That year, the SARS storm arrived
SARS, short for Severe Acute Respiratory Syndrome, is named by the WHO on March 15th of 2003. Before this it was known as an atypical pneumonia. Characteristics of the infection include the presence of interstitial pneumonia and the development of respiratory failure and it is more severe than the atypical pneumonia caused by known viruses and bacteria in the past. hence the name.
SARS’ Origin
SARS appeared earliest in Heyuan city of Guandong province in China, sometime during the beginning of November 2002 (WHO indicates Shunde district of Guangdong province as the site of origin). Chinese scholars believe that the earliest patient, Wang Xing-chu, was infected with the virus through contact with palm civets. The patient showed signs of pneumonia and was classified as a case of atypical pneumonia.
On April 16th of 2003, WHO officially announced the infectious agent of SARS was a newly discovered coronavirus and officially denominated it as “The SARS Virus”. The origin of SARS wasn’t clear but most believed it may have originated from China. There was an outbreak of atypical pneumonia in Guangdong between November 2002 and February 2003. Evidence indicates that the outbreak in Hong Kong was caused by a single case, a professor from Guangdong. He arrived and checked into a hotel in Kowloon and spread the virus to the hotel workers and guests. When the professor was hospitalized, the hospital didn’t detect the case soon enough so he was not quarantined,thus causing intrahospitalary infection. At the same time, infected guests of the hotel spread the virus worldwide. WHO, by the end of March 2003, proved that the atypical pneumonia in Guangdong was SARS. According to statistical data (data period between November 1st of 2002 and July 31st of 2003), there are 8,096 possible cases of SARS worldwide,causing 774 deaths in the major endemic areas includeing China (5,327 cases), Hong Kong (1,755 cases), Taiwan (346 cases), Canada (251 cases), and Singapore (238 cases).
Clinical Characteristics of SARS
Signs and symptoms of SARS are high fever (> 38°C), cough, and shortness of breath or difficulty breathing. Possible associated symptoms may include: headache, muscle stiffness, loss of appetite, fatigue, disorientation, rash, and diarrhea. X-Ray shows abnormal lung changes. SARS in grave stage may present interstitial pneumonia and decreased gas exchange leading to hypoxia, causing the patient to suffer difficulty breathing, oxygen deprivation, and even death.
How SARS Reached Taiwan
Sometime during the middle of March, WHO issued a pneumonia outbreak alert when cases of atypical pneumonia started emerging in Hong Kong and Hanoi, Vietnam. Taiwanese media started reporting related news on March 14th. Members of the Infection Control group of National Taiwan University Hospital were notified on the morning of March 14th about a middle-aged woman who was being treated at the ER due to fever with suspected pneumonia. Her husband had already been admitted into the ICU for treatment with the diagnosis of pneumonia and respiratory failure. After reporting this situation to the Infection Control Manager, Dr. Chang Shan-chwen, who was attending outpatients, immediately arranged to quarantine both patients separately (he hasn’t seen related media reports or received notifications from any health entities). That afternoon the news was being widely reported by the media that was starting to spread. They started to wonder whether these cases were related to the atypical pneumonia case being reported in Vietnam, Hong Kong, and China or evenwhether it is any special infection like the avian flu, so they arranged to gather international related reports that afternoon. On the afternoon of March 14th, National Taiwan University Hospital held an emergency meeting with the Infection Control group ,reaching the resolution to raise the level of protective measures to BSL-3 in quarantine of these 2 patients and activate emergency protocols and associated personnel. All members of the team were on duty over time on Saturday and Sunday to handle this emergent situation. Monday, March 17th, minor improvements were made to the protocol which was renamed Severe Acute Respiratory Syndrome (SARS) Infection Control Management. The week after was engaged in coordination and stipulation of associated infections control procedures and management with ER and outpatient units. This prevented the infection of National Taiwan University Hospital’s medical staff and other paramedics during the treatment and diagnosis of the first few cases, thus, differentiating Taiwan from Hong Kong, Vietnam, Singapore, and Canada where large amounts of medical staff were infected, causing an endemic countrywide. The discovery of the first case of SARS in Taiwan was on March 13th, a Taiwanese merchant received by National Taiwan University Hospital in Taipei City. The outbreak was well controlled during the first month, maintaining 0 death case, 0 community infection, and 0 border crossing record. Unfortunately, around the middle of April, in Taipei City Hospital appeared the first group infection of SARS. The Executive Yuan decided to close down the entire hospital around noon of April 24th. All patients, medical staff, and visiting family members, summing up to 900 plus individuals, all were required to stay in the hospital for 14 days for observation and quarantine. This was the first hospital in Taiwan that was shut down due to group infection. The group infection of SARS in Taipei City Hospital also marked the beginning of the spread of the virus throughout Taiwan. The first case of death owing infection with SARS appeared on April 28th (a patient visiting Taiwan). Ren Ji Hospital was also shut down on April 29th due to intrahospitalary infections of SARS. On May 1st, Head Nurse of Taipei City Hospital Ms. Chen Jingquiu passed away in Chang Gung Memorial Hospital at Linkou, the first infected medical staff member to die. WHO listed Taipei in Travel Alert System on May 8th. Later a series of hospitals presented suspected cases of group infections and several medical staff were infected with SARS and later died in line. It was not until July 5th that Taiwan was removed from the list of the endemic areas by WHO. The Center of Disease Control estimated an accumulated total of 697 cases of infection with 83 cases of death.
Dr. Chiang Chi-Huei of Taipei Veteran General Hospital :a memoir
At first, National Taiwan University Hospital thought they were really tight on the infection control; however, the ER was contaminated and they ended up shutting down the ER. Intrahospitalary infection appeared in Taipei City Hospital and Ren Ji Hospital successively, causing private hospitals to worry about the danger of the highly infective SARS and refuse to treat the infected patients. Other patients were concerned about getting infected, so they didn’t want to seek medical attention. This would obviously impact hospital performance, so the Department of Health asked medical centers to admit and treat these patients with high infectivity on behalf of the government. Therefore, the Department of Health ordered Taipei Veterans General Hospital to admit and treat the 14 patients transferred from Ren Ji Hospital. At the time, the hospital had already arranged to settle these patients into a quarantine area outside of the ER while I was ordered to simultaneously reinforce the infection control and reception of these patients to ward A144 of which I was in charge. That included the way of entering and exiting of these patients, and the medical staff’s movement route and self-protection guidelines. We changed the area near the entrance which was normally occupied by 6 insurance beds and made it into the preparation area for our medical staff members to wear isolation clothing, N95 masks, protective shoe covers, and eye covers. It was also the buffer area where medical staff members left the quarantined area for cautiousremoval of isolation clothing and accessories. Everything must be done in a non-contaminating fashion and later bathed in a public shower designated specifically for this cause before being able to dress back into their normal clothing to leave the ward or return to their offices.
There were already records of death or incapacitation of medical staff due to SARS, so the mention of it sent shivers down one’s spine. Truth is, medical staff members did not have a complete understanding of SARS and didn’t have any experience of taking care of SARS patients. It is understandable that they must be worried and fearful standing in the front line risking their lives to face this sudden unfamiliar disease with high infectivity and high mortality rate. And, being the Director of Pulmonology in charge of ward A144, and having the tough quality aquired from training in the military, I volunteered to become the first physician of Taipei Veterans General Hospital to be in direct contact with SARS patients. Firstly I moved all the TB patients to Evergreen Building and converted the negative pressure isolation ward that was used for TB into the settlement of SARS patient. I also taught resident physicians and nurses how to properly put on and take off the isolation clothing to avoid contracting any infections and prevent contamination of the environment causing intrahospitalary infection. During that period I participated in the establishment of the standard of care and attended the hospital’s SARS team’s meetings. It was common for SARS patients to develop respiratory failure,but the original nursing station was not equipped with cardiovascular function monitors and imaging like the ICU. However this monitoring system was rapidly installed within a week, allowing the physicians to quickly know the patient’s condition so that if any changes were to occur a quicker and emergent management can be executed to lower the mortality rate.
SARS, began with an infection in China that crossed into our country and started from a single case that evolved into intrahospitalary infection, and spread from north to south through traffic movements. People did not go out unless it was necessary; no one went to public places, hospitals, no interpersonal interactions nor entertainments, and people just stayed home. Unless there was an absolute necessity to go out, they would wear masks and keep interactions to a minimum. Relationships between people were at a freezing point. Because the mortality rate was high in the beginning and medical staff were infected and even died, Taipei City Hospital had fallen, the ER of National Taiwan University Hospital was shut down because of intrahospitalary contamination, and a lot of physicians were afraid of taking care of SARS patients, causing a portion of physicians to leave the hospital. I was the first physician in Taipei Veterans General Hospital to come in direct contact with these patients. Unluckily I had sprained my ankles a few days earlier, so I needed to walk with crutches. Every day I had to wear the heavy isolation clothing with a very thick N95 mask; it was all stuffy and hot. But I still led the medical staff of ward A144 into the quarantine room to treat SARS patients. Aside from directing and supervising strictly the quarantine procedure and treatment management, I did not forget to encourage my colleagues while we worked together to show our first line medical staff members support and reassurance at work. I remember the first day when I started to attend the SARS patients, practically everyone was wearing masks, and people seemed to avoid me when I stepped into the elevator. It was kind of sad. I even ate alone at the employee restaurant. A few days later the hospital wanted all medical staff taking care of SARS patients to self-quarantine as well, so the hospital arranged to send us our meals every day to the ward where we would eat within the unit. Even though being isolated in the ward unit to fully take care of the patients was quite tiresome and dangerous, saving a life is a very happy thing. My family would call me frequently to ask how I was doing. I knew they must be worried about my safety. At last, the medical staff of ward A144, through team work, saved 14 SARS patients who had respiratory failure.
Because of the self-quarantine, I had to be in the hospital around the clock every day. Besides entering the quarantine ward to execute medical treatment, I got online to read about any new articles about SARS and throught about approaches to treat SARS patients. Every day I assisted in the hospital’s SARS meetings and suggested treatment options and preventive measures. When facing family members of a patient, I had to report the patient’s current status and console the family members. Once some anxious family members fell on their knees in my office and asked me to please save their family! I told them I am not God, neither am I almighty! But I will do my best to save the patient! In my memory, the most prominent one is a very responsible head nurse that was transferred here with the first group of patients from Ren Ji hospital! At the time of her arrival she was still able to direct all patients on how to cooperate with our hospital’s policies for managements. But on the next day she developed respiratory failure and needed to be intubated and ventilated. Another female radiologist was already intubated and on ventilator due to respiratory failure. She was the one in the most critical condition in this group of patients. After a week or so of care, she improved so much that she was ex-tubated and was able to breathe on her own without use of ventilators. But because the patient was able to talk now, she was happy yet worried that she may not have time to settle important details with her family, she kept on calling her family and spoke none-stop. The next day she fell back into respiratory failure and was again intubated and on ventilators with superinfection by multiple organisms. We were really thankful that the Bureau of National Health Insurance allowed physicians to use all expensive medicines freely. After about a month, this patient was saved and went home. Early regulations of the Bureau of National Health for treatment standard were based on those in Hong Kong and other countries. But I personally had a lot of clinical experiences and animal research experiences, so I had my own judgment as to when was the appropriate time and condition for the use of a proper dose of corticosteroids. This was by discretion and choice, not global. This not only allowed the patient to create antibodies sooner but the side effects were kept minimum. I know for a fact that the virus cannot be killed by any drugs; you have to rely on your body’s immune system. The use of large amounts of corticosteroids may compromise the immune system causing the condition to drag on, but some patients had a very severe inflammatory response that might progress to acute lung injury causing shock. Because corticosteroid was still the most potent anti-inflammatory drug, I had to use it,only when the blood pressure lowered or when shock was developing. After the blood pressure stabilized, then reduction of the dose was appropriate. So none of my patients developed femoral neck necrosis. The early criteria to diagnosing SARS was travel history but afterwards presence of fever and respiratory symptoms would be suspected as SARS and all close contacts were forced to be quarantined.
In early clinical cases, we realized SARS can be divided into light, medium, and severe along with the changes observed on chest X-Ray. An article was published based on this clinical phenomenon for the reference of our citizens. For 8 months of follow-up, we researched the characteristics of the early stage of this illness, and traced which laboratory values were related to the severity of the illness. None of the patients I cared for had passed away during the time. After 8 months, based on lung function and changes observed on the chest CT, I published another article. This article was published in a well-known foreign medical journal and had the honor to be reviewed by the chief editor. This shows that the article was valued by American scholars and I felt proud. Fighting SARS may be a very strenuous and dangerous job, but being able to save lives and publish articles worthy for clinical reference is worth it.
This SARS event led me to realize that humans are very vulnerable! We may die rapidly thanks to a new flu. There is a time for everything and fate may play a role, so you must cherish every single day as it is valuable. Medicine can only treat infections by organisms and some viruses while other chronic diseases can only be controlled. Medicine still has a lot of room for improvement. The SARS epidemic showed us human’s weak point. Some people ran off because of ignorance while others showed the bright side of humanity. Because some people were very brave, even though they knew it was dangerous they still volunteered to save patients. These are two extremes. I hereby honor those medical staff members who gave their lives to combat this disease.
Internet News Report
【EpochTimes June 9 th】(CNA reporter Liu Te-chang Taipei)
Ren Ji Hospital’s head nurse Ms. Weng was infected with SARS while caring for SARS patients. She had finally recovered and was discharged today after being transferred to Taipei Veterans General Hospital where she was treated for 40 days. She thanks the medical staff of Taipei Veterans General Hospital for their care and, if her body allows, she is willing to go back to the front line to provide care for patients. She also encourages SARS patients not to give up easily.
Taipei Veterans General Hospital pointed out that Nurse Weng had cared for a patient with suspected SARS on April 19th and soon began to develop symptoms of fever and aches on the 22nd. After receiving treatment with venous infusion and antibiotics at Ren Ji Hospital on April 25th with no improvement, she was transferred into the current hospital for quarantine and treatment.
Taipei Veterans General Hospital’s Pulmonology Director Dr. Chiang Chi-Huei describes that at the time her Chest X-Rays displayed infiltrations in both lung fields, blood analysis revealed increased levels of white blood cells, CRP, and LDH but her lymphocyte counts were low. Antiviral medication, immunoglobulin, and antibiotics were promptly administered. On the second day of admission, May 1st, Chest X-Ray started to show evidence of increased lung infiltration. Series of arterial blood gas also showed signs of respiratory failure presenting increased CRP levels and decreased lymphocyte levels. Intubation was done on May 3rd for use with ventilator plus administration of antibiotics with large doses of corticosteroids as treatment. Chest X-Ray of May 6th showed improvement of the pneumonia. Fever started to go away on the 8th and by the 12th the patient was successfully removed from a ventilator and we reduced the use of all antibiotics with a tapering of doses of intravenous corticosteroids and a replacement of to the oral form.
Dr. Chiang Chi-Huei indicated that Nurse Weng, after treatment, showed steady improvement of her condition. She can currently breathe on her own smoothly, blood analysis shows that all has returned to normal, and chest X-Ray indicates little infiltration. Currently she only shows light coughs. Nurse Weng says that she is very thankful for the care Taipei Veterans General Hospital offered her during her combat with SARS. A lot of medical workers are being treated unequally. She hopes people will treat and see them as normal. At the same time, if her body allows it, she is willing to return to the front line for patient care. Her husband, children, family, and friends came to welcome her back on this day and also prepared a cake and sang happy birthday to celebrate her revival and discharge.
Caption:
Discharge after battle with SARS Ren Ji Hospital’s Head Nurse encourages patients to not give up
|
