ICU doctors battle coronavirus patients' rapid deterioration

Three weeks for symptoms to worsen. Rising demand for ICU beds. Three possibly preventable deaths if the right equipment had been present. Doctors tell stories from ICUs in Wuhan hospitals.

WUHAN • It took only a few minutes for Dr Peng Zhiyong to make a decision that he knew could be highly risky - admitting a patient diagnosed with "unknown viral pneumonia".

That was on Jan 6. Dr Peng, director of the intensive care unit (ICU) at the South Central Hospital of Wuhan University, signed off on accepting the patient into his department. Before that, the person from Huanggang, a city 76km from Wuhan in Hubei province, had been turned away by several hospitals.

The patient's mysterious, infectious pneumonia later proved to be caused by a new strain of coronavirus, 2019-nCoV.

Since last December, the disease has quickly spread from Wuhan to the rest of China and beyond.

As of last Saturday, confirmed infections had surpassed 35,000 in 25 countries. It is evolving into one of the most dangerous epidemics in the past 20 years.

But early last month, public awareness of the looming epidemic was still limited. Word started circulating among physicians in Wuhan of a rising number of pneumonia patients infected by a virus similar to the severe acute respiratory syndrome (Sars) - a deadly coronavirus that claimed nearly 800 lives in a 2003 outbreak.

A veteran physician with PhDs in anaesthesiology and intensive care medicine, Dr Peng was on the front line in Hong Kong 17 years ago during the Sars outbreak. His rich clinical experience gave him an acute sense of the new disease's virulent potential.

On Jan 3, Dr Peng learnt that gene sequencing results from the BGI Group had found that the new virus shared 80 per cent of the genetic code of the Sars virus.

"I knew at that time the new virus was likely to be passed through humans," said Dr Peng in a recent interview with media group Caixin.

After accepting the Huanggang patient on Jan 6, Dr Peng called the hospital president to ask that the hospital apply stringent quarantine measures in the ICU department. The ward was renovated in accordance with the highest quarantine standards for Sars control, with independent air supply, according to Dr Peng.

While some colleagues questioned whether the measures were excessive, Dr Peng insisted they were necessary. And he was proven right. The quarantine zone originally had 16 beds. All were filled three days after the first patient moved in.

The rapid course of the disease means that intensive care professionals are the main force battling the virus. As the epidemic continues unfolding, the number of critical patients is rising rapidly.

Now, the 150-member team of South Central Hospital's ICU department, led by Dr Peng, has been fighting against the virus for more than a month.

All medical workers have given up holidays. They work in shifts to keep the ICU running at full capacity. In the face of shortages of protective gear, doctors and nurses reduce food and water consumption while working, so that they can avoid leaving the quarantine zone and having to change their protective gear.

UNDERSTANDING THE VIRUS

As the battle on the front lines grinds on, the experts' understanding of the new coronavirus is becoming clearer.

In the latest edition of its treatment plan, China's National Health Commission confirmed that the virus is mainly transmitted through respiratory droplets and contact.

Infected patients show different degrees of symptoms ranging from minor, flu-like ones to fever, lung infection, respiratory failure and even multiple organ failure.

Compared with Sars, the new virus often causes minor symptoms at the beginning, but is more contagious and can cause infected people to deteriorate faster. The disease usually takes three weeks to escalate to critical condition, medical experts told Caixin.

Many patients with a severe infection suffered heart, renal function or circulatory system failure, said Dr Du Bin, director of the ICU at the Peking Union Medical College Hospital.

"We still understand very little about the pathogenesis of the virus and are not clear about the actual cause of the multiple organ failures," said Dr Jiang Li, ICU director at Beijing Xuanwu Hospital who is currently in Wuhan.

It makes the treatment of severe cases a challenge, Dr Jiang said.

Medical professionals at hospitals in Wuhan have been fighting the coronavirus outbreak for more than a month. In some hospitals, all medical workers have given up their holidays, working in shifts to keep the intensive care unit (ICU) running at ful
Medical professionals at hospitals in Wuhan have been fighting the coronavirus outbreak for more than a month. In some hospitals, all medical workers have given up their holidays, working in shifts to keep the intensive care unit (ICU) running at full capacity. However, the number of patients with severe infections keeps rising, and there is no relief in sight for ICU teams. PHOTO: NYTIMES

The rapid course of the disease means that intensive care professionals are the main force battling the virus. As the epidemic continues unfolding, the number of critical patients is rising rapidly.

According to official data as of last Thursday, there were 4,821 patients in critical condition, up from 962 the previous day.

"We are racing with death to snatch (the lives) of patients," Dr Peng said.

THE BATTLEFIELD

Dr Huang Xiaobo, ICU director at the Sichuan People's Hospital, arrived in Wuhan on the night of Jan 25 as part of the first wave of physicians to aid Wuhan's disease control. He was assigned the next day to the Wuhan Red Cross Hospital, where he encountered a devastating scene.

The Red Cross Hospital is a small district institution with 400 medical workers and 300 beds. On Jan 22, the hospital was designated by the Wuhan government as one of the institutions for treating patients with fever.

After that, it was overwhelmed, as more than 700 patients flooded in every day. Ordinary fever patients were mixed with those infected by the coronavirus, and the whole hospital was contaminated, Dr Huang said.

"All the beds were occupied, and even the hallway was packed by patients for observation. People only wearing one-time masks came in and out freely," Dr Huang said.

A large number of medical workers at the hospital were also infected, he added.

As of Jan 26, about 60 of the Red Cross Hospital's medical workers had either been diagnosed with the coronavirus or were under observation. The rest of the staff, from various departments, were transferred to the respiratory department after a short period of training. They were like "cannon fodder" rushing to a battlefield, Dr Huang said.

Following the urging of Dr Huang and his team, the Red Cross Hospital closed for three days to set up clear boundaries between the quarantine zone, clean area and buffer zones. Doctors also used the three days to examine all hospitalised patients and separate those infected with the coronavirus from those who were not.

On Jan 28, a second team of medical reinforcements arrived at the Red Cross Hospital. Two days later, the hospital reopened to receive new patients.

RACING WITH DEATH

The case of Dr Li Wenliang, a 34-year-old ophthalmologist in Wuhan, illustrates the rapid deterioration the disease can cause.

Dr Li was one of the whistle-blowers who first raised the alarm about the new virus. He was also infected while treating patients. He told Caixin in a telephone interview on Jan 30 that he expected to recover, and was determined to return to the fight.

But last Wednesday, Dr Li told Caixin in a message that his condition had worsened. In the early morning of last Friday, Dr Li died after an hours-long rescue attempt in the ICU.

"It evolves rapidly from good to bad," said Dr Jiang. "Sometimes, changes come in hours."

Dr Huang also remarked upon the rapid development of the new virus in patients. Unlike flu viruses such as H7N9 and H9N1, which often cause severe symptoms at the beginning, most patients infected with the coronavirus first show mild symptoms, but quickly deteriorate after a certain point, Dr Huang said.

Minor symptoms such as low fever and fatigue in the early stages also make the new virus more difficult to detect and control.

Dr Peng said it often takes three weeks for patients' symptoms to develop from minor flu-like ones to a critical or even fatal condition.

"People with strong immune systems may recover after two weeks, but the elderly and those with basic health issues could worsen to respiratory failure and other organ failures," Dr Peng said. "The second week is the watershed."

Among patients with mild symptoms, 15 per cent to 20 per cent seem to worsen in the second week, said Dr Du.

For those whose conditions turn critical, the third week is the test, doctors have observed. "Some get through the third week, but others won't make it," Dr Peng said.

Clinical records show that the average age of infected patients is 56, while those entering the ICU average 66, indicating that older people are more vulnerable to the virus.

The virus attacks the immune system, resulting in a drop in lymphocytes - disease-fighting white blood cells - as well as lung damage and respiratory failure. Some patients suffer multiple organ dysfunction, Dr Peng said.

"About one-third of patients I observed showed systemic inflammatory response syndrome that led to multiple organ failure and critical conditions," Dr Peng said. "It happened in only two or three days for some patients."

According to medical experts and front-line doctors, 15 per cent to 20 per cent of patients could develop severe conditions, and among these, 25 per cent to 30 per cent worsen to critical condition.

The mortality rate for the disease has yet to be widely agreed upon. Several ICU doctors estimate that the death rate among patients in critical condition ranges from 10 per cent to 40 per cent, meaning that the overall mortality rate may be 0.6 per cent to 1 per cent.

What is more worrisome is the damage the virus does to the lower respiratory system, causing serious consequences even after a patient recovers. Dr Du said it could take at least six months for patients to recover heart and lung function.

CUTTING TRANSMISSION REMAINS KEY

The mission of ICU doctors is to help patients maintain their body functions as long as possible, until the virus is exhausted, so that the patients' immune system can gradually recover, Dr Huang said.

But rescue efforts are sometimes restricted by a lack of equipment, Dr Huang added. He said that he has witnessed five deaths in the ICU at the Red Cross Hospital since he arrived.

Three patients would have had the chance to survive if a procedure called extracorporeal membrane oxygenation had been available. It circulates blood through an artificial lung back into the bloodstream, Dr Huang said. But as a small institution, the Red Cross Hospital doesn't have such equipment.

While more ICU professionals like Dr Huang and Dr Peng have gone to Wuhan to rescue patients from the brink of death, Dr Jiang said more efforts should also be made at the early stages to prevent mildly ill patients from deteriorating.

"What I want to do most at this moment is to solve the problem upstream, to find out patients who are in the process of deterioration and apply treatments for them as early as possible," Dr Jiang said.

Delayed treatment allows many patients with mild infections to deteriorate and miss the best opportunity to recover, Dr Jiang said. It is believed to be the major reason Wuhan has recorded a much higher-than-average mortality rate than the rest of the country.

ICU doctors fight hard to rescue critically ill patients from death, but that is a late remedy, Dr Jiang said.

The most effective way to tame the epidemic is to control the sources of disease, cut off transmission paths and protect vulnerable groups, she said.

"I guess none of the three things has been done well," she said. "What we are seeing is too late."

"It is easier to control the disease before patients' condition develops into severe conditions," Dr Peng said. "After that, it is much more difficult to cure, and would demand more of already-scarce medical resources."

For now, there's no relief in sight for the ICU doctors.

"The number of severe patients continues rising, and ICU doctors have to be prepared for a lasting war," said Dr Xi Xiuming, an intensive care medicine professor at Beijing Fuxing Hospital.


 • Di Ning, Wen Simin, Huang Yuxin, Chen Lijin and Wang Yanyu contributed to this story. This article first appeared in Caixin Global.

A version of this article appeared in the print edition of The Straits Times on February 12, 2020, with the headline 'ICU doctors battle coronavirus patients' rapid deterioration'. Print Edition | Subscribe