EMS and Covid-19 in Italy

    • marcolone95 wrote:

      Small does not mean "impossible"
      Of course not impossible, but quite improbable. Small, as in the 1.7 to 2.6% chance. At least in this very limited group (115) of persons who were at "ground-zero" Wuhan, with infected everywhere.

      Our patient here in Nordrhein-Westfalen wasn't anywhere near Wuhan or a known (assumed) infected patient. So where did he get the infection from? Possibly from mail received from china. Given the fact, that the virus can survive on dead surfaces for just about 9 days, that's even more improbable, since A: mail from China to Germany takes longer and B: our main parcel service (DHL) doesn't deliver parcels from China anymore. So he probably got it from another person. Since there is now other known case of Covit-19 around before him, it's likely he got it from someone without symptoms.
      We'll now see how it spreads. The man is in serious condition, intubated in the university hospital of Düsseldorf. He had symptoms for ten days before going to hospital with a then already very bad pneumonia. His wife is having milder symptoms and was isolated and now testes positive, too. She works in a kindergarten in her home disctrict. We'll see how that ends up.

      But what a actually mean is, you can get it anywhere. Given the high number of airway infections we had this winter, I assume, Covit-19 is already here and quite a lot of people are/were infected, but have mistaken it for a severe cold. And since almost no GP performs a throat swab or blood test before a patient shows more severe symptoms it could probably spread largely unnoticed.

      That fits the assumption of a big dark digit of mild cases. So - call me naive - I'm not really that unsettled right now.

      The post was edited 1 time, last by TheOssi ().

    • A strong decision. And a good idea.

      Our patient 0 here travelled to the netherlands, visited two generel physicians there, went to two hospitals here in germany and attended the carnival inhis home town before being tested positive. So there's a great number of possible further infections. At the carnival party alone were 300 people. They ate to be found and quarantined now, plus their families, maybe friends and coworkers, and the friends and families of those and... So actually we can give it up. It:s out there and it will be a matter of time, before we will have to go on and handle it like the flu or so. If you have symptoms, go to your doctor and let him treat you. Until now, with only 2-3% deceased (probably less, because of the infections, which go unnoticed), it's not as dangerous as the normal flu, so...
    • TheOssi wrote:

      it's not as dangerous as the normal flu
      Absolulty, the death rate is very low in under 65 Years old (less than 2%), the problem is that it increase for old people (and get worst for thoose who has already other disease) (around 20% of death rate), the real problem are the "frail" people such as old people, immunosuppressed, cancer patients and so on. They have a higher risko to get pneumonia and then ARDS or sepsis (they wold have the same problem with normal flue). The risk is that all thoose people develop a critical clinic situation and need to be take in ICU's, this maybe can lead a problem with the places and resources available in hospital.


      Personally, I think that is not so dangerous as desease,it but can take the Healthcare system to the limit due to the frail people in critical conditions (But it is jsut a personal opinion).
    • TheOssi wrote:

      It's becoming very silent here. Are you okay, my italian friends?
      Yes, sorry, I've so many things to do.

      I live in lombardy (the region with most infections), i'm 20km from Bergamo, the city with most of the cases. The situation is very serius, the ICU's are full and also hospitals, some dipartiments have changed their work and become new ICU, atcuallt we are thinking about to use fair areas as emergency hospitals.

      The EMS service under pressure, for red/yellow codes (urgent calls) the time to recive an ambulance is areund 20 minutes, but for non urgent call is more than 3 hour. We are creating COVID ambulances to handle the movements between hospitals or suspect COVID cases . Of course if a COVID patient at home has an urgent call, the send he nearest ambulance.




      As PPE, actualy our indicatios are to use ALWAYS surgical mask and gloves. FFP3, eye glasses,tyvek suit adn so on just for fever and short breathing, unknown unconscius patient or sospectet COVID patient.

      The govermanet decided to stop any movement, actualy you con leave your house just for : supermarket shopping, medical problems and go to work (if you work in some areas such as healtcare). It's like in china, everything who is not necessary is closed (pub's, restaurants, shops, schools, universities and so on) until 3rd of April.

      ANY healtcare number is unfer high pressure, 112 is full of calls and also general practitioner. The local healt autorities are full up of home quaranteen.
      Yesterday I was working for the Lombardy number for suspected cases (the 800 89 45 45) and we recived more than 1 milion calls in 24H.

      How about the situation in Germany? I've heard on the Tv news that now you alse have many infections (not as here in Italy) but they are increasing very quickly
    • We have about confirmed 2500 cases today (1500 yesterday). Luckily the death rate by now is way under 1%. Federal government yesterday decided to stop all non urgent surgery to keep the hospitals free for the urgent cases.
      In my working district we have only 7 confirmed cases by now (no one needes to be hospitalizised so far), but over 500 contact persons who must go into home quarantine. But they're not yet all found. Most of them go back to one infected who attended an indoors sports festival. We'll see how it will progress. I think not well.
    • Our Citys hospitals are also creating „Corona testing places“, some with the help from Volunteers from the German Red Cross or Malteser (its like a Drive in at McDonald’s). Infections arent that high, but a lot of people are beeing quarantined at Home, as @TheOssi said. EMS is currently working as normal, regarding arrival times and auch. Several states, including the one I‘m in have closed down Scholls bars, Clubs, Swimming pools and such, also Hospitals and retirement homes forbid visitors at the Moment.
      The government finally realized the danger and startet acting. Good Luck to you guys in Italy, I hope things get better now.
    • FaRa wrote:

      The government finally realized the danger and startet acting
      That's good to know, actually the only strategy is close down everything who is not necessary and stay at home. I hope that they're also thinking about an emergency plan in case of major infection, especially for ICU's who are very important to treat ARDS and pneumonia. The OMS studies reported that NIV's and HFNO are not effective to treat respiratory failure.

      FaRa wrote:

      Good Luck to you guys in Italy, I hope things get better now.
      Thank you so much, I hope that the very restrictive rules will work, it will take time before things get better, but we can do it.

      Good luck for you, get ready and NOT undervalue this virus
    • gabryzano wrote:

      The OMS studies reported that NIV's and HFNO are not effective to treat respiratory failure.
      Hi, I'm working as a doctor of anesthesia in Bavaria. Also in the city I'm living in the number of infections is still low. The hospital I'm workin in starts to shut down planned surgeries and starts to prepare to be aware of more infections to come.

      I quoted one sentence of your post above. In treatment of ARDS (acute respiratory distress syndrome) the treatment trial with Non-invasive ventilation (NIV) oder high flow nasal oxygen (HFNO) could be effective and the individual trial to cure patients suffering ARDS should be considered. In therapy of ARDS an individual trial of non invasive ventilation could always be effective independent from occasion of the ARDS, whether Corona, trauma or bacterial infection.
      The big problem in cure of Corona with non invasive ventilation is the possibility of creating an aerosol with infectious particles using the NIV with not completely sealed mask oder nasal cannula. Because of this fact it should be considered to prefer the invasive ventilation earlier in need of respirator therapy.
      If an initial therapy with non invasive ventilation should be performed it could be better to use not a face mask or nasal cannula but an NIV-Helmet. Medical personal should always wear the FFP2/3 mask. In need of treating a patient using a NIV mask oder HFNO with nasal cannula it could be better to wear a respirator mask for personal safety.
      Of course the possible use of NIV and HFNO is limited. If the patient suffers from low GCS, acidosis or pathological breathing no NIV should be used and the invasive ventilation should be chosen. Additional the concept of "down with the good lung" in prone position is not possible with NIV and HFNO and in that case the invasive ventilation with appropriate PEEP and endotracheal tubus should be chosen.

      If you or others have any questions concerning ARDS, ICU ARDS treatment or anything please let me know. Wish you all the best!
      Grüße, NEF-Fahrer

      ILS Schweinfurt (ID: 474) lstsim.de/leitstellen/474/

      The post was edited 1 time, last by NEF-Fahrer ().

    • Because of up-to-dateness of COVID-19 I decided to report about ARDS to give knowledge to everybody in this forum.

      ARDS is called Acute respiratory distress syndrome and is formally known as something like shock lung. The reasons leading to ARDS are diversified. Beside COVID-19 it could be trauma (accident, surgical trauma), pneumonia, sepsis, or anything else. Also the COVID-19 disease can lead to a bacterial super infection worsening the situation of the critical ill patient.

      ARDS is classified by the so called "Berlin Classification":

      - urgent beginning (possible within one week after "Hit" >> trauma or surgery or infection)
      - multiple infiltrates on both sides of the lung
      - heart failure, hypervolaemia, pleural effusion must be excluded
      - the Horovitz Index with PEEP >5mbar must be poor (the Horovitz Index can tell you the possibility of oxygenation in the blood. paO2/FiO2)
      • mild ARDS Horovitz Index 201-300mmHg
      • moderate ARDS Horovitz Index 101-200mmHg
      • severe ARDS Horovitz Index <100mmHg
      In treatment of ARDS a sufficient respirator therapy is needed if the patient is suffering from poor oxygen in arterial blood. As I told in the post before an individual approach with NIV or HFNO could be considered. If the patient suffers from poor GCS, acidosis, pathological breathing, ileus, gastrointestinal bleeding or no improvement of oxygen in arterial blood an approach in treatment with NIV or HFNO should be stopped or not be started. In that case an initial trial of treatment with invasive ventilation should be taken.

      The main thing in respirator therapy in ARDS treatment (and everytime we use a respirator to cure a patient it should be our dogma): lung protective ventilation!

      Lung protective means:


      - low tidal volume (5-6ml/kg Bodyweight O2)


      - adequate Positive end exspiratory pressure (PEEP) (linked with the FiO2; if high FiO2 is needed also use a high PEEP!)


      - High PEEP is no problem - the problem is high driving pressure!

      Driving pressure means the difference between peak pressure (pInsp) and PEEP. A low driving pressure means a more lung protective ventilation. For example PEEP 0 pInsp 35 >>> Driving pressure 35 >>> no lung protective ventilation; PEEP 15 pInsp 30 >>> driving pressure 15.

      - No problem with high CO2 in capnography. A pCO2 up to 80mmHg is no problem (except the patient is suffering a cerebral trauma!)


      - pO2 goal: >60mmHg


      - pH 7,15-7,20


      If there are ongoing problems with oxygenation of the patient use the prone position to do a respiratory therapy in terms of "Down with the good lung" for at least 12-16h.


      If needed Ilomedin could be vaporized to improve oxygenation (Ilomedin mixed in O2 performs a local vasodilatation in the lung and could improve the oxygenation by reducing the right-to-left-shunt.)


      If you performed all steps an the patient has still an pO2 <60mmHg >>> consider ECMO.


      Anytime if possible: Treatment of the cause for the ARDS (bacterial infection, sepsis, trauma, surgical trauma,...) This step is very difficult and at the moment not possible with the COVID-19 disease.


      That was a small information about ARDS and ARDS Respirator Therapy. Whish you all the best.
      Grüße, NEF-Fahrer

      ILS Schweinfurt (ID: 474) lstsim.de/leitstellen/474/

      The post was edited 1 time, last by NEF-Fahrer ().

    • OffTopic, but you gotta love the internet. Only in a forum about a small german dispatch- /commandcentersimulator, where people talk english with fellow paramedics from all over the world about current pandemics, you can still learn new stuff about ARDS which could be quite useful for your work on the mobile intensive care unit. Maybe I can concinve my employer that this counts as some of my 30 training hours I need to do daily, cause every other training sessions is beeing cancelled currently :P

      Edit, cause I forgot earlier:

      I recently talked to one of our emergency physicians while at work, especially about the plans regarding EMS and hospitals, cause due to our nature of work we are superspreaders. Reason was, some collegues of my girlfriend (also paramedic) will return from holiday in "red zones" or have planned to go to holiday there (well, now that everyone is forbidding entrance by foreigners, I doubt it). His words were, you probably can't quarantine everyone, as german EMS and hospitals suffers from lack of paramedics / nurses already, if we quarantine everyone with slight symptoms, or who was somewhere where there was a few cases (Tirolia for example, lots of germans have gone skiing there) the system will collapse. If you have no symptoms, go to work. If you have a light cough, or running nose, you could still work wearing protective mouth gear, only if your infection gets to severe, you should stay at home. Dont quote me 1:1 on this, maybe his choice of words were slightly less "confronting" or some stuff might go missing in translation, but long story short: go to work, look out for hygiene (which should be normal, with or without pandemics at our doorstep).

      The post was edited 1 time, last by FaRa ().

    • NEF-Fahrer wrote:

      use of NIV and HFNO is limited. If the patient suffers from low GCS, acidosis or pathological breathing no NIV should be used and the invasive ventilation should be chosen. Additional the concept of "down with the good lung" in prone position is not possible with NIV and HFNO and in that case the invasive ventilation with appropriate PEEP and endotracheal tubus should be chosen.
      Absolutly, NIV's or HFNO always should be considered as first treatement, but as you said, is not always workins as we all hope, and so you will need an invasive ventilation. Actually the ICU's here are full up of thoose cases. NIV's patients needs a continous control and trained personnel. Actually the only way to treat is the ICU, that's the main problem in our hospitals at the moment, as I think anywhere, the ICU's bed's are not many (usually around 5 bed's for small hospitals, 10 in medium hospitals and 30 in big hospitals). As yu can image, there are not so many ICU's bed's, so every hospital has other new ICU made up in some days to handle the emergency. Our hospitals now are 50%COVID patients and 50% for other reasons (of course non emergency care are not made).


      Of course you as anesthetist (I'm a nurse), you well know how to handle the situation with ARDS, pneumonia and so on. Thank you so much for the well made explication about ARDS. Personally, I wish you a good job, and get ready.

      FaRa wrote:

      His words were, you probably can't quarantine everyone, as german EMS and hospitals suffers from lack of paramedics / nurses already, if we quarantine everyone with slight symptoms, or who was somewhere where there was a few cases (Tirolia for example, lots of germans have gone skiing there) the system will collapse. If you have no symptoms, go to work. If you have a light cough, or running nose, you could still work wearing protective mouth gear, only if your infection gets to severe, you should stay at home
      Well, I agree with him, now doctors and nurse are working 12H shifts, you stop working only if you have symptoms.
      For EMS operators, don't forget you PPE