Anesthesia and Intensive Care resident, CPR instructor & former ambulance doctor from Italy... AMA!

Just curious, how are things in italy right now? I can read the news all day but it’s nice to have some true insight from someone who is actually on the front lines. Thanks! Stay well!

Not bad as they used to be, but reopening seems to have led to a number of people abusing their newly found freedom and doing stupid things such as going to the disco and stuff... And we're back up with the new cases, risking a second lockdown. Also, median age of new cases seems to be younger (at least for now) so we're raising an eyebrow for this as well. Intensive Care workers are shivering at the thought of going back to the previous situation, so everybody just stay at home :D

How capable are ambulances in Italy? I'm a paramedic in USA and am curious about the differences.

We have a totally different system so I'll have to explain that first (sorry if it's a little long, but it is necessary for context).

1) We don't have EMTs/paramedics, HUGE difference; 2) In many regions, especially from central Italy to the south, we don't have just one public society for territorial emergencies, but rather one public sided by a number of private societies sub-contracting different areas; 3) We have many different types of "ambulances" basing on the combination of the operators employed: driver, nurse, rescuer (usually drivers are also rescuers, except for the Red Cross and a few other societies), doctor (which may be a generic doctor or an anesthetist), volunteers who are more or less equal to rescuers. We also have helicopters (pilot+technician+nurse+anesthetist), medical cars (doctor+nurse and sometimes a driver, otherwise it'll be the nurse's duty) and regular ambulances (various combinations); 4) Usually BLS, ACLS and basic PTC (or equivalents) are the only requirements. Some societies will also require other certification such as PALS, but the requirements will change from region to region. Of course, less standardization means more likely issues in terms of quality assurance.

Generally speaking, the level is average with a huge variability between regions also depending on their funding (which is higher in northern Italy). We have smaller distances to travel so we usually can afford a "scoop and run" approach but at least in my experience the operators involved in territorial emergency are fairly capable at doing their "dirty work". Main problem here is that ambulance operators are not often motivated, as it's hard work and being employed in private societies will often mean you will get paid not much. Working on ambulances is a job often done by newly-graduate doctors, so that can be an issue.

May I ask for your experience too? (Hope I answered your question, otherwise please tell me and I'll gladly say more).

Thank you so much for the info! I'd be happy to explain more of the US system.

So US prehospital care is similar to yours in that there is a lot of varience depending on where you are. But at a minimum an ambulance will have 2 EMTs, or an Advanced EMT or a paramedic or some combination of the two. Some areas run only BLS, a combination BLS/ALS or strictly ALS. denser population areas typically get more funding for ALS care. You only see nurses in HEMS and typically nothing more qualified than that except in specialty teams designed for critical PT transfers from hospital to hospital, then you may have a PA or DO. The two main systems of EMS are private and governmental. Private companies typically just provide ambulance or air transport and government organizations are attached to Fire Departments. Many government EMS organizations in rural or smaller areas are volunteer so they don't get paid at all. Pay is typically not great on the ambulance here as well, so many EMTs and paramedics will transfer to paid Fire Departments with better wages and pensions. Many rural volunteer services have funding issues for equipment and sometimes transports can take over an hour to a qualified hospital by ground.

Well, the BLS/ALS part is basically the same concept here but it seems like a substantial difference is that. EMS here in Italy is quite often private-provided (at least in Rome, actually much more their public counterpart). We also have volunteers but, except for the Red Cross which has a fairly different organization than all other organizations, they hardly are involved in EMS at all in some regions but much more in others.

Do you accept the rule of God-Empress Dolly Parton, She Who Shackled the Stars, Silencer of Heathens, Daughter of the Fifth Moon, Speaker of Madness, Voice of War, and the one true heir to the Iron Throne?

I think I kinda got the reference, but surprisingly enough I have never ever watched that series! BTW, Dolly Parton is not exactly my genre... I sing baroque :D

Have you had any patients who have had NDE experiences? Where they died on the table had an outer body experience and transitioned into the next life, met a being of light and were told it wasn’t their time? I research NDE experiencers and third party experiencers like yourself. There are thousands of people who’ve had these experiences.

https://youtu.be/JL1oDuvQR08

I did know some people who had NDEs, plus another couple who got this close to dying but were saved just before (especially one whose airways were cleared of an obstruction just before losing consciousness): most of them reported feeling at peace and outside of their own body, as if they were fluctuating and watching the scene from above or another point of view. This being said, it is less common for providers like us to hear this from our patients because of their mental status while they are in ICU: they often are disoriented and it usually takes a lot of time for the brain to get back "in shape" enough to actually be able to report it. This kind of memory is usually elaborated at a second time, after discharge from ICU.

A little dark and existential question but here goes nothing: I went in for surgery and was put under. Thinking back on it, I often feel as if being put under anesthesia feels similar to what death will feel like. A complete absence of everything minus the part where you wake up. This actually made me less scared of the inevitability of death. How accurate would you say that feeling is?

Perception of the "end", and the way it is lived, is extremely different from subject to subject and particularly hard to investigate for the most obvious reasons: I've seen people die of very different deaths and not necessarily did the reason match with their feelings and emotions at the time, sometimes terrible diseases carried little to no burden and viceversa. Also, a lot depends on spiritual factors: does the person think they will go to heaven or that they will simply hit the "off" button? I'll go a little dark and existential as well: don't be afraid of death, just make sure you don't get there without having lived properly both in terms of health and of emotions and experiences. At which point, hopefully, you might even get to decide how it feels :)

In your career will you be expected to perform any of those three duties in a single occupation, or will you find a job specialising in one of them? Additionally, could you in theory find a job as an anesthesiologist (in surgery, perhaps) before transitioning to a job in intensive care? Let me know if the wording doesn't make sense haha

Edit: Are you a native Italian? I know university classes in Italy are taught in English but your writing is exceptionally easy to understand as if you were a native speaker.

It depends on where you end up working: most hospitals employ you in different services (usually one or more surgeries and Intensive Care, especially post-operative ones) whereas Pain Medicine and particular services like OB-GYN, ER, Pediatrics or Heart Surgery (and their relative ICUs) are usually reserved to people who will only work there because of their peculiar, often very specialized nature. As time goes by though, specializing in one or a few areas usually happens because working in too many places can be disorienting and compartmentalizing is well known to increase quality of care.

Thank you for your compliment! Truth be told, classes in Italy are usually strictly in Italian except for a very few number of degree programs (my university has one called "International School of Medicine" and a couple more, which are taught in English). Also, I wish I didn't have to admit that the average level at which English is taught here is actually appallingly low. My secret? I attended bilingual (or almost so) schools from age 5 to 12 :D

Have you ever considered doing a Peds Anesthesia or Peds intensive care fellowship?

I have a degree in Clinical medicine but now living in America I'm planning to study Nursing or Physician assistant (once a state grants them full independence).

I have trouble feeling sympathy for adult paitents. I love working with kids. I was on track to work in adult medicine so I moved to America because I knew I wouldn't have been able to deal with adult paitents for the rest of my life without punching one.

Yes, I have considered working in Ped/Neonatal Anesthesia and I will likely (or should I say, hopefully) attend my Pediatric Anesthesia rotation this coming year. I am also not too sure that working with kids may solve any issues with patient/doctor relationship considering that kids have parents... who can sometimes be pretty annoying as well.

This being said, I have never considered fellowships abroad for a number of reasons which include the fact that "clinical" fellowships in other countries (especially non-EU) forbid any practical activity, and this I cannot stand given the fact that I want to work on the front lines and couldn't care less about academic career and/or publications and stuff like that.

do you have any funny stories from instructing CPR?

A fairly common occurrence, when providing a course to a group of colleagues, is when someone names the mannequin after someone else who is usually either present or "that guy" who nobody When working with lay personnel, who are generally quite far from actually knowing what on earth is real CPR, a funny part is watching their terrified looks when the mannequin is pulled out of the bag and they KNOW they will have to do "that thing" :D

Do you blame China?

It's been a combination of a series of events, both bad luck and suboptimal management, but I think blaming only one part is reductive to say the least... In this case, and in many others too. It's not like the rest of the world managed the whole thing so much better, after all.

Can you recommend a good IFAK kit or other such first aid kit to throw in the car or carry bag? I'm looking to get into being prepared for situations and obviously will need training on some of the items proper uses. I know I can build one myself but until I'm comfortable with building my own I'm looking to get one that's already prepared.

Thank you and thank you for what you do.

Commercially available IFAK kits are more or less all the same, and a lot depends on how much space you have available and what occurrences you would like to be covered for. So if you want to tell me more specifically about that, and what country you are from, I can can help you with e.g. Amazon (of course I have no conflict of interest whatsoever).

I can tell you what I like to keep in my everyday bag though, which I believe can cover the vast majority of anything a normal person might encounter in their life (IFAK kits generally have them all, and something more too): -Band-Aids (you can also store them in your wallet); -Gauzes/handkerchiefs; -Disinfecting swabs; -Military-grade tourniquet (because you don't want any bs in case of a real hemorrhage). Not all tourniquets are appropriate: make sure it is an arterial tourniquet, that's probably one of the few things kits usually do not contain because good tourniquets are bigger than common small IFAK kits; -Gloves (personal safety always first); -Flashlight (phone); -Metronome for CPR (phone as well, just download any random app); -Rescue blanket (the gold/silver kind, to be clear).

Generally speaking, these are my suggestions when choosing/assembling a kit:

-Gloves at least, protection is always first. You can do more in an emergency with a well-protected pair of hands than with any other non-specialized equipment; -Don't care about sterile equipment: in a real emergency you wouldn't even disinfect the skin for a c-section, much less for any other minor thing. Just have some disinfectant; -Disinfectant can be appropriate for wounds or not, make sure it is when you buy it; -If it requires a lot of training, you probably don't need it: what I listed, everyone can use or simply find a 2-minute YouTube tutorial for; -Learning to use equipment is nice but not necessary, invest more time on CPR training because that's probably the only real emergency in which you might both be allowed and able to intervene AND actually save a life.

Hope I helped, hit me up if you need anything more! :D

I'm from the US. I'd like to just have a well rounded kit to keep in the car or in a go bag if I decide to go camping or hiking stuff like that. I appreciate the detailed response. Also getting CPR certified soon for work so thats def in the plans. Also with the IFAK recommendation would you mind a good tourniquet as well?

I was looking at this....

https://mymedic.com/products/myfak-firstaidkit?variant=19844419321952&utm_medium=cpc&utm_source=google&utm_campaign=Google%20Shopping&gclid=CjwKCAjwj975BRBUEiwA4whRB6Fpin4FLt9PaneOHolMtuU2cgYe5wLj-W3A6ImVvp0fHFNTSimMsRoC2AoQAvD_BwE

However $240 seems expensive but maybe not considering what's inside?

Thank you so much for the reply!

That kit looks a little overkill, honestly: there's a lot of equipment a layperson will never, ever have to use (for example, nasal airway devices). The price is good for what's inside, but I genuinely don't think you might need it. Personally, I would go with something like this, or at least this kind of kit. Compare it with what I previously wrote, but there should be more or less everything. If the thermal blanket is not there, I mean this As for the tourniquet, this is the kind of model I would go for which is reliable and also looks fairly cool :D

Oh, I forgot to mention scissors! I keep a multi-tool but that's more a matter of preferences.

Here in Canada, my wife spent two months in a coma in a critical care unit. She suffered a great deal from ICU delirium during and after the coma. It seems that in our area ICU delirium is not always known about or taken seriously (though that is slowly changing). In Italy, do you provide support for post-coma patients who suffer from it?

Some (very few, extremely well-funded) structures do, but basically no eventhough it should be addressed. What I can say is, most of the work is based on prevention rather than "simply" treatment: lights on/off at appropriate times, proper management of sedation etc., but unfortunately it is a fairly common occurrence and too much burden is left on the shoulders of family caregivers. It is of the utmost importance that family members talk about this with the personnel in charge of assistance to the patient, to discuss future strategies to help them manage this fairly obnoxious complication. Hopefully, this mentality will change around the world.

During my labor I had an epidural. It failed in the inserting part multiple times and offered only little comfort after it finally came through. How often do you find the epidural actually helps women during child birth? No trauma just curious.

Just a few hours ago, I placed an epidural on a woman who ended up delivering a baby with a pain which she reported as a fraction of what it was before :D Epidural is not a simple procedure, nor free of risks. If it succeeds, which is the vast majority of cases, it will not take away all the pain but it still will cut it by a huge measure and make delivery a minimally unpleasant experience. Sometimes it does not succeed despite the best efforts and practice, or it only does partly, which is indeed a bummer. But in my experience, it most often helps a lot and I believe it should be a basic right for all eligible women and a common good practice which should be advocated everywhere, every time!

What is the average salary of someone in your specialty in Italy? Anesthesia is one of the higher paid specialties in the US and it would be interesting to compare.

It varies greatly: as a resident I make a nationwide standardized salary of 25k/year for the first 2 years then 26k, work in a public hospital is usually paid around 2600 €/month. Private activity can instead vary enormously, since many structures usually pay around 40 to 60 €/h (except for Southern Italy, where pays are lower on average) but if you work "by the piece", e.g. you are THE anesthetist for a surgeon or stuff like that, you can make up to more than 10-15k a month if you know how to make your time count.

Wow. Well, we appreciate what you do but to put it into perspective, here in the US the janitor at the hospital will make much more than you as a resident. You mention 10-15k a month but is that average or is that for people that are at the top of the pay scale?

Have you ever thought of leaving Italy for better earnings elsewhere?

Yes I did but, to be honest, aside from the pay many people I know were not too happy of moving abroad for many reasons: people, healthcare systems, climate etc... Also, private work is harder outside of Italy and that usually accounts for a good deal of money for the bulk of clinicians. Lastly... we have better food :D

How many hours do you work a week?

The contract for residents of all specialties is standardized nationwide, and it requires 38 to 48 hours a week of work. This being said, this contract is almost never enforced: there can be times when I work half of that, others when I easily work over 60 plus on-call duty. On average, though, I can say I work around 45 hours a week. Residents in Anesthesia are not those who have it worst (I can say I work, but not to the death), surgical residents usually fare much, much worse than this.

Why do you guys insist of giving me basic anesthesia even though i've told you time and time again I stop breathing from it? This isn't directed at you personally, just in general.

There is a number of reasons and it also depends on things like the procedure involved, so the best thing I can tell you is to discuss it thoroughly with the anesthesia provider and ask them directly what their choice is and why. What do you mean by "basic anesthesia"? Depending on the procedure, stopping your breathing may be in fact necessary and, even if it is not the case, it very rarely is a dangerous occurrence but rather a fairly common side effect of sedative drugs :)