Saving Ex-Premier Tang Fei
I received an international call coming from Dongbei, China from Mrs. Tang on August 5th, 2010. She said that ex-Premier Tang was attended at a hospital in Dalian due to fever and malaise. At first he thought it was just a common cold, but the fever persisted, so they transferred him the next day, August 6th, to the Affiliated Zhongshan Hospital of Dalian University for a Chest X-Ray. Right lower lobe pneumonia was suspected, so he was immediately admitted to begin treatment with antibiotics. I was still worried about ex-Premier Tang’s fever, so I suggested that they return to Taiwan for treatment as soon as possible. However, they informed me that the Chinese hospital was courteous and assigned a medical team dedicated to his treatment regimen. Even though I still felt somewhat unassured, I wasn’t in any position to say anything at this point. Out of ethics and professionalism, I informed them sternly that if pneumonia was not under control it might progress into septicemia and ARDS. Then things would be very critical and returning to Taiwan for treatment would be difficult. I also asked them to call me immediately if there was any change and to return to Taiwan immediately. Ex-Premier Tang’s condition was on my mind but I didn’t want to make things awkward for them and affect the decision- making of treatment by the local hospital. I tried not to call them every day to inquire about ex-Premier Tang’s progress. Three days later, while I was on a family vacation trip at Hotel Royal Chiao Hsi, Yilan, I received a phone call from Mrs. Tang’s sister, informing me that ex-Premier Tang’s fever still persisted and asking me for my advice. I told her she must find a way to send me the chest X-Ray film taken in China so I could take a look at it before I could give advice.
August 11th, Mrs. Tang got very concerned. She called me herself to tell me that ex-Premier Tang got agitated and needed oxygen masks in order to breathe; all this gave me a bad vibe. Pneumonia may have progressed into septicemia. Mrs. Tang asked me to discuss with the Chinese attending physician about ex-Premier Tang’s condition, so I asked the physician what was the CRP level, which antibiotics was used, etc. Howerer they didn’t use English denominations; instead, they translated all medical denominations into Chinese, so we had difficulty communicating. In the end, I had to ask them to send me all the imaging exams performed, but they just sent me one chest X-Ray and it showed that both lung fields were already white with signs of infiltration. That was a very bad sign. Septicemia may lead to ARDS causing respiratory failure with possible death at any time being the worst complication! Mrs. Tang’s sister asked me not to make the condition sound too serious, as she was worried that Mrs. Tang wouldn’t be able to take the news, but out of professional concerns, I informed Mrs. Tang of my diagnosis on the condition with all honesty and urged her to return with her husband as soon as possible for treatment in Taiwan. Mrs. Tang said to me that there were no more flights to Taiwan that day and the Chinese had already arranged a transfer to Beijing 301 Hospital (now the No. 1 Hospital affiliated to General Hospital of the Chinese People's Liberation Army), which especially services Chinese Government Officials, with a medical team on standby. But I informed them that the condition was critical at this point! Plus the couple of days spent receiving treatment in the Chinese hospital didn’t show any improvement but instead turned for the worse; if they took a flight back immediately I wouldl do my best to treat, but if they kept stalling then I was not very sure about the outcome! Later I heard that they had also asked the Taiwanese Strait Exchange Association for help because Mr. Chiang Ping-Kung was his old friend; on the other hand his goddaughter asked Want Want Holdings Ltd. for a private jet assistance. Even though they agreed immediately, the private jet was too small to fit in all the necessary and emergent medical equipment, so they had to contact TransAsia airline to rent an aircraft for this trip and simultaneously contact International SOS for assistance. At around 5:30 that afternoon, Mrs. Tang asked me to travel in the aircraft along with the medical team to give her reassurance. I immediately reported this to the Superintendent Dr. Lin and obtained an oral permission for leave of absence, and instantly departed to China that very day and also asked the Pharmaceutical Department of Taipei Veterans General Hospital to prepare some special antibiotics, bronchodilators, corticosteroids, and other important medicines. However, I was about to attend an Annual World Pulmonology Conference held in Barcelona in the beginning of September organized by the European Respiratory Association, for I am a specialist in Pulmonology and Critical Care Medicine and was the Board Director of Association of Critical Care Medicine. At the time a travel agency had my passport,and I was still at the hospital and had even taken off my lab coat. But with no time to lose, I took a cab and went to the travel agency to retrieve my passport and headed towards SOS office to meet up with others to then take their private shuttle to the Taoyuan International Airport at 7:30 for a 10 o’clock flight with a capacity for 300 passengers with the TransAsia airline for a private direct flight to Dalian. We were in such a rush that we didn’t even have time for dinner. I was able to have many things set up and ready in just 2 hours. Perhaps it was because I had received military training as I was a military physician that I was quick physically and mentally about how to prepare for possible medical emergencies and what meds were needed, or whether intubation was required and ventilation was required, or in case of arrhythmia, what was the most effective treatment. So basically every segment from drugs to medical treatment was all in my control, but what if any misfortune happened to the patient on the plane? I wouldn’t know how to face my country, so my pressure was unbearable. Even if I was worried, I must still carry on with the attitude of fulfilling my mission. We were on a direct flight from Taiwan, departing at 10 o’clock arriving in Dalian at about 1:00 A.M. Thanks to prior contact with the Strait Exchange Association, they had arranged to permit our flight to fly directly from Taiwan to Dalian and land. The airport was well lit at midnight just for the few of us who were passing through. This demonstrated that the Strait Exchange Association did their best in extending us a helping hand out of humanity and that ex-Premier Tang was an important political figure.
I was the most experienced and also expertized in critical medicine, so I was in charge of all related procedures and actions. The international medical team was formed by a specialist in emergency medicine and a nurse for medical management and an administrator in charge of communication and records. They formed part of the certified staff, so they did not need to present visa and they got paid when dispatched. I was appointed and went voluntarily, so I was the only one that must have my Mainland Travel Permit at hand to acquire visa on arrival.
Caption:Me (right) and the SOS team at the waiting room in Taoyuan Airport waiting to board our flight to China
(2010/08/12)
Ex-Premier Tang Fei suddenly felt respiratory discomfort yesterday while traveling in Dalian. A trip to the ER for diagnosis revealed pulmonary infiltration. He was extremely weak but conscious. With the help of Taiwanese Strait Exchange Association President Mr. Chiang Ping-Kung and Chinese Straight Exchange, a TransAsia private plane was dispatched last night at 10 o’clock from Taiwan to Dalian. It was estimated they would arrive today at 6 A.M. at Taoyuan International Airport and immediately transfer Tang Fei to Taipei Veterans General Hospital for treatment. Tang Fei’s arranged private flight took off on the 11th at night to Dalian with Taipei Veterans General Hospital medical crew and equipment on board.
(Picture by Gao Yu Shin)
The staff of the Dalian airport and the Strait Exchange Association led us through customs quickly and in a very courteous manner. It seemed like the entire airport had loosened up procedures to facilitate this medical urgency. I believe the Chinese had mobilized a lot of their personnel to come help out. Even though I really appreciated it, it also gave me a lot of pressure. I told my medical team that we must be grateful for their help as they were facilitating our mission. We rode the ambulance and reached the Zhongshan Hospital of Dalian quickly and right in front of the ward entrance. This also surprised me. It didn’t seem like there was a special ward as such that gave the ambulance direct access in Taiwan. We saw a classic Japanese style architecture after we got off the ambulance. It was supposed to be only for the privileged political figures. They even had a red carpet laid down on the passage toward the ward. On our way in, I kept on reminding the other team members to be humble and gracious and not to attempt to change any medical orders or facilities of the host hospital. All that needed to be done was keep the intravenous infusions and oxygen flowing. After all we were visitors, we should not make things uncomfortable for them. The fastest way to accomplish our goal was to lay low and keep things peaceful. The group of us passed by the living room and then into a private ICU. Inside was a special medical team composed of a couple of nurses and physicians, and this medical team was led by Dr. Liu Ting who was the Deputy Superintendent of Zhongshan Hospital of Dalian and who also happened to be a Pulmonologist. This hospital was said to have been constructed during the time when the Japanese invaded Dongbei. The hardware facilities and environment of the hospital were pretty good, well designed. It was near 2 A.M. by the time we entered the ward. Their medical team gave us ex-Premier Tang’s medical and imaging files. The medical team members bid their farewell reluctantly and asked to take a photo with ex-Premier Tang and his wife.
Caption: Mrs. Tang (middle from the right) and I (2nd from the right) in a shot invited by the Deputy Superintendent of Zhongshan Hospital of Dalian Dr. Liu Ting (3rd from the left) and medical staff.
Caption: Ex-Premier Tang Fei (man wearing the oxygen mask) with the medical staff.
Caption(left): Mrs. Tang with the Deputy Superintendent of Zhongshan Hospital of Dalian Dr. Liu Ting
Caption(right): Me with the Deputy Superintendent of Zhongshan Hospital of Dalian Dr. Liu Ting
But I was very nervous and really wanted to take ex-Premier immediately because even though ex-Premier Tang was already on 100% oxygen therapy, he seemed to still have difficulty breathing and have tachycardia. Finally after taking the photo, we settled ex-Premier Tang and his wife onto the ambulance and rushed to the airport. On the way, I immediately proceeded to allot work: the nurse monitored the heart rate, blood pressure, and blood oxygen content; the specialist monitored consciousness and any minimal changes that occurred; finally I quickly and correctly carried out the management.
On the plane we settled ex-Premier Tang in the front seat by the aisle on the right; next to him was an ER physician and a nurse, both from Shuang Ho Hospital. I was seated on the left of the aisle where I could see any changes in ex-Premier Tang’s facial expression, complexion, and respiration. First I asked the nurse to prepare the drug I was going to use; erythromycin and imipenem which were antibiotics for typical and atypical pneumonia, then corticosteroids for inflammation and pulmonary edema, followed by administration of bronchodilators, all the while monitoring pulmonary vascular vital signs (body temperature, blood pressure, heart rate, respiratory rate, blood oxygen partial pressure PO2) every 10 minutes. I asked the nurse to finish administering all the drugs before takeoff. At that time the ER physician asked me if there was a need to prepare for intubation for use with ventilators. I looked at the PO2 which was around 91 mmHg, hard to decide whether or not to intubate. I decided to observe on and asked the pilot to fly at the lowest permitted altitude to prevent severe oxygen deprivation or else intubation could not be avoided. I knew ex-Premier Tang’s condition was critical but in order to steady everybody’s tension and working mood, I must keep calm and be attentive to any changes occurring with his condition. After half an hour of observing progressive stabilization of pulmonary vascular functions, I felt some relief but still I wasn’t able to catch any sleep. I’d never pulled an all-nighter in my life, but to complete this life-saving mission, I couldn’t slack off even for one second as I was afraid of any changes that might occur at any moment. This was a 2–hour-long flight, but it felt longer. Finally at around 5 A.M. we landed safely at Taoyuan International Airport with an ambulance waiting by the runway. We took the ambulance immediately to the Shih-Yuan Building of the Taipei Veterans General Hospital with the media outside fighting to get a glimpse of the delivery. I was tired as I had’t slept for an entire night but I was glad that I completed the mission of having brought back ex-Premier Tang safely to Taiwan. Still at the same time I knew the challenging part of the mission was just about to begin!
The goal was to find the real causing agent and determine a supportive therapy that caused the least damage. Even though I was the attending physician, there was also a medical team formed by the hospital, led by the Deputy Superintendent Dr. Lee Shou-Dong, and consisting of specialists of Infectiology, Respiratory Therapy, Cardiology, and Nutrition. I had to prepare a presentation immediately after my return to report ex-Premier Tang’s current condition and collect the data of imaging and clinical studies performed by the Chinese hospital to demonstrate that there was septicemia that led to ARDS and cardiac failure. On the imaging was shown that both lung fields were edematous and white, with signs of infiltration and severe hypoxia. The most important thing to do at the moment was to choose the appropriate antibiotic to use. The Chinese hospital had already used an array of antibiotics, so, after assessment, I believed ex-Premier Tang had a community-acquired pneumonia, the dreaded Legionellosis, which was why I had already used erythromycin on the plane. That very day urine analysis and culture were done to check for this organism, and luckily it was as I had suspected. But due to the delayed use of the appropriate antibiotic, there already occurred multiple organ failure (including: the heart, lungs, liver, and so forth). Even though we had begun using the appropriate antibiotic, the important issue now was how to improve the hypoxia and decrease the occurrence of arrhythmia if we did not want death to ensue at any moment!
Improvement of hypoxia may be done in 2 ways, the easiest and most commonly used in the case of ARDS is to intubate and connect to a ventilator. It is the easiest and least complicated method which was also what the other specialists suggested in Tang’s case. But my assessment pointed to the fact that ex-Premier Tang didn’t have much sputum and didn’t require a higher positive expiratory pressure for breathing, so I suggested a non-invasive respirator to aid in respiration and at the same time we could avoid infections that arose easily from the uses of ventilators. I was against everyone else’s opinion and even said I would be held 100% responsible if we went my way. The Deputy Superintendent couldn’t understand. He thought this was a team so the decision should be made based on the majority. He seemed to favor more the Director of Pulmonary ICU and the Director of Pulmonary Therapy, both of whom were trained solely at Taipei Veterans General Hospital. However, I told the family about the situation and explained my thoughts and theory. The family members knew that I took care of him with all my best effort for almost 24 hours in his most critical state so I might have this completely thought through to reach the best medical arrangement. They agreed right then to my opinion and management. After about a week or so of therapy, the condition of hypoxemia had improved and the respirator use might be ceased after evaluation. But then I realized that the bed he was using had previously held a patient from National Taiwan University Hospital who was infected with a resistant strain of Acinetobacter baumannii. Indeed we cultured this organism from ex-Premier Tang’s sputum. This meant there was resistance to colistin, so only the combination of Tigecycline and Amikacin could be used. However, having thought over the possibility of hepatotoxicity caused by the use of Amikacin, we switched to inhalation which was a new form of therapy. At the same time I proposed to transfer ex-Premier Tang out of ICU to a normal ward for continued treatment. After yet another week, we were able to control the vicious resistant strain of Acinetobacter baumannii. Later, though we removed the respirator and the nasogastric tube, swallowing was still a bit difficult. This might be caused by the exacerbation of Myasthenia Gravis, so I administered corticosteroids and a drug to treat Myasthenia Gravis (Mestinon). We then discovered he was manifesting side effects to the drug Mestinon, so we stopped this drug. Another week or so went by when we finally improved the swallowing dysfunction. Finally, the DLCO value was around 50% of the normal value by the time ex-Premier was discharged from the hospital. After 3 months of exercise and recuperation at home, he regained lung function in totality.
Thinking back now, when ex-Premier Tang entered the ICU, Mrs. Tang who was waiting outside was tired yet nervous, and began to cry when my wife went to console her. My wife stroked Mrs. Tang’s shoulder softly and said to her, “Believe in Dr. Chiang as he will do his best to treat. Ex-Premier Tang will get through this and get better.” At this time, Mrs. Tang acted like she suddenly remembered something and grabbed my hand and said “Dr. Chiang, thank goodness for you! My grandfather and my life were both saved by you! So please save Tang Fei’s life as well!” Thanks to my professional and correct diagnosis, I was able to save ex-Premier Tang’s life!
Speaking of how I met ex-Premier Tang, the first encounter was at Tri-Service General Hospital when his father was hit by a scooter and had signs of pneumonia and respiratory difficulty plus the fact that he was at an advanced age of 90. His condition was pretty critical. I was the attending physician and I did my best to save him and eventually stabilized his condition. Tang Fei, who came to visit at the time, was the Air force Chief of Staff. This was when I met him, and his father was discharged from the hospital shortly after. Later when ex-Premier Tang was the Air Force Commander in Chief, Mrs. Tang was in the USA during the flu season, and unfortunately she returned with a flu that progressed into pneumonia, hemoptysis, and difficulty breathing. She returned immediately to Taiwan and also had to be admitted into ICU due to the severity of her condition. I was yet again the attending physician and administered oxygen in the ICU and stopped her bleeding emergently along with the use of antibiotics to save her life. She was discharged about a week later.
Maybe saving ex-Premier Tang this time was due to fate, but I personally believe that saving someone’s life shouldn’t be based on connections or social status. One must do one’s best professionally to save a patient. If I must mention a difference, maybe it is the fact that I saved 3 members of the same family, so the pressure of needing to succeed is higher. Other than that, this mission of having been able to bring back the ex-Premier from China to Taiwan for medical attention, apart from leaving a historical image in front of the camera, also constructed a good mode of cooperation between the medical teams on both sides of the straits. In this case, the work that I put into and the discrimination that came from colleagues, were exhausting at a point. Howere, being able to save someone is still a very happy and satisfying thing!
(The following is a clip from an associated piece of news) ** translated
Critical 11 hours to save Tang Fei [If we don’t pick up our pace then it may be too late]
udn.com／date of update:2010/10/01 09:46 reporter Chang Chia-Fang／Taipei
Ex-Premier Tang Fei was discharged yesterday. The doctor expressed that, at the arrival in Taiwan, Tang Fei’s condition was very bad. Legionellosis had already caused septicemia and failure of multiple organs. If not treated within 8 hours, chances of death were almost 100%.
Attending physician and Director of the Department of Pulmonology at the Taipei Veterans General Hospital, Dr. Chiang Chi-Huei, said that recalling the scene of being on the International SOS private plane on their way back still makes him nervous. He said that Tang Fei had Legionellosis that caused pneumonia and septicemia, and the accumulation of toxins had already caused arrhythmias and multiple organ failure. His condition was critical. “A single organ failure has a 50% chance of death, let alone having 3 at the same time. If it had not been for the private plane, the immediate use of erythromycin, large doses of corticosteroids, and antibiotics on the plane, ex-Premier probably wouldn’t be here with us”.
During the 11 hour long flight, Dr. Chiang Chi-Huei didn’t dare to close his eyes. Tang Fei’s heart rate was about 110 beats per minute at the time. Even after the use of 100% oxygen, they still weren’t able to raise the blood oxygen concentration. Dr. Chiang Chi-Huei was ready to intubate at any moment. After the arrival of the private plane, the hospital immediately administered non-invasive respiratory mask with positive pressure breathing and highly concentrated pure oxygen. The medical personnel monitored the concentration of oxygen in his blood, inflammatory score, breathing, and so forth around the clock along with drug use adjustment. They finally took him out of critical state after a week.
Chiang Chi-Huei emphasized that Tang Fei’s respiratory functions had only recovered by 50%. “Air flow conduction is not a problem, but gas exchange is not as good”. He still needs physiotherapy and uses small doses of corticosteroids. He said that Tang Fei was able to survive mainly because of the time given with the use of a private plane and the diagnosis with appropriate treatment that came in time. If not, septicemia not treated within 8 hours might have led to death. The air craft Tang Fei boarded for his return had a capacity for about 200 passengers, bigger than the normal private SOS planes. There were a doctor and 2 nurses on board. The cost of this plane was about 3 million NTD.
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