So my message is, if you are in the middle of an outbreak or where the virus is spreading actively, you have to be prepared to reshape your hospital, and to use techniques that are following the pace that this virus has imposed on your hospital. Don’t try to cope with what you are accustomed to doing, such as a CT scan for every patient, immediate ICU recovery, prone supine strategy from the very beginning. You can't cope because you have not enough nurses to supine 18 patients at the same time. So it's a sort of different triage.

And let me say that this kind of triage, which is absolutely not common for Italy, is something that is not easy to do. It has not been so easy to convince people that we were in a sort of war scenario, and the only solution was to completely change our way of treating patients. Now we have teams that weren't present until a few weeks ago because we now have different patients in different locations in our hospital with different needs, and a disproportion between those needs and our ability to catch them.

Dr. Mandavia: How do you protect your staff?
Dr. Storti: This is absolutely a crucial issue. Luckily, we had enough PPE (personal protective equipment) to wear. We immediately briefed people how to wear it and protection strategies. We still had physicians and nurses [who tested positive for COVID-19]. However, I do believe that the larger portion of them were infected when our patient one hadn’t been identified yet.

Dr. Mandavia: What is the role of your lung ultrasounds? Anything unique to COVID-19?
Dr. Storti: Our hospital has a high competence in ultrasound because we did a very extensive job in training people in the last ten years. Every single floor of this hospital has an ultrasound machine, or more than one, and all the physicians—pediatricians, neurologists, surgeons, intensivists, whoever is working here—are able to perform point-of-care ultrasound. Because we were so confident with point-of-care ultrasound, we decide to use it at the very beginning: the triage, to assess coronavirus lung involvement and decide where to bring the patient. Sometimes we received young people with only lung involvement, ranging from pneumonitis to ARDS. We also see elderly [patients] with other pathologies or comorbidities. Ultrasound is very useful to better assess the patient in the ED.

Around this area, under this “tsunami of patients,” many other hospitals were overwhelmed and sort of collapsed just because they were referring patients to a CT scan, waiting for a CT scan report, and waiting for the scanner to be available for the next examination. That made EDs very slow in addressing a large number of patients. Bringing ultrasound into the middle of the decision tree has been really, really effective.

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