Rome - Wednesday, March 18, was the most difficult day in a series of difficult days that began less than a month ago. It was the day Italians saw a long line of army trucks leave the cemetery of the northern town of Bergamo laden with the corpses of coronavirus victims.
The city's only crematorium — which has been active 24 hours per day, seven days a week for the last week — could no longer accommodate the dead, who were now being taken, in a somber procession, to crematoriums in nearby towns. Antonio Ricciardi, the head of Bergamo's largest funeral company, said he's carried out almost 600 burials or cremations since March 1.
"In a normal month, we would do about 120," he said. "A generation has died in just over two weeks. We've never seen anything like this, and it just makes you cry."
March 18 was also the day that Italy announced a record number of deaths in a single day — 475 — a record not just in Italy but anywhere in the world since the beginning of the COVID-19 pandemic. The following day, Thursday, Italy's death toll surpassed China's.
Yet it was only February 21 when Italy announced its first "real" coronavirus case, a 38-year-old man in the Lombardy town of Codogno. Rome had already seen three cases — two Chinese tourists from Wuhan and an Italian researcher repatriated from the same city — but this was its first independent case with no known connections to China or other infections.
To this day, "patient zero," whoever infected the 38-year-old, has never been found. The Codogno patient — athletic, in excellent health — remains in the hospital after weeks in intensive care and on artificial respiration.
Italy's response to the breakout was to lock down the north's 16 million people on March 8; the next day, awas announced. On March 11, the government announced restrictions to almost all commercial activities with the exceptions of supermarkets and pharmacies.
But the disease marched on. By March 18, the numbers were staggering: 35,713 infections, 2,978 deaths and 10% of those infected in intensive care. On Thursday, authorities reported 415 new deaths, bringing the death toll to 3,405, and the national lockdown was extended indefinitely.
Bergamo — a lovely medieval hilltop village of 120,000 residents — has become the hardest-hit city in the hardest-hit country outside of China. Northern Italy has one of the best public health care systems in the world, and Bergamo is no exception.
But by March 18, the situation in Bergamo was dire. There is a lack of doctors, nurses, beds, respirators and protective equipment. Doctors and nurses are at the limit of their physical resistance.
Italy's Ministry of Health said that 10% of the infected are health care workers. Despite that, the pleas coming from the medical community are for their patients, not for themselves.
"War has literally exploded and the battles are uninterrupted, night and day," a Bergamo doctor named Daniele Macchini warns on his Facebook page. "One after the other, those empty departments fill up at astonishing speed.. All the patient's charts say the same thing: interstitial bilateral pneumonia. We are no longer surgeons, urologists, orthopedists, we are now all simply doctors who suddenly became part of a single team to fight this tsunami which has overwhelmed us…Suddenly the emergency room is at collapse…The intensive care unit is full, more units are created. Each ventilator is like gold…The health care workers are exhausted…Doctors move beds and patients, give medicine in place of nurses. Nurses with tears in their eye because we can't save everyone."
And so, in just under a month, one of the world's best health care systems nears collapse. And with that, doctors prepare to make harrowing choices as to who can live and who may die.
The Italian association of anesthesiologists and intensive care doctors has put out a sobering document on the moral choices that doctors may have to make when resources are scarce. Dr. Marco Vergano, an anesthesiologist, intensive-care unit doctor and the lead author of the document, said he and his co-authors wrote it in response to the distressing moral choices his colleagues in the north of Italy had to make about who to treat when there aren't enough resources to treat everyone.
The document suggests that ICU treatment be given "to those patients with the highest possibility of therapeutic success, therefore we must prioritize 'the highest hope for survival' … This means we do not have to necessarily follow a 'first come first served' criteria for access to intensive care."
Furthermore, the document states, "It may be necessary to impose an age limit to entry into intensive care … in order to reserve what may be extremely scarce resources for those who, first of all, have the highest probability of survival and, secondly, may have more years of life saved."
Vergano stressed that these are "last resort' recommendations to be used only when all other options are exhausted. With numbers rapidly increasing daily, that day may be fast approaching.