(Wuhan) – It took Peng Zhiyong only a few minutes to make a decision that he knew could be very risky: admit a patient diagnosed with “unknown viral pneumonia.”

That was January 6. Peng, the director of the Intensive Care Unit (ICU) at the Central South Hospital of Wuhan University, signed the patient’s acceptance in his department. Before that, several hospitals rejected the person from Huanggang, a city 76 kilometers from Wuhan in Hubei Province.

The mysterious infectious pneumonia of the patients later turned out to be caused by a new strain of coronavirus known as 2019-nCoV. Since December, the disease spread rapidly from Wuhan to the rest of China and beyond. As of saturday confirmed infections of the virus exceeded 35,000 in 25 countries. It is becoming one of the most dangerous epidemics of the last 20 years.

But in early January, public awareness about the impending epidemic was still limited. The news began circulating among doctors in Wuhan about an increasing number of pneumonia patients infected with a virus similar to SARS, a deadly coronavirus that claimed almost 800 lives in an outbreak in 2003.

As a veteran doctor with Ph.D. A graduate in anesthesiology and intensive care medicine, Peng was a first-line doctor in Hong Kong 17 years ago during the SARS outbreak. The rich clinical experience gave him an acute sense of the virulent potential of the new disease. On January 3, Peng learned that BGI Group gene sequencing results discovered that the new virus shares 80% of the genetic code of the SARS virus.

“I knew at that time that the new virus would probably pass through humans,” Peng said in a recent interview with Caixin.

After accepting Huanggang’s patient on January 6, Peng called the hospital president to ask him to apply strict quarantine measures in the ICU department. The room was renovated according to the highest quarantine standards for SARS control with independent air supply, according to Peng.

A doctor uses protective equipment to enter the quarantine area at Wuhan South Central Hospital.

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

Now, the team of 150 members of the UCI department of the South Central Hospital run by Peng has been fighting the virus for more than a month. All medical workers have given up vacations and have worked shifts to keep the ICU running at full capacity. In the face of a shortage of protective equipment, doctors and nurses should reduce food and water consumption while working to avoid leaving the quarantine area and changing suits.

As the battle progresses in the front, the understanding of the new coronavirus becomes clearer. In the latest edition of its treatment plan, the National Health Commission confirmed that the virus is transmitted primarily through droplets and respiratory contacts. Infected patients show different degrees of symptoms ranging from mild flu-like symptoms to fever, lung infection, respiratory failure and even multiple organ failure.

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

Many serious patients suffered from organic failure of the heart, renal function or circulatory system, said Du Bin, director of the ICU at the Hospital of the Medical Union of Beijing.

“We still understand very little about the pathogenesis of the virus and we are not sure what is the real cause of the failures in multiple organs,” said Jiang Li, director of the ICU at Beijing Xuanwu Hospital, which is currently located in Wuhan. It makes the rescue and treatment of serious patients a challenge, Jiang said.

The rapid course of the disease means that intensive care professionals are the main force fighting the virus. As the epidemic continues to develop, the number of critical patients increases rapidly. According to official data until Thursday, there were 4,821 patients in critical condition, compared to 962 the previous day.

“We are running with death to snatch (the life) of patients,” Peng said.

The battlefield

Huang Xiaobo, director of the ICU at the Sichuan People’s Hospital, arrived in Wuhan on the night of January 25 in the first wave of doctors to help control Wuhan’s disease. He was assigned to the Wuhan Red Cross Hospital the next day, where he encountered a devastating scene.

The Red Cross Hospital is a small district institution with 400 medical workers and 300 beds. On January 22, the hospital was designated by the Wuhan government as one of the institutions to treat fever patients. After that, he was overwhelmed as more than 700 patients were flooded every day. Patients with ordinary fever mixed with those infected with the coronavirus, and the entire hospital was contaminated, Huang said.

“All beds were occupied, and even the hallway was full of patients for observation. People who used masks at once went in and out freely, ”Huang said. A large number of medical workers in the hospital were also infected, he said.

Until January 26, approximately 60 of the medical workers at the Red Cross Hospital had been diagnosed with the coronavirus or were under observation. The rest of the staff, no matter from which department, was transferred to the respiratory department after a brief training. They were “like cannon fodder” running towards a battlefield, Huang said.

At the request of Huang and his team, the Red Cross Hospital closed for three days to establish clear boundaries between the quarantine zone, the clean area and the buffer zones. The doctors also used the three days to examine all hospitalized patients and separate those infected with coronavirus from those who did not.

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

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The Red Cross Hospital was full of patients on January 22.

Running with death

In case of Li Wenliang, a 34-year-old ophthalmologist in Wuhan, illustrates the rapid deterioration that the disease can cause. Li was one of the complainants who first triggered alarms about the new virus and also became infected while treating patients. He told Caixin in a telephone interview on January 30 that he hoped to recover and was determined to return to the fight.

But on February 5, Li told Caixin in a message that his condition worsened. In the early morning of February 7, Li died after a one-hour rescue attempt at the ICU.

“It evolves rapidly from good to bad,” said Jiang of Beijing Xuanwu Hospital. “Sometimes changes come in hours.”

Huang, from the Sichuan People’s Hospital, also commented on the rapid development of the new virus in patients. Unlike flu viruses such as H7N9 and H9N1, which often cause severe symptoms at first, most patients infected with the new coronavirus show mild symptoms but deteriorate rapidly after a certain point, 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.

Peng said it often takes patients three weeks to develop from mild flu-like symptoms to critical or even fatal conditions.

“People with a strong immune system can recover after two weeks, but the elderly and those with basic health problems could worsen respiratory failure and other organs,” Peng said. “The second week is the basin.”

Among patients with mild symptoms, 15% to 20% seem to get worse in the second week, said Du of the Peking Union Medical University Hospital.

For those whose conditions become critical, the third week is the fatal test, doctors have observed.

“Some exceed the third week, but others will not succeed,” Peng said.

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

The new coronavirus attacks people’s immune system, resulting in a fall of lymphocytes or white blood cells that fight disease, as well as lung damage and respiratory failure. Some patients suffer from multiple organ dysfunction, Peng said.

“About a third of the patients I observed showed a systemic inflammatory response syndrome that led to multiple organ failure and critical conditions,” Peng said. “It happened in just two or three days for some patients.”

According to medical experts and first-line doctors, 15% to 20% of new coronavirus patients could develop serious conditions, and among them, 25% to 30% worsen a critical condition.

There still has to be a widely accepted mortality rate for the disease. Several ICU doctors estimate that the mortality rate among critically ill patients varies from 10% to 40%, which means that the overall mortality rate can be 0.6% to 1%.

What is more worrying is the damage of the virus in the lower respiratory system of people, which causes serious consequences even after a patient recovers. Du from the Beijing Union said it could take patients at least six months to recover heart and lung function.

War of attrition

The mission of the ICU doctors is to help patients maintain bodily functions as long as possible until the virus is depleted so that the patients’ immune system can gradually recover, Huang said.

But rescue efforts are sometimes restricted by lack of equipment, Huang said. The doctor said he witnessed five deaths in the ICU at the Red Cross Hospital since his arrival. Three of them would still have had the chance to survive if there was an available procedure known as extracorporeal membrane oxygenation (ECMO), which circulates blood through an artificial lung back into the bloodstream, he said. But as a small institution, the Red Cross Hospital does not have such a team.

While more ICU doctors like Huang and Peng have come to Wuhan to rescue patients from the brink of death, Jiang said more efforts should also be made in the early stages to prevent patients with mild illnesses from deteriorating.

“What I most want to do at this time is to solve the problem upstream, discover patients who are in the process of deterioration and apply treatments as soon as possible,” Jiang said.

Delayed treatment allows many mild patients to deteriorate and miss the best chance to recover, the doctor said. It is believed to be the main reason why Wuhan has recorded a death rate much higher than average than the rest of the country.

ICU doctors fight hard to rescue critical patients from death, but that is a late remedy, Jiang said. The most effective way to control the epidemic is to control the sources of disease, cut off transmission routes and protect vulnerable groups, he said.

“I think none of the three things have been done well,” he said. “What we are seeing is too late.”

“It is easier to control the disease before the patient’s condition becomes serious conditions,” Peng said. “After that, it is much harder to cure and would require more medical resources already scarce.”

For now, there is no relief in sight for ICU doctors.

“The number of serious patients continues to increase, and ICU doctors must be prepared for a lasting war,” said Xi Xiuming, professor of intensive care medicine at Beijing Fuxing Hospital.

Read more about Caixin’s coverage of the coronavirus epidemic.

Di Ning, Wen Simin, Huang Yuxin, Chen Lijin and Wang Yanyu contributed to this story.

Contact the reporter Han Wei (weihan@caixin.com) and editor Bob Simison (bobsimison@caixin.com)

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