SARS resources and comments

[Dave Farber <dave () farber net>]

------ Forwarded Message
From: "Steven J. Davidson" <davidson () pobox com>
Reply-To: "Steven J. Davidson" <davidson () pobox com>
Date: Sun, 16 Mar 2003 22:14:20 -0500
To: dave () farber net
Subject: SARS resources and comments

Dave, for [ip] as you see fit.
/Steve
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This is the best source for knowing what's up in the US and a good source
for keeping track of the world-wide situation:

CDC updates on SARS
http://www.cdc.gov/ncidod/sars/

What follows are two sets of comments directly from the frontlines in the
ICU in Hong Kong shared over the emed-l mailing list for emergency medicine.
I've forwarded this report so that people have facts.

Note that ICU staff are not going home to their families.  As a physician, I
find that observation chilling.

Regards to the list./Steve
--
Steven J. Davidson, M.D., M.B.A., Chair, Dept of Em Med
Maimonides Med Ctr., Brooklyn, NY (718) 283-6030
Read my column "Leadership Outlook" from EMN
at  http://www.emedconcepts.com

-------------------------------------------------------------------
Tom Buckley writes:

Thank you for your support.  I have no problem with posting to another list.

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.

What you see and read on CNN, BBC etc is 24 hours out of date.

Regards

Tom Buckley Consultant Intensivist
Department of Anaesthesia and Intensive Care
Prince of Wales Hospital Shatin, Hong Kong

ph (852) 2632-2735 (W)
fax (852) 2637-2422 (W)
ph (852) 2791-6434 (H)
fax (852) 2791-6394 (H)
email tombuckley () cuhk edu hk

-------------------------------------------------------
Date: Sun, 16 Mar 2003 11:40:18 +0800
From: Tom Buckley <tombuckley () cuhk edu hk>
Subject: Re: WHO statement on SARS

Dear All,

I have not read all of the below because we seem to be close too or are the
centre of this form of atypical pneumonia.

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. Patients invariably have a low WCC and maybe thrombocytopenic.
Patients invariably have an elevated CPK.  No ECG changes and Troponin T
negative.  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.
Once intubated however they remain relatively static but very oxygen and
PEEP dependent.  Those ventilated have solid lungs.  Interestingly one
patient developed a pneumothorax on the medical ward and after chest drain
and re-expansion his pneumonia involves only the side without a chest drain.
Another patient (ventilated) has developed surgical emphysema.

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.

Tom Buckley Consultant Intensivist
Department of Anaesthesia and Intensive Care
Prince of Wales Hospital Shatin
Hong Kong

ph (852) 2632-2735 (W)
fax (852) 2637-2422 (W)
ph (852) 2791-6434 (H)
fax (852) 2791-6394 (H)
email tombuckley () cuhk edu hk




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