Italy's caregivers face daily moral dilemma of who to treat in hospital

"You are asking me which criteria we use to choose who to hospitalise?" he takes time to rationalise the question.

"It is a complex question: in normal times it is decided upon the patient's clinical condition," explains the doctor of internal medicine in a Milan hospital who agreed to speak to TRT World on the condition of anonymity, "now the only regulatory principle is the number of available beds."

A moral truth that clashes with the numbers put forward every day by the Lombardy Welfare Commissioner, Giulio Gallera. Critical care beds were brought to 1600 – an increase of 110 percent. However, that is still not enough. 

"We are quashed by a huge ethical problem - continues the doctor - do we provide reception or treatment to patients? We choose right away who to treat, relegating those who we exclude to a greater chance of dying."

Lombardy continues to be the epicentre of Covid-19 in Italy with 43 percent of the total cases. Numbers leave an enormous margin of error, as confirmed by the head of the Civil Protection Angelo Borrelli who said it is "presumable" that for each infected person detected there are ten more undetected.

In early March this year, the Italian Association of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) issued new guidelines that modified access to intensive care - nationally. 

Predicting "a strong discrepancy" between the care needs and the resources of critical care, it ordered prioritising those who have "a longer life expectancy."

Age and medical history are decisive factors. Every time a bed frees up, doctors in the ward have to decide who will occupy it: an additional emotional load for a community that is already on edge and working in exhausting conditions. 

The most severe Italian health crisis since World War I is forcing doctors to take unprecedented decisions in times of peace.

Triage is the method used in emergency rooms where access to treatment does not take place based on the order of arrival but the priority of the patients' conditions. 

The same logic is applied in hospitals with insufficient means compared to the number of people that require treatment, such as in times of calamities or disasters. Prioritising in such a manner has profound ethical and moral implications.

"Already at the pre-triage, when the distinction between lung and non-lung patients occurs, we make the first choice. At this moment we only take patients with lung complications. If the doctors know there are two beds free out of 210, what to do if a third patient needs treatment? Every day this ethical problem arises, which is absolutely stressful; we cannot treat them all."

"At the beginning, the criterion was age: between an 80-year-old patient and one of 60, I would pick the latter. Now we can't even do this anymore because observation beds are finished and treatment ones even more," says the doctor. 

"So the comorbidity (the coexistence of several pathologies) and the clinical picture are main criteria. A diabetic, a cardiac or an obese patient - who are less likely to survive interstitial pneumonia compared to a person that is older but in better health - will risk waiting because the latter has more chances of surviving."

The main discriminant is the respiratory aggravating factor that Covid-19 brings: hypoxemia or low blood oxygen. 

"There are various degrees of breathing support: masks or nasal rings that administer a little oxygen; another mask equipped with a reservoir that keeps the respiratory field rich in oxygen; there is a third type, the CPAP, or high flow oxygen ventilator; the last resort is intubation," he explains, "The CPAP is made with cylindrical helmets: to keep helmets inflated you need pressurised air but not all beds have oxygen and air outlets."

Patients under the most invasive treatment – put in a pharmacological coma and with a tube passed through the throat to push air into lungs that no longer can expand independently - must have vitals monitored continuously. 

"Not all bed stations have a power outlet or monitors that allow you to connect the needed equipment. It is not just a question of software but rather lack of infrastructure, and this is also a criterion for picking which patients to treat," explains the doctor from Milan.

War footing

The whole national health system is affected. Wards have been reconverted, meaning that those with other ailments cannot be treated. 

"It is as if we were at war and suffer side effects: all cardiology intensive units have been converted into Covid wards, so those who have a heart attack cannot be cured, like those who need cancer surgery. Hospital administrations struggle to talk to each other; we need to ask to transfer a cancer patient as if it were a personal favour."

Warfare is a widely used metaphor these days. "I rather wind up with the earthquake metaphor: instead of the injured, we get patients with compromised lungs. Our first aid team, made up of doctors and nurses trained to cope with emergencies, was not used to seeing so many patients, so compromised, all at once, for days and days. By now we are only hospitalising patients with pneumonia," explains Professor Roberto Cosentini, head of emergency medicine at the Papa Giovanni XXIII hospital in Bergamo city, the most recent epicentre of the epidemic in Lombardy.

"It is a difficult scenario from the organisational and logistical perspective but also the emotional and psychological one. It is as if every day there was an earthquake, a viral shock going on for a month, which in nature does not happen. A jolt, two jolts, then it settles down and the injured are rescued. Here we went on for a month - he corrects himself - 37 days." 

Cosentini speaks in the past tense as if the worst is already over, at least in Bergamo. "Our hospital was quickly reconverted to address the emergency with 350 Covid beds and 90 intensive care beds. As an ER, we became a sort of 'breath unit' organised on three levels of intensity."

In Bergamo, residents say that the surreal silence of the empty city is broken only by the continuous sound of ambulance sirens. Funeral companies are overwhelmed; the army is in charge of carrying the coffins piling up. In the entire peninsula, proper funerals or memorials cannot be carried out as the virus decimates an entire generation, at least in Lombardy.

"Elderly with pre-existing conditions" they get called. In the local newspaper, the news pages have been replaced by obituaries: photos and names that return a face to the figures of this tragedy. 

Hospitals are closed for visits, and Covid patients on the brink of death cannot say goodbye to loved ones. They die in solitude, without a caress— a shortage which doctors, nurses and volunteers often make up for through tablets and video calls.

"Patients are deprived of family comfort, it is additional suffering," points out Cosentini with a heavy heart, "it is a very particular, very deep and close relationship with Covid patients. It is an exceptional situation, for us but also for the patients themselves, who are actually different from those we usually see. We both feel part of the same tragedy." 

When the Red Cross doctors go to pick up a critically ill patient from home, family waves from afar, without knowing if they will ever see each other again.

Going into battle unarmed

In the province of Bergamo alone 1,759 people have died from Covid-19, but there may be many more. Many deaths were not attributed to the coronavirus because they died at home and therefore were not swabbed, Bergamo's Mayor Giorgio Gori told media.

"We cannot rule it out. Old people who have a very small reserve volume or in a compromised situation, are kept at home by their relatives," comments Cosentini.

In the hardest-hit areas where beds are running out, relatives assist elderly patients at home until death. "Indeed, these deaths could have slipped Covid's statistics. The paradox is that elderly and compromised patients hardly survive, and if they are hospitalised, they are taken away from their families," he adds. 

"In these cases, the decision whether or not to treat the sick falls on the one hand on the relatives and the other on the hospitals that have to manage less beds than the demand."

Paola Pedrini, secretary of the Italian Federation of General Practitioners (FIMMG) of Lombardy defines the numbers released as "increasingly unreliable." 

She says that confusion over coronavirus emergency figures should not hide the responsibility of the generals in the "Caporetto" of Italian public health, referring to the Italian army's humiliating defeat in World War I in the Battle of Caporetto. 

The FIMMG asked that health workers be immediately put into safe care. Her anger is that many general practitioners in Italy have been left at the front line to manage all those patients and are not admitted to hospitals. 

In the province of Bergamo, 130 out of 700 general practitioners contracted coronavirus. Italy has the highest number of infections among healthcare workers - 51 doctors have died so far. 

"According to the indications of the World Health Organization (WHO), there are various degrees of protection, depending on the proximity to the patient. If you have to perform manoeuvres that allow the dispersion of flügge, those droplets that transmit the infection, you must wear specific devices," explains the Milanese doctor. Devices and gear available at Milan or Bergamo's hospitals – but hard to find elsewhere.

"They give us only one daily kit that we have to take off and put back on," explains Loredana, a doctor who voluntarily reached the hospital of Desenzano del Garda in Lombardy, from her hometown in Abruzzo to support the emergency response. 

"Whoever has the (Hazmat) suit is because he bought it from his own pocket, besides we have a cotton uniform on top of which we use a normal coat. Then FFP2-mask topped with a surgical one that I bring from home and not-insulating eyes protection."

Another doctor comments: "Sticking to the military comparison, in the battle against an enemy called a virus - because in the wards it is a war-like situation – it's simple to understand that if you send your soldiers in unarmed, they will die."