Wednesday, March 18, 2020

Lessons From Italy’s Hospital Meltdown. ‘Every Day You Lose, the Contagion Gets Worse.’




 “The most devastating part is that they are dying alone,” she said. “Families see the patient for the last time at the emergency room. The next time is at the mortuary.”

Such a lonely death is hard to take, the nurse said: “It’s not our culture. We’re very connected here.”






By
Marcus Walker 
and
Mark Maremont 
March 17, 2020 






BERGAMO, Italy—Ambulances here have stopped using sirens. The frequent blaring only adds to local fears. Besides, there are few other vehicles on the road in Italy’s national lockdown.

Most are headed to the Papa Giovanni XXIII Hospital, a large, modern medical facility in a prosperous Italian city that has been overwhelmed by the coronavirus disease. There aren’t enough ventilators to intubate all patients with Covid-19 who have severe breathing trouble. The intensive-care unit is taking almost no patients older than 70, doctors said.


A normally disused section of the hospital is filled with the critically ill and the hissing sound of oxygen. Patients lie quietly, with worried or exhausted faces, visible to others in the series of half-open rooms. Each focuses on the struggle to breathe. There are patients with airtight oxygen helmets over their heads, like transparent buckets taped at the neck.

“Some of them would have needed intubation in intensive care,” anesthesiologist Pietro Brambillasca said. The rest ought to be better isolated, he said, where they can’t contaminate anyone.

That is no longer possible. The number of ill has outstripped the hospital’s capacity to provide the best care for all.

The coronavirus is devastating Bergamo and pushing a wealthy region with high-tech health care toward a humanitarian disaster, a warning for the U.S. and other developed countries. The city’s experience shows how even advanced economies and state-of-the-art hospitals must change social behaviors and prepare defenses ahead of a pandemic that is upending the rules.


A passing ambulance in Bergamo, Italy. Photo: Cozzoli/Fotogramma/Ropi/Zuma Press

Some U.S. doctors are trying to understand how the coronavirus defeated all efforts so far to contain it in Lombardy, the Italian region that includes Bergamo and Milan. They seek lessons but don’t have much time, as the pandemic, now coming under control in China, takes off throughout the West.

Maurizio Cereda, an intensive-care doctor and anesthesiologist in Philadelphia, recently circulated a list of lessons from Italy to colleagues. Dr. Cereda, now at the Hospital of the University of Pennsylvania, trained in Milan and has been in close touch with Italian colleagues in Bergamo and elsewhere.

Many of the lessons relate to public health, to avoid overwhelming hospitals. “Mild-to-moderate cases should be managed at home, not in the hospital, and with massive deployment of outreach services and telemedicine,” he wrote. Some therapies could be delivered at home, he said, via mobile clinics.

Another lesson: Italian emergency-medical technicians have experienced a high rate of infection, Dr. Cereda said, spreading the disease as they travel around the community.


Italy's EpicenterLombardy, the Italian region that includesBergamo.Daily casesSource: Italy's Ministry of Health

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He also warned that smaller hospitals “are unprepared to face the inflow of patients” and are likely to collapse. He suggested admitting the sickest patients to bigger facilities and using dedicated ambulances for suspected coronavirus patients to avoid infecting the entire fleet.

Italy’s death toll from the coronavirus hit 2,158 on Monday, up 349 since Sunday. The country is on course to overtake China’s 3,099 deaths within days. Its large elderly population is especially vulnerable to Covid-19, the respiratory disease caused by the coronavirus.

About two-thirds of Italy’s dead, 1,420 people, are in Lombardy, the ground zero of Europe’s epidemic. It is where the virus is all the more deadly because hospitals in the worst-hit towns have reached their limits. Bergamo, in particular, has become Italy’s symbol of an epidemic spinning out of control.

Studying the dire turn of events in Italy has helped U.S. doctors better prepare, said Brendan Carr, chair of emergency medicine for The Mount Sinai Health System, a New York City hospital network.

Dr. Carr said he and other U.S. physicians have had informal calls with Italian doctors in recent weeks. “It’s terrible to hear them talk, but it benefits us to learn from it,” he said. One lesson, he said, is to build capacity for the expected influx of Covid-19 patients before it’s needed. Mount Sinai is clearing out space and creating new ICU beds, he said.

Bergamo shows what happens when things go wrong.

In normal times, the ambulance service at the Papa Giovanni hospital runs like a Swiss clock. Calls to 112, Europe’s equivalent of 911, are answered within 15 to 20 seconds. Ambulances from the hospital’s fleet of more than 200 are dispatched within 60 to 90 seconds. Two helicopters stand by at all times. Patients usually reach an operating room within 30 minutes, said Angelo Giupponi, who runs the emergency response operation: “We are fast, in peacetime.”

Now, people wait an hour on the phone to report heart attacks, Dr. Giupponi said, because all the lines are busy. Each day, his team fields 2,500 calls and brings 1,500 people to the hospital. “That’s not counting those the first responders visit but tell to stay home and call again if their condition worsens,” he said.


Dr. Angelo Giupponi, head of the operations center at Papa Giovanni XXIII Hospital in Bergamo, which takes emergency calls and dispatches ambulances. Photo: Marcus Walker/The Wall Street Journal

Ambulance staff weren’t trained for such a contagious virus. Many have become infected and their ambulances contaminated. A dispatcher died of the disease Saturday. Diego Bianco was in his mid-40s and had no prior illnesses.

“He never met patients. He only answered the phone. That shows you the contamination is everywhere,” a colleague said. Mr. Bianco’s co-workers sat Sunday at the operations center with masks on their faces and fear in their eyes.

The Papa Giovanni XXIII Hospital, a 950-bed complex that opened in 2012, is among the most advanced in Italy. It treats everything from trauma and heart surgery to organ transplants for children.

More than 400 of the beds are now occupied by confirmed or suspected coronavirus patients. The intensive-care unit has swelled to around 100 patients, most of whom have Covid-19. New cases keep arriving. Three of the hospital’s four top managers are home sick with the virus.


Dr. Mirco Nacoti of Papa Giovanni XXIII Hospital in Bergamo. Photo: Marta Panzera

“Until three weeks ago, we did everything for every patient. Now we have to choose which patients to put in intensive care. This is catastrophic,” said anesthesiologist and intensive-care specialist Mirco Nacoti.

Dr. Nacoti worked for Doctors Without Borders in Haiti, Chad, Kurdistan and Ivory Coast, and he is one of the few medics in Bergamo who has seen epidemics. Yet, those were diseases with vaccines, such as measles and rubella.

He estimated that around 60% or more of the population of Bergamo has the coronavirus. “There is an enormous number of asymptomatic people, as well as unknown dead who die in their home and are not tested, not counted,” he said. “The ICU is the tip of an iceberg.”

Hospitals in the U.S. and across Europe must organize in advance, Dr. Nacoti said, and governments need community lockdowns early rather than late.

“An epidemic doesn’t let you proceed by trial and error,” he said. “Every day you lose, the contagion gets worse.”

Bergamo, a city of about 120,000 northeast of Milan, sits at the heart of one of Italy’s wealthiest regions. Companies nearby make San Pellegrino mineral water, luxury yachts, and brakes for Ferrari cars. The city’s hilltop core, a medieval citadel, is normally filled with tourists.

When Bergamo discovered a clutch of coronavirus cases in its outlying towns around Feb. 22, Dr. Giupponi of the Papa Giovanni hospital emailed Lombardy’s regional health authorities. He urged them to empty out some hospitals and use them exclusively for coronavirus cases.

Regional managers at the time were dealing with an outbreak south of Milan. “We haven’t slept for three days and we do not want to read your bullshit,” Dr. Giupponi recalled their reply.

Since then, Italy’s lockdown has turned Bergamo into a ghost town.

Death notices in the local newspaper, the Bergamo Echo, normally take up just over a page. On Monday, they filled nine pages. “And that’s just the ones that are in the paper,” Dr. Nacoti said.


A funeral this month in Bergamo. Photo: Cozzoli/Fotogramma/Ropi/Zuma Press

Doctors taking a break at the Papa Giovanni swap stories of woe, including the call from an elderly care home reporting suspected virus sufferers who were over 80 years old. The hospital said the elderly residents had to stay put.

“None of us have ever seen such a thing,” trauma surgeon Michele Pisano said. “We’re trained for emergencies, but for earthquakes, not epidemics.” Dr. Pisano has little to do these days: Italy’s lockdown means there are virtually no car crashes, bicycle accidents or broken bones from skiing. He helps out in the coronavirus wards however he can.

In small towns around the province of Bergamo, the pressure on local hospitals is even greater.

Dr. Nacoti helps at a hospital in San Giovanni Bianco, located in the foothills of the Alps. On Sunday evening, the facility had around 70 coronavirus patients. The hospital, which specializes in outpatient surgery, normally has 20 beds.

Recently arrived patients lay on gurneys, filling the emergency room and a corridor while they wait for beds to become free.

Upstairs, more than 50 patients were administered oxygen through helmets or masks. Some were in critical condition, but the hospital has no intensive-care unit and no ventilators.

“We thought seven beds downstairs and seven upstairs would be enough,” senior nurse Fiorella Busi said.

The hospital had planned to send severe cases to Bergamo. “But we got indications that, if patients are over 65 or 70, they won’t get intubated,” said Davide Grataroli, one of the hospital doctors. “So, we’ve chosen to manage them here as best we can.”

That has been the situation for nearly three weeks. The patients know that the lack of intensive-care facilities dooms those not strong enough to survive the disease with limited help. “They accept it with resignation and no complaints,” said Ms. Busi, the nurse.

 

Write to Marcus Walker at marcus.walker@wsj.com and Mark Maremont at mark.maremont@wsj.com

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