Lorenzo Menicanti, MD, head of cardiac surgery at Policlinico San Donato in Milan, Italy -- one of the most active centers for cardiac surgery in Italy -- is performing heart surgeries only on an emergency basis, as all of his cardiac intensive care unit beds have been reassigned to patients with COVID-19.
Menicanti works in the heart of the Lombardy region that has been hardest hit by the novel coronavirus, where about 560 patients were intubated as of last Thursday. Health officials there were preparing a total of 900 ICU beds for more patients -- but these were expected to fill up by early this week, Menicanti said.
Government epidemiologists said peak infection will occur a few days after that.
"We'll see if the rules we imposed in our country will achieve the result that we're hoping for," Menicanti said about a country-wide lockdown during an interview with 番茄社区. "If the infection continues to progress in this way, we will have a big problem to satisfy the needs of the whole population."
Public health experts have said that Italy's experience with COVID-19 could be a sign of things to come in the U.S. Since Feb. 23, Italy has been releasing infection data, starting at 132 cases and two deaths that day. Now, three weeks later, .
Currently, the U.S. count stands at 3,774 cases and 69 deaths according to Johns Hopkins University's unofficial tracker -- about 500 more cases than where Italy's stood on March 5, though the U.S. death rate so far has been much lower.
Some public health officials have sounded alarms about a lack of healthcare capacity to handle a large-scale crisis in the U.S., which has about 100,000 critical care beds and could quickly see healthcare worker shortages if staff become infected or must be quarantined because of suspected exposure. Physicians on social media have rallied behind , calling for precautionary social distancing measures now to prevent a tsunami of illness that can push the system to the brink, as Italy is now experiencing.
"We could expect [the U.S. impact of coronavirus] to be somewhat similar without action," Shaun Truelove, PhD, of the global disease epidemiology and control department at Johns Hopkins' Bloomberg School of Public Health, told 番茄社区. "Italy ... has awakened a lot of people to the potential impact of this virus, particularly of its capability to completely overwhelm health systems."
"Italy is the first [outside of China] to experience the full fury of this virus, so I think it's important for other countries to look at Italy and use it as an example of why we need to act quickly," he said.
Italian hospitalists shared their experience with 番茄社区, telling physicians to prepare for a worst-case scenario that none of them expected to be unraveling in their own country.
Clinical Situation
At Policlinico San Donato as of late last week, the mean age of admitted COVID-19 patients is 70, and half have underlying conditions, Menicanti said.
Only five patients have been discharged after 20 days of hospitalization. For those admitted to the ICU, which opened at this hospital on March 1, none have been discharged, except those who have died. The youngest person on a ventilator is 48; the oldest is 94, Menicanti said.
In general, about 10% of positive patients are admitted to intensive care, according to a by Maurizio Cecconi, MD, Humanitas University in Milan, and colleagues.
Should the ICU demand in Lombardy exceed the 900-bed supply, the regional government will set up a large ICU in a local conference center, Menicanti said.
About 5% of healthcare workers at his hospital have been dismissed due to illness or quarantine, but this isn't putting a huge strain on the system just yet, he said. Hospital workers are diligent about and have sufficient access to personal protective equipment; Menicanti said he has seen more problems among general practitioners in the community who may not have had proper protection when assessing COVID-19 patients. His hospital is currently caring for some of them, he said.
Unlike the U.S., Italian healthcare professionals have had no problem getting access to tests for the virus.
Menicanti's facility hasn't had a ventilator shortage, though "another part of the region did have a problem in the previous days, but now that's settling down," as the government is bringing in additional supplies, he said.
Difficult Choices
Giovanni Guaraldi, MD, of the University of Modena and Reggio Emilia, which is in the neighboring region of Emilia-Romagna, said at his hospital, physicians were thinking carefully about how to treat older patients, concerned that those 80 and over may never get off respiratory assistance once it's started.
"This is also difficult to communicate" to the family, Guaraldi told 番茄社区.
One Italian medical society even to help healthcare professionals navigate difficult choices if they are faced with them in the coming days or weeks. The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care's guidance equates the potential moral choices to wartime triage, or catastrophe medicine.
The principles advocate benefiting the largest number of patients, prioritizing intensive care for those with the best chance of success.
"We are Italian, we are not so cool, not so detached from reality," Menicanti told 番茄社区. "So we try to cure and treat all the patients. Of course, if in the future there will be a shortage of ventilators, we will be obliged to make some choice."
Guaraldi said the province of Modena has recently decided to have a dedicated hospital for coronavirus patients, bringing total capacity to 800 beds for a population of about 800,000.
"It's not [that] we are not able to cope," he said, but "it's not sustainable."
Treatment and Preparedness
While it's difficult to predict the clinical evolution of the disease -- "we've got very little biomarkers to understand who is doing well, who is not," Guaraldi said -- the standard treatment is an HIV protease inhibitor plus chloroquine. When disease severity worsens, physicians are trying an investigational antiviral, as well as immunosuppressants because the disease can ignite a severe autoimmune response.
Guaraldi said tocilizumab (Actemra), an interleukin-6 inhibitor used to treat rheumatologic diseases, has been particularly effective in those cases. "If it's done, not too late," one sees results in 24 hours, he said.
As for remdesivir, Gilead's investigational antiviral that was originally developed for Ebola, Guaraldi said his hospital has had difficulty obtaining the drug for compassionate use.
"Sometimes it arrives and the patient already is dead," he said, noting that timing of the request is difficult: "It's important to be able to ask for compassionate use of remdesivir at an early stage, but if it is too early, they will not approve it. And if it takes 3, 4 days to come, it may be too late to use it."
In terms of preparedness, Cecconi -- who recently co-authored a on the experience in Lombardy -- urged during an that physicians need more than just surge capacity planning to fight the battle against COVID-19.
"Do not think that you can win this battle just by increasing your capacity," he said. "Containment, mitigation maneuvers, slowing down maneuvers are equally important, if not more important, than anything we can do as doctors."
The fight will be won through government authority and citizen support, he said.
"If the moment comes where your government in the U.S. or any other country mandates self-isolation or any other maneuver, I think it really is the personal responsibility of every citizen to do that, because if you don't take down the transmission of the virus, then the capacity of your system will be overwhelmed."
Toll on HCPs
Guaraldi had five patients die on Wednesday alone: "We were very depressed," he said. He hasn't seen this kind of devastation since the AIDS epidemic.
Many of the patients who die "were quite healthy when I admitted them to hospital, and in one week they die," he said. And often, they're alone because they're in isolation, and because their family members are quarantined.
In the AIDS epidemic, "you could die nearby the person you love. Now you die alone," he said. "It's just healthcare workers that are fully dressed that will stay nearby the people who are dying."
"They know their relatives are going to die and they start calling you," he said. "It's so difficult, because we have no time to answer." It's also more important to be near the patients themselves, "and make them feel they're not alone."
The psychological toll is combined with physical exhaustion. Guaraldi said he arrives at the hospital at 7 a.m. and leaves at 11. He doesn't eat during that time.
"People who stay at night, in the morning they are really destroyed," he said.
Doctors are also being pulled from their normal specialties to pitch in on the front lines or cover other healthcare gaps.
"Neurosurgeons, orthopedists, we are all pushed to treat patients with infection, that is not our specialty," Menicanti said.
A surgeon at a large hospital in Rome, who spoke on the condition of anonymity as his hospital has prohibited clinicians from speaking to the press, said the country's General Medical Council has given physicians materials related to infectious disease in the event of a staff shortage.
He has heard the hospital sees only about 8-10 COVID-19 patients a day, but he's prepared for that to change.
"If I have to ... intubate a patient I can do it, if I have to check the parameters, I can do it, but of course I wouldn't be able to cope with all the anesthetists' tricks," the surgeon said.
Most of his surgeries have been cancelled. Only patients with cancers that risk spreading, for example, can risk a hospital visit.
Menicanti's elective surgeries have been cancelled, and his emergency surgeries are being done at one of four other hospitals in the area: "If the problem is not so emergent, the patient has to wait." He's concerned that people may die of typically treatable conditions.
U.S. Facing a Similar Fate?
Hopkins epidemiologist Truelove said the U.S. is similar to Italy in that it does have a large elderly population, though it skews a bit younger.
"We may be spared a little compared to Italy in terms of the absolute percentage of severe cases, but we could expect it to be somewhat similar, without action," he said. "I think we are acting much more quickly than Italy did, and hopefully we're ahead of where they were at this point with closing schools, universities cancelling classes, and mass gatherings cancelled."
The U.S. does appear to be a bit more aggressive about "flattening the curve" of the initial wave of stress on the healthcare system, he said. Italy didn't put the hard-hit Lombardy on lockdown until March 8, and a country-wide quarantine only went into effect March 10.
"When Italy closed schools, everyone thought it was a holiday and still interacted," Truelove said. "Here, you walk down the street in Baltimore, and it's pretty quiet. People are taking this seriously and staying home."