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I am a physician with a doctoral degree in infectious diseases. In mainland China, there are few physicians working on infectious diseases, and fewer involved in their management.
I have always kept a watchful eye on emerging infectious diseases. But this time, COVID-19 almost passed me by.
On January 18, I received one of my patients who I had seen many times. I conducted a physical exam, performed hand hygiene, took blood samples (the patient had a normal white blood count) and a chest X-ray (there were some lung markers). I then suggested that he go home, take a rest, drink sufficient water, take febrifuge if necessary, and revisit me if he developed an unusual severe fever or shortness of breath.
My patient revisited our fever clinic without unusual severe fever or shortness of breath in January 21, whilst I was not on duty.
After two days, I was invited to complete a consultation in the emergency room (ER) and saw the patient again. He had attempted to attend my fever clinic, but had been blocked from admission of patients from Hubei province and directed to go to the ER. He was planning to go to another hospital, then he changed his mind and came back to my clinic. His peripheral blood leukocytes were in progressive decline (9.9, 3.3+, 2.9+G/L) during 5 days, and his lung CT featured with interstitial lesions. All these characteristics indicated viral pneumonia. We sat together and talked about his epidemical history again, the patient apologetically said that one of his colleagues who worked in a different unit on another floor in his office building had been diagnosed as having “the disease” one or two days before.
I immediately contacted the local Center for Disease Control (CDC). I collected his pharyngeal sample by myself in an attempt to control the increasingly panicked atmosphere around me. My colleagues and clinical radiologists had been trained by me to strictly perform hand hygiene, and I myself disinfected the surfaces of equipment and the environment in the fever clinic. Later that day the patient was confirmed as presenting with pneumonia with SARS-cov-2, the5thcase in Tianjin, and the 1stcase in my hospital.
Reviewing back, the patient-centered clinical approach and communication compensated for the blind spots of the patients' perception and the national guidance at the time. It was identifying this 1stcase in my hospital, and the 2ndcase in the patient’s workplace, that helped to control the spread of the virus in my hospital, in his company and in Tianjin. The patient immediately contacted his colleagues working in the same company and his relatives who had a fever - 16 of them were confirmed to be infected with the novel coronavirus. The second case in our hospital was identified during the first 25.5 hour shift.
Ten hours later, I received permission to recruit the first Tianjin medical corps (TMC) to fight the COVID-19 outbreak in Wuhan. This became my battlefield. With their strong hearts, four 80-plus-year-old parents, my wife and my son quickly supported me once again to participate in what was my fifth national medical rescue operation (I had fought SARS, was involved in the relief after Wenchuan, the Yushu earthquakes, and Xinjiang polio emergency tasks). My team left for Wuhan on January 26th.
In Tianjin airport, our mission was “to win the battle, and to achieve zero infection”. For myself, I was confident and capable of achieving this goal, but would be tested by the next 12 days. We did not learn about the transmission dynamics of the disease for some time, but wore face masks in the meantime.
Some experts and I inspected a branch camp of Wisco2ndhospital and went to the 4th floor of a building which had ever been used for admitting patients with infectious diseases, and had been abandoned for more than one year. The layout of the 2nd,3rd and 4th floors were all similar, and designed with three different holding zones (red zone for patients, yellow one for semi-contaminated area, and green one for clean area) and two different channels (for patients and not for patients).
I was appointed into the infection control group as an expert that afternoon. The correct orders of putting on and taking off personal protective equipment (PPE) had not been determined yet. When we compared all of the collected videos on the donning and doffing of PPE, there were inconsistencies. I decided to use recommendations by WHO and by US CDC as a reference, and strengthen the hand hygiene in every doffing step. Five of my infection control team (ICT) had no experience of how to work or use PPE in the red zone. I worked the first three shifts (four hours per shift) on the first working day demonstrating how to wear PPE to healthcare workers (HCWs).
The next day I went to the second floor alone, but found that patients and local HCWs were walking across all zones. The whole floor was now contaminated as red zone. After intensive training on PPE and disinfection methods, I led a new team to decontaminate the floor.
Through the safe green channel hew up in more than one hour we then sent our first group of 20 medical staff to the predetermined red zone, and accepted more than 50 patients with COVID-19.
After 10 hours we sent another two groups of staff in and took two groups out. Every HCW donning and doffing PPE was personally checked by me and my IPC colleagues. This one-on-one checking significantly reduced the exposure risks, and also greatly reassured our team mates who entered into the red zone. This protocol was later praised in a piece of briefing by the national Health Commission. In the following days, we insisted on this practice, corrected risks hidden in the details, and developed good control procedures and habits.
My TMC mates were recruited from 32 hospitals in Tianjin. Many factors, such as their previous training, PPE styles and sizes, and psychological frame-of-mind made it challenging to ensure PPE use was to the WHO recommendations. I tried to encourage the 20% who best adopted WHO recommendations, and found the another 10% who demonstrated and insisted in poor PPE use. The progress to PPE good use was on-going.
In the morning of 30th Jan, I learned that, because they were not trained on infectious diseases, many physicians in other fields were confused as to how they should manage COVID-19 patients. I shared my views of treatment with a group of medical colleagues, and we came to an agreement to formulate a layered management scheme according to the risk factors (SaO2, ageing, complications, etc.), and prioritize patients who needed intensive monitoring and care. I then went into the red zone to work with staff on the frontline. Twelve high-risk patients were screened out, and given more attention.
Our medical team members began gaining confidence working in the red area. After my training, good PPE use and hand hygiene practice became standard amongst local pharmacists, clinical technicians, security staff, cleaning staff, IT staff, and temporary employees for waste transport. We were all equally important and supported each other.
A pay rate of 800 RMB per day (8 hours) was not attractive enough to recruit staff to clean the red zones. I trained our experienced nurses to implement environmental cleaning and disinfection. I was deeply touched when I saw them uncomplainingly laying down their nursing duties and picking up cleaning cloths and mops, lifting the whole bucket of pungent disinfectant to remove the accumulated dirt and growing number of the new virus. They were the most lovable people in this situation.
I trained and taught 39 physicians and nurses from Wisco 2nd hospital how to protect themselves and patients, whilst they would be caring COVID-19 patients in red zone on the 4th floor of the hospital with colleagues from Tianjin. I was in charge of all IPC tasks alone on the 4thfloor. Then another group from two hospitals in Beijin and Xuzhou joined the new team in the 4th floor. I repeated the training to them and trained more trainers to make the system more effective. None of the teams became infected with the new virus during their 4-6 working weeks (tested by PCR, antibody and CT scan).
My experience of managing COVID-19 went beyond our medical corps and Wisco 2ndhospital. Protocols were adopted by many hospitals, care homes, community health centres, and child and maternal healthcare centre across Qinshan district, Wuhan. I worked to provide them with the most effective and available knowledge, skills and behavior to dispel their fear of infection and to improve their practice. Despite treating many hundreds of patients with COVID-19 there was zero infection of our HCWs during their 6 working weeks.
During my days off I continued providing training and conducted interventions on IPC measures to chefs, stewards, cleaners and security personnel. And I paid attention to good PPE use (referencing WHO recommendation) in every shift on the fourth floor in Wisco 2nd hospital to maintain standards.
I am pleased to have been able to contribute what I have learned over the years from visits to the Centre Hospitalier Régional Universitaire de Lille and from the International Conference of Prevention and Infection Control and HIS to protect my colleagues, my team members and everyone around me.
Fighting is going on, and I never leave. I worriedly learned the current COVID-19 situation in UK, I am willing to share my experience to colleagues in UK and in the world.
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