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Wang Weici, MD, deputy chief of vascular surgery at Wuhan Union Hospital West Campus, China, graduated from medical school in 2012. But on January 27, she began her training anew.
This early in the fight, no one knew how much her skills ― old and new ― would be needed. Or how perilous and challenging the days ahead would become for Wang and her colleagues.
Now, after more than 2 months, the city of Wuhan has ended its lockdown.
But in late January, as the then-unnamed COVID-19 outbreak flooded hospitals throughout the city, the number of new cases had been escalating, and the death toll was mounting. So Wang and her colleagues — who specialized in everything from orthopedic surgery to endocrinology — were taught to diagnose and treat patients who were sick with and dying from this mysterious, pneumonia-like disease.
On Tuesday, April 7, the city of Wuhan ended its lockdown. But in late January, the fight had just begun, and neither Wang nor her colleagues knew just how challenging everything would become. In those early days, everyone was still learning how to navigate this new and perilous terrain.
The various specialists learned how to use respirators, how to put on and take off protective gear, and how to enter and exit isolation units where beds for coronavirus patients were located ― an area they referred to as "the cabin."
On February 1, Wang's hospital was designated a COVID-19 treatment center. That first day, they admitted a 43-year-old man who was physically fit and had no underlying disease. He died the next day, she said.
The newly trained doctors began their shifts in the cabin right away. Wang was struck by the fact that her patients gasped for breath just while trying to relate their medical history. There was no way the patients could answer all her questions, she said. And there were so many of them.
"Only 2 days after I first saw severely ill patients, the beds of the ward were full," Wang told Medscape Medical News in interviews conducted in Mandarin.
But medical experience kicked in, steeling her and her colleagues to the impending crisis. "My colleagues not on the front line perhaps felt more fearful," she said. "Like bungee jumping off a bridge, only those who are on the bridge feel scared. After you jump off, you can open your eyes to see what is happening instead."
So many hospitals were designated coronavirus treatment centers that few remained available to treat non-COVID-19 patients. Physicians from other specialties were transferred in, just as Wang had been, reducing care for other patients. And when non-COVID-19 patients came to the hospital, almost all were emergency cases.
Initial Confusion and Chaos
By February 3, 2 days after opening, all 810 beds at Wuhan Union Hospital West Campus were full.
"Even our family and friends couldn't get a bed," Wang said. "We doctors were worried about our parents and children."
Overall, the result was mass confusion. Pneumonia patients worried about whether they had COVID-19, and in the beginning, they didn't know which hospitals would take them.
When treatment facilities were first announced online, only designated hospitals were listed. But most people didn't have access to transportation, it was difficult to call an ambulance, and some mistakenly thought that they couldn't leave home at all, Wang said. When friends asked her where they should go, she directed them to their local emergency departments.
Although nondesignated hospitals were given orders not to reject non-coronavirus patients, they may have done so anyway, owing to the overflow of COVID-19 cases, furthering the virus's spread.
A Transformed Ward
Inside Wang's coronavirus ward, most of the doctors were surgeons ― not internal medicine, respiratory, or infectious disease physicians. Doctors and nurses learned together how to use blood-gas analyzers and noninvasive and invasive ventilators for critically ill patients.
Initially, Wang said, "everyone was kind of at a loss. We felt that we were a nonbranded army and could not do the work needed to treat severe pneumonia." But, she said, that feeling faded quickly. "We've found that everyone has become very capable in the management of COVID-19."
Wang, second from the right, and her colleagues wrote their names on their gowns to know who was under the layers of protective gear.
As a multidisciplinary team, her ward of surgeons put their specialties together to treat patients with COVID-19 and other conditions, such as diabetes, anemia, or fractures.
One critically ill patient, she recalled, had severe aplastic anemia combined with COVID-19 and depression. The disease caused him to lose hope, and one morning, he suddenly attempted suicide. Wang's colleagues found him with stab wounds to his stomach. The doctors snatched the knives, but the patient refused treatment. So two surgeons quickly changed into protective suits, entered the cabin, and held the patient still to suture the wound.
Being a surgeon in that case was an advantage, Wang said.
Protection in the Cabin
Nurses spent even more time than doctors inside the cabin, Wang said.
They often have the most difficult roles in this outbreak ― they're responsible for high-exposure, close-contact work, such as drawing blood, giving injections, and treating patients while they recuperate. They also do much of the heavy lifting, like supporting a patient to get to the bathroom ― all while wearing the N95 respirators that make breathing difficult.
Yet, as is now happening in US hospitals, personal protective equipment (PPE) was in short supply. One of the most dangerous procedures in the cabin is intubation, Wang said. Although the intubating anesthesiologist had a face shield, there was not always enough for the nurses who performed sputum suction and extubation, which are equally dangerous from an infection-control standpoint.
To put on the layers of necessary protective gear before entering the cabin, medical workers must go through over a dozen steps in three different areas and two passageways. Wang said, "With limited supplies, the doctors try to leave as many protective suits as possible for the nurses."
To minimize the number of precious protective suits used, only one or two doctors stay inside the cabin to manage 50 critically ill patients ― which is at the limit of their capabilities. The goal is to make the most use of each protective suit by staying the full 6 hours for each shift.
"You can't eat or go to the bathroom, so sometimes I wore diapers," Wang said. "The supply of protective equipment has significantly improved compared to when the department was opened, but our supply of medical protective clothing and medical N95 masks are only enough for the protective use of cabin personnel."
Timely, Preventive Treatment Key to Patient Outcomes
After initially opening on February 1, Wang's ward had several consecutive patients who had severe blood diseases, such as acute lymphocytic leukemia, severe aplastic anemia, multiple myeloma, and chronic myeloid leukemia, all of whom passed away. But they also saw older patients with hypertension and diabetes ― and even a 94-year-old ― who recovered.
"The doctors do not have magic drugs for patients, but they can at least provide symptomatic treatments, such as fluid and protein supplementation, anti-infection, steroids, and different levels of breathing support," she said.
Treatment for COVID-19 in China follows the Guidance for Coronavirus Disease 2019, which was released by the National Health Commission of the People's Republic of China and which is constantly updated, Wang said.
General treatment guidelines include rest, supportive treatment, antiviral treatment, the provision of adequate nutrition, keeping patients hydrated, monitoring vital signs, and delivering oxygen therapy.
"Treatment is adjusted according to changes in the national diagnosis and treatment plan, but use of abidol, anti-infection drugs, thymosin, acetylcysteine, and alpha-interferon nebulization have remained constant," Wang said. "Later, chloroquine, Chinese medicine, and trastuzumab were added." For critical cases, they also provide respiratory and circulation support, she said.
Even after being on the front lines for close to 2 months, Wang can't say for sure what works and what doesn't. Some patients who were treated with certain antivirals recovered, she told Medscape Medical News, but at this point it's hard to tell exactly what led to recovery and whether the same treatments would work for other patients. What is crucial, she said, is the close monitoring of symptoms and the timely use of respirators.
In late January and throughout February, China mobilized. Emergency specialty field hospitals were constructed, makeshift hospitals for mild and suspected cases were created, oxygen tanks were used to address the shortage of oxygen supply in hospitals, ventilators were shipped in, and 42,000 medical workers came to work on the front lines in Wuhan.
By late February, the number of patients discharged from the hospital had gradually increased, and beds began to free up. At that point, patients were largely able to receive timely treatment, Wang said.
After more than 80,000 cases and 3000 deaths, official Chinese reports claimed there were no new local cases 4 days in a row, from March 18 to 21. As of March 24, the number of deaths per day had dropped into the single digits, according to official Chinese reports.
Although the accuracy of these numbers have come under heavy scrutiny from multiple sources, such as the Washington Post , Wang said she experienced a break in the storm.
"The mortality rate has decreased, the severity of the illness itself has decreased, the treatment methods have kept up, and the panic has gradually subsided," she said.
The focus has shifted from COVID-19 to other diseases, and the doctors' original areas of expertise have come back into play.
Advice to the Rest of the World
Wang said that until the end of February, her ward felt extraordinarily tense and strained. The doctors and nurses feared infection and were given the choice to not go inside the cabin when there wasn't enough PPE. What PPE there was ― usually only enough for 3 to 5 days of regular use each week ― was used sparingly.
By March, Wang finally felt there was enough PPE and other medical equipment to go around.
Wang had recommendations for other countries working to prepare for the surge, including measures already taken in Italy and elsewhere. She suggested that hospitals create coronavirus-specific wards that can meet isolation standards and ensure that they have adequate materials and medical staff (something few countries have yet achieved).
Wang, on the left, with a patient who was discharged after recovery.
To prevent further spread of the virus, she said, hospitals should "treat suspected patients in a centralized center and do not let them back home." To that end, she suggested making hotels or isolation dormitories available for patients if there aren't enough hospital beds. She noted that hospitals may need to redistribute their resources, including ventilators, blood gas analyzers, and extracorporeal membrane oxygenation units.
It wasn't until the decline of new patients this month that Wang felt hope that Wuhan's crisis would end. Her ward is now half empty.
Ultimately, Wang hopes those in the United States and elsewhere will do what they can to make the same sacrifices that Wuhan medical workers made. "Don't repeat the same tragedies that struck too many Wuhanese families," she said.
Medscape Medical News © 2020
Cite this: Life in the 'Cabin': Two Months Fighting COVID-19 in Wuhan - Medscape - Apr 14, 2020.