Novel coronavirus pneumonia: 6 front-line doctors

Wen Jie Wu Jing On February 24, a month after the closure of the city, Wuhan, which was alternately attacked by snowstorms, rain and air-conditioning, had its lowest temperature continuously set above zero At the new crown fever clinic in the early morning of each major hospital, painful patients and crowded people are almost gone At the end of January, when the outbreak was the most serious, the emergency department once rushed into hundreds of people overnight, and it is also slowly cold The number of newly diagnosed patients is decreasing, and the patients are isolated and treated in isolation point, shelter and designated hospital according to the degree of illness The burden of outpatient and emergency care is gradually relieved What is still breathless is the breath of death in the critical and critical wards The novel coronavirus pneumonia death rate in Wuhan was 17 before January 22nd, and 1987 days after the death of the city The total number of deaths in the country reached 2596, far exceeding the total number of deaths in the SARS period In more than one month, although the number of critical medical workers coming to Wuhan from all over the country reached 11000, close to 10% of the national resources of critical medical workers, it failed to prevent the rise of the death toll According to statistics, the mortality rate of Wuhan patients is still as high as 4.26% In the intensive care unit, death is very common After the medical staff tried their best, some patients still died Some doctors and nurses, at some moment, felt frustrated and only slept by sleeping pills In addition to the shortage of severe beds and equipment, more importantly, in front of this new virus, some of the previous experience in the treatment of viral pneumonia will be overturned and come back again Many of the current experience has not passed the test of time, and the treatment of severe patients is controversial △ on February 19, 2020, the rescue room of the outpatient department of Central South Hospital of Wuhan University Wu Jing she The day before the closure of the city, Zheng Ruiqiang, director of the Department of critical medicine of Subei people's Hospital of Jiangsu Province and one of the members of the treatment expert group of the National Health Care Commission, received a call, and Wuhan Pulmonary Hospital was in urgent need of support At this time, Hu Ming, director of ICU of lung hospital, has been working for more than 20 days, exhausted That night, Zheng Ruiqiang arrived at the lung hospital At that time, a patient needed rescue He went to the operating table without saying anything Qiu Haibo, Tong Zhaohui, Du bin, etc of the treatment expert group have also arrived in Wuhan at this time They are stationed in ICU Wards of Jinyintan hospital, Pulmonary Hospital, Central South Hospital, people's Hospital of Wuhan University and other hospitals They rescue critical patients together with local doctors of critical medicine In the early stage of the epidemic, the number of beds in ICU was very limited In each hospital, 2% - 5% of the total beds were occupied Many critically ill patients could not enter the ICU, so they had to stay in the newly isolated ICU The increase rate of patients is far faster than that of new wards The death rate of critical patients in these critical wards is very high The first group of medical teams from Shanghai came to support Jinyintan Some medical staff took over a critical ward on January 27, where more than 30 patients lived At the beginning, 2-3 people died every day This ward is temporarily reconstructed from the general ward of the surgical building, which is called the critical ward In fact, there are only more medical oxygen machines and monitors A nurse recalled that "according to our previous experience, all the patients in the hospital should live in ICU", but the original ICU ward of Jinyintan hospital had been full for a long time Just because you live in an ICU doesn't mean you can be rescued Lung department hospital and Jinyintan hospital are the first designated hospitals for the treatment of critical patients They do not have fever clinics, but specially receive critical patients and severe patients transferred from other hospitals In the early stage, some patients had a rapid onset and were seriously ill In addition, 120 vehicles were in short supply, so the turnover between hospitals was not smooth When they were really sent to Zheng Ruiqiang and Hu Ming, they were already dragged to the point of "dying" "It's like a person falling into the water He's flapping back and forth It's too late for you to save him when he's exhausted." Hu Ming said that this situation lasted for a long time On February 17, they received 30 transferred patients at one breath, "but many patients came in shock." From the beginning of the epidemic to now, many designated hospitals are trying their best to expand the number of ICU beds, such as Jinyintan hospital At first, there were only ICU rooms on the seventh floor of the south Later, there were more ICU beds on the fifth floor and the sixth floor of the south So were lung hospitals The number of ICU beds increased from 10 to 20 Some doctors estimate that there are about 400 ICU beds in Wuhan These 400 beds are still far from enough The treatment time of critical patients is about one month, and the bed turnover is very slow Zheng Ruiqiang has been here for one month In his ICU ward, there are 10 beds in total, only four or five of them have been transferred out, and four or five of them have died The newly admitted patients are only about 10, while the average time for the transferred patients to stay in the ICU is four weeks △ on February 18, 2020, the doctor's rest area on the 13th floor of the inpatient department of Wuhan Pulmonary Hospital Wu Jing she One of the problems that make Zheng feel headache is that in the early stage of the disease, some severe patients are very tolerant to hypoxia That is to say, the oxygen concentration in the air inhaled by the normal person is 20.9%, while the oxygen concentration that the patient can inhale into the lung is less than 20.9% due to the impairment of the lung function, but in this case, the performance of the patient is no different from that of the normal person, and it is difficult for the medical staff to judge the abnormality When Zheng Ruiqiang went to a designated hospital with weak rescue ability, he often found that some patients seemed to breathe as much as normal people, but in fact, when he checked the blood oxygen saturation (in medicine, the blood oxygen saturation is usually used as a parameter to observe the patient's breathing and circulation, that is, the blood oxygen concentration), only more than 80%, which is much lower than 98% of normal people At this time, the negative impact began, "because of the lack of oxygen, the patient will breathe hard, which is a damage to the lung itself" The false image in the early stage led to some medical staff to form a wrong judgment, "it seems that the patient is good, but if you ask, he will feel uncomfortable, fidgety and so on." Previously, there were media reports that some nurses thought it strange that they had a good speech with a patient yesterday The next day at work, he died suddenly "It seems that it's gone suddenly, but in fact, hypoxia and its impact on patients have existed for some time." In Wuhan, in the early days, these patients had almost no respiratory support except for taking antiviral drugs Unless the patient is aware of breathing difficulties, the medical staff will give high flow nasal catheter oxygen therapy There are two reasons for this situation: first, the lack of manpower, unable to detect the patient's oxygen saturation in real time; second, the oxygen supply in overcrowded hospitals can not meet the needs of so many patients In the designated hospitals with strong ability, usually with sufficient oxygen supply, they will give high flow nasal catheter oxygen therapy or noninvasive mechanical ventilation to these severe patients with decreased blood oxygen saturation in time, which are simple and easy to implement respiratory support The new coronavirus has obvious lung damage and respiratory support is very important, but it is not omnipotent "Noninvasive oxygen inhalation and high flow oxygen inhalation are of course simple When there is lack of oxygen, you will increase the oxygen supply concentration to 100%, which is not adjustable," said Zheng Ruiqiang "When the oxygen concentration goes up, but the patient's efforts to inhale cannot be controlled, the lung function may be damaged." Many experts believe that, unlike other viral pneumonia, this disease can use non-invasive ventilator and high flow oxygen to relieve some patients' symptoms, but for some severe patients whose lung function has been damaged, this way is difficult to solve the problem Research shows that these critical patients often face multiple organ failure, such as severe myocardial damage, renal failure, circulatory failure and so on, in addition to respiratory failure The index of troponin, a marker of myocardial damage in some critical patients, is even 10 times higher than that in patients with myocardial infarction Although the fifth edition of the guidelines states that when respiratory distress and / or hypoxemia cannot be relieved after standard oxygen therapy, high flow nasal catheter oxygen therapy or noninvasive ventilation may be considered If the condition does not improve or even worsen in a short period of time (1-2 hours), intubation and invasive mechanical ventilation should be carried out in time But there is a great controversy among doctors about invasive intubation Doctors from respiratory department are generally opposed to it They are worried that at the moment of intubation, the droplets splashed from the patient's throat form aerosol, which makes the medical staff face a greater risk of infection Luo Fengming, deputy director of respiratory and critical care medicine department of West China Hospital of Sichuan University, also worried that after intubation, patients will face secondary risks such as bacterial infection, because when intubation is performed, the airway is opened, and the barrier function is lost "We originally had the function of filtering in the upper respiratory tract, and the risk of fungal infection is greater after intubation." More importantly, "is there any evidence that early intubation is effective?" Luo Fengming expressed his confusion He led the West China medical team to support the Red Cross Hospital Six patients were intubated and five died In Luo Fengming's novel coronavirus pneumonia, interstitial lung disease (interstitial inflammation of the lung, mostly caused by virus, is irreversible pulmonary disease) It is obvious that in his past treatment experience, many patients with intubation have poor therapeutic effect Our hospital has counted that even if he is transferred to ICU tube, most of the patients with interstitial lung disease must be treated Death, so I think most intubations should be careful " In addition, in practice, intubation treatment is equivalent to surgery, but also requires the signature of family members and myself In this large-scale treatment period, communication costs are too high On the contrary, most of the doctors insist on early intubation, just like Zheng Ruiqiang, "if early intubation, 50% of the patients with severe diseases have hope." Zheng Ruiqiang believes that after the use of invasive intubation, doctors and nurses can calm and relieve pain for patients, and let patients breathe less After more than one month's observation, Xu Haibo, director of imaging department of Central South Hospital of Wuhan University, proved the importance of early intubation from the change side of lung CT: "lung lesions are light at the beginning, with low density and light thin type After three days, the lung will undergo consolidation immediately According to my experience, the next 5-10 days is the critical period, which determines whether the person is dead or alive." "Don't look at his symptoms now If he doesn't intubate, protect his lungs from rest and exchange blood oxygen, the patient will die immediately." In addition, in the early treatment, Zheng Ruiqiang has found that many patients have the outflow of nitrogen dioxide and respiratory acidosis when making tracheoscopy for patients Although the amount of sputum is not much, there is often this kind of jelly like mucus sputum at the far end, which is very viscous In other words, some patients may be suffocated if they do not have early intubation intervention and suck out the sputum △ on February 7, 2020, the emergency gate of Wuhan Red Cross Hospital has been surrounded Wu Jing she Before all the confirmed patients were admitted to the designated hospital in Wuhan (24:00 on February 5), Zheng Ruiqiang did two things every day: go to some designated hospitals to get out the "real severe patients" and transfer them to the ICU of the pulmonary hospital for treatment He is not alone in doing so There are 9 teams in total, each of which is composed of a member of the expert group of the national health and Health Commission and a local expert in Wuhan