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Welcome to SARS Info Center.
The information on this page is purely for reference only. Information appearing here is gathered froom a variety of third-party sources and these parties hold the necessary copyright to the information. This site merely collates information for the purpose of educating the public on SARS. |
What you are going to read below is an unedited version of the emails of Dr Tom Buckley. The information has been received through an anonymous sender via email. We do not guarantee the correctness nor accuracy of the information, but it is hoped that soome light will be shed from the availability of this information.
I thought they may be interesting to the medical community. He authorized me to post them on this website. I tried to withhold information that could violate patients privacy. I also withheld names of message authors Dr Buckley replies to. And email addresses. Please do not misuse this information. This is here as a testimony to the life "in the trenches down in Hong Kong " and to the efforts of the PW Hospital . But above all, this aims at sensitising health professionals to the REAL THREAT that this epidemic represents. Do take it seriously, Prince of Wales hospital's staff has been severely contaminated. This could happen elsewhere . It will if no precautions are taken. Do not indulge in wishful thinking. Masks are more effective. Dr Axel Ellrodt. France. March 28th 2003 Dear All, In reply to Les Galler's questions..... >I think it would be extremely helpful to us all if you have the time to >summarise some of the practical measures (albeit not evidence but >experienced-based) regarding some of the practical aspects of looking after >these SARS patients. >I would be very grateful to hear about your thoughts (anecdotal or >otherwise) about the best isolation precautions - in particular: The number of cases continues to grow in HK. The Government has closed schools and quarantine procedures have started. The situation in the hospital has essentially been contained but we are seeing cases of HCW (24) becoming ill after isolation procedures have been instituted. Reasons given by these HCW for catching the disease in order of importance are: 1. Nebuliser use I have previously mentioned the difference between ourselves (non infectious diseases hospital) vs PMH (infectious diseases hospital). PMH staff are well educated in infection control - it is part of their culture. In our cluster of hospitals (three in total) the standard of infection control in our ICU will become the standard. Only two nurses who saw the patient first admitted to ICU have become infected. They found the masks poorly fitting and uncomfortable. Some general points: 1. Recognize that infection control awareness
needs still to be raised. All potential sources of contamination. As far as ICU we have upgraded our infection control measures on a daily basis. PERSONAL 1. N95 masks at all times 2. sequence of gowning 3. sequence of degloving 4. nothing goes into or out of the unit that is not necessary – includes pens 5. pagers are wrapped in a glove 6. Many Chinese people wear glasses. For those of us who do not we are wearing goggles or buying glasses. N100 masks have gone to Iraq. We purchased them for their comfort and for the psychological boost. We have since found other manufacturers with N95 masks. Personal HEPA filters will not arrive until next week. Maybe not necessary because touch wood we seem to be holding our own. UNIT PATIENTS >* housing the patients (negative pressure rooms - do you have any of these?, HEPA filtration systems within the rooms) We only have 4 negative pressure rooms with Ventilation cycles above 12/hr. One of the major differences between our hospital and the ID hospital is that it admits patients to single rooms on the ID wards. Viral load of these patients is high. Our general wards have bays where patients are cohorted and may be part of the problem with HCW becoming infected. Our rooms are independently ventilated. >* masks - what are you and your staff doing - is there any local >experience suggesting that N95 masks are enough (assuming a good fit), or >the masks with personal HEPA filtration systems (N100 variants). What do >your nursesdo when they are looking after these patients for long time >periods? This is a big problem. HCW becoming ill on the wards are the nurses. ICU nurses have been spared this because our infection control measures are as high as we can make them. We would like to decrease the amount of time nurses are exposed but that means more nurses and increased exposure. >* what are you doing with your ventilated
patients wrt exhaled gas No mask CPAP, no BiPAP AT ALL. >* I would also be very interested (if you have the time of course) to describe >the strategy that is being used to keep up the morale of the nursing and >ancillary staff, especially in the ICU environment. Senior nurses and my self brief honestly
nurses every day Hope this is helpful Regards Tom Buckley
03-26-2003 We now have 24 Healthcare workers in PWH caring for the first wave patients with SARS, ie 41 OF 543 staff or 7.5%. ICU rate is 2%. 2 RNS who admitted the first patient to ICU. Even though the N95 went on straight away compliance was obviously not good. The mask was very uncomfortable and poorly fitting. There was only one size available from one manufacturer initially. Health care assistant (cleaner) was exposed to ICU on 19/3/03. She had no prior training on infection control. Other departments report much higher staff infection rates. 68% in the medical ward where patients are housed!!!! Reasons give for the failure rate in order of priority include 1. POOR FITTING MASKS, UNCOMFORTABLE Princess Margaret hospital is the Infectious Diseases Hospital in Hong Kong. No HCW has developed this disease despite there being 90 patients admitted. The only difference between PWH and PMH is the physical environment in that they admit patients initially to a single room. They are following our infection control measures. 15 patients admitted to another hospital - one member of whom had been exposed to Ward 8A at PWH. They all live in the same housing block. Regards Tom Buckley On 3/26/03 12:23 PM, "xxxxxxxx" > wrote: > We are starting to see the "second
wave" of SARS cases in Toronto. Dozens of health care workers
from the hospital caring for the index case in Toronto have been
placed in quarantine due to symptoms suggestive of SARS. >
Their Emergency Department and ICU have been shut down, no new
admissions to > the hospital. Three paramedics have been hit.
Public health officials are > also placing family members
of SARS patients with exposure in quarantine. > They have
been advised that the quarantine is "voluntary" unless
they don't > follow it...then it will be involuntarily enforced. xxxxxxxxxxx Hospital
03-26-2003 We now have 24 Healthcare workers in PWH caring for the first wave patients with SARS, ie 41 OF 543 staff or 7.5%. ICU rate is 2%. 2 RNS who admitted the first patient to ICU. Even though the N95 went on straight away compliance was obviously not good. The mask was very uncomfortable and poorly fitting. There was only one size available from one manufacturer initially. Health care assistant (cleaner) was exposed to ICU on 19/3/03. She had no prior training on infection control. Other departments report much higher staff infection rates. 68% in the medical ward where patients are housed!!!! Reasons give for the failure rate in order of priority include 1. POOR FITTING MASKS, UNCOMFORTABLE Princess Margaret hospital is the Infectious Diseases Hospital in Hong Kong. No HCW has developed this disease despite there being 90 patients admitted. The only difference between PWH and PMH is the physical environment in that they admit patients initially to a single room. They are following our infection control measures. 15 patients admitted to another hospital - one member of whom had been exposed to Ward 8A at PWH. They all live in the same housing block. Regards Tom Buckley 03-26-2003 Race distribution. Overwhelmingly Chinese Regards Tom === Tom and others, Do we know the "race" distribution of cases? Is this showing a major predisposition to affect those of Asian origin? xxxx xxxxxxxxx Intensive Care Unit 03-26-2003 Today I was going to summarize my experience BUT I mentioned last night 30 tourists from Beijing. More information: Visitor to Ward 8A (original index ward at PWH) flies to Beijing on 15/3/03 having fallen ill. Flight contains 39 tourists from HK. The 39 have returned to HK and 9 are ill with SARS. Contact tracing is urgently trying to find passengers on both flights. Reported in the news that this is now in Beijing. 280 reported cases in HK SAR yesterday. I think as the layers get deeper and deeper that contact tracing will be irrelevant. Yesterday evening there was an air of optimism especially as it seemed the situation in PWH had been controlled. There was some apprehension about the community and what was happening out there. Gave a talk to a group of family physicians about SARS and on the way home listened to the news. Scary particularly the details about the Beijing flights. This is a real roller coaster ride in terms of emotions. What is even more scary is that 1. Schools have not been closed. Politicians will not take the tough decisions. When they do it will be too late. If this comes to you (and I sincerely hope it does not) it will potentially overwhelm your critical care services. Regards Tom Buckley Tom Buckley <tombuckley À ccm-l@list.pitt.edu HK update 03/25/03 09:33 Dear All, I hope this is not the calm before the storm. The hospital is stable. ICU has stabilized and we are now discharging patients. However more and more of the originally least ill patients are now ventilated. 15 at last count. Some of these show no signs of improvement. Number of admissions to hospital still
climbs steadily. 6 per day on average. All are family members
of contact patients EXCEPT (and this is extremely worrying) we
are seeing HCW presenting with atypical pneumonia. Three ICU nurses have come down with this. It is of little consolation that as a percentage of our total work force we are lowest. The Observation ward and medical ward were much slower at implementing their infection control measures cf ICU. What is apparent is that adherence to technique
is just so important. We have had to think way out of the box
in terms of infection control. 10,000 N100 masks have gone to Iraq!! Just heard on the news that (5 according to yahoo Singapore - webmaster) of 30 tourists travelling to Beijing have have returned home with SARS. Tom Buckley 03-24-2003 Some one asked about pulse steroids. 03-24-2003 Dear All, Good news 1. Younger patients are improving to the point of discharge and the first discharge of a ventilated patient occurred this morning. This is wonderful news and sends out a very strong positive message. 2. The situation is broadly under control within the Prince of Wales Hospital but Bad news 1. Some staff in the Observation ward (staff admissions), on the ward (patient admissions) and in ICU appear to have the disease albeit in a milder form. Looking for rational explanations for nurses presenting with signs and symptoms. E.G. ICU nurse with previous exposure to index patient's ward is very good friends with the other 4 nurses who have signs and symptoms. Are our infection control measures safe? 2. This pneumonia is out there in the community. The numbers are increasing daily and a third hospital is being prepared for the influx. How big this is going to get is any ones guess. 3. Official figures of the outbreak in Guangdong province are 300 cases with 5 deaths. Unofficially has the numbers much higher. Younger patients (<50 years) appear to be doing better. Older patients and those with comorbidity are dying. So far 4 deaths in ICU. Casual observations Hope this is helpful. I appreciate very much all the comments made. I have forwarded them to the staff within ICU. I am amazed at their courage. Tom Buckley 03-23-2003 There are now 145 confirmed case in the Prince of Wales Hospital. New cases (first contact) tend to bring their families (second contact). Close family contacts seem to have a very high rate of infectivity. The outbreak within the hospital appears to have been contained but it has put an enormous strain on the system. Through out HK yesterday there were an additional 20 cases admitted to hospital. Total as of yesterday stands at 217. General observation is that the second wave is not as severe as the first ? picked up earlier. New cases include Immigration Officer, Ambulance man, Family Physicians x 5, and a Paediatrician. ICU nurse described yesterday had a CT chest and the lungs were clear. She has been discharged. Physicians feel that she has not contacted this form of atypical pneumonia. Our infection control measures appear to be holding. Nurses are coming to help. We are running courses to educate them in the absolute basics of ICU care. Hopefully they can provide some relief for very tired staff and if the numbers increase in the community they will be called upon. In ICU patients are improving. We have discharged four patients in the past 24 hours and admitted only two. Huge psychological boost to everyone - patients themselves, patients on the wards, care givers and hopefully the public. Big issue now is how large is the third wave going to be!!!! Chinese newspapers are full of this and can explain concepts of waves. English newspapers barely mention the problem - more concerned about Iraq. Regards Tom Buckley 03-22-2003 Cases continue to appear but at a slower rate. PWH now has 137 cases - basically first and second contacts. Patients on the ward improving. Physicians believe it is the pulse steroids. ICU is taking a fair amount of strain here - we have referred two cases to other ICUs in Hong Kong. There are 6 cases on the general ward who we (ICU staff) feel may need to be admitted to ICU Second wave is actually quite small. I think this is a reflection on the hospital contact team who have done an incredible job. Is there a third wave. If so it will be large. ICU cases are generally improving with decreasing oxygen requirements. Some X rays have actually improved. 1-2 possible discharges. My greatest worry appears to have come true. One ICU nurse ill earlier in the week has come down with this. While she is Ok I cannot account for her as a primary contact. If she has this from an ICU patient then she presented within 12 hours with a cough!!! Please do not forward e mails to newspapers.
The initial purpose of the e mail was provide some information
as wide as possible to the intensive care community so that you
could prepare. It has snow balled and I have provided ongoing
information to impress on you the magnitude of the problem and
how it might affect your own facility. Regards Tom Buckley 3-22/21-2003 De : Tom Buckley A : ccm-l@list.pitt.edu Copie : xxx <xxxxxxxxxxxx> Objet: Re: Precaution details... Reçu le : 22/03/03 01:58 Dear James, Because all the patients have had the same exposure we do not change. However we admitted a case from another hospital on Saturday the 15th who was completely unrelated to our outbreak. I asked staff to change to enter that isolation room. This may have been a background atypical pneumonia that we see 2-3 x per week and we obviously didn't want cross contamination. N95 masks are worn thoughout the hospital by ALL staff. The portable HEPA filters can either half hood or full hood. We are getting the half head. Ears are exposed and we can hear each other. Full head is like a plastic bag over your head and if the battery fails....... No BiPAP being used at all - includes staff with atypical pneumonia as well as non health care workers. Healthy staff (ICU doctors and nurses) are all working - no time for sleep. Regards Tom On 3/21/03 10:22 PM, "Jamesxxxxxxxi"
<xxxxxxxxxxxxxx> wrote: De : Tom Buckley A : axel ellrodt <axel.ellrodt@wanadoo.fr> Objet : Re: Tom ? HK update Ribavirin efficiency ? Reçu le : 22/03/03 01:54 Theoretically ribavarin should work BUT we don’t know for sure. Tom On 3/21/03 8:48 PM, "axel ellrodt" <axel.ellrodt@wanadoo.fr> wrote: BBC reports neb ribavirin efficient according
to HK sources, 3-21/20-2003 Dear xxxxxxxx, We are using routine community acquired antibiotics but all our cases who have had contact with ward have not responded. We are now only admitting cases to our hospital who have had contact with our original case. We are now seeing the second wave - relatives of primary contacts. So far no staff have been infected once isolation procedures were put in place. No one is wearing ordinary surgical masks. There have been some close calls with some nurses being reported as having atypical pneumonia after precautions have been taken but in all cases our contact tracing team has established that there was an earlier contact. Everyone has been wearing N95 masks and while I think (though don't know for sure) that N95 is satisfactory staff have not been wearing them properly or they do not fit. We are switching to the N100 masks not because they are ~ 5% more efficient but because the nurses have found them more comfortable to breath through (less resistance) and they fit more comfortably on the face. The N95 masks, despite a variety of brands and sizes have been uncomfortable and difficult to breath through. There is also the psychological aspect as well. We are going to try BIPAP. I do not expect it to work (hypoxic respiratory failure only) but because of the higher flow rates (along the lines of the nebulized ventolin in the Index Case) and potential for environmental spread I want it to be as safe as possible. So besides all our "usual" precautions we are going to do this in one of our isolation rooms - increased ventilation flow rates and personal HEPA units. If the staff can tolerate them we will distribute to all staff. Many problems with these but I cannot afford to lose one nurse. Mind you haven't made a final decision about the BiPAP. Last night senior xxxx (staff member) rang me to say she was resigning. She is petrified. HK Government is down playing the whole thing presumably because of the economic implications but own hospital has been taken over completely by this infection. We currently have 24 cases of atypical pneumonia in ICU - now is that impressive or what. It also appears to be out in the community. GPs are being admitted. All of our patients in ICU are either on 100% O2 or they are ventilated (some prone). Pulse steroids have been given by the physicians to patients on the general ward. They initially improve but are now septic and being referred to ICU. Sorry to ramble. I am very tired but hope this is helpful Tom Buckley On 3/21/03 4:04 AM, "xxxxxr" <xxxxxxxxxxxx> wrote: > Dear Tom 3-20-2003 It was announced on the news early this morning that the Department of Healths investigation is centred on a Hotel in Hong Kong. Visitor from China developed symptoms on 15th Fed. Stayed two days at this hotel and was visited by approximately 9 people including person who later died in Toronto and our index case. (Note from webmaster: another member of CCM-L reports : The Guangzhou doctor checked into Metropole Hotel in Hong Kong 9th floor on Feb 21 & was admitted to hosp on 22 Feb.) I had two calls during the night for two admissions. Time to go down stairs and assess the situation. Tom Buckley 3-20 Tom Buckley Only four have been discharged from hospital and some of the milder cases are improving. In ICU we have only managed to discharge two to the ward. One of them was on her second admission. The rest in ICU are static or appear to becoming septic. Major discussion last night as to the likely length of infectious period. After RSV literature review and expert opinion it has been decided that patients can be discharged home >21 days after the start of fever. Administrators are talking about halfway house for hospital staff. Tom Buckley On 3/20/03 6:11 PM, "xxxxxxxxxxxxxxxxxxxxxx
wrote: They are telling us that the "earliest victims" are now recovering...and I hope this is true. The discrepancy between your reports, and the news, is frightening (though not unexpected). I hope you are doing well. 3-20 Dear All, I have read all posts and am very reassured by the kind comments. All suggestions have been discussed with the appropriate people. What a great community. The number of cases continues to increase in our hospital. I have bee able to control admissions to ICU somewhat but am starting to see sicker and sicker patients with large O2 deficits referred to ICU. Only one more intubated and ventilated in ICU. Patients remain in single organ failure. Collective ICU decision is that pulse steroids
given on the ward are not working. Patients still deteriorating.
Initial settling of temp followed by increasing O2 requirements
and the almost inevitable rise in temperature. Physicians would like a cure NOW. Patience is a virtue. Staff morale is as well as expected. I have personally spoken to every nurse and doctor on the floor about isolation procedures this morning. We are upgrading our infection control measures to include N100 masks and personal HEPA filtration systems. So far no staff have contacted this apart from those with initial contact. One xxxxxxxx nurse mentioned in an earlier post is better. However staff are being stretched to the limit especially the nurses. Senior nurses need support as well as they are feeling the strain. I have just spoken to three other colleagues in other ICUs around HK. Increasing numbers of cases. Family physicians are seeing increasing cases and Department of Health is suggesting all family physicians and their staff wear "surgical masks". My wife, a family physician has been wearing an N95 mask for the past week. This hospital is essentially closed except for atypical pneumonias. ICU has no other cases. Some patients on the General wards are improving. If you have not read my posts before today please take these seriously and take every precaution you possible can to prevent its spread. My observations may not be eloquent nor scientific but I hope they convey the seriousness of the situation and that you are better able to prepare for this war. Regards Tom Buckley 3-19 Most of our patients have been relatively benign initially only to deteriorate several days later. Tonight we have admitted a second XXXX (staff member, deleted for privacy) . I first saw him 6 days ago as he was about to be discharged from the Observation Ward. Tom Buckley 3-19 The whole hospital is being sealed off. The original and adjacent wards where this started are completely isolated, as well as A& E and ICU. Infection control measures include (in ICU) Gown, gloves, handwashing and hand wash,
hairnet, N95 mask, surgical scrubs, visors for all patient procedures Space suits being investigated as are N100 masks. We find out tomorrow if two nurses not from ICU have developed the disease. They have had no previous contact before isolation procedures instituted. It has been assumed that if they have the disease then the N95 mask has failed. Not necessarily failure of the mask but failure of technique. Considerable time has been spent educating staff as to how best to wear these masks. The problem is that there is such a variety of face shapes and sizes that despite multiple different models and sizes staff still have problems getting the mask to fit. I obtained all seven N100 masks in Hong Kong and the nurses report favourably on these. There is a valve to breath through so that the resistance is less than an N95O and they seem to fit the Chinese face better. Only disadvantage is cost USD10 vs 80cents. We will see tomorrow I hope. Tom Buckley n 3/19/03 9:39 PM, "xxxxxxxxxx" < xxxxxxxxxxxxxxx wrote: > By the way, how are you protecting
yourself against infection? Given the 3-19 Yes I remember reading about this in medical school in the 70s. I have thought about this and the possible benefits of an anaerobic environment. Problem is that there is extensive consolidation of the lungs and we do not have any means of providing extracorporeal oxygenation while we collapse the lungs. Most patients are static in terms of their oxygenation and certainly not deteriorating. Functionally they are improving. So am watching and waiting. The side effects of pulse steroids I am anxiously watching for. Tom Buckley That was the reply to : On 3/19/03 8:33 PM, "xxxxxxxxxxxxxxxxxxxxxx wrote: At the Cleveland Clinic 30 years ago, patients with Tuberculosis purposely had their lungs dropped as their primary treatment. The TB was markedly stifled due to the change from a high aerobic environment to an anerobic environment. Patients even had ping pong balls surgically inserted into the apex of their chest in order to keep their look in a down position. I read your e-mail in regards to the clearing of the lung after the lung was brought back up from the pneumothorax. You may want to consider the implications of this observation. xxxxi MD, FACEP 3-19 Dear All, Yesterday was a bad day. 7 admissions to ICU. Total of 24 admissions to ICU. 10 new cases admitted to hospital all in association with the original ward outbreak. Unfortunately 2 died last night. Both elderly with significant co morbidity. Contingency plans well in place but so far have not had to expand beyond ICU. Interesting news last night. Appears to be a paramyxovirus. Preliminary data thus far but it appeared in early nasopharyngeal PCR results in 6 of 15 patients. Also isolated in urine in one patient. Also reports of same result from Taiwan and Germany. Overnight in ICU despite the two deaths patients are stable though not improving. Two new admissions overnight but no more mechanical ventilation. Spontaneously breathing patients - respiratory rates improving but no improvements in A-a gradients. New admissions have all received pulse steroids on the general wards - is this limiting the inflammatory process (they are still deteriorating requiring ICU admission) or is this functional improvement due to natural course of the disease. My impressions are that we will be left with patients with ALI/ARDS. We have been trying to wean and extubate a 23 year old medical student whose oxygenation and ventilation are very good. She has now failed the oxyvent twice now. Finally gave myself a kick in the pants and realised I am expecting too much. This girl has ARDS and we are trying to extubate her after 3 days. 8 of 53 cases with atypical pneumonias are in ICU 16 of 43 cases are patients/visiting relatives It appears the younger fitter patients are not getting as ill. Yesterday I was well and truly frightened and I could see the fear was palpable around the hospital. I would love to be able to thank each and everyone of you personally for your support and encouragement. I have passed on many comments to the nursing and medical staff. They continue to amaze me. Medical staff helping me with infection control, equipment procurement, staff support have bent over backwards to help. Over the last few years I have become very disenchanted with the direction of intensive medicine. I am privileged to belong to such a community as ours. Thank you. Thank you to xxxx for his vision. Back into it. Tom Buckley 3– 18 >Date: Tue, 18 Mar 2003 15:55:13 +0800 >Dear All, >Current number of cases in hospital 97 of whom 50% are HCW or medical students. Second wave commencing. Limited so far to families of primary contacts. Doctor gets sick, treats himself for 3-4 days at home, deteriorates and comes to hospital. Family members meanwhile start developing symptoms. Six in all. ICU situation critical. Increased ICU admissions (4 today). Seems that patients have 3-4 days of relatively benign symptoms, then develop x ray changes with minor increase in (A-a)O2 gradient followed several days later by increased oxygen requirements when they are referred to ICU. Now expecting two to die. Physicians on the ward have commenced pulse steroids in a lot of patients. They don' work and as I said to them even
if they do I will seem them later on with nosocomial sepsis. 3-17 On 3/16/03 11:05 PM, "xxxxxxxxxxxxxxxxxxx
wrote: Time line from what I can gather. Male visits China for Chinese New Year (end of Jan/early Feb) with 2 other relatives. Return to HK on 25/2/03 and son is admitted to ward in early March. Other relatives develop fever 9 - 11th March. Mother in law admitted to hospital 13/3/03. Other exposed staff and patients start presenting 11/3/03. First admissions to ICU 13/3/03. Status at 0700hrs Monday the 17th. 13 patients admitted to ICU seven of whom require mechanical ventilation. Patients decompensate very quickly when breathing spontaneously. Quick impression overnight to check patients all alive. Gas exchange has improved on majority of patients. Older patients have shown a slower improvement but they were intubated first. Younger patients deteriorate later, initially require 100% O2 but then improve quite dramatically. Ventilatory strategy. Lung protection - VT 6-7 ml/kg Prone ventilation in one young male - dramatic improvement in PaO2. Older man with preventilation pneumothorax not doing well Younger man with surgical emphysema and now bilateral chest drains also not doing well. My own personal observation here is that our care should be straightforward Oxygenate, ventilate and keep them alive while riding out the inflammatory storm. There are no magic bullets. Time for a proper ward round. Once again thanks for all the kind words.
It is very, very reassuring and I Thank you xxxxxxxxxxxxx from Glasgow for the references. So busy I had not been able to get around to a lit search. Regards Tom Buckley Regards Tom Buckley 3-17 Infectious disease update may be helpful. I am told that the incubation period appears to be 5-7 days. Patients present with high temperature which then settles. Patients then develop chills and rigors with high fever. Chest x ray may initially be clear but then changes (bases in particular) start on Day 3-4. Patients are lymphopenic with platelets decreasing over 3-4 days after initially being normal. APTT is prolonged, PT tends to be normal. LFTS are difficult to interpret because of various drug effects. If anything low rise (100) in ALT. We now have 80 cases of atypical pneumonia in this hospital (64 yesterday) and over 50% are either Health Care Workers or Medical students. Today we have admitted 4 cases to ICU one of whom requires ventilation. Infectious diseases experts are talking about nebulized ribavarin and pulse steroids. ICU is seeing the serious cases of the first contacts. We are all waiting apprehensively to see if there is a second wave. No update on the micro. There are sporadic cases elsewhere in Hong Kong some of whom were contacts with the original patient in our hospital. Antibiotics, antivirals steroids have not shown any improvement in patients clinical condition. Limiting transmission Limit contact Regards Tom Buckley Subject: Update Events are starting to over take us in terms of case load though some ventilated patients have improved. We have no deaths as yet. I am moving two noninfected cases to OT and coronary care is about to be evacuated for more of mine. I have 5 beds left in ICU. We will have to start thinking about triage of cases!!! I have only talked about my own contingency plans. There is major reorganization going on within the Hospital Authority. We now have 87 cases in the hospital (3 more than yesterday) Only figures of Hospital Care workers presented in the press because the extent of the problem has not been identified in the community but 60% of our cases are either medical students or HCW. All staff who have had direct contact with this ward have developed the illness within 4-5 days. Visiting relatives to other patients have developed this illness. All minor staff have developed it. So far chlamydia and mycoplasma are negative. I have convinced physicians not to give pulse steroids in ICU paients but will continue with Ribavarin and hydrocortisone. Microbiologists are talking about the absence of a second wave and that with 2-3 days we should know if this isolated incident has been contained. Most worrying is that TWO of my nurses are sick. One had contact with the infected ward when she visited a friend. Other is a little difficult to analyze so I have asked the contact tracing team to investigate. SHE IS 'atypical' in the extent that she has a cough, no temperature, x ray changes and a low WCC. No contact with the infected ward. I obviously need feedback from the (contact tracing team) on this case urgently. Nurses are extremely upset. My email address says 'hk' and yes I am from Hong Kong. I would love to be skiing at Vail in the Back Bowls or fishing at Lake Wanaka in New Zealand right now. More importantly I would love my family to be out of here. Many different threads - my apologies. Regards Tom Buckley 15 and 16 March So just a brief summary of our experience. Male arrives on the medical ward having been admitted thru A & E. Other patients and STAFF start to develop symptoms - fever, headache, dry cough. Unresponsive to various combinations of cefotaxime, chlarithromycin, levofloxacin, doxyclycline and Tamiflu. All microbiology is NEGATIVE (after one week). Physicians have started patients on ribovarin and steroids. As of yesterday there were 64 patients with "atypical pneumonia" in the hospital - a large number of whom are staff. Patient visitors, medical consultation staff, medical students visiting patients have all developed symptoms and to a large degree CXR signs. While most of our cases revolve around the patient admitted to the medical ward we have admitted (to ICU) another patient from another hospital with atypical pneumonia. In ICU we have twelve patients admitted so far Five are ventilated. Seven breathing spontaneously but very oxygen dependent. My impressions; CXR reveal progressive bilateral infiltrates
starting at the bases. Post mortem on an Indonesian maid (not in our hospital) showed evidence of ARDS and myocarditis. So far 2-3 of our older patients with chronic disease have deteriorated fastest. Medical staff - younger and fitter have faired better. Their radiological findings have deteriorated in all but one case. We receive 2-3 admissions per day. So far
no-one has shown any improvement. ICU is now closed for all but atypical pneumonias. All our other "clean cases" have been transferred to other ICUs. All elective surgery is being cancelled and wards are being closed and evacuated. Al ambulances are being diverted. We are taking strictest possible isolation procedures available to us including hand washing, gloves, gowns, N95 masks and visors. Masks are worn throughout the hospital. Staff are not going home to children. Please take the warning below seriously. My impression is that even with minimal contact with an infected person people have been becoming ill. Staff morale in ICU is high but If ICU staff start developing symptoms then this is a big problem as we have instituted isolation procedures earliest. Other hospitals in Hong Kong are admitting sporadic cases. I am off to a noon update. Any suggestions will be gratefully received. [And an update 18 hrs later:] I am told that the incubation period appears to be 5-7 days. Patients present with high temperature which then settles. Patients then develop chills and rigors with high fever. Chest x ray may initially be clear but then changes (bases in particular) start on Day 3-4. Patients are lymphopenic with platelets decreasing over 3-4 days after initially being normal. APTT is prolonged, PT tends to be normal. LFTS are difficult to interpret because of various drug effects. If anything, low rise (100) in ALT. We now have 80 cases of atypical pneumonia in this hospital (64 yesterday) and over 50% are either Health Care Workers or Medical students. Today we have admitted 4 cases to ICU one of whom requires ventilation. Infectious diseases experts are talking about nebulized ribavarin and pulse steroids. ICU is seeing the serious cases of the first contacts. We are all waiting apprehensively to see if there is a second wave. No update on the micro. There are sporadic cases elsewhere in Hong Kong some of whom were contacts with the original patient in our hospital. What you see and read on CNN, BBC etc is 24 hours out of date. Regards Tom Buckley |
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