Battling SARS in Hong Kong: An Expert Interview With Thomas A. Buckley, MD

[Guest guest]

Hi All,

 

See this, from Medscape, today, at

http://www.medscape.com/viewarticle/455489

 

NOTE that there is NO mention of use of TCM to treat SARS in that article.

Phil

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Battling SARS in Hong Kong: An Expert Interview With Thomas A. Buckley, MD

Alfred J. Saint Jacques, MBA

May 14, 2003 — Editor's Note: The earliest cases of severe acute respiratory

syndrome (SARS) started to appear in November 2002, but evidence of an

outbreak outside of the initial cases did not occur until a couple of months

later,

in 2003. When cases of this aggressive disease started to show up at the

Prince of Wales Hospital in Hong Kong, Thomas A. Buckley, MD, recognized it

as an unusual entity and started looking for answers. He reached out to

colleagues on the Internet and started to describe individual cases. When he

realized that this was a new entity, he then started reporting to colleagues who

had not yet heard about the outbreak or needed more information. He also told

of the toll SARS was taking on the staff, as many became infected.

Despite being in the middle of this overwhelming outbreak, Dr. Buckley

continued to report conditions and insights that helped other clinicians deal

with

the outbreak as it arrived on their doorsteps?in the U.S., Canada, and

elsewhere. He provided tips and made observations that are being used as

standard guidelines in practice today. He also went on to warn that the

incidence of cases was not being reported accurately by the Hong Kong

government at that time.

Although the SARS epidemic shows signs of improving, it is certainly not over.

To discuss the current situation in Hong Kong and gain further insights,

Medscape's Alfred Saint Jacques interviewed Dr. Buckley, who is adjunct

associate professor and consultant intensivist at the Chinese University of Hong

Kong.

Medscape: Could you describe the current situation in Hong Kong and how it

has evolved over the last few days?

Dr. Buckley: The situation in Hong Kong is improving. Single-digit figures of

new

cases per day seem to be the norm, and there appear to be no new " hot

spots. " At Princess Margaret Hospital (PMH) where I am working now, there

are only 10 SARS patients in the ICU. Many will have a difficult time weaning

from mechanical ventilation over the next few weeks. With so few cases now in

PMH, the hospital is looking at reopening for non-SARS cases.

Medscape: A number of news reports have said that the government of China

has not been cooperating with the World Health Organization (WHO) regarding

disclosure of SARS cases and mortality. Please tell me how that is going in

Hong Kong and what kind of impact it is having on your ability to treat existing

SARS patients.

Dr. Buckley: The big unknown is, of course, China. While Hong Kong's

numbers are declining, the same is not true in China. Hong Kong therefore

remains at risk from SARS because of its proximity to China.

Medscape: What are the issues and obstacles that you are facing right now,

and how are you handling them?

Dr. Buckley: My main concerns at the moment have to do with the rebuilding

and restructuring of the intensive care unit at PMH. The intensive care unit

will

expand from 14 beds to 24 beds with the possibility of a 14-bed Infectious

Diseases ICU. With so many doctors and nurses in the ICU having contracted

SARS prior to my arrival, I am left with the task of finding staff to care for

this

expanded ICU.

Medscape: What kind of precautions are you and other medical staff members

taking to avoid getting SARS?

Dr. Buckley: A control center has been set up in the lobby near the elevators

adjacent to the four ICU wards that contained SARS patients. Central to this

control center are staff specifically designated as " policemen. " Their role is

to

educate and ensure compliance with the infection control policies established.

On exiting the elevator, staff should:

Wearan N95 mask previously fit-tested.

Washhands.

Put on a hat, goggles, face shield, inner material gown, and outer

paper/plastic gown.

Washhands.

Put on latex gloves.

Staff cannot enter the ICU unless they have complied with the above. There are

no exceptions. A " policeman " has the central role of ensuring compliance with

these protocols. Central to SARS prevention has been staff education, with all

staff attending courses and undergoing practical assessment.

Within the ICU, SARS precautions are related to:

Patientfactors — closed system suction, HEPA filtration systems or full

face shields for procedures, and removal of bodily wastes.

ICU environment factors — scavenging, ventilation, viral filters, cleansing,

and covers for computers and telephones.

Medscape: Have those precautions been successful in keeping staff from

getting SARS?

Dr. Buckley: Yes. Since I arrived at PMH and implemented these guidelines, no

further staff have contracted SARS. There was one medical staff member who

became ill two days after I arrived, but this person was probably incubating the

disease from exposure prior to these guidelines being imposed.

Medscape: Have you been in contact with WHO on a regular basis?

Dr. Buckley: I have had no contact with WHO members at all. That is not to

say that the hospital hasn't.

Medscape: What clinical insights could you provide your colleagues in case

they have to diagnose and treat SARS patients?

Dr. Buckley: Here are a few things that clinicians must know:

The hypoxemia is severe and the CXR can deteriorate rapidly. Patients

desaturate at the slightest provocation — talking, movement, coughing.

Thereis a preponderance of barotrauma, even in nonventilated patients —

pneumothoraces, pneumomediastinum, and surgical emphysema.

Weaningfrom mechanical ventilation can be difficult and prolonged. While

oxygenation eventually improves, many patients are easily fatigued.

Do not use a nebulizer. This is probably the single most important factor in

the spread of droplets on the medical ward at the Prince of Wales

Hospital in early March. The patient who received the nebulizer was

later identified as the index case for that hospital. Many patients,

healthcare workers, and relatives who entered that ward contracted

SARS.

Medscape: Can you provide some critical care insights that you have learned

since this outbreak started? Are you doing things differently in order to stop

the

spread?

Dr. Buckley: Infection control education and enforcement is the key to

preventing staff from contracting SARS. It is extremely important to centralize

and coordinate supplies so that they are readily available when the first case

arrives in the emergency department, not after the first contact.

The term " universal precautions " is redundant. In the future, infection control

measures will come to dictate how we initially interact with a patient.

Healthcare workers and, in particular, community-based family physicians will

have to assume a patient has an infective process until proven otherwise.

Medscape: What have you and other staff members been going through in order

to get through this crisis?

Dr. Buckley: It has been extremely worrying for healthcare workers, not only for

the patients but also for their own personal safety and their families. While

the

extreme anxiety that was evident at the very beginning may have subsided, it

has been replaced by a more chronic level of anxiety. I am sure many

healthcare workers will be reassessing their priorities in life.

Medscape: What other insights to this crisis can you provide?

Dr. Buckley: Hospital design will improve as a result of the SARS outbreak in

Hong Kong. It is quite evident that many hospitals are not designed to cater to

the possibility of an outbreak of an infectious process. Hospitals have been

turned upside down in Hong Kong to protect staff. Future improvements will

occur in hospital ventilation systems as well as isolation procedures and flow

of

patients and healthcare workers in the hospital setting.

Medscape: Do you see an end in sight to the SARS epidemic in Hong Kong

and China?

Dr. Buckley: Hong Kong appears to be settling down, but China remains an

unknown quantity. Medical staff are in short supply and the medical facilities

in

rural areas are rudimentary. These factors may have an enormous impact on

the eventual outcome in China.

Reviewed by Gary D. Vogin, MD

 

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Best regards,

 

 

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