Alessandro Galli is a Doctor working in Lombardy, Italy. One of the most heavily affected regions of the country.

Ale came to Australia on exchange when we were 17 years old and I am so glad to have his friendships all these years later. Now, more than ever I am learning so much from his perspective on things & I thought you might too…

When I asked Ale if he was happy for me to share this, he welcomed it and was interested to hear people’s perspectives on the questions he poses.

So please take the time to reflect and comment below so he can read them.
Only in this way I think we will be a stronger and better society when all this will be over.

“Dear Friends,

sorry for answering with delay, last night I came back from the hospital to my room in Bergamo and I was so tired that went straight to bed without dinner.
(And this morning I discovered that there was a Lasagna waiting for me in the kitchen!)

This is a long email, I am trying to catch you up guys, and to recall the passages of these intense weeks. Giving you some questions and sharing some prospectives.

It is extremely helpful to feel your friendship right now, and I understand your fear. It is the same feeling we were experiencing two weeks ago.

I am fine, so is my family. They are quarantined in a tiny village in the middle of the Alps. They are in the dangerous age.

Three weeks ago we realised that things were growing big in an unbelievable way, that Emergency departments in Lombardy were under assault with Respiratory failures, and the number of positive swabs to SARS-CoV-2 was rising exponentially.

Authorities in a first moment sent a message of encouragement not to fall into panic and fear. “Milano non si ferma” (” Milan does not stop”).
It was not clear the threshold between public health and economic effects of a possible general quarantine.

Soon after, the situation was perfectly clear: there was no place for all positive patients in hospitals.

Not enough place in the EDs, neither in the wards, nor in the sub intensives. Not even in the ICUs.

The tsunami, the surge, was overwhelming us.

Authorities decided to shut down everything. Hospitals in which there still was elective surgery and regular ambulatory activities were imposed to stop all non urgent cases. In some Centers they started to use ORs as adjunctive beds of ICU.

The Director of the School of Anesthesiology and Intensive Care of University of Milano (my University), Doctor Pesenti, was appointed to coordinate the emergency in Lombardy.

University asked all residents to change rotation and to go to work in hospitals were there was need of help.

First, I gave my availability to go to help at the coordination center, in the Central Building of Lombardy.

I thought that in this moment having “the big picture of the forest” could be more helpful rather than being in the first line, “struggling for a tree”.
After two days I realised that it was not the best allocation of resources.

I am 31, I have energy, and I have almost finished my residency.

I could not leave elder colleagues, exposed to the virus and literally risking their life, while I was sitting in a desk, undergoing all office and “politics” dynamics.

I could not leave those few first year residents alone in the wards, deciding who needs to be treated with CPAP and who does not have chances.

I asked to be moved to Bergamo, and the following day I was wearing the white scrubs of the hospital ( isn’t it strange? White.. you can tell the colour of the underwear of everybody!)

Meanwhile whole Italy was shut down. People started to really understand that we are facing an historical moment, and everybody is involved with it.

We are all sailing in the same boat.

Bergamo welcomed me warmly; doctors and nurses are now seen as “heros” and people clap at us.

I found a Bed and Breakfast hosting me for free, and the solidarity of these people really warms my soul.

General hospital is huge. Never been in such a big and complete hospital. They have all wards, they usually perform all kinds of surgery, and the building itself is very efficient.

Now it is scary walking around this huge structure and listening the eco of my steps.

Sometime you cross the way of porters and you can anticipate it by hearing the high flow oxygen of the patients. The first patient I saw made me shiver a bit. He had fear. And so had I.

I am working in a general ICU, 16 beds. Next to mine, there are a neuro, a cardio, a paediatric and a stroke unit. They all have roughly the same number of beds. They are all COVID dedicated now.

80 ICU bed, they say the biggest COVID ICU out of China.

Patients are mostly man, a lot of them obese, few comorbidities, > 50 yo.

They are mostly pure pulmonary, with some case of AKI and we are noticing procoagulant tendency.

Turn over is very low, we still are managing the “first wave”, and in one week only one pt was discharged in the ward.

Some of them do not make it. The majority is still intubated and ventilated, proning, using NO, using CO2 removal, very few ECMO.

We are now starting doing tracheostomies ( yesterday I did my first one.)

We are using Clorochina for 10 days, Lopinavir-Ritonavir or Remdesivir ( anti-protease), and some cases we are trying Tocilizumab ( anti IL-6). Lung US is scary, they have all B lines, and bad hepatisation of the lungs.

We are protecting ourselves with FFP3 ( N95 respirator), wearing surgical gowns, surgical gloves, hair cuff, and plastic glasses. So far, PPE are available for everybody. Sometime some boxes of FFP3 are stolen from some worker, and this is sad.

I share with you some thoughts.

1- Heros? No, thanks.
People is clapping at health care providers, calling us “Heros”. I tend to be extremely skeptical facing this manifestations.

Until yesterday legal issues were a huge problems leading to defensive medicine. I am afraid that easily things will mutate again toward that prospective.

Furthermore, I am a worker, not a “hero”. I am only doing my job and I want to be protected and find myself in the most safe environment possible.

As Italians we tend to give more credit to single Persons rather than the “Sistem”.

We tend to attribute responsibilities and glories to the individuals, rather than the team.

I think this is very big mistake and dangerous approach, especially in these days.

2- Communication
As a consequence of this individualism, we are having hard time to collect data.

The 5 different ICU barely talk to each other, and we are not homogenous in the treatment of these patients.

Lack of communication leads to the waste of huge opportunity.

3- Relationship with technology, too few: our IT service sucks.
We do not have access to data recorded, an we need to copy ( HAND MADE!) all data we want, and rewrite them on a dataset. You perfectly understand what this mean.

4- Relationship with technology, too much: CTRL-Z.
My generation is grown with computer and screens. Following generations even more.

In every keypad there is the short cut CTRL-Z that allow us to erase the last procedure.

I feel we tend to let this shortcut into our soul, and we are increasingly less prepared to definitive decision. “Forever” is a word I tend not to use anymore. We don’t believe anymore in “forever”.

But now, it is war time over here. We are facing choices that include the concept of “forever”.

If the bed in ICU is 1, and I have 10 patients, I need to make decisions that stand forever.

I can work to add 9 more beds, but meanwhile, I need to allocate properly the resources, and to choose whoever has a chance and deserve an intensive treatment, leaving the other behind.

Furthermore, by shifting to a datafied society, in which basically all aspects of life are somehow coded, and having increasing availability to store this huge amount of data, we tend not to throw away anything, anymore.

We tend to loose the habit of choice.

And now, as a society, and physically us as intensivists, we are asked to go back to the concept of Choice, and to the concept of Forever.
Personally, these are the biggest challenges I am facing.

In the hospital there are some Cappuccin Friars walking around and giving spiritual support to both Patients and Workers.

I stopped one one them, and we talked a bit.

I asked him my questions about values of life. I cannot agree that the life of a 90 years old person has the same value of the life of a 19 years old.

It is a big big concern this, because ethical, philosophical and spiritual believes of the deep inside from anyone are challenged by reality.

I don’t have solutions so far, Literature is still on its way.

We have our questions and our heart.

This is a very big opportunity to look deeply into it, and share it with our neighbours.

Only in this way I think we will be a stronger and better society when all this will be over.

Hope you all are fine,
I will keep in touch.

Ciao,
Ale”