In these days of health emergency, in which anesthesiologists are called to work hard to ensure adequate health care for patients suffering from Covid-19, I feel the need to make some considerations by virtue of my many years of experience in the field.
I was Councilor for Health of the Campania Region, as well as Head of the Anesthesia and Intensive Care Service of the "Federico II" Polyclinic in Naples, when in 2003 the SARS epidemic spread. In 2009 I experienced the H1N1 pandemic on the front line, at the head of that same intensive care unit, in the meantime restructured from scratch and equipped with 14 beds, including two isolation rooms, which were accessed through a filter area. I have seen desperate parents, children, grandparents. Even then the organ primarily affected by the infection was the lung. Pneumonia which in a few days evolved into serious interstitial pneumonia up to configuring a clinical and radiological picture of full-blown ARDS: an aggressive pulmonary pathology feared by us resuscitators which, even today, despite the progress and the multiplicity of ventilation assistance techniques, is accompanied by a high mortality.
SARS and H1N1 infection affected both young and old, although the latter were more exposed to unfortunate events especially in the presence of concomitant previous pathologies. In 2009, the then Minister of Health, Ferruccio Fazio, due to the state of difficulty caused by the aggressiveness of the infection, established the national ECMO network, made up of 10 centers identified throughout the country, able to provide the patient with a possible therapeutic bulwark to treat the so-called "white lung" (ie non-ventilated). With the use of ECMO, the extracorporeal circulation, making up for the exchange function no longer guaranteed by the lungs, allows blood oxygenation and promotes healing. The resuscitation center of the "Federico II" was identified among the 10 at a national level.
I remember with satisfaction, not without emotion, the story of a young woman, six months pregnant, who we hospitalized in desperate conditions. We had the task of safeguarding both lives, that of the mother and that of her son. We then decided to deliver the baby and to put the patient on ECMO immediately afterwards: a courageous, risky but necessary choice. Indescribable was the joy of hearing the baby's first cry (born premature but healthy) and, a week later, of seeing that the mother could breathe with her own lungs.
I have never seen a pandemic like the one we are witnessing today. Covid-19 is characterized, in fact, compared to SARS and H1N1, by the strong contagiousness. The first cases in Lombardy, probably underestimated, together with improper conduct adopted by unsuspecting citizens (I am thinking, for example, of improper trips to the emergency room), have contributed to bringing the entire north of the country to its knees.
Again the lungs. Again the spectrum of the lung's exchange functions, again "the white lung". The members of the governing bodies of SIAARTI (Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care), as happened in 2009, aware of the problems caused by the pathology and above all of its evolution, have established a task force that issued guidelines aimed at safeguarding the health of suspected patients (or with confirmed infection), as well as healthcare workers. A flow chart was developed in which specific therapeutic approaches were recommended with progressive intensity of care according to the severity of the patient's clinical picture. All of this is the result of the experience that resuscitators have acquired and acquire daily in the field by dealing with serious pathologies that put the patient's life at risk.
Who are the anesthesiologists resuscitators? They are doctors who, by virtue of their decisive contribution to the operating room, have allowed the progress of surgery; they are doctors who, in resuscitation, rub shoulders with nurses, experts in the critical area, save many human lives, often sacrificing their social and family life. Professionals who usually don't seek the honors of glory and don't get the attention of the press, but who, in silence, contribute to safeguarding the health of patients. They are doctors capable of having an overview of the patient, endowed with profound knowledge of the complications that may arise, to avoid which they are forced to make rapid, complex and often decisive decisions. They are doctors who have brought the problem of aggressive treatment and the need to regulate advance declarations of treatment to the fore in public opinion.
How does the reviver feel at the end of a shift? Exhausted, tired, discouraged if the patient does not respond to therapy, but enthusiastic because he is aware that he has also contributed to saving human lives.
Today they are defined as heroes for the superhuman effort they are making to face the current context of urgency. But, once the emergency is over, let's remember that anesthesiologists are heroes every day, because every day they fight to save patients in critical condition.
Today, due to the pandemic, public opinion is understanding the importance of the role of the anesthesiologist. Today, public opinion is aware of the problem, known for some time by those in the sector, of the serious shortage of intensive care places throughout the national territory. A few days ago I was reading an interview in which it was believed that the anesthetists, called back to work, faced with the danger of contagion, would have pulled back. I don't agree and I feel the need to point out that our category has been trained to always be on the front line and ready to meet any need.
Italy will emerge from this drama, I hope without paying a very high price. However, I hope that the events of these days will serve as a warning to cost containment policies in this crucial sector of the healthcare system: the policy of rigor at all costs does not pay and unfortunately we are verifying it on our skin.
Finally, I read of some perplexities raised regarding the legitimacy of the measures adopted by the President of the Campania Region Vincenzo De Luca. I don't have the technical skills to express a merit assessment in this regard, however I feel the need to publicly thank the President of Campania who intervened quickly and drastically with his usual hard fist. If Campania has fewer deaths than Lombardy, as I hope, we will owe it to him too.
°°°°The author is emeritus professor of Anesthesia and Intensive Care at the Federico II University of Naples and former president of the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care
