5 days to go

In Italy Covid 19 arrived around end of February, initially in Lombardia and Veneto and then in Piemonte (my region), Emilia Romagna and less violently in many other regions.

I’m working in a teaching hospital of medium size, quite close to the Lombardia borders. Our first patient arrived on the 28 February. A severe respiratory failure.
In a few days we had tens of patients arriving every day, for the whole month of March most of them where in severe respiratory distress. All the same, interstitial pneumonia, severe hypoxaemia, need to intervene immediately to save them the life.
We rapidly learned how to evaluate the patients, could send home about 40% of them, the others needed to be treated with oxygen and many with mechanical ventilation. We learned that Non Invasive ventilation directly in the ED is much better than invasive ventilation, and now much less patients would need ICU.
We learned that even if medical treatment is not yet completely validated, it is important to start it early, with the aim to stop the inflammation storm that is provoked by the virus, and is responsible of all the complications, vascular, pulmonary etc.
Above all we learned that with a pandemic the hospital, starting from the emergency department, needs to reshape itself quickly. We set up a pre-triage to sort the suspect Covid patients, then a double pathway for the suspect and non suspect. This means to double medical and nurse staff because there is the need to stay in one area only to limit the spread and not waste the Personal Protective Equipment (PPE). Besides, you need to know your resources and try to increase them. The critical issues are: oxygen supply, space to keep the correct distance from one patient to another, in particular for those who are doing ventilation or need to be intubated, to have a clear diagnostic pathway, food and water for the personnel, some space for rest, never remain with shortage of PPE end have available a psychological support.
On proposal of PPE, it is necessary to train your staff to the correct use and management. How to wear, unwear and dispose them.
The Covid storm for us lasted 2 months, in which we saw 840 patients and admitted 460 of them. In our ED we treated with early CPAP or Non Invasive Ventilation 75 patients. In Italy, we have beds for acute critical care in the ED, and keep critical patients up to 2-3 days for stabilisation.
At the beginning we observed a dramatic reduction of non-Covid emergencies, probably because people had fear to come to the hospital, then we reassured that the ED was ready to receive everyone in a safe way, and so progressively they came back.
An experience, professional and human, that has we will never forget and that has outlined the importance of competence and dedication. The 27 of May is the Emergency Medicine Day, the day where the value of Emergency medicine as a specialty and a discipline is celebrated and underlined. Never like this year we and the population have touched this value. We need to take this in mind. Emergency Medicine can not be substituted or derogated to anything else.

Roberta Petrino MD, HonFESEM– Director Emergency Department, S. Andre Hospital Vercelli.
Past-president European Society for Emergency Medicine (EUSEM)
Member of the Council Società Italiana di Medicina di Emergenza e Urgenza (SIMEU)