The ambulance leaves with sirens blaring. Little information arrives during the journey: it is a code red, an unconscious man found in a park, perhaps an illness, perhaps a trauma. It’s a very hot day at the end of July Palermowe have been following a shift since the early hours of the morning 118. When we arrive at the location of the call, it turns out that the reality is different: the patient is drunk, probably also on drugs, he doesn’t cooperate and passers-by warn us that since the early hours of the morning he had been throwing a fit and bothering anyone passing by the public gardens.
We need to call the police and keep him calm, hoping that the situation does not degenerate. «Cases like this happen almost every day», the operators of “number 4”, a medicalized ambulance (i.e. with a driver, a nurse and a doctor on board) of the operations center, explain through gritted teeth. Palermo-Trapani which, with its 30 resuscitators and a fleet of 90 vehicles including helicopters, ambulances and medical vehicles, guarantees rescue services throughout the Western Sicilyincluding Ustica, the Egadi islands, Pantelleria and Lampedusa.
The loneliness of the street doctor between quick diagnoses and summary trials
«Our job is to make decisions that can change a life in a few minutes, without the certainty of a diagnosis, without a CT scan, without analysis and often without even a safe environment in which to operate», says the doctor on duty. «And yet one case that ends up on the front pages of the newspapers is enough for our commitment to be reduced to a summary verdict: they got everything wrong». The reference is to the case of Abderrahim Fakirwho died in Bologna after the intervention of a police patrol and an ambulance 118: the climate of contempt, if not downright “social hatred”, unleashed after that event weighs heavily on the morale of women and men who deal with emergencies throughout Italy.
Service that works and saves lives: every year in our country there are six million rescue missions 118. One million in Lombardy alone, more than 600 thousand in Lazio, 430 thousand in Sicily, 500 thousand in Emilia-Romagna, just as an example from North to South. The data OECD – an organization that collects and compares the health performance of 38 countries around the world – certify that throughout the country, aid for time-dependent pathologies (such as heart attacks or strokes, in which a few minutes of delay can mean life or death) is excellent, with mortality data well below average.
From the applause of the pandemic to the accusation of being the enemy
So why this witch hunt that has transformed the doctors of the 118 into scapegoats for an event which the competent authorities will certainly investigate but which is only an infinitesimal part of their work? “Unfortunately, people have short memories,” the resuscitator tells Panorama Fabio Gencowho manages the Palermo-Trapani operations center, where we are guests. «We went from being the heroes of Covid, when we were the only ones bringing help in the total absence of local medicine, to being a sort of “enemy”. With very heavy accusations, which weigh on us every time an operation goes wrong. But the first rule of an emergency is the safety of the scene: if the police are in action to guarantee it, the healthcare personnel must wait before carrying out any intervention.” It may seem like a difficult choice to understand, but an injured doctor can no longer help anyone. «No one denies that there may have been errors, in the case of Bologna as perhaps in others», continues Genco. “But turning every problematic intervention into an attack on rescuers risks obscuring the daily work of thousands of professionals who operate in extremely complex conditions.”
And we are able to truly experience these complex conditions first-hand, in this day spent alongside them. While the case of the psychotic patient was resolved without damage, the critical issues are increasing in the operations center. The ambulances are finished: many are stopped in line outside Emergency room which, already at 11 in the morning, are overcrowded up to 270% of their accommodation capacity, and therefore unable to receive other patients. “This is a problem that affects all of Italy,” he says Mario Balzanellinational president Sis 118 (Italian company system 118). «An important part of the ambulance fleet is in fact always blocked in front of the emergency rooms. It is a real operational kidnapping, I call it “barellopoli”. This lengthens response times and reduces rescue capacity precisely when it is most needed.”
The siege of the emergency rooms and the race against time
And in fact in Palermo, in the meantime, they bend over backwards to be able to help everyone. “An elderly lady fell in the bathroom, she can’t get up”, the operators at the station tell us. «But the vehicles are all busy. And before her there are six more urgent cases: during the summer we carry out more than 800 operations a day, with helicopters always in flight.” But the critical issues don’t end here, why do it today territorial emergency it means operating in an increasingly difficult context: there is a lack of resuscitators, crews have to cover increasingly large areas, stations are decreasing and travel times are getting longer. Added to this are road accidents, assaults, exhausting shifts and ambulances often busy due to inappropriate calls.
For Balzanelli, one of the priorities would be to restore direct telephone access to 118without the passage from 112. «The single emergency number makes an initial screening between those who need medical assistance and those who don’t», says the director of Sis. «But this way you lose more than 90 seconds. And in an emergency, time is life: in cardiac arrest, every minute reduces the probability of survival by about 10 percent, while in a stroke it means losing millions of neurons.” But that’s not all: an intervention for cases of individuals under the influence of drugs or alcohol like the one we witnessed in Palermo can end up blocking the ambulance, resuscitator and law enforcement for many hours, while other people wait for problems that put their lives at risk. The critical issues are therefore innumerable: it is therefore surprising that we stop pointing to the finger rather than the moon, and think only of the Fakir case.
The weight of retrospective judgments and the need for real resources
«After episodes that arouse media attention it is inevitable that the work of 118 is subjected to a collective judgment dictated by emotions. But the risk is that decisions taken in a few minutes, in conditions of uncertainty and with limited information, are judged a posteriori, already knowing the final outcome”, he adds Narcissus Mustardgeneral manager of Ares 118 Lazio. And the rush by some medical-scientific societies to ask for inter-ministerial technical tables to understand how to act in these specific cases of psychomotor agitation and psychotic delirium, which, compared to the 6 million rescue interventions every year, are little more than residual, is also inexplicable.
There are no much more serious problems in the field of 118? Obviously yes. «Moreover, we know well how to proceed when dealing with patients in psychotic delirium: we don’t need technical tables», concludes Genco. I once intervened to sedate a person weighing almost 150 kilos, aided by 5 police cars. We were stuck for hours trying to get him to hospital without harm, I had to give him general anesthesia and intubate him on the spot. Any intensive care doctor has similar stories to tell.” More than tables and demagogy, therefore, resources, means and more understanding are needed, not only on the part of politicians but also of public opinion. Meanwhile it is late afternoon, the shift is over in Palermo. “Number 4” changes crew and sets off again with sirens blaring. We don’t know who he will find this time: a heart attack, an accident, another person who is delusional and threatening.
However, we know that, whatever problem there is on the other end of the call, someone will have to decide what to do in a few seconds, on the street, with the fear of being attacked and with resources that are never enough.
And whoever is waiting for that ambulance will never know how many hours of shift those rescuers already have behind them, nor how many emergencies they faced before getting to them. He will only know one thing: that in the worst moment of his life, he will hope to see them arrive, as soon as possible, with the sirens blaring.
