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In recent months, there are a few words that have entered the common lexicon of many discussions about coronavirus. One of them is “intensive care”. The number of hospitalized patients in serious condition, in fact, is one of the most important signals to understand where the epidemic is. But resuscitation rooms, a word that in Italy is synonymous with intensive care, not only treat patients with COVID-19. It is often forgotten due to the constant flow of news about the coronavirus, but it is good to remember that in the intensive care units of Italian hospitals there are thousands of other patients.
We try to understand what is around an intensive care bed, especially who cares for patients and how the work of doctors and nurses has changed from March to today.
A person must be hospitalized in intensive care when his vital functions are seriously compromised: if he were not subjected to intensive care, he would run the risk of dying in a few days or, in more serious cases, in a few hours. Hospitalization in the intensive care unit guarantees very special clinical support, 24 hours a day, which cannot be guaranteed in other departments. It means that the professional and technological efforts of the hospital are concentrated within an intensive care unit, with the aim of keeping patients alive by maintaining their vital functions, such as the function of the lungs, heart, kidneys and other organs of the body, necessary for survival.
The coronavirus epidemic has brought intensive care to the center of hospital activity. Beds have been added to respond to the massive influx of patients. Medical personnel were recruited and in many hospitals, especially in Lombardy, Veneto and Piedmont, medical specialists were also employed. Systems that deliver oxygen to instruments used to breathe patients have been improved. Extraordinary investments to face a non-ordinary disease.
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Whenever a resuscitator walks through the doors of the ICU, he knows that a mistake could result in the life or death of the patient. It is difficult to compare such a high level of stress with that of many other professions. In recent months, the incessant arrival of seriously ill patients has caused a significant increase in work and a significant emotional impact on doctors and nurses.
Due to the limitations of much of the data published every day, it is not possible to know how many people have actually been admitted to intensive care since the outbreak began to date. We only know the number of patients currently hospitalized: according to the latest update published by Civil Protection, there are 2,849. The peak was recorded on April 3 with 4,068 people hospitalized. Since February 20, the day of the hospitalization of “patient 1” -a 38-year-old man from Codogno, in the province of Lodi-, everything has changed: from the clothing of the staff to the drugs used to combat the consequences of COVID -19.
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Let’s start with the dressing. It may seem like a minor detail, but it is a very important phase, because the risk of contagion is high and can only be avoided with personal protective equipment. A waterproof surgical gown should be worn over the classic cotton gown, with drawstrings at the back. Gloves are often taped to adhere to the dress. On the face, there is the FFP2 mask and the transparent visor.
A health worker wears protective gear before resuscitation begins (Michele Lapini / Getty Images)
Each hospital has its own organization, but the shifts usually cover three phases of the day: from 8 to 14, from 14 to 22 and, the night shift, from 22 to 8. The workload is such that these hours, without However, they only remain on paper. Between one shift and the next there is a handover between doctors who finish their shift and those who start working. It lasts about an hour, although the time depends on the conditions of the hospitalized patients. When a case is very complex, the transition can take a long time because communication between colleagues is important to allow you to make more informed decisions.
There is no fixed relationship between the number of rescuers and patients. It can range from one to four, that is, a rescuer monitoring four patients, up to one to twelve in the case of night shifts. On the other hand, the relationship between the number of nurses and patients cannot vary: it must always be one to two in the case of critical patients, that is, one nurse for every two patients. In fact, in the intensive care unit, the work of the nurse is essential, because patients are often unconscious and need continuous assistance.
Since March, the organization has undergone major changes in many Italian hospitals. To respond to the emergency, hospitals have transferred many doctors and nurses from other wards to intensive care. Not everyone has the skills to deal with this particular and delicate type of work, so the first to be transferred were operators who had already worked in resuscitation in the past. Then it was the turn of the doctors and nurses who earned a master’s degree in intensive care but worked in other departments. Compared to all other areas of the hospital, those working in intensive care must be familiar with the complex instrumentation that supports vital functions. The studies, and then the experience in the ward, help doctors and nurses to assess a change in the patient’s health conditions as quickly as possible and intervene immediately.
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In recent months, help has largely come from those who work in the operating room, where the patient’s condition – sedated Deep and mechanically ventilated – they are similar to those encountered in intensive care. This is the main reason that has led hospitals to postpone many scheduled interventions: it is one of the most underestimated collateral damages of this epidemic, which could cause gravi delays in treating many people with other illnesses.
During the first round of visits, the status of the patients is checked and it is important to observe the data displayed on the screen that is placed next to each bed. Different software, in fact, collect and process information through the sensors of the machines that help patients with a compromised vital function.
The intensive care monitoring station at Bologna’s Maggiore hospital (Michele Lapini / Getty Images)
Rescuers control what is called “gas exchange.” They do this through a test called “blood gas analysis” or simply “blood gases”: This test is used to understand how much oxygen and how much carbon dioxide is circulating in the patient’s blood. In summary, from this analysis you can understand if the lungs are working.
To treat severe forms of COVID-19, the most widely used tool is the ventilator, that is, a machine that breathes instead of the patient. A mechanical ventilator carries a mixture of oxygen and other gases into the lungs and then takes them out. Intubation is the most invasive option: it serves to almost completely replace breathing.
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The ventilator must be calibrated very carefully so as not to damage the lung tissues with excessive pressure. The most sophisticated models are capable of constantly adjusting the air supply using algorithms that process the data coming from the sensors. Periodically, doctors must check the health of the lungs with a chest CT scan, but moving such fragile patients is a complex operation.
Patients in serious condition undergo very powerful anesthesia to allow the body to consume as little energy as possible. Patients must always sleep because otherwise their brain would “tell” the body to breathe more and in that case the lungs could not bear the effort. The sick are unconscious and immobile, completely dependent on doctors and nurses.
The indication on the type of anesthesia is given after a complete examination that is used to analyze any allergies or diseases. The use of drugs such as sedatives and analgesics should be studied in detail and also varies according to the length of hospitalization: in long-term administration, in fact, the effects of drug tolerance, the onset of addiction and the risk. abstinence after cessation of anesthesia.
Some medications, such as cortisone, are also used to treat COVID-19, but much depends on the condition of the individual patient. Other medications (pain relievers, antibiotics and antifungals, opioids) are important to reduce the risks and possible consequences of a long hospital stay. Also, during hospitalization in an intensive care bed, a person can lose up to 50% of their muscle mass, so passive physiotherapy sessions are required to avoid joint locking and muscle maintenance.
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When conditions improve, the lungs begin to function sufficiently to render the ventilator useless: at that point, the work of the ventilator slowly reduces and patients begin to breathe on their own. This process can take days or weeks; When patients are sufficiently autonomous from the respiratory point of view, they are extubated and they resume breathing naturally.
The longer you stay in resuscitation, the more chances of complications increase. The intubation process itself blocks coughing and therefore the filtering function of the lungs is limited: due to these conditions, a bacterial pneumonia can develop which can occur in conjunction with COVID-19. The same goes for the flu. But these dangers in intensive care also apply to all other pathologies that require the use of ventilators: in these cases the risk of dying is greater.
Intensive care at the Maggiore hospital in Bologna (Michele Lapini / Getty Images)
But it’s not just the lungs. COVID-19 can also cause damage to other organs – in the presence of severe kidney failure, for example, patients must undergo dialysis. The cardiocirculatory system, which is closely connected to the lungs, may also need support. Patients can be put into “cardiopulmonary bypass” through a machine called ECMO (Extracorporeal membrane oxygenation), it is used in the most severe cases and cannot be used with all patients because it is a very complex tool with a risk factor.
All health and care updates are documented three times a day. More they come All patients’ next-day schedules are discussed on a daily basis, for example, when a patient is ready to begin breathing on his or her own or needs to be transferred for a more specialized examination, such as a chest CT scan. All these steps are contained in the patient’s medical record.
At the moment in Italy there is no protocol that gives anesthetists precise intervention guidelines: each case is examined and evaluated directly by the doctor, who has the professional, legal, ethical and moral weight of the decisions.
At the Papa Giovanni XXIII hospital in Bergamo, for example, in March the flow of patients was so high that doctors, by their own admission, had to make very difficult decisions. In those weeks, in fact, 94 people were in the intensive care unit, all intubated. But even in this second wave of the epidemic, despite the months that passed from March to April, many hospitals across Italy are in trouble and intensive care is filling up with seriously ill patients.
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