Dr. Mandavia: Yes, tell us a little bit about that.
We immediately understood that this was a war scenario. We had so many patients at the same time that we couldn't cope by using the gold standard. What I mean by gold standard is that every ICU physician knows perfectly how to handle and treat an acute respiratory distress syndrome (ARDS) patient. The problem is that you have to treat 15 ARDS patient at once and your team is decreased in terms of people able to work the shifts. It was immediately clear that we first had to reinvent our way of approaching this patient.
On day one, we were completely overwhelmed and astonished about what was going on. But immediately we tried to react and have a different approach. For example, we had too many patients with ARDS to refer them to the CT scanner. The patients were presenting with a severe respiratory distress, PO2/FiO2 very low, and a fever and a flu in the few days before. So, the diagnosis was not so complicated.
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What was really challenging was to triage these people with something which was very quick, very simple, very effective, addressing clinical decisions. Otherwise we couldn't cope. So we managed these patients only with blood gas analysis, chest X-ray, and ultrasound evaluation. And, of course, their previous medical history. Those have been our pillars to have the final diagnosis.
Deciding when you have to distribute your resources in the proper manner became very important: where to refer the patient, who could stay in emergency department for 24 or 48 hours, who should be intubated immediately, and who to refer to the stepdown unit. We have redefined the wards in our hospital and created from scratch a stepdown unit from zero to 18 beds. We have erased neurology and the neurology ward, and moved in ventilated patients to be treated by a multidisciplinary staff, including a pulmonologist and an intensivist, to enlarge our ICU capacity.
When coronavirus infects people, you create a ratio which is roughly like this: You create one ICU patient, you create five to 10 stepdown unit patients, and you have 10 to 20 patients who simply need to be oxygenated. For these number of patients, it has been so important the oxygen sockets and the total amount of oxygen supply in our hospital increases fivefold. So we had to ask the factory that brings our oxygen to refill our oxygen reservoir once per day.
Dr. Mandavia: Besides the oxygen, what other areas do you have constraints on? What else should physicians anticipate?
We were the first ICU in Italy to have the first coronavirus diagnosis, whom we call Patient One. Of course, we know now that the virus was already circulating here in Italy for sure 15 days before. And this is important because [since the day of the first diagnosis], we received a number of patients where we had to use 15 liters [of oxygen] per minute. When you have 80-100 patients, you have to apply 15 liters per minute, your oxygen delivery in your pipelines are not sufficient. So we were forced also to rebuild the different oxygen sockets inside the hospital and to empower our oxygen pipelines in order not to have a crash in our oxygen system.