A fight for survival

by Peter Blackburn Doctors around the world face a lack of resources and surging demand while some are forced to decide who receives intensive care beds, as coronavirus threatens their own safety and ability to care.
Location: International
Published: Tuesday 24 March 2020

‘You have to be prepared for this – that is the only thing I would say to my colleagues. This new reality we are living started on the 23 February – and we are now living in a totally different world. I cannot think of my life before this. No one can understand, it is not possible.’

Fabiano Di Marco is the head of the respiratory unit at the Hospital Papa Giovanni XXIII in Bergamo, just outside Milan. Since the rapid escalation of the COVID-19 crisis in Italy, Dr Di Marco’s life has been turned upside down – at work and away from the hospital ward. 

Dr Di Marco has been in the hospital almost every day for 14 to 15 hours, organising care for between 50 to 70 new patients each day with severe respiratory failure, managing a team of around 20 staff left in tears by the sheer weight of demand and the significance of the decisions they are forced to make. On the rare occasion he is at home, Dr Di Marco has been forced to decide between wearing a mask for the safety of his family and not doing so he doesn’t scare them.

‘It’s a total mess – it’s like a war,’ Dr Di Marco, also a professor at the University of Milan, says, speaking to a New York Times podcast.

 

Allocation arrangement

The Bergamo hospital has around 1,000 beds. As the coronavirus outbreak soared the hospital was dealing with around 350 patients with severe respiratory failure owing to infection at any one time, more than 50 per cent of hospital functions were dedicated to dealing with coronavirus and doctors were having to create a new system of allocating intensive care unit beds – based not on age and vulnerability, but on likelihood of survival.

‘We had to teach cardiologists, dermatologists, rheumatologists – specialists of something very different – how to treat these patients. You try to find a solution but day by day it is no longer enough. I can tell you that my colleagues, physicians and nurses, they cry every day. I am 47, I have with me 20 colleagues – it is a huge responsibility. I am scared they will be sick. We cry every day and today we have 460 nurses at home because they are sick. It’s a huge number.’

Dr Di Marco adds: ‘As doctors we are used to treating patients and it is normal, it is not usually so emotional, but this is different when the patient is your colleague – we have now admitted tens of doctors or nurses. Yesterday the chief of my department came to the emergency room to be with a low level of oxygenation – he has a bilateral pneumonia due to the coronavirus … He is someone who was trying to organise the hospital three days ago. We are scared.

‘We have hundreds of very sick patients, but we have tens of ICU beds. You can find many scores of gravity (in order to choose which patients are given priority) but these have been thought of for another reason.

'For instance, if you are 80, you have severe respiratory failure and also renal failure, I have to admit you to the ICU because you are seriously ill and you have a high probability to die. But now we need another score – one that helps you understand the probability of you to benefit from the ICU bed. We don’t have this score. We are trying to do this now.

'For this, higher the age, higher is the score. But when you have few beds for many people the age is absolutely the opposite. If you are 85, I’ll give the bed to another who is 45.’

 

Heartbreaking decisions

It is a situation doctors across the world face, chair of the University of Pennsylvania’s medical ethics and health policy Ezekiel Emanuel says – noting physicians are likely to have to decide ‘who lives and who dies’.

‘It’s horrible, it’s the worst thing you can have to do,’ the oncologist said on 21 March.

Dr Di Marco says on one day 20 patients with coronavirus died, at this hospital alone. And given the circumstances these are not always the most dignified deaths.

He says: ‘Another important thing is we have not had the opportunity to allow the relatives to come to the hospital – it is a danger for them and for other people and… we do not have enough personal protective equipment. The mask, something to cover the shoes and the gown – it is impossible to find these in Europe, not just in Italy. It is impossible to find.

‘The patients are alone – and they die alone. This is difficult for us. We try to call the relatives every day, but I have to tell you that sometimes, in the confusion of this new organisation with dermatologists trying to treat patients with severe respiratory failure, with doctors crying, sometimes no one remembers to call the relatives. So, it happens that the relatives call the hospital and the person is already dead.’

 

Cure out of sight

It is far from an isolated experience.

Marco Pavesi, an anaesthetist in Milan, wrote a piece published in the New York Times..

‘None of us have experienced a tragedy like it,’ he writes.

Dr Pavesi continues: ‘We know how to respond to road accidents, train derailments, even earthquakes. But a virus that has killed so many, which gets worse with each passing day and for which a cure – or even containment – seems distant? No.

‘We always think of calamity as something that will happen far from us, to others far away, in another part of the world. It’s a kind of superstition. But not this time. This time it happened here, to us – to our loved ones, our neighbours, our colleagues.’

Dr Pavesi, who works at the Policlinico San Donato in Milan, Lombardy, at the heart of the coronavirus outbreak, says the hospital recorded its first case on 21 February and immediately sprang into action: a taskforce of intensive-care doctors moving to the worst-affected areas, all planned surgeries postponed, beds given over to coronavirus and conversions of theatres and anaesthetic rooms to become wards. The patients who arrive stay for many days and require great resource.

Dr Pavesi says: ‘My colleagues … throughout the country, are showing a great spirit of sacrifice. We know how much we are needed right now; that gives us strength to withstand fatigue and stress. How long such resistance will last, I cannot say. Some colleagues have tested positive for the coronavirus, and a few have needed intensive care. For us all, the dangers are great.’

He adds: ‘As an anaesthesiologist devoted to surgical emergencies, I haven’t had many direct dealings with coronavirus patients. But there was one. An elderly man in a fragile condition, he was set to have tumour removed. The surgery proceeded as normal: I put him to sleep, and he awoke four hours later, without pain. That was in mid-February. A week later, the tell-tale symptoms began to show: a high fever, a cough. Before long, pneumonia. Now he’s in intensive care, intubated and in a critical condition. He is one of many who have become a number.

‘For now, we are in the thick of tragedy.’

 

Unprepared

The sudden impact of the coronavirus has also been felt in Spain where videos emerged of healthcare staff treating patients lying on corridor floors as hospitals were overwhelmed.

Pelayo Pedrero, a doctor in Madrid and head of labour risk prevention at doctors’ union AMYTS, told Bloomberg on 21 March: ‘This thing blew up on us. No one was ready for this. They didn’t buy the supplies; they didn’t prepare the hospitals to receive and treat all these patients. Not just in Madrid or Spain, but all over Europe.’

In China, where the outbreak began, few doctors have spoken out about the crisis. But Ai Fen, director of emergency at Wuhan Central Hospital, gave an interview to the Chinese magazine Renwu, or People – an interview which was later removed from the internet, despite internet users saving screenshots.

In her interview on 10 March Dr Fen describes some of the moments during the outbreak that she would not be able to forget, including an older man staring blankly at a doctor giving him the death certificate of his 32-year-old son and a father too sick to get out of the car outside the hospital who died by the time she could meet him.

 

Third wave

Dr Fen also says she had seen many colleagues become ill and die from the virus.

In China – where strict measures, such as the lock downs of cities, appeared to suppress the first outbreak – thoughts immediately moved to the future, with public experts expecting second and third outbreaks across 18 months. 

Professor Li Lanjuan, a member of Beijing’s ‘expert team’ dealing with the virus, says she was ‘very worried that imported cases could trigger another large-scale epidemic’ in the country, describing the efforts so far as an ‘arduous task’ for medical workers.

Speaking to China News, she adds: ‘The mission in Wuhan has not been accomplished and there are still many critical patients.’