Hospital Spread of Infection, WHO Allowed in China, & N-95 Masks (Lecture 14)
Welcome to another MedCram coronavirus update! So I wanted to go over the recent numbers. And total deaths is a 910. That means that it’s surpassed SARS. Total recovered is a good three and a half times now. The total number of deaths about a week ago, they were substantially below the total number of deaths. So we’re seeing an improvement here in the total number of recovered.
Now, these numbers are provided to us from the WHO, the CDC and a number of other agencies. Recently here, there’s been some news that China seems as though, but the WHO is now being allowed to go in, and that team is being headed up by Dr. Bruce. Aylward, according to the New York Times article. If we look here, or the others, that they have listed. Here is actually on the cruise ship just south of Tokyo. You can see that there.
I wanted to talk about a recent article that was just published in JAMA, the Journal of the American Medical Association, on February 7th, and we will put a link in the description below that links to the article. I think it’s an excellent article, and basically it’s a description of a hundred thirty-eight patients that were admitted to University Hospital in Wuhan and describes exactly what happened to them.
This is an article that looked at patients that were admitted from the first of January until the 28th of January. And at this hospital, there was a total of 138 patients. How do they diagnose these? All of these were positive for coronavirus, but they did not look at serum viral titers or serum viral load. They looked at sputum.
So that’s one of the weaknesses of the study. The other thing I want to mention here is that these are a hundred thirty-eight patients that were sick enough to come to the hospital. That’s really important to understand because this is going to give you a limited look at what happens to patients who are sick enough to come to the hospital and seek medical attention.
So what they noticed in the article is that first of all the patient has symptoms, then they typically developed shortness of breath, then they became admitted to the hospital, and then after they were admitted to the hospital, one of two things happened: either they were admitted to the Intensive Care Unit or they were admitted to the regular floor.
And then we’ll talk about where it goes from there. Now, in terms of timing, that’s important to get to as well. From the time of symptoms to the time of shortness of breath was about five days according to their survey, and then from shortness of breath to admission here at the 138 was two days on average, and then from admission to intensive care, if they were going to go to the Intensive Care, was one day.
So let’s talk about what those symptoms were. First of all, the average age of patients admitted into the study was 56 years old, and unlike previous reports that showed a real high predilection to men, only 54 percent of these patients were male. When I say ONLY, look more like a 50-50 kind of mix as opposed to 60 or 70 that have been shown before.
So what were the symptoms? Fever was seen in 98.6 percent of the patients, kind of an ironic figure given that 98.6 degrees Fahrenheit is the average temperature for human being. Aa fever is defined by the way as a temperature of greater than 100.4 Fahrenheit or 38 degrees Centigrade. Fatigue was seen in about 70% of patients; cough was seen in 59 percent of patients; low lymphocytes, what we call lymphopenia, a common sign that you can see in viral infections, that that was seen in as high as 70% of patients. Prothrombin time, a PT, that sort of a measure of the blood’s ability to coagulate, and when you have a high PT, that means that your blood is a little bit more thin, and that was seen in about 58 percent of patients; and elevated lactate dehydrogenase, which is another lab value typically seen in viral infections, that was seen in about 40%.
Now when they looked at CT scans, 100% of those patients have what they call ground glass opacities, that’s inflammation in the lungs and that’s consistent with what we would see in a viral pneumonia of any type. So in other words, what we’re seeing here is not very specific for coronavirus, but could in fact be seen in the flu, could be seen in other types of viruses that could do this.
One of the things that they saw is that there was a substantial amount that had just nausea and vomiting, and that was kind of unusual. It wasn’t as high as 80 to 90%, but it was there.
In terms of treatment for these patients, almost all of them received oseltamivir, which is a flu medication; also, antibiotics were used on the majority, and in about 45 percent of patients steroids were used. They weren’t really able to tell whether or not any of this stuff had a benefit to the patient. Of course, this study was not designed to look at that.
So let’s look at the 138 patients that came in. The first thing I’m going to mention to you, and we’re going to talk about this at the end, I think this is probably the biggest thrust and the biggest surprise out of this paper, was that 41 percent of these patients, or total of 57 patients, were patients that did not come to the hospital with the coronavirus, but in fact picked it up there. We call that a nosocomial infection.
So yes, there were patients at the hospital that were there for a completely different reason, and they developed coronavirus at the hospital, and there were health care workers that went to work without coronavirus and picked it up taking care of patients at the hospital.
What percent of the patients in the hospital that were treated for coronavirus had that? A substantial; amount 41%! We’ll talk about that at the end of this presentation. So of these 138 patients, regardless of whether or not they came to the hospital with it or not, or develop that there, what happened to them?
So of the 138, and on average after about one day, there was a decision to have them moved to the Intensive Care Unit. About 36 patients, or 26 percent, of the 138 went to the Intensive Care Unit, and 74% were stable enough to be admitted to the regular floor.
So let’s focus our time a little bit on what happened to the patients in the Intensive Care Unit. So why did they have to go to the Intensive Care Unit? Well, there are many reasons why somebody could go to the Intensive Care Unit. For instance, they could go into ARDS; they could have serious arrhythmias, or they could go into shock.
Sometimes you can have more than one of these things, so don’t expect all of these things to add up. But if you look at of the 138, how many of them had ARDS? 16 percent of patients admitted to the hospital have to go to the Intensive Care units for ARDS reasons. Of the people who are admitted, 12% of the 138 had arrhythmias, and eight percent of people admitted to the hospital had to go to the Intensive Care Unit because of shock.
Now if you want more information on ARDS, please look at our ARDS video, How Coronavirus Kills, and that describes what ARDS is in detail. And what are the treatments that the Intensive Care Unit can use to treat these kinds of things?
Now, of those that went to the Intensive Care Unit, what kind of oxygen supplementation do they need? There are three basic types of oxygen supplementation that you’ll see in the Intentional Care Unit. One is known as high-flow oxygen. The other is non-invasive positive pressure ventilation. This is kind of like CPAP, but it’s actually called BiPAP because the ventilator helps you when you take a breath in, so it gives you a higher pressure when you’re breathing in, and lower pressure when you’re breathing out. We call that non-invasive positive pressure ventilation, and then, of course, full-out ventilators.
So of those people that went to the Intensive Care units, how many have to go on high-flow? 11%. How many have to go on non-invasive positive pressure ventilation basically wearing a tight mask? 42%. And how many actually have to go on the ventilator? Up to almost half the patients, 47%. And of those people, 4 patients have to go on ECMO. ECMO is basically where you bypass the heart and lung on a machine to oxygenate the patient until their lungs get on inflamed, or they recover from the infection.
那么，那些去了重症监护病房的人中，有多少人必须坚持高流量？ 11％。基本上要戴好口罩的无创正压通气要进行多少次？ 42％。到底有多少必须使用呼吸机？多达近一半的患者，占47％。在这些人中，有4名患者必须接受ECMO。基本上，ECMO是您在机器上绕过心脏和肺部给患者充氧的方法，直到患者的肺部发炎或从感染中恢复过来。
So overall, you can see that these patients, which were fully in the phase of the viral infection where patients were coming to the hospital, they were very sick. We can see here that of the 138, a quarter of these patients, more than a quarter, are going to the Intensive Care Unit, meaning that this cohort look to be a little bit sicker than previous descriptions.
Again, I caution you to understand that this 26 percent is not 26 percent of all people who get coronavirus infection, but rather 26 percent of people who get coronavirus infection and then develop symptoms severe enough to have to have them into the hospital.
So let’s talk about what’s happened to these patients. So the last update, as of February 3rd, 2020, let’s get an update, of all of these 138 patients, 47 patients have been discharged home. There have been six patients that have died, and the remaining 85 patients are still in the hospital. So, the six that have died out of the 138 leaves us with a mortality of about 4.3 percent. That’s the base of the mortality based on the hospitalization because we don’t yet know what’s going to happen to these 85 patients.
Let’s talk a little bit about what happened to these people in the ICU specifically. So there were 36 people that went into the Intensive Care Unit. What has happened to them since they were admitted to the hospital? Well, of those 36 patients, we know based on the report that 11 still remain in the Intensive Care Unit, that nine have been actually discharged home, that 10 have gotten well enough to be transferred to the floor, and that all of the six that died, all of them were in the Intensive Care Unit.
So you can see here that of the 36 that initially came in, nineteen of them have improved to the point where they are either gone home or on the regular floor, and 11 still remain, and we’re going to see where that goes.
Okay, let’s talk about 57 patients of the 143, or 41% of them, develop the infection in the hospital. Of those 57, 17 of them were actual patients that were in the hospital for another reason, but a full 40 of these were healthcare workers.
Let’s go back to these 17 patients that were there. They said that 7 of them were on the surgical ward, and that 5 of them were on the internal medicine ward, and that 5 of them were on the oncology ward. Now, of these 40 patients that were actually healthcare workers there at the hospital, 31 of them, or 78%, were working on the wards. 7 of them, or 18%, were in the emergency room, and 2, or 5%, were working in the Intensive Care Unit.
They talked about in the paper, about 1 patient who presented with nausea and vomiting, which we said was kind of a typical, and he was admitted to the surgical ward while he had coronavirus, and they believe based on history and based on deductive reasoning that about 10 people were infected because of his symptoms and his virus.
So what this paper highlights, I think, is the transmissibility of this virus. And what we really need to highlight here is hand washing, and the key here is that you’ve got to wash for 20 seconds, and as we’ve said before that’s like singing Happy Birthday twice. Wash your hands with soap, and you need to do this before, of course, before you go into a patient’s room, before you put on gloves, before you are done a gallon, and you need to do it after. And why is that? Because you’re using your hands to take off your personal protective equipment that would have the virus on there and really avoid touching your face with your hands.
Now, what about masks? Well, if you are suspicious that the person that you are about to examine has the coronavirus, and you are a healthcare worker, they’re recommending n95 masks. If you suspect that the patient is the one that has the virus, then they ought to be wearing a regular surgical mask in addition to n95 masks. So this is for the patient, and this is for you. As a healthcare worker, you should also be doing eyewear protection. And you can see what the workers over in China are now currently wearing. They got the message. They understand what it is that’s going on, and they’re going to make sure that that doesn’t happen again.
And what this article, I think, really shows is the delicate balance that you have to strike when you have patients with a virus coming into a setting where there are other patients that don’t have the virus. And I believe that is really the thrust as to why they are building these hospitals dedicated to the virus so that they don’t cross-infect other people, other health care workers, and that they can have the infrastructure in place to deal with the contamination that can occur in these places.
Please stay tuned for other videos that we’re going to really delve into what it is that you either as a healthcare individual, or as a citizen, can do to improve your chances of not getting the virus. Or number two: if you do get the virus, beating it. So stay tuned for those videos coming up.