The fight against death pauses every day at 1pm
At that time, doctors in the intensive care unit of Policlinico San Donato phone relatives of the unit's 25 critically-ill coronavirus patients, all of whom are sedated and have tubes down their throats to breathe, to update the families. Lunchtime used to be for visiting hours at this Milan hospital. But now, as the country grapples with a coronavirus outbreak that has killed more than 2,000 people, no visitors are allowed in. And no one in Italy leaves their homes anymore.
When the doctors make the calls, they try not to give false hope: They know that one out of two patients in intensive care with the disease caused by the virus is likely to die.
As the COVID-19 epidemic expands and the disease progresses, these beds are in increasing demand, especially because of the breathing problems the illness can bring. Every time a bed comes free, two anaesthesiologists consult with a specialist in resuscitation and an internal medicine physician to decide who will occupy it.
Age and pre-existing medical conditions are important factors. So is having a family.
"We have to take into account whether older patients have families who can take care of them once they leave the ICU, because they will need help," says Marco Resta, deputy head of Policlinico San Donato's Intensive Care Unit.
Even if there is no chance, he says, you have to "look a patient in the face and say, 'All is well.' And this lie destroys you."
The most devastating medical crisis in Italy since World War Two is forcing doctors, patients and their families to make decisions that Resta, a former military doctor, said he has not experienced even in war. As of March 16, 2,158 people had died and 27,980 been infected by coronavirus in Italy – the second highest number of reported cases and deaths in the world behind China.
Resta says that 50% of those with COVID-19 who are accepted into intensive care units in Italy are dying, compared with a usual mortality rate of 12% to 16% in such units nationwide.
Doctors have warned that northern Italy – where the universal healthcare system is ranked among the world's most efficient – is a forerunner of crises that the disease is bringing around the world. The outbreak, which hit the northern regions of Lombardy and Veneto first, has crippled the local network of hospitals, putting their intensive care units under colossal strain.
Over three weeks, 1,135 people have needed intensive care in Lombardy, but the region has only 800 intensive care beds, according to Giacomo Grasselli, head of the intensive care unit at Milan's Policlinico hospital, which is separate from San Donato. Grasselli coordinates all the state-run intensive care units across Lombardy.
Such dilemmas are not new in the medical profession. When treating patients with breathing difficulties, intensive care doctors always evaluate their chance of recovery before intubation - an invasive procedure that involves inserting a tube into the mouth and down the throat and airway.
But these high numbers mean doctors must choose more often, and more quickly, who deserves a greater chance of survival - a triage that is particularly wrenching in a Catholic country that does not allow assisted dying, and where the population is, according to statistics agency Eurostat, the oldest in Europe with nearly one person in four aged 65 or older.
"We are not used to such drastic decisions," says Resta, a 48-year-old anaesthesiologist.
Take a Chance
Italian doctors say that so many elderly COVID-19 patients are showing up with breathing problems, they can't take a chance on those who have a slim hope of recovery.
Alfredo Visioli was one such patient. When he was diagnosed, the 83-year old from Cremona was living a busy, active life, at home with a German shepherd, Holaf, that the family had given him. He cared for his 79-year-old wife, Ileana Scarpanti, who had suffered a stroke two years ago, said his granddaughter Marta Manfredi.
At first, he only had intermittent fever, but two weeks after he was diagnosed with COVID-19, he developed pulmonary fibrosis - a disease resulting from lung tissue becoming damaged and scarred, which makes it harder and harder to breathe.
Doctors in the hospital at Cremona, a town of about 73,000 in the Lombardy region, had to decide whether to intubate him to help him breathe.
"They said there was no point," said Manfredi.
She would have liked to hold her grandfather's hand, she said, while he was in a morphine-induced sleep before he died.
Now Manfredi is worried about her grandmother. Ileana also caught COVID-19 and is now in the hospital, though she is responding well to a mouth respirator that is helping her breathe. No-one has told Ileana her husband is dead.
Lombardy intensive care coordinator Grasselli said he believed that, so far, all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated.
But he added that this approach is under strain. "Previously, for some people we would have said, 'let's give them a chance for a few days.' Now we have to be more stringent."
This triage is happening outside of hospitals, too.
On Friday, the mayor of Fidenza, a city just outside the Lombardy region, shut access to the local hospital for 19 hours. It was overcrowded with COVID-19 patients and hospital staff had worked 21 days without a break. While the closure was aimed at keeping the hospital going, it meant some people "died at home," said the mayor, Andrea Massari.
The new coronavirus first appeared in Italy in January, but the outbreak took off in February in the small town of Codogno, around 60 km (40 miles) southeast of Milan. Some medical experts believe it may have been introduced by someone who traveled to Italy from Germany.
Rome moved quickly to isolate the north of the country, at first locking down 10 towns in Lombardy and one in Veneto. But that didn't stop the virus. Within a week, 888 people had tested positive for the disease and 21 had died. Cases grew exponentially. Small towns were hit first, putting an immediate strain on small hospitals.
Since last week, Italy has entered complete self-isolation. It has closed all schools, offices and services and ordered everyone without a compelling and authorized reason to stay home. The measures, which are being followed by other European countries, are aimed at stopping the spread of the virus.
Italy's authorities are particularly anxious to slow its onset in southern Italy, which has a far less well-funded system than the north.
Private hospitals are usually reserved for paying patients. But the government has ordered them to offer free medical care to COVID-19 sufferers. Policlinico San Donato, which is privately held but licensed to work with public sector clients, dispatched teams of anaesthesiologists and other specialists to the worst-affected towns. Fourth and fifth-year medical students were called into hospitals to help. Cardiologists were enlisted to help in emergency rooms and COVID-19 wards.
Now, nearly all operating rooms in the Lombardy region have been converted into intensive care units, said Grasselli, the intensive-care coordinator. Hospital staff work overtime. Some are substituting for infected colleagues. Patients are being transferred across regions.
According to Grasselli, the ratio of nurses to patients in the region's intensive care units is normally one to two. Now, it's one nurse for every four or five patients. "We have totally reorganized our hospital system," he says.
"Greater Life Expectancy"
All infected people who arrive at a hospital struggling to breathe receive oxygen, Grasselli says. The issue is to what extent - and for how long - to keep them artificially respirated.
Those with lighter breathing problems are connected to an external machine with a mask or, if the patient doesn't respond, a face-covering helmet. If their condition deteriorates, doctors must decide whether to admit them to intensive care, where they would be intubated.
But there's a problem: Intubating can be taxing on the body, especially for older patients, says Grasselli. Even if elderly people survive, many can develop other problems, like trouble walking or cognitive difficulties. Even so in the past, doctors tended to try intubating even older patients, generally because they had the resources to do so, he said - adding that he would never intubate his 84-year old father.
Before the coronavirus broke, "we more often had the luxury to try to intubate patients who were at the limit," said Mario Riccio, head of anaesthesiology at the Oglio Po hospital near Cremona.
Now that's changed. Italy's Association of Anaesthesia, Analgesia, Resuscitation and Intensive Care published new guidelines on March 7. Because it expects a "huge imbalance" between the clinical needs of the population and intensive care resources over the next few weeks, it told those on the front lines: Give priority to those with "greater life expectancy."
"Let Me Die at Home"
Italy's mass quarantining of its population adds emotional stresses to the suffering. Family members are not allowed to travel in ambulances with relatives, and coronavirus units are closed off to anyone who is not a doctor or a patient.
Some patients who are not at the point of needing intensive care feel imprisoned in overrun wards.
"Take me away from here. Let me die at home. I want to see you one more time," Stefano Bollani, a 55-year-old warehouse worker texted his homemaker wife, Tiziana Salvi, from the pre-intensive care unit of Policlinico San Donato, where he is being treated for pneumonia after contracting the virus.
The couple have not seen each other since she dropped him off in their car outside the Milan hospital nearly two weeks ago. All she knows, she says, is that his condition seems to have improved in recent days. "These are things a husband shouldn't (have to) write to a wife who is outside, who can't see him," she adds.
And some older patients have resisted going to hospital. Carlo Bertolini, a 76-year-old agronomist in Cremona who had made a name for himself locally with a detailed history of the town's past vineyards and taverns, was initially very reluctant to seek help, his daughter said.
Bertolini, who lived alone, started feeling sick at the beginning of March. Eventually, his best friend called an ambulance which took him to the town hospital. When he spoke to his daughter on the phone from the hospital, he described the huge numbers of patients and the cacophony of the ward. "I feel like I'm in a war," he said, according to his daughter, Mara Bertolini.
Carlo was then transferred to the intensive care unit of a bigger hospital in Milan. Mara and her sister were able to visit dressed in hazmat gear – masks, gloves, white coat – to look at him through the window of the intensive care unit. "They told us he was the one with the most serious condition in the ICU," she said.
The former military doctor Resta says the situation in Lombardy feels worse than the 1999 war in Kosovo, where he served in the air rescue team flying patients from Albania to Italy.
Whenever a patient with coronavirus is accepted into his hospital, he says, the staff write an email to their relatives assuring them that their loved ones will be treated "like family." He says the hospital is trying to activate a system of video-conferencing, so that patients can see their relatives during the 1 p.m. call.
A doctor, not a relative, is often inevitably the last person a dying COVID-19 patient will see. Loved ones can't even approach coffins for fear of catching the virus.
The last Mara Bertolini heard of her father Carlo, the wine historian, was when someone from the morgue called another family member to say they had his body.
She holds no grudge against the hard-worked doctors, she said.
What struck her most about her father's last week of anguish was the look on the doctor's face when she met him.
"I couldn't tell whether it was worry or sadness," she said.
"All he said to us was, 'Stay home.'"