From the Corriere della sera (google translation)

«Inside the emergency room a large room with twenty beds has been opened, which is used only for mass events. We call it Pemaf, or Emergency Plan for the maxi-influx. This is where triage, or the choice, is made. "
It is not an easy conversation with Christian Salaroli, 48, a wife, two children, medical director, anesthesiologist and resuscitator of the Papa Giovanni XXIII hospital in Bergamo, one of the most stressed of these weeks, just seven kilometers away from the Alzano cluster Lombard , one of the most mysterious and persistent of this epidemic. It is not because of the topic it deals with, it is not because of the emotion that flows through it, which we have a duty to dry, even if it says a lot about what is happening where we are really fighting. «It is decided by age, and by health conditions. As in all war situations. I'm not saying it, but the manuals we studied on. "

So that's true?
"Indeed it is. In those beds only women and men with Covid-19 pneumonia, suffering from respiratory failure, are admitted. The rest of them at home. '

 Then what happens?

«We put them in non-invasive ventilation, which is called Niv. The first step is that ».

What about the other steps?
«I come to the most important. In the early morning, the resuscitator passes by with the emergency room carers. Your opinion is very important. "

Why does it count so much?
"In addition to age and the general picture, the third element is the patient's ability to recover from an intensive care operation."

What are we talking about?
«This Covid-19-induced is an interstitial pneumonia, a very aggressive form that impacts so much on the oxygenation of the blood. The most affected patients become hypoxic, that is, they no longer have sufficient quantities of oxygen in the body ».

When does the time to choose come?
«Soon after. We are obliged to do it. Within a couple of days, at most. Non-invasive ventilation is only a transition phase. Since unfortunately there is disproportion between hospital resources, ICU beds, and critically ill people, not all are intubated. "

What happens then?
«It becomes necessary to ventilate them mechanically. Those on which you choose to continue are all intubated and pronated, or put on your stomach, because this maneuver can promote ventilation of the lower areas of the lung ».

Is there a written rule?
«At the moment, despite what I read, no. As a rule, even if I realize that it is a bad word, patients with serious cardiorespiratory pathologies, and people with severe coronary artery problems, are carefully evaluated, because they tolerate acute hypoxia poorly and have little chance of surviving the phase criticism ".

Nothing else?
"If a person between 80 and 95 has severe respiratory failure, you probably won't proceed. If you have a multi-organic failure of more than three vital organs, it means that you have a one hundred percent mortality rate. He is now gone. »

Do you let him go?
"This is also a terrible sentence. But unfortunately it is true. We are not in a position to tempt what are called miracles. It is reality ».

Isn't that always the case?
"No. Of course, even in normal times it is evaluated on a case-by-case basis, in the wards we try to understand if the patient can recover from any intervention. Now we are applying this discretion on a large scale ».

Who is let go of Covid-19 or of previous pathologies?
“This is that they don't die of coronavirus is a bitter lie. It is not even respectful of those who leave us. They die of Covid-19, because in its critical form, interstitial pneumonia affects previous respiratory problems, and the patient can no longer bear this situation. The death is caused by the virus, not by anything else ».

And you doctors, can you endure this situation?
«Some come out crushed. It happens to the primary, and to the newly arrived boy who finds himself in the early morning having to decide the fate of a human being. On a large scale, I repeat it ».

Doesn't it bother you to be the arbiter of the life and death of a human being?
«For now I sleep at night. Because I know that the choice is based on the assumption that someone, almost always younger, is more likely to survive than the other. At least, it's a consolation ».

What do you think of the latest government measures?
"Maybe they're a little generic. The concept of closing the virus in certain areas is correct, but it arrives at least a week late. What really matters is another thing ».

Which?
"Stay home. Stay home. I don't get tired of repeating it. I see too many people on the street. The best answer to this virus is not to go around. You don't imagine what's going on in here. Stay home. "

Is there a shortage of staff?
«We are all doing everything. We anesthesiologists perform support shifts in our operating room, which manages Bergamo, Brescia and Sondrio. Other ambulance doctors end up in the ward, today it's up to me ».

In the big room?
"Exact. Many of my colleagues are accusing this situation. It is not only the workload, but the emotional one, which is devastating. I have seen crying nurses with thirty years of experience behind them, people who have nervous breakdown and suddenly tremble. You don't know what's going on in hospitals, that's why I decided to talk to her. "

Does the right to care still exist?
«Right now he is threatened by the fact that the system is unable to take on the ordinary and the extraordinary at the same time. So standard treatments can have serious delays ».

Can you give me an example?
“Normally the call for a heart attack is processed in minutes. Now it can happen that you wait even for an hour or more ».

Do you find an explanation for all this?
«I'm not looking for you. I tell myself it's like war surgery. We only try to save the skin of those who can do it. That's what's going on. '

Was just reading that he's been gagging the Center for Disease Control and Prevention from telling the full truth to the public.

#makeamericaadictatorship

Yep. 
Young sick people = valuable 

Old sick people = expendable 

...home. June 2020. 

That's a bit sobering, Xioni. Having been through this kind of thing just over a year ago I don't fancy another go at it! I still have a dodgy voice. I had collapsed lungs and a chest infection - but having spent all that NHS money on me I hope they will protect their investment!

powerful stuff

What scares me about Xioni's post describing the current situation in Italy is that Italy is potentially only in the early stages of the epidemic. What happens if we are in a position where, say, 10% of the population has it?

More from across the Pond:

"New York Governor Andrew Cuomo has confirmed that the executive director of the New York and New Jersey Port Authority is among more than 100 individuals with the virus in the state."

If that's a response to Xioni's post, then you've really got the wrong end of the stick. The article is about the horrendous decisions faced by doctors, who have to decide if a patient is likely to survive the procedure that is designed to save lives.

Yes, that's right. The young, you see, have a full, productive life ahead of them. Old folks don't, therefore it makes sense to focus resources on the young. Ordinarily there are enough resources to go around that everyone can be treated, but if that fails then you let the oldest and sickest die, so that younger and fitter people can survive. 

It's what the translated Italian article says and it's what'll happen here should numbers continue to escalate beyond the NHS' capacity.

What is the capacity of the health service in the Republic? How much capacity and spare capacity does it have? How many ICU beds?

All critical questions - the Chinese found that as they increased the number of ICU beds and ventilators, the mortality rate started to drop.

Yes,  it's a very slippery slope when you start attributing    more "worth"  to one section of  community over another.

Not really. I have firsthand experience of this when my mum had a severe stroke (at 48), as she was deemed to be worth less than others who needed the equipment that was keeping her alive. My dad and I were asked by the doctor if they could turn the machine off, as "others need it" - the answer, of course, was "yes".

(Luckily for me two weeks before we'd discussed what would happen if one of us was being kept alive by machine - turn it off, was the unanimous verdict!)

I saw it again when my dad developed lung cancer at 67. They wrote him off as worthless and were most surprised when he turned up one month later. They needn't have worried, though, he died less than a month after that - all without even knowing whether it was small-cell cancer or not. Again, lack of resources - keeping someone alive for an extra couple of months was deemed less worthy than allocating the resources to others who would get more value from them.

To think otherwise, incidentally, is most naive. We simply don't have unlimited resources and on a daily basis tough decisions have to be made.

Perhaps not, but they have a life now. 

The answer is obvious Lionel, thousands of people would die.

So, if you were a doctor working in that Italian hospital and you had the choice of saving someone who was 90 (to use the number from the article), versus someone who was 50, who would you pick? You can't pick both, as you don't have enough resources.

THAT is the decision that is having to be made and - if things continue - it's the decision that'd have to be made here. And, as I mentioned, I've seen that sort of decision acted out twice in front of me with my own parents.

I’m guessing you’re not big on empathy and compassion 

No, that's me 

It's what I keep saying, it's the concentration of the cases in a small and heavily populated area that is causing the high number of deaths, it's pretty much a European Wuhan.

Let's hope they get it under control soon and that we don't get any other cluster like this.

Heh, I'm an only child who has no parents or grandparents and no children - so my view will be different from someone like you who still has their parents.

Out of interest, what would your answer to the question I posed to Chunky Pea be?

I think people who accuse doctors of ageism underestimate the above decision. If you can only save one of two cases, then you somehow have to choose, if you don't choose then you may harm both.

I loved both my parents and I was devastated at the loss of both of them. However, even amidst the grief I knew that logically things had to happen as they did. I would hope that those who lose parents/grandparents to this would realise the same applies in their case - no doctor would want to let someone die if they could help it, but there are times circumstances dictate that must happen.

I wonder what will happen when your parents die? You have this to come, you know, as do most people on here I'd wager. It's not pleasant to go through but thanks to our societal taboos it's not something most people talk about.

In fact, if you are lucky enough to still have parents etc, please ask them whether they would want to be kept alive by machine. If I hadn't done that with my mum, I'd have spent the last 21 years wondering if I'd done the wrong thing by saying "yes"...

They shouldn't forget to do a public information message about Brexit.