What COVID-19 is taking away from us

Cardiologist Dr Massimo Mapelli from Milan, Italy, discusses personal experiences from the ‘front line’ of this viral pandemic 

Last year I admitted Mr C., the father of my best childhood friend, for elective investigations in the hospital where I work as a cardiologist, a tertiary referral centre for cardiovascular diseases in Milan, the Italian economic capital. At that time, he was 70 years old, but I never thought of him as one of my older patients; to me, he was still the same person who used to drive us in his Ford to basketball practice in the small gym of the town where we lived. I was in fact sitting on his sofa—my BMX parked in their driveway—when the World Trade Center was attacked on 9/11.

Given the risk factors, symptoms, and coronary angiography showing a multivessel disease, an uncomplicated coronary artery bypass graft surgery was performed. After 10 days, he returned home to his quiet life with his wife. In the meantime, she convinced their grandchild, a lovely, blond 2-year-old boy, that his grandpa had temporarily gone to a mysterious place where someone (me, technically) was fixing his broken heart.

Mr C. and his wife became sick at the beginning of March, initially with severe fatigue and low-grade fever. After 2 weeks of high-dose antipyretic therapy, his wife improved, while he gradually worsened. After a long wait, the ambulance service finally transported him to the closest hospital in advanced respiratory failure. Chest CT scan revealed an extensive interstitial pneumonia with typical COVID-19 findings. ‘Seventy percent of the lungs are involved’ the physicians told the family on the phone, because they were in lockdown following the government ordinance. Despite prolonged non-invasive ventilation, he died of progressive respiratory failure a week later. None of his family members were able to say farewell to him, and the funeral was forbidden like all other gatherings of people.

The province of Bergamo, the area where Mr C. lived, is the largest Italian epicentre of the pandemic. At the date of writing, official numbers in Lombardy report ∼12 050 dead and 65 381 confirmed infections,¹ but much higher numbers have been speculated.² The people from this region will always remember the image of army trucks loaded with coffins to be moved to other regions’ cemeteries because of the lack of space in local ones. The local newspaper obituary section now occupies 10 times the space it did last year, and everyone has at least one deceased family member or friend. In the hospitals, patients die alone without the affection of loved ones. People are taken to emergency departments only in the presence of advanced pneumonia, otherwise they remain at home with long-lasting fever without undergoing a diagnostic swab, and therefore without the dignity of a diagnosis.

Figure 2.

Photos from the ‘frontline’: 1. Ready for another day. Units from other departments have offered to replace sick colleagues. 2. To cope with the growing workload, nursing staff have increased, and their shifts are more frequent. 3. ‘Andrà tutto bene’ Although overly optimistic, ‘everything will be fine’ is repeated like a mantra to exorcise fear in these days of the epidemic. 4. Cardiology patients have been moved to other departments to avoid in-hospital infection. 5. Arianna, one of our Fellows, discusses a patient with a nurse inside the COVID area. During these days the physical distance from patients has increased. Photos by author, Massimo Mapelli.

COVID-19 is a severe test for the Italian healthcare system. From 9 March, the whole country has been in lockdown, and all non-essential activities have been suspended. Hospitals have cancelled every non-urgent visit and admission, allocating increasing areas to COVID-19 patients. Despite the use of protective personal equipment, many colleagues fell ill and remained at home in quarantine (Figure 1). Over 100 Italian doctors have lost their lives.

Figure 1.

COVID-19 admitted patients and healthcare workers.

At a personal level, this is a period of special feelings and peculiar unexpected events. In 2014, during the Ebola outbreak, I was in North Uganda in a non-profit hospital. Even if most of the cases were reported far away from our working station, the fear of getting sick and dying was palpable and I never expected to experience the same emotions a few kilometres from my birthplace.

The head nurse of our department was hospitalized for a week, finally improving with antiviral therapy and discharged to compulsory quarantine. While I took care of her, she texted me from her room every 3 h a full list of symptoms and vital parameters. From her bed, she was still organizing the nurses’ shifts. To avoid any kind of contact, she was taken home by ambulance, and her car is still parked in the hospital parking lot.

I performed blood gas analysis on our anaesthesiology department chief, also admitted for COVID-19. A few hours after I had tested him, he was transferred to a more specialized hospital to take part to an experimental protocol.

A cardiologist from my team, a middle-aged man without comorbidities, has been more seriously affected, with progressive respiratory failure. He has undergone prolonged cycles of non-invasive ventilation. To be prepared for all eventualities, a nurse had to completely shave the brown beard he had grown over many years. Like many other teams, we also have a WhatsApp group where we exchange clinical information, news, and urgent communications. These evenings it is full of messages; while we rest on our sofas at home, he updates us on how he feels, texting from under the CPAP helmet.

Every day we call patients’ relatives. They cannot stop thanking us for what we are doing, even when we feel frustrated or inadequate. Although more demanding and risky (healthcare workers account for 9% of cases), most doctors and nurses in my department have volunteered to take turns in the COVID area, a distinct area separated by a barrier made with past cardiology congresses’ posters. Some medical personnel now live away from their families to protect them. I have not seen my 4-month-old son for 40 days, meaning I have missed more than a quarter of his life. Every evening I enjoy seeing pictures of him with his mother on my cell phone. The head of our department, a university professor of cardiology, is currently working his 45th consecutive day. Not only is he working at the forefront in this difficult situation, but he also has to deal with the stress of having friends and colleagues amongst patients. We have supported each other for weeks by repeatedly talking about the common goal of having a huge party when everything is over.

However terrible, this crisis has definitely made us more united, both among colleagues and with patients. We feel that the thin wall built to separate the doctors from the sick has fallen, making us more fragile but more sensitive. These hard times are taking many things away from us and from families, as with Mr C. and the thousands of people who have seen their relatives dying.

But they are teaching us again what it really means to be a doctor and to be part of a wonderful team. When everything starts up again—because it will start up again!—let us never forget it.

Conflict of interest: none declared.

Massimo Mapelli^1,2*

¹Centro Cardiologico Monzino IRCCS, Milan, Italy; and ²Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy

*Corresponding author. Heart Failure Unit, Centro Cardiologico Monzino, IRCCS, Milan, Via Parea 4, 20137, Milano, Italy. Tel: +39 0258002930, Fax: +39 0258002266, E-mail: massimo.mapelli@cardiologicomonzino.it

References

References are available as supplementary material at European Heart Journal online.