Sunday, 9 February 2020

Life and Death in a Wuhan Coronavirus ICU

A Chinese doctor who warned about the outbreak before it was officially recognised died of the virus yesterday, triggering a wave of public mourning and praise for medical staff. In an interview with Caixin Global, Dr Peng Zhiyong describes what doctors and nurses are facing at Ground Zero in Wuhan.
The Straits Times, 8 Feb 2020

WUHAN • In the coronavirus epidemic, doctors on the front lines take on the greatest risk and best understand the situation. Dr Peng Zhiyong, director of acute medicine at the Wuhan University South Central Hospital, is one of these doctors.

In an interview on Tuesday with Caixin, Dr Peng described his experience in first encountering the disease early last month and quickly grasping its virulent potential and the need for stringent quarantine measures.

As the contagion spread and flooded the intensive care unit (ICU), he observed that three weeks seemed to determine the difference between life and death.

Patients with stronger immune systems would start to recover in a couple of weeks but, in the second week, some cases would take a turn for the worse.

In the third week, keeping some of these patients alive might require extraordinary intervention. For this group, the death rate seems to be 4 per cent to 5 per cent, Dr Peng said.

After a 12-hour day shift, Dr Peng spends his evenings researching the disease and has summarised his observations in a thesis.

The doctors and nurses at his hospital are overwhelmed with patients. Once they don protective hazmat suits, they go without food, drink and bathroom breaks for their entire shift.

This is because there aren't enough suits for a mid-shift change, he said.

Over the past month, Dr Peng has been brought to tears many times when forced to turn away patients for lack of staffing and beds.

He said what really got to him was the death of an acutely ill pregnant woman when treatment stopped for lack of money - the day before the Chinese government decided to pick up the cost of all coronavirus treatments.

This is the interview with Dr Peng:

SCREENING CRITERIA TOO TOUGH IN THE BEGINNING

Caixin: When did you encounter your first novel coronavirus patient?

A Jan 6, 2020. There was a patient from Huanggang who had been refused by multiple hospitals. He was sent to the South Central Hospital emergency room where I attended the consultation.

At the time, the patient's illness was already severe, and he had difficulty breathing. I knew then that he had contracted this disease.

We debated at length whether to accept the patient. If we didn't, he had nowhere to go; if we did, there was a high likelihood the disease would infect others and we would have to do a very stringent quarantine. We decided to take the patient in the end.

I called the hospital director and told him the story, including the fact that we had to clear the hospital room of other patients and to remodel it after severe acute respiratory syndrome (Sars) standards by setting up a contamination area, buffer area, cleaning area, and separate the living areas of the hospital staff from the patients'.

On Jan 6, with the patient in the emergency room, we did quarantine remodelling in the emergency room and did major renovations to the ICU.

South Central Hospital's ICU has 66 beds. We kept a space dedicated to coronavirus patients. I knew the infectiousness of the disease. There were bound to be more people coming in, so we set aside 16 beds.

We did quarantine renovations on the infectious diseases area because respiratory illnesses are transmitted through the air, so even air inside the rooms has to be quarantined so that it cannot escape. At the time, some said that the ICU had a limited number of beds and that 16 was excessive. I said it wasn't excessive at all.





Caixin: You predicted back in January that there would be person-to-person transmission and even took quarantine measures. Did you report the situation to those higher up?

A This disease really did spread very fast. By Jan 10, the 16 beds in our ICU were full. We saw how dire the situation was and told the hospital's leadership that they had to report even higher. Our head felt it was urgent too and reported this to the Wuhan city health committee.

On Jan 12, the department sent a team of three specialists to South Central to investigate. The specialists said that the clinical symptoms resembled Sars, but they were still talking about diagnosis criteria, that kind of stuff.

We replied that those standards were too stringent. Very few people would get diagnosed based on those criteria. The head of our hospital told them this multiple times during this period. I know other hospitals were doing the same.

Before this, the specialists already went to Jinyintan Hospital to investigate and made a set of diagnosis criteria. You had to have had exposure to the South China Seafood Market, you needed to have had a fever, and test positive for the virus. You had to meet all three criteria in order to be diagnosed. The third one was especially stringent. In reality, very few people were able to be tested for the virus.

On Jan 18, the high-level specialists from the National Health Commission came to Wuhan, to South Central Hospital to inspect it. I told them again that the criteria were too high. This way, it would be easy to miss infections. I told them this was infectious; if you make the criteria too high and let patients go, you're putting society in danger.

After the second national team of specialists came, the criteria were changed. The number of diagnosed patients rose quickly.





Caixin: What made you believe that the new coronavirus could be transmitted between people?

A Based on my clinical experience and knowledge, I believed that the disease would be an acutely infectious one and that we had to do high-level protection. The virus isn't going to change based on man's will. I felt we needed to respect it and act according to science.

Under my instruction, South Central Hospital's ICU took strict quarantine measures and, as a result, our department had only two infections. It pains us to see the coronavirus develop to such a desperate state. But the priority now is to treat people; do everything we can to save people.





THREE WEEKS THAT DETERMINE LIFE AND DEATH

Caixin: Based on your clinical experience, what's the disease progression of the new coronavirus?

A Lately, I've been spending the daytime seeing patients in the ICU, then doing some research in the evenings. I just wrote a thesis. I drew on data from 138 cases that South Central Hospital had from Jan 7 to Jan 28 and attempted to summarise some patterns of the novel coronavirus.

A lot of viruses will die off on their own after a certain amount of time. We call these self-limited diseases.

I've observed that the breakout period of the novel coronavirus tends to be three weeks - from the onset of symptoms to developing difficulties breathing. Basically, going from mild to severe symptoms takes about a week.

There are all sorts of mild symptoms: feebleness, shortness of breath, some people have fevers, some don't. Based on studies of our 138 cases, the most common symptoms in the first stage are fever (98.6 per cent of cases), feebleness (69.6 per cent), cough (59.4 per cent), muscle pain (34.8 per cent), difficulty breathing (31.2 per cent), while less common symptoms include headaches, dizziness, stomach pain, diarrhoea, nausea and vomiting.

But some patients who enter the second week will suddenly get worse. At this stage, people should go to the hospital.

Elderly people with underlying conditions may develop complications; some may need machine-assisted respiration. When the body's other organs start to fail, that's when it becomes severe, while those with strong immune systems see their symptoms decrease in severity at this stage and gradually recover. So the second week is what determines whether the illness becomes critical.

The third week determines whether critical illness leads to death. Some in critical condition who receive treatment can raise their level of lymphocytes, a type of white blood cells, and see an improvement in their immune systems, and have been brought back, so to speak.

But those whose lymphocyte numbers continue to decline, those whose immune systems are destroyed in the end, experience multiple organ failure and die.

For most, the illness is over in two weeks, whereas for those for whom the illness becomes severe, if they can survive three weeks, they're good. Those who can't will die in three weeks.





Caixin: Could you give more details on the clinical research? What percentage of cases would develop from mild to severe conditions? What percentage of serious cases would develop into life-threatening cases? What is the mortality rate?

A Based on my clinical observations, this disease is highly contagious, but the mortality rate is low. Those that progressed to the life-threatening stage were often elderly, with chronic diseases.

As of Jan 28, of 138 cases, 36 were in the ICU, 28 recovered, five died - that is to say, the mortality rate of patients with severe conditions was 3.6 per cent.

On Feb 3, another patient died, bringing the mortality rate to 4.3 per cent. Those hospitalised tend to have severe or life-threatening conditions. Patients with slight symptoms are placed in quarantine at home.

We have not gathered data on the percentage of cases that progress from slight symptoms to serious symptoms. If a patient goes from serious condition to life-threatening condition, the patient will be sent to the ICU.

Among 138 patients, 36 were transferred to the ICU, representing 26 per cent of all patients.

The percentage of deaths among life-threatening cases is about 15 per cent. The mean period to go from slight condition to life-threatening condition is about 10 days. Twenty-eight patients recovered and were discharged. Right now, the recovery rate is 20.3 per cent, while other patients remain hospitalised.

It is notable that 12 cases were linked to South China Seafood Market; 57 were infected while being hospitalised, including 17 patients already hospitalised in other departments; and 40 were medical staff, among the 138 cases (as of Jan 28). That demonstrates that a hospital is a high-risk zone and appropriate protection must be taken.





HOW THE VIRUS ATTACKS

Caixin: What is the greatest risk a patient in serious condition faces?

A The biggest assault the virus launches is on a patient's immune system. It causes a fall in the count of lymphocytes, damage to the lungs and shortness of breath. Many patients in serious condition died of choking. Others died of the failure of multiple organs following complications resulting from the collapse of the immune system.


Caixin: A 39-year-old patient in Hong Kong suffered cardiac arrest and died quickly. A few patients did not have severe symptoms in the early stages but died suddenly. Some experts argue that the virus triggers a cytokine storm, which ravages the stronger immune system of young adults. Eventually, excessive inflammation results in a higher mortality rate. Have you seen such a phenomenon in the coronavirus outbreak?

A Based on my observations, a third of patients exhibited inflammation in their whole body. It was not necessarily limited to young adults.

The mechanism of a cytokine storm is about whole-body inflammation, which leads to a failure of multiple organs and quickly evolves into the terminal stage. In some fast-progressing cases, it took two to three days to progress from whole-body inflammation to the life-threatening stage.





Caixin: How do you treat serious and life-threatening cases?

A For serious and life-threatening cases, our main approach is to provide oxygen, high-volume oxygen. At first, non-invasive machine-pumped oxygen is given, followed by intubated oxygen if conditions worsen.

For life-threatening cases, we use Ecmo (extracorporeal membrane oxygenation, or pumping the patient's blood through an artificial lung machine). In four cases, we applied Ecmo to rescue patients from the verge of death.

Currently, there are no special drugs for the coronavirus. The primary purpose of the ICU is to help patients sustain the functions of their bodies. Different patients have different symptoms. In the case of shortness of breath, we provide oxygen; in the case of kidney failure, we give dialysis; in the case of coma, we deploy Ecmo.

We provide support wherever a patient needs it to sustain his life. Once the count of lymphocytes goes up and the immune system improves, the virus will be cleared.

However, if the count of lymphocytes continues to fall, it is dangerous because the virus continues to replicate. Once a patient's immune system is demolished, it is hard to save a patient.





Caixin: There is news of some drugs that work. People are hopeful about the effect of the US-made remdesivir, which cured the first case in the United States. What do you think of these drugs?

A There are no 2019 novel coronavirus-targeted drugs so far. Some patients may recover after taking some drugs, along with supportive treatment. But such individual cases do not indicate the universal effect of the drugs.

The effect is also related to how serious each case is and their individual health conditions. People want a cure urgently, and that is understandable. But we need to be cautious.


Caixin: Do you have any advice for coronavirus-infected patients?

A The most effective approach to the virus epidemic is to control the source of the virus, stem the spread of the virus and prevent human-to-human transmission. My advice for a patient is to go to a special ward for infectious diseases, early detection, early diagnosis, early quarantine and early treatment.

Once it has developed into a severe case, hospitalisation is a must. It is better to contain the disease at an early stage. Once it reaches the life-threatening stage, it is way more difficult to treat and requires more medical resources. With regard to life-threatening cases, try to save them with ICU measures to reduce the mortality rate.





Caixin: How many patients with life-threatening conditions have you treated? How many have recovered?

A As of Feb 4, six patients in the ICU of South Central Hospital have died. Eighty per cent of them have been improving, a quarter are approaching their discharge and the remainder are still recovering in segregated wards.

The patient who impressed me most came from Huanggang. He was the first to be saved with the assistance of Ecmo. He had contact with the South China Seafood Market and was in a very serious condition. He was transferred to the ICU and we saved him with Ecmo. He was discharged on Jan 28.





LIFE ON THE FRONT LINES

Caixin: What's your workload and the pace of your days like?

A The ICU is overloaded. There are three patient wards with 66 beds in South Central Hospital, housing 150 patients. Since Jan 7 when we received the first patient, no one has taken any leave. We took turns to work in the ICU. Even pregnant medical staff did not take leave. After the epidemic got worse, none of the medical staff went home. We rest in a hotel near the hospital or in the hospital.

In the segregated ward, we wear level-3 protective gear. One shift is 12 hours for a doctor and eight hours for a nurse. As there is a shortage of protective gear, there is only one set for each medical staff member a day. We refrain from eating or drinking during our shift because the gear is no longer protective once we go to the washroom.

The gear is thick, airtight and tough on our body. It felt uncomfortable at the beginning, but we are used to it now.





Caixin: Did you experience a very dangerous moment? For example, in the case of intubation, what do you do to prevent yourself from being infected?

A It is a new coronavirus. We are not sure of its nature and its path of spread. It is not true if we say we are not afraid. Medical staff members do fear to some extent. But patients need us. When a patient is out of breath and non-invasive oxygen provision fails, we must apply intubation.

The procedure is dangerous as the patient may vomit or spit. Medical staff are likely to be exposed to the danger of infection. We strictly require doctors and nurses to apply the highest-level protection. The biggest problem we face now is the shortage of protective gear. The protective stock for ICU staff is running low, although the hospital prioritises the supply to us.





SAD STORY OF PREGNANT PATIENT

Caixin: Is there anything that moved you in particular? Did you cry?

A I often cried because so many patients could not be admitted to the hospital. They wailed in front of the hospital. Some patients even knelt down to beg me to accept them, but there was nothing I could do as all the beds were occupied.

I shed tears while I turned them down. I have run out of tears now. I have no other thoughts but to try my best to save more lives.

The most regretful thing to me was a pregnant woman from Huanggang. She was in a very serious condition. Nearly 200,000 yuan (S$39,800) was spent after more than a week in the ICU. She was from the countryside, and the money for her hospitalisation had been borrowed from relatives and friends. Her condition was improving after the use of Ecmo, and she was likely to survive. But her husband decided to give up. He cried as he made his decision.

I wept too because I felt there was hope for her to be saved. The woman died after we gave up. And exactly the next day, the government announced a new policy that offers free treatment for all coronavirus-infected patients. I feel so sorry for that pregnant woman.

The deputy director of our department told me one thing, and he cried too. Wuhan Seventh hospital is in a partnership with our hospital, South Central Hospital. The deputy director went there to help in their ICU. He found that two-thirds of the medical staff in the ICU were already infected.

Doctors there were running "naked" as they knew they were set to be infected, given the shortage of protective gear. They still worked there nonetheless. That was why ICU medical staff were almost all sickened. It is too tough for our doctors and nurses.

Translated by Sun Huixia and Dave Yin. This story was originally published by Caixin Global.









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