Italy is the new epicenter of the coronavirus pandemic, with more than 69,000 confirmed COVID-19 infections, as of Tuesday night. The death toll is staggering — 6,820 dead, more than anywhere else in the world — and hospitals are nearing a breaking point as doctors and nurses struggle to keep up with the endless torrent of sick and dying patients.
The crisis is most acute in the Lombardy region of northern Italy, where Dr. Francesco Castelli works as the the director of the infectious and tropical diseases department at the University of Brescia and the Brescia Spedali Civili hospital. He is also coordinating his hospital’s clinical response to COVID-19.
Castelli spoke to the Globe by phone Sunday about his experience on the front lines of his country’s coronavirus outbreak. The interview has been edited for length and clarity.
Q: When did your hospital see its first case of COVID-19? How has the number of cases grown since then?
A: The first case was admitted early morning on the 23rd of February, and it seems, from day to day, we have had a cumulative number of about 1,700 patients, and this was during the last month. Fortunately, we could discharge in good health a proportion. Unfortunately, we also had many deaths. But it was very quick and very rapid. We had to allocate beds to admit COVID patients in the matter of a few days by quickly emptying other wards — internal medicine, pneumology, even surgical wards — because there was a mounting wave of patients knocking at our doors. So far, we have 700 beds for COVID patients, and they are all filled up. We have another 100 patients, more or less, waiting at the emergency department.
Q: What therapeutics are being used at your hospital for treating and managing the symptoms of COVID-19 patients?
A: As you may know, there is no registered drug for COVID patients, no FDA-approved or EMA-approved drugs. So following the experience of our Chinese colleagues, we started using hydroxychloroquine and some antiviral drugs, but mainly for the early stages of the disease. We have also used, in a compassionate way, the drug which has been developed for Ebola, remdesivir, and now we are part of an international clinical trial that will be starting soon with remdesivir. Also, in the most advanced stages of the disease, we used anti-inflammatory drugs, such as tocilizumab, as part of a national treatment program. Many research clinical trials are also underway.
Q: How has COVID-19 caused fatalities in your patients?
A: The case fatality rate is higher in older people than in young people. Young people rarely have a severe disease, at least in my experience. But after 60, but even more, after 70 and 80, there’s an important case fatality rate. So older age is a bad prognostic factor. Other prognostic factors of severity are comorbidities, such as hypertension, cardiac diseases, diabetes and obesity. You can have severe cases even in young people when you are obese. In severe cases, the disease may progress to a stronger inflammatory response — what we call cytokine storm — which progresses to respiratory distress and finally, it may progress to severe respiratory distress, requiring intubation, and eventually to death.
Q: Does your hospital have enough ventilators?
A: Of course, we would have needed more intensive care beds. We would have needed more ventilators, that’s for sure. But even in non-ICU wards now, we’re trying to do our best so that we use ventilators even in normal medical wards in order to give everybody a chance. But now we have in our wards people that in normal times would have been admitted in intensive care units. We are trying to get more and more [ventilators]. We are struggling with that.
Q: What about personal protective equipment for doctors and nurses, such as respirator masks?
A: So far, we have adequate supply. But of course, it’s a day-by-day struggle. I know that the supply of masks, gloves, coats, and other equipment is increasingly difficult. However, luckily and fortunately, we have been protected, even though a number of physicians and nurses got infected in my hospital. When you have to take care of 700 patients, the possibility of contact is obviously high.
Q: How many healthcare workers at your hospital have been infected?
A: I can’t give you the exact number, but I can say that was one of the major problems because when a physician gets the infection, even if he has no severe symptoms, he cannot work and has to stay home. So we have double the work with limited staff. That was the case with nurses, and that has been the case with physicians and also for some laboratory technicians. It is a substantial problem. As a matter of fact, nearly 10 percent of the total number of cases in Italy is among healthcare workers.
Q: What ethical dilemmas are doctors facing with so many patients and such a limited supply of ventilators?
A: Of course, when we are overwhelmed, you can face some difficult dilemmas. But we try to offer our support to every single patient. The most severe need ICU [care], but we also treat severe cases in our non-ICU wards to the best of our knowledge and competence. But we have many dilemmas. We are trying to offer all patients the best that we can even if we do not have the possibility of sending all them to the ICU.
Q: What are the emotional and psychological challenges of treating all of these patients?
A: We have some psychological pressure for many reasons. First, many patients die and that is something that is not good, of course — and how they die, because they die without the possibility of having their parents with them, so they die alone. Second, when you see many colleagues falling ill, that is also psychologically demanding. Third, we are also under psychological pressure because many of us have a family at home, so when we go back to our houses, we also have the fear of being infected and infecting some members of our family.
Q: Why do you think the coronavirus was able to spread so quickly in northern Italy?
A: It’s a question I don’t really have the answer to. As a matter of fact, when the first cases appeared, we knew that the epidemic was approaching us. Why it was so violent, that is something I do not know. I must say that people are quite compliant with the strict measures that the government put in action. But probably, when the measures were enforced, the epidemic was already among us. You have to consider also that Lombardy is the most industrialized region in Italy and also the most inhabited region. We have 10 million inhabitants in Lombardy and we are a very industrialized area of our country with many international connections both from the west and the east. So it is not unexpected that the epidemic came to our places. However, the rapidity of the spread of infection was a surprise. When it arrived, it was already too late. We were the first country in Europe to be hit. We didn’t have the possibility to learn from other countries and I hope that now other countries will learn from Italy and really prepare.
Q: Are you hopeful Italy may soon turn a corner?
A: We are in the middle of the storm. I don’t really know when the storm will be finished. But Italy has adopted really strict rules and restrictions. You cannot gather. Shops are now closed. Universities are closed. Schools are closed. Our streets are now empty and so I think that these measures will be able to at least slow down the epidemic. I’m confident of that. We are fighting. We are doing our best and I hope that in the near future, but I don’t know when the near future will arrive, the epidemic will slow down.
Q: How are you personally managing all of the stress that comes with your work at the hospital?
A: I am 62 years old now. I have lived in many parts of the world. I have already faced very challenging situations. And now, given the situation, I do not allow myself to show fear and panic. I owe that to my younger colleagues and nurses. I have to be calm. I have to try to keep my professional view of things. I have to try to help my younger colleagues cope with the situation. It is not always easy. Of course, myself, being a human being, I often am sad, frustrated and sometimes disconsolate. But now, when you’re trying to drive the boat in a storm, you have to drive it until you reach the closest safe harbor. That is my goal, and I hope that with the help of all, the boat will reach the safe harbor. I hope as soon as possible. That is my duty.