woman attached to an oxygen respirator; someone had
hung a bottle of water onto her gurney, a detail which struck me as
particularly humane. The place was overflowing; 70 men and women so cramped
they could barely breathe. But it wasn't chaotic; it was strangely ordered, the
commitment to duty was palpable. I'll never forget it,” Dr Castelli said.
The
chief medic of the emergency room, Dr Stefano Paglia, had been there for eight
days. He had not once set foot outside during this period; he communicated with
his wife and daughters through WhatsApp, and managed to snatch a couple of
hours sleep between one wave of incoming patients and another.
Because
there were two waves of admissions per day, a dozen or so patients at a time,
either in the early morning or at sundown. They were the people who, unable to
sleep, had tossed and turned anxiously all night, waiting until the daybreak to
seek help; or those who, seeing their condition worsening throughout the day,
feared what the nighttime could bring.
Dr
Castelli met the entire staff. “Their faces were drained, exhausted. They felt
no one was grasping the severity of the problem.
He said:
“I told them that I wasn't there to check up on them, just to bear witness to
the incredible work they were doing. I want people to know what they did in
Lodi, when the town of Codogno was already on lockdown: their accomplishment
was pure heroism, and I don't use that term lightly, as so many people do
nowadays.
“They
quite literally were heroes. As they were filling me in on the situation, I was
almost moved to tears by the resilience and competence of that team of doctors
and nurses."
That very
night, 10 patients were transferred from Lodi to Sacco Hospital, with the most
serious cases going to the resuscitation unit at Humanitas Hospital, which had
freed up some places in intensive care.
Forty-eight
hours later, on Saturday, they managed to close admissions in the Lodi Hospital
for one day to give the entire staff a breather.
Dr
Paglia and Dr Enrico Storti, the chief medic at the resuscitation unit in Lodi,
have devised a no-nonsense technique for immediately identifying patients with
Covid-19 - one we could christen the Lodi method, and one that will go down in
medical history.
"It's
not based on the temperature of the patient, but on breathing difficulties, and
the area it stems from," explains Dr Castelli.
“This
method was used to identify the first patients who needed to be isolated, then
to distinguish between the most severe cases and the milder ones; they would
have a chest X-ray, and the level of oxygen saturation in the blood would be
measured after having made them walk up and down the corridors for 50m. That's
how they managed to deal rationally with the emergency throughout the night of
Feb 20."
A reef constantly being hit by
waves
On
the afternoon of Feb 27, Dr Castelli wrote his report, comparing Lodi to a reef
“constantly being hit by waves”.
It
is the part of Italy that has taken the most knocks, but it is one with a low
population density; the contagion needs to be contained, because if it spreads,
then it could be a catastrophe waiting to happen: "If the waves go over
this reef," he wrote, "just beyond it is Milan. And we cannot allow
that to happen."
I
interrupt him. Over three weeks have passed since that day, and I ask if that
wave has hit Milan.
Dr
Castelli said: “No. At least not with the same tidal force. But the chance of
being overcome by a tsunami is very high. It all comes down to whether the
population will stay in their homes, isolating themselves from each other.
“I don't
know what is happening on the outside, but I hear that the streets are finally
emptying; when over the past few days I've seen photos of the bars along the
Navigli, thrumming with people during happy hour, or people dining at
restaurants, I thought it was madness, sheer madness. An omnipotent, delusional
idea that young people are immune to contagion.”
This
was a conviction that is proving hard to overturn, owing in no small part to
the ages of the deceased.
“Of
course, most viral pneumonias affect the elderly, but young people have been
infected too; let's not forget that 'patient one' is 38 years-old, and that the
first person he infected, besides his wife, was a 42 year-old. Both are alive,
no longer on life-support, but they did do a stint in intensive care.
“There
is just one solution, however old you are, and it is to reduce contagion. We
can look to the Japanese for an example: culturally speaking, they tend to keep
more of a distance from each other, but still, they are showing an incredible social
conscience at the moment. The scenes of people fleeing to go back to their
homes in the south of Italy are atrocious, if you think that many of them were
bringing the risk of contagion to areas that have far less structures and
resources.”
For doctors, every day requires a
little bit more effort
The
medics of the intensive care unit of the Sacco were the first to drastically
modify their lifestyles: Some of them chose to sleep in hotels near the
hospital, returning home only once their children were safely out of harm's
way; one doctor rented an apartment for fear of infecting his family.
They're
deeply concerned, they eat alone, they have explained to their children – even
the youngest – why they can't kiss or hug them; they have isolated themselves in
their own homes.
“I
don't sleep next to my wife any more, I sleep on the sofa-bed, we have no
physical contact whatsoever; just imagine if I suddenly started coughing at
night, and realised I had contracted the virus and risked infecting her too. We
eat at opposite ends of the table, we're careful not to touch each other's
cutlery, and as soon as we finish, I make sure I'm the one who loads everything
into the dishwasher.”
And their
work life requires the same attention, with no detail overlooked, nothing
forgotten, every day requires a little bit more effort.
“I
keep thinking that we don’t have enough: one more bed is not enough, one more
doctor is not enough, and we'll never have enough surgical gloves. When you
treat someone who is ill, you change the second glove constantly, even ten
times.
“The
first one is like a second skin, it comes up to your elbow and you never take
it off when you're working. The other one gets changed endlessly, so as to
avoid the risk of contagion.
“When
you get undressed, you use a glove to remove every article: I take off my
surgical visor to clean it, and I have to change the glove; I take off my
scrubs, and again, I change the glove; if I change footwear, I change the glove
again. This hospital has maintained a high state of red alert, with constant
drills, but we need to be careful not to be struck down by exhaustion.
"When
it's the middle of the night and your efforts are being concentrated on the
sick, you can sometimes forget if you've followed every safety procedure, and
that's when anxiety strikes. You can never be too focused.”
Every
single day this week, space has been made for new beds, but it seems there are
never enough. “On Friday, March 6, we were asked to double the number of beds
by the day's end. We were supposed to install 22 beds, but it was technically
impossible.
“We
could have used another ward in the unit, but there wasn't enough compressed
air, a vital component for attaching ventilators. It was 2.30pm when the
meeting between the hospital administration and the engineers came to a close.
Half an hour later, the technicians filed in, and before 7pm a line of air
vents with compressed air had been built into the walls.
“I
saw an intensive care unit set up at record speed. It was so well-constructed
that it seemed like it had always been there, nothing unstable, no loose wiring
or tubes. We've been asking for improvements in the ward for four years, and we
got them in four hours.
"We
only seem able to act when an emergency is on hand, never when something needs
to be scheduled. It makes me angry that this country is incapable of doing
ordinary things, but then capable of producing miracles.”
The
22 beds were filled immediately, with people arriving from Lodi, Cremona and
Bergamo, which is now the most critical hotspot.
To
fight this war, the Sacco has concentrated 25 doctors in the resuscitation
unit, and the number of nurses has doubled from 30 to 60, but every day the
workload intensifies.
“There
are plans to build another floor for intensive care, but the nurses are
fundamental, without them there's no point in calling in doctors or installing
oxygen tubes, they are the ones who make the difference. As soon as this thing
kicked off, they arrived en masse, on a voluntary basis, all ready to do
battle. In times like these, the original motivation that made us choose this
job comes to the fore in all of us.”
This will all be over - and we'll
grow our beards back
What if
there are too many people infected who need respirators, if there aren't enough
new beds? It's not hard to envision the breaking point being close at hand.
“The
fundamental rule of good medicine has to be a compassionate approach to the
balance of care. This doesn't mean abandoning some patients, just
distinguishing between the level of care required.
"It's
very important that the Italian Order of Anesthetists and Resuscitators has
issued a memorandum with recommendations of medical ethics in exceptional
conditions, such as the one we find ourselves in right now. A sober and frank
document which, in the face of limited resources, reiterates that ‘we must prioritise
greater life expectancy.’”
His
22 patients are completely sedated, some of them intubated face down - a
technique developed in Milan by the group headed by professors Gattinoni and
Pesenti, and then used all over the world.
"They're
all asleep, they won't remember the pain. When they come back to thank us with
a tray of pastries - because this is what will happen, in our experience - they
will only remember how thirsty they were.”
Of
those first four patients in Codogno – who were admitted more than three weeks
ago, even though it seems like a century has passed – one died after three
days, two are still there attached to the machines, asleep, and one has left
the ward and is breathing on his own. The road ahead is long and every day sees
us adding at least one new bed in intensive care, so as to be ready for all
eventualities.
"We're
exhausted, and fear has become our constant companion since four of us – two
pulmonologists and two residents – have been infected. One of the most
difficult moments, the one that creates most tension, is when there is a shift
change, and lots of us are getting undressed and dressed at the same time; all
it takes is for someone to start coughing to cause mass alarm and for a
thermometer to suddenly appear.”
“We
all had beards in my ward; we shaved them off that morning so that our masks
could adhere more securely. But every day in our WhatsApp resuscitators group,
I repeat: ‘Remember that we'll get our beards back. When it's all over -
because this will all be over - we'll grow them back.'"
Nembro: The death
bells stop tolling
On
March 7 in the small town of Nembro, the death bells stopped tolling.
“We
decided not to ring them anymore since that Saturday, the day of the four
funerals. It would have meant that the whole day would be filled with the sound
of the death knell, and this would have caused untold anguish for the entire
community. We thought it was best to just let things be,” said Catholic
priest Don Matteo Cella.
Nembro,
with its 11,500 residents and numerous churches, all under a single parish, is
tended by five priests. Four were taken ill, only one was left standing, the
youngest: Don Matteo, 40 years old, originally from San Pellegrino Terme.
A
small village east of Bergamo in Italy's Lombardy region, Nembro is the gateway
to the Seriana Valley and where Italy's America's Cup Luna Rossa sailboat hull
was built. It now risks going from being a headline to going down in history as
the town with the highest percentage of victims in the Covid-19 epidemic.
History
has a tendency to repeat itself - the 1630 plague wiped out nearly
three-quarters of the town's 2700 inhabitants; only 744 lived to tell the tale.
Last year,
120 people died in Nembro, 10 a month; now 70 have died in the space of just 12
days.
I
went in search of the parish priest, but I found his assistant, the curate, Don
Matteo, who usually tends to the younger members of the flock; he gives me an
account of the recent terrible events.
“From
the beginning of the epidemic, according to the parish statistics, we held 39
funerals in the church, 26 at the cemetery, and we have 26 deceased waiting to
be laid to rest. That comes to 91 people, without counting anyone who may have
died in the past few days that we have not heard about yet, or even of
non-Catholics,” he said.
The
village is like a freeze frame, a surreal vision: nobody in the streets, the
shops are all closed, and the grocery stores and the pharmacy only make home
deliveries.
.
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