Dr. Ivo Boškoski is a Consultant Gastroenterologist at Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome. The Gemelli University Hospital is the second-largest hospital in Italy and one of the largest private hospitals in Europe. With 23,000 to 25,000 annual cases, their endoscopy unit is one of the largest in the world.
As of this writing, we don’t know whether the third wave of COVID in US will peak this winter. But can we be prepared in case it does? Where better to look than Europe? UK, Germany and France are in going into a lockdown again.
Dr. Boškoski feels Italy will follow the other countries in a couple of weeks. He’s working in a red-zone now. In this interview, he tells us of his first-hand experience about the situation in Rome. Learn how his endoscopy division is preparing for what’s to come from mid-November to December.
Watch this timely interview to prepare your practice if the situation changes in your region.
◘ Effect of COVID right now – insights from the red zone (Lazio region, Italy)
◘ “I’m afraid it will already be too late” – For people who haven’t got their colonoscopies done in the last six months
◘ 92% of loss of volume – from 23,000 endoscopies per year (pre-COVID)
◘ Future of GI from Dr. Boškoski’s lens – This is the time to Scope Forward
The Transcribed Interview:
Praveen Suthrum: So, Dr. Ivo Boškoski thank you so much for joining me on this conversation. You’re speaking from Rome, Italy today and I wanted to start by welcoming you first.
Dr. Ivo Boškoski: Thank you.
Praveen Suthrum: How is the COVID situation in your area right now?
Dr. Ivo Boškoski: Well, my area here is the Lazio region. You know, Italy is divided into regions, and the Lazio region is a red zone. So, I am in the red zone right now. And the hospital where I work is the biggest hospital in the region and I can say in Italy it’s the biggest Oncology Board. And right now, we are facing a dramatic situation from several points of view. The first one is that we are in a very crowded area. All the patients are coming here. There are several hospitals in Rome and in the region but we’re most hit by the crisis. And the second is that many doctors and nurses are positive. Some of them are in critical situations and every day there are different departments that are closed. So, for instance, today I was supposed to meet a guy from neurology to work on a stem cells project. He just sent me a message saying that he’s in quarantine, that he’s positive and that’s it. We cannot meet. He can’t even talk because he’s coughing all the time.
So, this is unprecedented times and unprecedented situations. We do not know how this will evolve. We can expect the peak of this situation in mid-December if not earlier. We are facing a dramatic situation now but the drama is still to come. From an endoscopy point of view, I can say that now we are doing endoscopies to people that strictly need it – to bleedings, to cancers, and situations that cannot be postponed, and what we are postponing is fecal blood positive testing. You have Cologuard in the USA; we do not have it here. But if somebody has an indication to colonoscopy it is right now, that’s not the case. All these people who got their colonoscopy in probably in six months and for most of them it will be too late, I’m afraid. So, the number of deaths is not directly only correlated to COVID but to what it will provoke in other sectors.
So, from one point of view, it is an unprecedented economic crisis. From another point of view, it is an unprecedented humanitarian crisis with all this suffering and in the end, it will hit also the future of everybody from surveillance point, from follow-ups. The second very important point is that every hospital is dealing with car accidents, routine surgeries, appendicitis, cholecystectomy, oncological patients, etc. If we consider urgent surgeries and urgent medicines for people seeing diabetic ketosis, people that need urgent care, this is the point. And even if today somebody who came to the hospital with a heart attack there is a high chance that they cannot be seen immediately because there is somebody that is not breathing due to COVID. So, this is the drama of this situation.
Simply we do not have enough resources. We are in the richest country in Europe, in the richest continent. We have medical treatments that are avant-garde. Any kind of oncology treatments, drugs of the future, and so on. But we can’t deal with a situation that is a pandemic. Infectious disease… that from one point of view is really simple. It’s an infection. You need to do prevention. You don’t need to do complex surgeries. You don’t need complex drugs. You need prevention. You need to wash your hands, wear a mask; don’t meet people, and so on. This is the cheapest and easiest way of prevention. But still, we have a high impact on the society and the hospitals and everything.
Praveen Suthrum: In the GI department itself what kinds of volume are you seeing now compared to last year same time and compared to the first wave you know, when COVID began?
Dr. Ivo Boškoski: So, the center where I work is a digestive endoscopy center. It is one of the biggest centers in the world with a net endoscopy volume of 23,000 to 25,000 endoscopies per year. We do 1,300 ERCP procedures. We do three to four thousand endoscopic ultrasound procedures and the rest is colonoscopies, gastroscopies, and polyp resections, complex ESD (endoscopic submucosal dissection), and bariatric endoscopy, and all that. So, if we compare that numbers to March, our calculation is of 92% of loss of volume – only for March and April. Then in May, June, and July, we had a rise of the cases and now we are again in the decrease. Not like in March because we are doing also routine cases. But those have been decreased for 20% overall. So, compared to last year we are around 60% and this is only for gastroscopy and colonoscopy because ERCP is done for people that really need it – cholangitis, cancer, and so on. There is no diagnostics ERCP, operative is operative and it doesn’t have an impact. We also published about this in different papers. The impact is important especially from an economic point of view because this revenue from what endoscopy gives is not the same from the last year. And on the other hand, we have costs. We have costs on training, on donning and doffing. We have the costs of personal protective equipment. We have the cost of disposal of personal protective equipment. And we give the cost for people that can’t work and are staying at home because they’re in quarantine, infected and it’s a disaster.
Praveen Suthrum: And you’re expecting the situation to peak now in mid-November onwards towards leading up here. How are you preparing from a GI department standpoint? You know, in case it peaks.
Dr. Ivo Boškoski: We are prepared. We had all the time been prepared since March. So, now we are doing procedures with two masks. One is the N95 and over that, we have the surgical mask because we are in a strict contact with the patients. And we have a program for out-patients and in-patients. And it is different. For the outpatients, there is a dedicated personal also this is a cost that is phone calling the patients at home making an interview if they have been in contact with somebody if they have symptoms, and so on. Then they come to the hospital and there are three separate zones. In the first zone, they get interviewed again. Let’s say today the patient has a gastroscopy or colonoscopy and they get the interview then we do a rapid testing. Now we have also RNA rapid tests and they wait 15 to 30 minutes for this. And if it’s negative then they go to endoscopy. They come in the suite; an endoscopy is performed. And for the in-patients, they go to RNA based testing for the virus, for the Sars-Cov-2 then they get hospitalized. And if there is a procedure that should be done let’s say two days after the initial testing, they get another test just before the procedure in order to be sure that they are not positive.
We have more than 50 operating theaters for surgery. Now we have eight endoscopy theaters and many other rooms for procedures. This is a very big hospital. We have 1,800 beds and we have three dedicated operative theaters for COVID positive patients because if somebody has COVID and needs an urgent appendicectomy you do it. Urgent gastroscopy we do it. So, procedures are done all the time and if we do not know if the patient is positive or negative, we treat those patients as positive. You need all the equipment and this is costs.
Praveen Suthrum: Yeah, and so coming to the cost. How are you managing the economics because your budgets have increased and I’m sure what the department earns would have dropped. So, from that standpoint how are you planning and managing that especially in light of what is going to come. You know we’ve seen one or more waves depending on how you count the wave until now but from this point on expecting the situation to peak again. How are you managing the economics of this situation and again drawing it to GI in particular?
Dr. Ivo Boškoski: In March, we were suffering from the lack of PPEs (personal protective equipment), and also, we came with a publication in gastrointestinal endoscopy on methods and ways to reuse respirators and so on. Fortunately, today this is not the case because our hospital made the reserves of all the PPEs and this is an important cost. This is a private entity that gets money from the region and we still haven’t been paid for this. So, the hospital is going with its own funds. How do we manage it? We simply treat cases; we give the maximum of the care to everybody and we’ll see what will happen. The management is aware of not wasting unnecessary PPEs and everybody knows that it should not be wasted. We are very sensitized on that and from time to time we go for trainings in donning and doffing because many colleagues have been infecting especially during doffing and during removing all the of the equipment because if you remove it in the improper way, it is the moment that you get infected.
Praveen Suthrum: Yes, it is a pretty serious situation. I wish you all the best doctor. So, I wanted to spend a moment and switch gears a little bit and ask you – in the light of the future of GI… on what your thoughts are? Now you know, again thank you for reading the book Scope Forward. So, I’m curious to know what you think applies in a European context and what do you see as the future from your lens?
Dr. Ivo Boškoski: So, it is a very exciting time to be in the interventional gastroenterology world also in the diagnostic world because there are many new things coming from the devices’ point of view, from artificial intelligence, deep learning, and so on. So, still, nobody managed to write a book like that here in Europe and this is something that we need right now. So, I really did read it with pleasure and it’s like the missing ring between what we have and what we’re doing. But when you’re reading it in a book that has thoughts that somebody has already elaborated it’s very useful for interventional endoscopies like me dealing with new technology. My world is new technology, applying new things to what I’m doing and so on also the team where I work. So, I really appreciate your efforts and I simply loved it. It’s what we need right now especially in this… We need to look forward not only to scope forward. We need to look forward. Scoping forward is very important but looking forward to the future is also important. This crisis will pass sooner or later and we need to be ready when we will be there.
Praveen Suthrum: Thank you Dr. Boškoski. Is there anything else that you wanted to share before we close?
Dr. Ivo Boškoski: You should translate the book into Italian.
Praveen Suthrum: Yeah, I should. I should find somebody to do that yes. Thank you so much.
By Praveen Suthrum, President & Co-Founder, NextServices.