Striving For Excellence: The Dilemma Faced by Italian Cardiologist During the COVID-19 Pandemic

Italy was the first European nation to be severely affected by the COVID-19 pandemic. On July 17, data from the John Hopkins University COVID-19 Dashboard showed that Italy was the 14th country with the most confirmed cases; fifth country in the world with the most number of COVID-19 mortalities; and third European country after the UK and Spain, with the most number of confirmed COVID-19 cases – more than 243,000 cases and 35,000 deaths: a bronze medal not certainly enviable.

During the months of March and April – which was the peak of the COVID-19 pandemic in Italy – the efficacy and resources of the national health system were heavily tested. The Italian National Health System redirected most of its resources – health care personnel, wards, intensive care units and devices were focused on the management of patients affected by SARS-COV 2 infection. This was challenging and required a fine balance between the need to respond adequately to the COVID-19 pandemic and the importance of maintaining health care services for urgent non-COVID-19 medical conditions, which also needed to be treated.

Routine nonurgent, elective procedures were dramatically reduced, and in certain geographical regions – especially in the Italian northern regions where the impact of the COVID-19 infection was greater – elective nonurgent procedures were completely abolished. It is important to note that there was also a significant reduction (more than 50%) in reported hospitalizations for acute cardiovascular events including acute coronary syndromes even in geographical regions not heavily affected by COVID-19. These findings have been published in a survey of the Italian Society of Cardiology.
Significant delays in the access of patients with STEMI to cardiac catheterization laboratories occurred due to the reticence of patients regarding hospital admission, possible COVID-19 contamination, longer activation time of emergency networks and time-consuming protective measures in place for health care workers. This was demonstrated in a recent publication by an early career cardiologist, Enrico Baldi, MD. The retrospective study showed that for patients with out-of-hospital cardiac arrest, there was a longer arrival time of the emergency medical service and increased mortality among patients treated during the COVID-19 pandemic compared to the pre-COVID-19 period. In addition, there was a lower rate of bystander assistance for these patients during the COVID-19 period.

During the COVID-19 pandemic, many specialists and young cardiologists were requested to assist in the care and management of COVID-19 patients, and thus requested to transform their clinical skills to care for patients with a new, largely unknown, aggressive disease.  

The COVID-19 pandemic slowed down, and in some cases, temporarily paused the educational training programs of young cardiovascular physicians. However, it also provided an opportunity for young cardiologists to develop competence in different medical fields such as intensive care and respiratory disease. Thus, COVID-19 provided a unique opportunity for professional growth and diversification.

There has not been a similar disease in the past 50 years, which caught health care systems largely unprepared – especially in Italy, being the first European country to be affected by the COVID-19 pandemic. At the early onset of the pandemic, there were no established clinical management strategies. The only experience and expert opinion advise was initially derived by from the modest information coming from China. Therefore, Italy paid a very high price with more than 11,000 health care workers infected, 100 clinicians killed by COVID-19 and many with burnout syndrome.

During the COVID-19 pandemic, I was assigned to a non-COVID-19 medical department. As an early career interventional cardiologist in Italy it was hard for me to perform routine daily clinical work in a setting of  completely deserted corridors, empty  waiting rooms with the knowledge that nearby, behind secure walls were long rows of intubated and ventilated patients.

My experience with the COVID-19 pandemic has helped me empathize with early career cardiologists and Fellows in Training who have experienced emotional trauma from providing health care to COVID-19 patients, felt the impact of social isolation from family and colleagues, or was affected by relocating their cardiovascular training to a different university or hospital system distant from their original training location.  

There are positives from all of this. We have seen the explosion in the use of telemedicine and virtual tools as a means to reduce the spread of COVID-19. In addition, professional societies across the globe have efficiently adapted to the challenge, providing regular updates on COVID-19 management, promoting research dedicated to COVID-19 via registries and surveys, and collaborating with each other to learn from the different international experiences related to COVID-19 health care delivery and management. I am hopeful that Italy will rise from her experience and not only be known as the first European country to be hit with the COVID-19 pandemic but also that the Italian health care system emerged stronger and better post-COVID-19.

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This article was authored by Monica Verdoia, MD, PhD, interventional cardiologist at Ospedale degli Infermi, ASL Biella, Eastern Piedmont University, Italy.