Steve Quayle News Alerts

March 28, 2003
Judy Gerstel, Health Editor

With his 10-week-old twins sleeping in the next room, Dr. Randy Wax, an intensive care physician at Mount Sinai Hospital, sat down at his computer a couple of Saturdays ago. What he saw on the screen made his skin crawl. It was an e-mail posting from a Hong Kong colleague.

As an intensivist, which is what critical care doctors call themselves, Wax specializes in tricky medical situations. The 1994 graduate of the University of Toronto Faculty of Medicine did post-grad work in critical care medicine at the University of Pittsburgh. He's taught simulation-based resuscitation. He serves as a flight physician with an airborne critical care team. He is no stranger to crisis situations and trauma.

But Wax knew that the mysterious respiratory illness wreaking havoc and putting doctors on respirators at Hong Kong's Prince of Wales Hospital was the same illness they were dealing with at Mount Sinai in downtown Toronto. Dr. Tom Buckley's e-mail, dated March 16 ÷ Hong Kong is 13 hours ahead of Toronto ÷ described the situation in the intensive care unit at Prince of Wales Hospital in Hong Kong, where they were dealing with a severe form of pneumonia that nobody could identify or knew how to treat. Worse, the people caring for the patients were getting sick in droves, some of them so seriously that they might not survive.

Wax thought about three patients at Mount Sinai, all members of a family that had already lost two adults to an atypical pneumonia.

Three members of that family had travelled to Hong Kong.

Wax found comfort in knowing that the Mount Sinai patients were in isolation and that everybody caring for them was wearing gowns, gloves and special surgical masks that block viruses.

"I think I'm at very low risk," he says. "I'm worried for everybody, but I think we should be okay."

But at Prince of Wales Hospital in Hong Kong, they weren't okay. Buckley, a New Zealander with 15 years of experience in Hong Kong hospitals, was at the front line of a battle with an unknown, stealthy enemy.

In two weeks, the count climbed from one patient with severe acute respiratory disease to 163 as of Wednesday. More than half are health care workers; some are on respirators.

Buckley has been working around the clock, sleeping on his office floor and trying to quell the panic and maintain the morale of a vulnerable and rattled staff.

At the same time, since March 16, he's been posting a diary on an Internet site for physicians.

March 16:

"So just a brief summary of our experience. Male arrives on medical ward having been admitted thru (Emergency). Other patients and STAFF start to develop symptoms ÷ fever, headache, dry cough. Unresponsive to various combinations of cefotaxime, chlarithromycin, levofloxacin, doxycylcline 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.

"Patients visitors, medical consultation staff, medical students visiting patients have all developed symptoms...

"So far 2-3 of our older patients with chronic disease have deteriorated fastest. Medical staff ÷ younger and fitter ÷ have fared better.

"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 elective surgery is being cancelled and wards are being closed and evacuated. All ambulances are being diverted.

"We are taking strictest possible isolation procedures available to us including hand washing, gloves, gowns, N95 masks and visors.

"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."

Poignantly, Dr. Buckley closed his March 16 e-mail posting with an appeal.

"Any suggestions will be gratefully received."

Among those who responded was Wax, who had been off work the previous week.

He says, "I e-mailed Tom to let him know that a physician in Toronto had been admitted to hospital with SARS. I wasn't sure what infection control was taking place, but before the disease was recognized, infection control procedures probably were not done at that time. I was going to work the next day in our ICU and knew that we did have some SARS cases in the hospital and I told him that I was hoping that with appropriate precautions we'd all be safe here in Toronto."

Late that night, Buckley wrote back: "Surgeons, physicians and ourselves decided unilaterally to invoke our own standards. ... Public Health Officials have downplayed the outbreak. ... If ICU staff contract this pneumonia then we are well and truly up the creek."

He posted this update:

"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 rigours with high fever.

"Chest x-ray may initially be clear but then changes start on Day 3-4.

"We now have 80 cases of atypical pneumonia in this hospital (64 yesterday) and more than 50 per cent are either health care workers or medical students.

"ICU is seeing the serious cases of the first contacts. We are all waiting apprehensively to see if there is a second wave.

Late in the afternoon of March 17, he wrote:

"Events are starting to overtake us in terms of case load...We will have to start thinking about triage of cases!!!

"All staff who have had direct contact with this (medical) ward have developed the illness within 4-5 days.

"Visiting relatives to other patients have developed this illness.

"Most worrying is that TWO of my nurses are sick. One had contact with the infected ward when she visited a friend.

"Nurses are extremely upset."

Buckley also sent e-mails to correspondents:

"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.

March 18:

"Current number of cases in hospital 97...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. . . .

"Staff morale throughout our hospital critical. I have spent several hours talking with nurses who have a great deal of anxiety. They are coping well ÷ maybe because they feel they do not have a choice."

March 19:

Dear All,

"Yesterday was a bad day. 7 admissions to ICU. 10 new cases admitted to hospital all in association with the original ward outbreak. Unfortunately, 2 died last night.

"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.

"Back into it."

Later March 19:

"The whole hospital is being sealed off.

"Infection control measures include (in ICU):

"Gown, gloves, hand washing and hand wash, hairnet, N95 mask, surgical scrubs, visors for all patient procedures.

"Hypochlorite deep cleaning of all surfaces.

"Hepa filters.

"Education.

"Encouragement of antisocial behaviours, e.g. not eating together, going outside hospital for meals.

"Personal hygiene ÷ showers, hand washing.

"Space suits being investigated as are N100 masks. ...The problem is that there is such a variety of face shapes and sizes...I obtained all seven N100 masks in Hong Kong and the nurses report favourably on these."

March 20:

"The number of cases continues to increase in our hospital.

"So far no staff have contacted this apart from those with initial contact. However staff are being stretched to the limit especially the nurses.

"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 pneumonia."

March 20"It was announced on the news early this morning that the Department of Health's investigation is centred on a hotel in Hong Kong. Visitor from China developed symptoms. Stayed two days at this hotel and was visited by approximately 9 people including person who later died in Toronto."

March 21:

"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.

"Last night senior (staff member) rang me to say she was resigning. She is petrified. HK government is downplaying 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.

"It also appears to be out in the community. GPs are being admitted."

March 22:

"Cases continue to improve but at a slower rate. Patients on the ward improving. Physicians believe it is the pulse steroids.

"Second wave is actually quite small. I think this is a reflection on the hospital contact team who have done an incredible job.

"My greatest worry appears to have come true. One ICU nurse ill earlier in the week has come down with this. While she is okay, I cannot account for her as a primary contact."

March 23:

"There are now 145 confirmed cases in the Prince of Wales Hospital. New cases (first contact) tend to bring their families (second contact).

"The outbreak within the hospital appears to have been contained but it has put an enormous strain on the system.

"New cases include immigration office, ambulance man, family physicians x 5, and a pediatrician."

March 24:

"The situation is broadly under control within the Prince of Wales Hospital, but this pneumonia is out there in the community. The numbers are increasing daily. Official figures of the outbreak in Guangdong province are 300 cases with 5 deaths. Unofficial (report) has the numbers much higher."

March 25:

"I hope this is not the calm before the storm. The hospital is stable.

"Number of admissions to hospital still climbs steadily.

"Nurses who have worked in highly contaminated areas are ill.

"What is apparent is adherence to technique is just so important. We have paid attention to the minutest detail ÷ telephone handling, computer keyboards, door handles, handling food.

"10,000 N100 masks have gone to Iraq!!"

March 26:

"Reported on the news that this is now in Beijing.

"This is a real roller-coaster in terms of our emotions.

"What is even more scary is that: 1. Schools have not been closed; 2, The `sevens' rugby tournament is still going ahead this weekend; 3, The Rolling Stones are due in HK this weekend.

"Politicians will not take the tough decisions. When they do it will be too late."

March 26:

Buckley told the Asian Wall Street Journal newspaper that the situation "seems to be a lot quieter."

He said his colleagues keep telling him that he looks exhausted.

He also said he planned to go with his family to see the Rolling Stones perform today if the rock group doesn't cancel.

"We will all be wearing masks," he said.

Later that night, the Rolling Stones cancelled their Hong Kong concerts.

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