Interview: Hi, I'm Annalisa

We speak with Annalisa Malara, a resuscitation/reanimatology physician, who discovered the first case of COVID-19 in Italy in February 2020.

Dr. Annalisa Malara, is a resuscitator physician at the ASST Hospital in Lodi, Italy

On February 20th, 2020, the first Italian case of COVID-19 was diagnosed at the hospital of Codogno, a town of 15,000 inhabitants in the plain between the Italian regions of Lodi and Piacenza. The patient was in critical condition, with a serious picture of ARDS. The early diagnosis saved his life, but also saved that of many others.

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Annalisa is a young physician who lives and works in Lodi, Italy. Hers is a demanding job, which takes up most of her time and thoughts. She is a resuscitator in the intensive care unit of the Lodi Central Hospital (Italian: Ospedale Maggiore di Lodi). Some days she also works at the Codogno Hospitai. On the morning of 20 February, Annalisa was on duty in Codogno, not aware that the events of that work shift would change her daily life and that of millions of people. We met her almost 4 months after the diagnosis of the first COVID-19 case in Italy, after several interviews with televisions and newspapers, and after awards and honours. She was granted the Merit Knighthood of the Italian Republic, known as the “Cavaliere al merito della Repubblica Italiana” and will receive the "Rosa Camuna" award, the highest honor of the Lombardy Region. Once the lights went off and her shift came to an end, we sat on the grass in a park and tried to get to know her, trying to understand how this story had an impact on her life.

esanum: How are you, Annalisa?

Annalisa: I'm fine, though very tired. We've been working hard for months. The number of COVID-19 patients in the ICU has decreased considerably, but the pace of work has remained high.

esanum: Do you think this episode has changed your life?

Annalisa: This pandemic has changed my life as much as it has changed everyone's, no more, no less. It's an epochal event, the kind you live through intensely and leave traces within you. As a child I walked in over a meter of snow in the square in Cremona (Italy), and my mother said that I would never forget that moment, because it was unique and probably it would never happen again. From a personal point of view, I consider the coronavirus an experience, to be put aside once it is over, just like the snowfall of 1985.

As for my professional life? It hasn't changed. I go to the hospital every day to do my best, like I always have. My professional goals have remained the same. I'd like to become an increasingly capable physician, with study and experience. This interested me before, this interests me now.

esanum: You've become famous. Type your name in any web search engine and you have dozens and dozens of pages about you and the diagnosis of the first patient affected by COVID-19 in Italy. How does it feel?

Annalisa: I am pleased to have given my contribution in this situation, as well as the acknowledgements I received. I share them with all those who have worked with me. In this profession, teamwork is fundamental.

esanum: Have the sudden spotlights had any effect on the people around you?

Annalisa: Fortunately, in most situations, nothing has changed. I've remained "Annina" to everyone, or almost everyone. Unfortunately, someone showed some coldness and detachment towards me, I'm not sure why. Those who know me know that I don't particularly like being the center of attention, but that morning in Codogno I was there and when I was asked to tell how things had gone, I did it. Not to look for the front pages of the newspapers, but to convey messages, especially at a time when everything and the opposite of everything was being said about the pandemic.

esanum: How do you think this story was told?

Annalisa: The spotlight was turned on and everything was very spectacular. I'm not saying that journalists wrote things that weren't true or that the video interviews reported anything I didn't say. But I am saying that the focus on my words were placed not where I wanted to put them, but where the person who told the story wanted them. Maybe this is inevitable. My first interview was with "Repubblica" (newspaper) at the beginning of March. When the journalist called me on the phone, it was the first time I was interviewed, I answered the questions to complete the information that the media already had obtained from the press release of the Health Directorate. I wasn't expecting so much uproar, because I wasn't saying anything other than what was already known. Dr. Paglia, head of emergency in Lodi, had already told the story to "Repubblica" a few days earlier. But, evidently, that wasn't enough. The media wanted to know who was the physician in Codogno that day, they wanted to tell a story and they wanted a protagonist. But the tone of the story had emphasis here and there.

What happened in Codogno reflects a good clinical practice to which I and my other colleagues are accustomed to when dealing with the diagnostic-therapeutic path of a patient. When there is a diagnostic hypothesis, however remote, if it is believed to be in some way plausible it is not discarded a priori. One goes to the bottom of the issue and tries, within a complete diagnostic path, to guarantee the maximum protection of the patient. The diagnosis itself had been exceptional, especially for the implications it has had for the community. But it was the result of a scrupulous clinical approach. There was nothing heroic or striking. The echo the event had was striking, certainly. The diagnosis alarmed our country and the whole of Europe, enabling a whole series of protective measures to be put in place for health care and the community. We discovered that the virus was not in a faraway place, difficult to spot with the finger on a map, but it had arrived among us.

esanum: You were credited with courage and perseverance for forcing through protocols that did not include swab testing. Shouldn’t you be credited with bravery, even for that?

Annalisa: I don't really see myself as a hero. That's the kind of sensationalist tone I've never used in any interview. True, the situation made me think of a coronavirus infection. True, the protocol didn't include a swab test for SARS-CoV-2. False, that I had to fight to get the test done. I'm always trying to put the focus on the sick person. So if I want to treat him or her as best I can, I don't have to dismiss any assumptions. I had a patient with an extremely serious condition, with a very compromised lung CT scan, who wasn't responding to therapy and was getting worse rapidly. The hypothesis was plausible, which is why I shared it with my manager. The protocol did not provide for the test, but nobody forbade me to do so. Sure, to get the exam I had to make a lot of phone calls, but I didn't have to take up any fight. My evaluation was immediately shared, all the choices were shared between me, my superiors, the various consultants approached regarding the matter. I repeat, I had to put oil in the gear, that was needed, but no fight.

esanum: If that morning it had not been you in Codogno, but another anaesthetist-resuscitator, would the story have gone the same way?

Annalisa: I can't answer that. I think I did what any other scrupulous doctor would have done at the time.

esanum: We spoke to some of your colleagues. They said you were very good, that not everyone would have gotten there so quickly. Don't you give yourself any credit?

Annalisa: Credit? That I did my duty. And that it was done in a timely manner. The timeliness of the swab made it possible to get the health system up and running quickly. Timeliness made all the difference, I admit that.

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One of the halls of the Codogno Hospital, Italy

esanum: The hospital in Codogno, reopened a few weeks ago. Normality is slowly coming back. Now, In telling your story there was a lot of emphasis on some aspects, very little on others. Choose one of those aspects that, in your opinion, deserved more attention.

Annalisa: I have always talked to all the journalists about the fantastic work done by the nursing team. Almost none of the journalists wrote about it, and whoever did it dedicated perhaps a line to this. The nurses in Codogno found themselves handling probably the first case of COVID-19 in Europe and in my opinion they did it in an exemplary way. I was very impressed. The Head Nurse, Giorgio Milesi, had only been in this position for a few weeks. Yet, as soon as he heard about the suspected diagnosis, he ran the department efficiently. He banned access to the ICU, got access to the PPE, trained the staff. No one backed down, all the nurses worked around the clock. No one showed fear or anger, feelings that would have been completely understandable. No one, especially at a time when very little was known about this virus.

I was supposed to finish my shift at 4 pm that day, but I stayed at work until the next day. I didn't feel like leaving my colleague, who arrived in the afternoon to replace me with such a complicated patient, alone. I didn't even want to involve other colleagues, expose them to risk. The nurses did the same thing, nobody went home. It was by choice, and to protect their families and the community. Everyone stayed on that ward for over 36 hours. The nurses, the unlicensed assistive personnel (UAP), everyone was really exemplary.

esanum: If you could go back, would you redo the interviews you did or would you try to remain anonymous?

Annalisa: Remaining anonymous today is impossible. My name started circulating along with my personal phone number, and I immediately found myself answering a reporter's questions. One day my phone started ringing uninterruptedly and for several days it kept ringing, every hour. Sometimes I thought that if I was in Spain that February 20 at my sister's, I would have saved myself a lot of unpleasant situations.

I would do the interviews again, of course, because I did them with the idea of transmitting messages. I didn't always succeed, but I tried. Many colleagues felt represented by me and I was very pleased about that. When I was describing the difficulties of working in the hospital at the center of the outbreak, I was talking about the difficulties of all my colleagues, not just mine. There was then a moment when what had been done in Codogno was questioned, for me it was my duty to speak out on this and defend the work done. Not only mine, but that of all of my colleagues. I tried to use the media interest that had been unleashed on me to convey useful information based on my clinical experience, at a time when everyone went on television to say anything and the opposite of anything, often without having seen even one patient suffering from COVID-19.

esanum: In this regard, what do you think about how the physicians narrated and publicly commented this pandemic?

Annalisa: I have been working a lot and I have not had time to read newspapers or watch television in this last period. I am not an expert in communication, but this experience has taught me that the same story can present itself in very different ways depending on who is telling it. In a health emergency situation, like a pandemic, we cannot afford this. We physicians have to learn to communicate well, not only with each other, with patients and family members, but also with the media.

I work as a team, I am used to communicating with colleagues, we cannot do without that. I work in intensive care, I often talk to patients' families and give unpleasant news. I have never spoken to journalists, not even on television. Given the importance of the messages that we physicians have to convey at certain times, I think we should think seriously about this. To improve, even in this field.

esanum: Instead of a last question, please mention anything that you would like to portray as a wrap-up to our chat.

Annalisa: The park seems to have regained its dimension, it hosts the children playing, the couples on benches, the grandparents walking slowly. This newfound simplicity soothes me. It's been a hard experience for everyone. I don't know what will happen in the future, whether there will be a second wave or not, whether it will have the same violence or not. We all need serenity now. There will be time to reflect further on what happened, there will be room for personal and general reflection. Now it is time for me to think about my sister, who is waiting for me in Spain.

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