An Emergency that started far away from us, but which quickly became ours.
By Lt. Dr. Manuel Tamani, CBRN Manager, Emilia Romagna Region, Italian Red Cross Military Corps Italy
It was the first week of February when we first heard about a flu in China and when the government started to implement security checks at the airports to check temperature of travelers arriving into Italy. We had 35 airports to check, representing a daily average of 1100 flights. These checks resulted in the delay of numerous flights, creating frustration and misunderstanding from the passengers, the pilots, the crews. After a couple of weeks, the first hotspot was identified in Lombardy, the most populated region of Italy, and from that day onwards it has been a spiral of events.
Actions taken and difficult adjustment.
The government started to take a range of actions to tackle and contain the pandemic, although at that time no one was yet using that term. The Ministry of Health established SOPs (Standard Operational Procedures) for all the actors of the emergency system, trying to rely on the available assets used during the last health emergency (H1N1 2009). However, few days later, it became clear that a radical change of methods and procedures was needed since the new virus was more aggressive and could spread faster. The Ministry had to modify and adapt their assets and SOPs many times until they reached the optimal solution, but these numerous changes made it difficult for all the actors to follow-up and adapt. As a result of these many changes, the Italian medical emergency numbers (118/112) received numerous calls from individuals with inquiries about the new rules to apply. To cope with this flood of calls, the number of ambulances, as well as the number of medics and nurses in the vehicles was doubled.
Additionally, the government had to take a difficult decision: the lockdown of three regions at first (Lombardy, Emilia-Romagna and Veneto), inevitably followed by the lockdown of the entire country some days later. The government also allocated additional resources to hospitals, to be able to receive thousands of sick people in the ERs (Emergency Rooms). But some crucial resources were missing. For instance, 90% of the emergency operators on the field in Italy were volunteers and only 10% of them were properly trained to use all the mandatory PPE (Personal Protective Equipment). Moreover, the amount of PPE necessary to support medical staff was not available and since it was difficult to find them on the market, the government’s stockpiles emptied rapidly.
The entire health system was about to reach its breaking point, when the peak of new daily cases went from 2000 to 3000. Hospitals couldn’t treat the severe cases in the Intensive Care Units (ICUs) due to a lack of beds. Hundreds of new ICUs were built but it was still not sufficient to meet the need. The Ministry of Health decided to put patients under quarantine directly at home, therefore freeing beds for the more severe cases.
During the month of March, all of our healthcare personnel worked in double shifts. The emergency operators had to put on PPE before reaching the infected person and performing any operation, creating additional difficulties for the workers: lack of sight, lack of free movements, higher temperature inside the suit, sweat, breathing difficulties due to the masks. After their operation, personnel had to return to their barracks and sanitize the vehicles and the equipment inside.
“From this crisis, new rules have emerged, regulating every action we take, from going outside our home to medical emergency procedures. In fact, people don’t completely realize that this crisis far from over.”
The light at the end of the tunnel.
The first half of April was not different, but the situation evolved in the second half of the month: less calls and less ICU cases were registered. At the end of April, we started to see the light at the end of the tunnel. On the 22nd of April, for the first time since the start of the outbreak, the daily number of new infections was less than the number of recovered patients. On May 4th, the lockdown was eased due to a limited number of new cases and half of the factory and shops started to re-open after 2 months of inactivity. On May 18th, all shops and factories restarted their activity and we tried to return to ‘normal’, if we can call it normal.
From this crisis, new rules have emerged, regulating every action we take, from going outside our home to medical emergency procedures. In fact, people don’t completely realize that this crisis is far from being over. They are impatient to quickly go back to the life they had before this emergency but, in my opinion, we will never return to that situation.
For us, the end of the lockdown brought new challenges: we had to identify asymptomatic patients, still infectious, we had to restrain ourselves to act like we normally do in ambulances, and to make the right decision when choosing whether to wear PPE or not.
Due the lockdown, numerous people which were kept in their houses couldn’t reach some of the basic needs. To support the most vulnerable, the Italian Red Cross and other associations started to set up many services for quarantined people:
– Delivery of groceries;
– Delivery of pharmaceuticals;
– Delivery of free food for the “new poor”, created by the lockdown;
– Delivery of masks from the government to the population of the entire country.
These services, like the emergency ones, had to be carried out by protected personnel with different levels of PPE, although it is very hard to change minds, and to train people to do basic actions with PPE and to follow the right procedures to avoid cross-contamination.
New feelings to consider.
Emergency operators experienced the fear: fear for their own lives, for their parents, for their friends, for their colleagues. But no one escaped from its duty, they sometimes made more than 48 hours of continuous shift without returning home. Some of them, already infected by the virus, decided to remain in the hot zone and to continue to assist all the patients. People were scared, locked in their houses with no possibilities of going outside except for groceries or work (only few continued to work). Every time we arrived, we could see the fear in their eyes, the fear that they had the virus and the fear of us, dressed in PPE and difficult to recognize, only showing our eyes behind googles. It was difficult to maintain all the patients calm.
This emergency also taught me that every statistic, even the most accurately calculated, is wrong. No theoretical projections have proven to be right during this emergency in our country. Psychologically and personally, I think that it was one of the worst emergencies I have ever experienced. You might have realized, but in this article, I tried to write as little as possible the name ‘COVID-19’, just because I hope that progressively we can all forget the feelings we had during this crisis.
Italy, like the rest of the world, wasn’t ready to respond to this emergency. We need much more fully trained personnel and a monthly-based training calendar. Due to regional laws, there was a difference of SOPs between the regions but in future we should push to have national ones. Moreover, we must have an augmented stockpile of PPE, strategically distributed in warehouses across the country. Italy should also become independent in the production of PPE. In fact, this emergency showed us that in case of a longer and more widespread pandemic, we are facing difficulties to reach the sufficient stock of PPE in time. It might be a utopia, but I believe that the SOPs should be written at the EU level, to make it easier for all the first responders to work together and to help each other inside the EU zone.
Some numbers to conclude, as of May 21st:
• over 220 000 people were infected
• over 32 000 deaths
• over 134 000 recovered
However, 60 000 individuals remain infected by the COVID-19 and we won’t make a step back until this number reaches ZERO.
About the Author
Lt. Dr. Manuel Tamani has a been a volunteer for the Italian Red Cross since 2001. He graduated in industrial chemistry in 2010 with a specialization in risk analysis and management of CBRNe threats. He holds many instructor specializations, ranging from first aid to emergency driving, from CPR to CBRNe. Manuel has a background working for various chemical laboratories (pharmaceutical, disposal sterial device). In 2016, he became production manager in a medical device company for pharmaceutical and para-pharmaceutical products). From 2009 to 2012, Manuel worked as the coordinator of the Red Cross regional branch. In 2013, he became the regional CBRNe manager for the Emilia-Romagna branch, before being named chemical expert at the National Technical CBRNe committee of the Italian Red Cross. In the COVID-19 crisis, he collaborates with many branches of the Red Cross in writing SOPs, controlling PPE certifications and making specific training classes, even online.
