Inside Italy's coronavirus hospital

Dr Antonio Castelli shares what it is like to face Covid-19 on the front line at the Luigi Sacco Hospital in Milan.

A man walks past a billboard raising awareness on the measures taken by the Italian government to fight the spread of Covid-19 in Naples on March 22, 2020. PHOTO: AFP

Milan: Our beards will grow back when it's all over

"Antonio, what do you think?'

“What can I say? It was a great vacation, Prague is gorgeous.”

“No, Antonio, I mean the news.”

There was a moment's silence, the time it took my wife to bring up the breaking news on her cellphone about the first cases in the region of Lodi, in northern Italy.

"It's here now, too, Antonio. We're creating an emergency task force, you need to get back right now."

It was 7.40am on Friday, Feb 21, when Dr Antonio Castelli, 56, head of the resuscitation unit at the Luigi Sacco Hospital in Milan received a phone call from Dr Giacomo Grasselli, the medical director of the intensive care unit at the Policlinico hospital in the Lombardy capital city.

Dr Castelli was at the wheel of his car, alongside him, his wife, who he first met when they were medical students and who now works at the same hospital as a heart surgeon.

The Luigi Sacco Hospital in Milan is the point of reference for epidemiological emergencies in northern Italy. It was the first hospital to have been fully converted to deal with the coronavirus, which causes the respiratory disease Covid-19.

On their way back from Prague, Dr Castelli and his wife had planned to stop off for a couple of days in the Austrian Alps. But Dr Castelli's foot never left the accelerator, he headed straight for the Brenner Pass, arriving at his ward in Milan by 2pm.

He found it deserted, not a soul in sight, and he immediately realised that years of drills, simulations and studies had now become a reality. This was no movie. The time has come to shave off his beard, the beard he had been cultivating for 30 years.

An almost empty 24 Maggio and Gorizia streets in Milan, on March 22, 2020, due to the coronavirus crisis. PHOTO: EPA-EFE

"When I entered my resuscitation unit, it was empty, totally abandoned, no patients, just the chaos left behind from a quick getaway. So I went to the infectious diseases unit, the one run by Professor Massimo Galli, where we had simulated how we would deal with the Ebola crisis five years ago,” he said.

“It was a hive of activity there; in the time it had taken me to get from the Brenner Pass to Milan, they had managed to evacuate the entire ward, install four beds in a biocontainment unit to treat those with highly infectious diseases, and to fill them with the first patients from Codogno, the center of the outbreak in the Lombardy region,” he added.

One of them - only 42 years-old- was the person dubbed “patient two”, who was linked to “patient one”.

He said: “Everything seemed to have snowballed at an unprecedented pace. By the following Monday, Feb 24, the number of beds needed in intensive care had increased to 11.”

As soon as he turned his phone on at the end of his night-shift, he received a call from Dr Grasselli, asking him to go to the Lodi hospital to see what support they might need in the face of the dramatic escalation of coronavirus cases.

Dr Castelli jumped in his car without a second thought, no stretch of the imagination could bring him to picture what he would find there.

“The least serious case seemed to be a woman attached to an oxygen respirator; someone had hung a bottle of water onto her gurney, a detail which struck me as particularly humane. The place was overflowing; 70 men and women so cramped they could barely breathe. But it wasn't chaotic; it was strangely ordered, the commitment to duty was palpable. I'll never forget it,” Dr Castelli said.

The chief medic of the emergency room, Dr Stefano Paglia, had been there for eight days. He had not once set foot outside during this period; he communicated with his wife and daughters through WhatsApp, and managed to snatch a couple of hours sleep between one wave of incoming patients and another.

Because there were two waves of admissions per day, a dozen or so patients at a time, either in the early morning or at sundown. They were the people who, unable to sleep, had tossed and turned anxiously all night, waiting until the daybreak to seek help; or those who, seeing their condition worsening throughout the day, feared what the nighttime could bring.

Dr Castelli met the entire staff. “Their faces were drained, exhausted. They felt no one was grasping the severity of the problem.

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Footage shot inside Oglio Po hospital in Italy shows the massive strain healthcare facilities face from the coronavirus outbreak.

He said: “I told them that I wasn't there to check up on them, just to bear witness to the incredible work they were doing. I want people to know what they did in Lodi, when the town of Codogno was already on lockdown: their accomplishment was pure heroism, and I don't use that term lightly, as so many people do nowadays.

“They quite literally were heroes. As they were filling me in on the situation, I was almost moved to tears by the resilience and competence of that team of doctors and nurses."

An ambulance arrives at Humanitas Gavazzeni hospital first aid service in Bergamo, Italy on March 21, 2020. PHOTO: EPA-EFE

That very night, 10 patients were transferred from Lodi to Sacco Hospital, with the most serious cases going to the resuscitation unit at Humanitas Hospital, which had freed up some places in intensive care.

Forty-eight hours later, on Saturday, they managed to close admissions in the Lodi Hospital for one day to give the entire staff a breather.

Dr Paglia and Dr Enrico Storti, the chief medic at the resuscitation unit in Lodi, have devised a no-nonsense technique for immediately identifying patients with Covid-19 - one we could christen the Lodi method, and one that will go down in medical history.

"It's not based on the temperature of the patient, but on breathing difficulties, and the area it stems from," explains Dr Castelli.

“This method was used to identify the first patients who needed to be isolated, then to distinguish between the most severe cases and the milder ones; they would have a chest X-ray, and the level of oxygen saturation in the blood would be measured after having made them walk up and down the corridors for 50m. That's how they managed to deal rationally with the emergency throughout the night of Feb 20."

A reef constantly being hit by waves

On the afternoon of Feb 27, Dr Castelli wrote his report, comparing Lodi to a reef “constantly being hit by waves”.

It is the part of Italy that has taken the most knocks, but it is one with a low population density; the contagion needs to be contained, because if it spreads, then it could be a catastrophe waiting to happen: "If the waves go over this reef," he wrote, "just beyond it is Milan. And we cannot allow that to happen."

I interrupt him. Over three weeks have passed since that day, and I ask if that wave has hit Milan.

Dr Castelli said: “No. At least not with the same tidal force. But the chance of being overcome by a tsunami is very high. It all comes down to whether the population will stay in their homes, isolating themselves from each other.

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Streets in Milan and Venice were practically deserted on Thursday as prime minister Giuseppe Conte further restricted movement and closed all shops in order to fight the coronavirus contagion.

“I don't know what is happening on the outside, but I hear that the streets are finally emptying; when over the past few days I've seen photos of the bars along the Navigli, thrumming with people during happy hour, or people dining at restaurants, I thought it was madness, sheer madness. An omnipotent, delusional idea that young people are immune to contagion.”

This was a conviction that is proving hard to overturn, owing in no small part to the ages of the deceased.

“Of course, most viral pneumonias affect the elderly, but young people have been infected too; let's not forget that 'patient one' is 38 years-old, and that the first person he infected, besides his wife, was a 42 year-old. Both are alive, no longer on life-support, but they did do a stint in intensive care.

“There is just one solution, however old you are, and it is to reduce contagion. We can look to the Japanese for an example: culturally speaking, they tend to keep more of a distance from each other, but still, they are showing an incredible social conscience at the moment. The scenes of people fleeing to go back to their homes in the south of Italy are atrocious, if you think that many of them were bringing the risk of contagion to areas that have far less structures and resources.”

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For doctors, every day requires a little bit more effort

The medics of the intensive care unit of the Sacco were the first to drastically modify their lifestyles: Some of them chose to sleep in hotels near the hospital, returning home only once their children were safely out of harm's way; one doctor rented an apartment for fear of infecting his family.

They're deeply concerned, they eat alone, they have explained to their children – even the youngest – why they can't kiss or hug them; they have isolated themselves in their own homes.

“I don't sleep next to my wife any more, I sleep on the sofa-bed, we have no physical contact whatsoever; just imagine if I suddenly started coughing at night, and realised I had contracted the virus and risked infecting her too. We eat at opposite ends of the table, we're careful not to touch each other's cutlery, and as soon as we finish, I make sure I'm the one who loads everything into the dishwasher.”

A nurse rests after a 12-hour night shift at the Cremona hospital, south-east of Milan on March 12, 2020. After weeks of struggle, they are being hailed as heroes. But the Italian healthcare workers are exhausted from their war against the Covid-19. PHOTO: AFP

And their work life requires the same attention, with no detail overlooked, nothing forgotten, every day requires a little bit more effort.

“I keep thinking that we don’t have enough: one more bed is not enough, one more doctor is not enough, and we'll never have enough surgical gloves. When you treat someone who is ill, you change the second glove constantly, even ten times.

“The first one is like a second skin, it comes up to your elbow and you never take it off when you're working. The other one gets changed endlessly, so as to avoid the risk of contagion.

“When you get undressed, you use a glove to remove every article: I take off my surgical visor to clean it, and I have to change the glove; I take off my scrubs, and again, I change the glove; if I change footwear, I change the glove again. This hospital has maintained a high state of red alert, with constant drills, but we need to be careful not to be struck down by exhaustion.

"When it's the middle of the night and your efforts are being concentrated on the sick, you can sometimes forget if you've followed every safety procedure, and that's when anxiety strikes. You can never be too focused.”

A patient is wheeled into a newly opened Covid-19 hospital wing in Rome on March 17, 2020. PHOTO: NYTIMES
At Palazzo Marino in Milan, chairs are placed outdoors and at a safe distance before a meeting on March 20, 2020. PHOTO: NYTIMES

Every single day this week, space has been made for new beds, but it seems there are never enough. “On Friday, March 6, we were asked to double the number of beds by the day's end. We were supposed to install 22 beds, but it was technically impossible.

“We could have used another ward in the unit, but there wasn't enough compressed air, a vital component for attaching ventilators. It was 2.30pm when the meeting between the hospital administration and the engineers came to a close. Half an hour later, the technicians filed in, and before 7pm a line of air vents with compressed air had been built into the walls.

“I saw an intensive care unit set up at record speed. It was so well-constructed that it seemed like it had always been there, nothing unstable, no loose wiring or tubes. We've been asking for improvements in the ward for four years, and we got them in four hours.

"We only seem able to act when an emergency is on hand, never when something needs to be scheduled. It makes me angry that this country is incapable of doing ordinary things, but then capable of producing miracles.”

The 22 beds were filled immediately, with people arriving from Lodi, Cremona and Bergamo, which is now the most critical hotspot.

To fight this war, the Sacco has concentrated 25 doctors in the resuscitation unit, and the number of nurses has doubled from 30 to 60, but every day the workload intensifies.

“There are plans to build another floor for intensive care, but the nurses are fundamental, without them there's no point in calling in doctors or installing oxygen tubes, they are the ones who make the difference. As soon as this thing kicked off, they arrived en masse, on a voluntary basis, all ready to do battle. In times like these, the original motivation that made us choose this job comes to the fore in all of us.”

This will all be over - and we'll grow our beards back

A group of nurses wearing protective mask and gear pose for a group photo prior to their night shift at the Cremona hospital, south-east of Milan, on March 13, 2020. PHOTO: AFP

What if there are too many people infected who need respirators, if there aren't enough new beds? It's not hard to envision the breaking point being close at hand.

“The fundamental rule of good medicine has to be a compassionate approach to the balance of care. This doesn't mean abandoning some patients, just distinguishing between the level of care required.

"It's very important that the Italian Order of Anesthetists and Resuscitators has issued a memorandum with recommendations of medical ethics in exceptional conditions, such as the one we find ourselves in right now. A sober and frank document which, in the face of limited resources, reiterates that ‘we must prioritise greater life expectancy.’”

His 22 patients are completely sedated, some of them intubated face down - a technique developed in Milan by the group headed by professors Gattinoni and Pesenti, and then used all over the world.

"They're all asleep, they won't remember the pain. When they come back to thank us with a tray of pastries - because this is what will happen, in our experience - they will only remember how thirsty they were.”

Of those first four patients in Codogno – who were admitted more than three weeks ago, even though it seems like a century has passed – one died after three days, two are still there attached to the machines, asleep, and one has left the ward and is breathing on his own. The road ahead is long and every day sees us adding at least one new bed in intensive care, so as to be ready for all eventualities.

"We're exhausted, and fear has become our constant companion since four of us – two pulmonologists and two residents – have been infected. One of the most difficult moments, the one that creates most tension, is when there is a shift change, and lots of us are getting undressed and dressed at the same time; all it takes is for someone to start coughing to cause mass alarm and for a thermometer to suddenly appear.”

“We all had beards in my ward; we shaved them off that morning so that our masks could adhere more securely. But every day in our WhatsApp resuscitators group, I repeat: ‘Remember that we'll get our beards back. When it's all over - because this will all be over - we'll grow them back.'"

A view of the town of Nembro in the province of Bergamo, where Italy is considering setting up a new quarantine red-zone due to a high number of coronavirus cases in the area. PHOTO: REUTERS

Nembro: The death bells stop tolling

On March 7 in the small town of Nembro, the death bells stopped tolling.

“We decided not to ring them anymore since that Saturday, the day of the four funerals. It would have meant that the whole day would be filled with the sound of the death knell, and this would have caused untold anguish for the entire community. We thought it was best to just let things be,” said Catholic priest Don Matteo Cella.

Nembro, with its 11,500 residents and numerous churches, all under a single parish, is tended by five priests. Four were taken ill, only one was left standing, the youngest: Don Matteo, 40 years old, originally from San Pellegrino Terme.

A small village east of Bergamo in Italy's Lombardy region, Nembro is the gateway to the Seriana Valley and where Italy's America's Cup Luna Rossa sailboat hull was built. It now risks going from being a headline to going down in history as the town with the highest percentage of victims in the Covid-19 epidemic.

History has a tendency to repeat itself - the 1630 plague wiped out nearly three-quarters of the town's 2700 inhabitants; only 744 lived to tell the tale.

A nurse wearing protective mask and gear comforts another as they change shifts on March 13, 2020 at the Cremona hospital, south-east of Milan. PHOTO: AFP
Nurses wearing protective mask and gear embrace on March 15, 2020 at the Cremona hospital, south-east of Milan. PHOTO: AFP

Last year, 120 people died in Nembro, 10 a month; now 70 have died in the space of just 12 days.

I went in search of the parish priest, but I found his assistant, the curate, Don Matteo, who usually tends to the younger members of the flock; he gives me an account of the recent terrible events.

“From the beginning of the epidemic, according to the parish statistics, we held 39 funerals in the church, 26 at the cemetery, and we have 26 deceased waiting to be laid to rest. That comes to 91 people, without counting anyone who may have died in the past few days that we have not heard about yet, or even of non-Catholics,” he said.

The village is like a freeze frame, a surreal vision: nobody in the streets, the shops are all closed, and the grocery stores and the pharmacy only make home deliveries.

Empty streets in Nembro, one of the municipalities most affected by Covid-19, on March 15, 2020. PHOTO: EPA-EFE

Until a fortnight ago, the Town Hall square was chock-full of children; now there is not a soul in sight. Everything is static, as if frozen where it was on that Saturday at the beginning of March when the government decided to close the whole of the region of Lombardy.

Don Matteo - underlining that he is not a doctor and that he does not wish to overstep the mark - limits himself to chronicling the facts that have devastated his community.

“We believe this thing has been around since the beginning of the year or even since Christmas, without being identified. For a start, the nursing home in Nembro had a peak of anomalous deaths. In January, 20 people died of pneumonia, the last one, this week, was the chairman of the Giuseppe Pezzotta Foundation, affectionately known as Bepo.

"The whole of last year, there were only seven deaths there. And so the number of funerals began to swell, week in, week out, with everyone talking about this severe pneumonia going round," he said.

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Prime Minister Giuseppe Conte said on Saturday (March 21) that all Italian businesses must close until April 3, with the exception of those needed to maintain the country's supply chain.

“Before Mardi Gras, half the town was in bed with fever. I remember that while we were discussing whether to hold the celebrations and the parade with the children, we had to close down the ‘homework space’ because most of the volunteers who supervised the kids were sick. But there was no talk of coronavirus back then in Italy; who knows how many of us were already sick and then got better," he added.

“Gradually everything ground to a halt; we started off by suspending Mass in church, but we kept tending to the sick, meeting their families, for as long as possible, because you cannot refuse them comfort. We tried to exercise as much caution as possible, but today I am the only priest who is still healthy, the others are all down with fever. Don Giuseppe is in hospital, and Don Antonio, the parish priest, was taken ill but has now recovered.

"Then we started holding the first funerals of those taken by Covid-19, in the presence of close family only. In the week of March 2, we buried 14 people, when usually there are only two at most.”

Even ambulances go silent to spare residents from anguish

The last funeral rites to be celebrated before the government put a stop to them were for Massimo, a 52 year-old, who worked in graphics and printing. He was a volleyball enthusiast, the sport played by his three daughters, aged 25, 15 and 12.

Don Matteo officiated the last rites on the afternoon of Saturday, March 7.

“Only his wife and daughters were present, a few friends waited at a safe distance in the main square for the passing of the hearse. Massimo was never tested, he died at home in the days when panic was skyrocketing and the emergency was at its peak; our family doctors were the first to get sick or to end up in quarantine, it was difficult to get any answers, it was havoc.

"He had a high temperature for a week, it kept creeping up, then he began experiencing respiratory problems. They called for help, but when the paramedics arrived, there was nothing more that could be done.”

Since that week, not only has the death knell been silenced, but when possible, the ambulances go about their business in silence to reduce the fretfulness which the constant sound of the siren can trigger.

A woman stands next to her relative’s coffin inside the cemetery of Zogno, near Bergamo, northern Italy, on March 21, 2020. PHOTO: AFP

Now that funerals can no longer be held, Don Matteo can only accompany the deceased to the cemetery.

He said: "The families notify us, and we go to bless the coffins or the urns before the remains are buried. It's very sad, detached, I do my best to bestow a minimum of humanity.

"They are people who died in hospital in exceptional circumstances, in complete solitude, with relatives who saw an ambulance leave with their loved ones, then never heard anything until the announcement of their death, and the call to collect their personal belongings. And I'm not talking about one isolated incident.”

As soon as he felt well enough, the parish priest, Don Antonio started calling all the families in mourning to comfort them.

Amid the crisis, a strong sense of community has been rediscovered

Don Giuseppe Corbari, parson of the Church of Robbiano, holds Sunday mass as he looks towards selfie photographs sent in by his congregation members and glued to empty pews in Giussano on March 22, 2020. PHOTO: AFP

When the shops closed, the Town Council asked the parish to help them spread the word that groceries could be delivered; the shops got organised, and Don Matteo put together a team of 40 young people between the ages of 15 and 17, who went door-to-door to put flyers in all the mailboxes.

“Another incredible thing,” he tells me, “are the volunteers who bring medicine to the sick, the elderly and those in quarantine. A strong sense of community has been rediscovered, and the territory has shown a deeply moving sense of human kindness.”

The town tries to keep updated, people want to know who has died, who has been hospitalised; but sometimes, in this constant back and forth of messaging on WhatsApp, some colossal misinformation gets passed on, often due to confusing people of the same name.

“Yesterday morning there were reports that the former parish priest, who was with us until last year and who is hospitalised, had died. A lot of people got in touch with me to express their condolences, but between one call and another, he also phoned to tell me that he was better and that he could finally speak again. I didn't have the courage to tell him that the town was already mourning his passing.”

Last Sunday dealt a major blow for the community, when Ivana Valoti, the 58 year-old obstetrician died in the very hospital she worked in Alzano.

“Word had gone round that she was better, we knew that she had taken care of her mother, who died two weeks ago of coronavirus, but people were hopeful for her. Then, suddenly, she had a seizure and she never recovered. We were all grief-stricken, because Ivana assisted in the delivery of most of the children in the town. She represented the life that is created, and her untimely death was the hardest blow.”

In this emptiness and silence, Don Matteo evokes technology to celebrate Mass in the vacant church and then uploads it to YouTube. Parish groups meet in video chat rooms or through Zoom.

A nun prays during streaming of Sunday mass in the Chapel of the San Giovanni Bosco Oratory on March 22, 2020 in Saluzzo, near Cuneo, north-western Italy. PHOTO: AFP

Every morning he records a podcast with his observations on the day's Gospel; parishioners find it on every platform, from Spotify to Apple, from Facebook to Twitter, and they share it. Five hundred people download it every day.

“Now I have to go and finish editing tomorrow's one, it's the Gospel of Matthew that talks about debt, numbers and forgiveness.”

I listened to it, and one sentence stuck in my mind: “The cold, hard precision of numbers often transforms them into ruthless cages, but we have to forgive until we lose count.”

Mario Calabresi is the former editor-in-chief of La Repubblica and a former board member of the World Editors Forum.