One month after the death of Dr. Li Wenliang, Wuhan Central Hospital suffered heavy losses. On the morning of March 9, Caixin reporters confirmed from multiple sources that Zhu Heping, the retired deputy chief physician of the Ophthalmology Department of Wuhan Central Hospital, died of COVID-19 at the age of 66 after rescue efforts failed.
Zhu Heping is the fourth doctor in Wuhan Central Hospital in a month and the third doctor in ten days to die from COVID-19 infection. He is also the third person to die in the ophthalmology department of the hospital. Previously, the hospital’s ophthalmologist Li Wenliang, chief physician of thyroid and breast surgery Jiang Xueqing, and chief ophthalmologist Mei Zhongming died in the line of duty on February 7, March 1, and March 3 respectively.
At present, at least one deputy chief physician of the cardiothoracic surgery department and one deputy chief physician of the urology department of Wuhan Central Hospital are also hospitalized in Wuhan Pulmonary Hospital due to infection with new coronary pneumonia. "They are all on ECMO and are in critical condition," a head nurse at the hospital told Caixin reporters.
According to figures obtained by Caixin reporters, more than 230 people have been diagnosed with COVID-19 at Wuhan Central Hospital, which has more than 4,000 employees. Although the total number is still smaller than that of several major hospitals in Wuhan, the proportion of infections among medical staff and the number of deaths are still high. They all rank first among hospitals in Wuhan.
“Our understanding of the pathogenic mechanism of the new coronavirus is still very limited, and we cannot scientifically explain why so many outstanding doctors in the Central Hospital died of new coronavirus pneumonia. But we at least know that so many medical staff are infected, which is related to our medical staff. It is related to the fact that the hospital has been on the front line of the epidemic from the beginning, and it is also related to the so-called "outside loosening and internal tightening" before January 20, which led to a large number of nosocomial infections," a department director of the hospital concluded to a Caixin reporter, "It is related. Department personnel do not spread misinformation that is preventable and controllable, so that more people can Hundreds of doctors and nurses devoted themselves to treatment without knowing about the epidemic, and even after falling ill, they were unable to report it to the relevant departments. Their sacrifices could not alert their colleagues and the public in time, which is the most painful loss. and lessons learned.”
A published internal material
Recently, Caixin obtained an internal material from Wuhan Central Hospital, titled “Instructions on the Response to the Novel Coronavirus Epidemic” (hereinafter referred to as “Instructions on the Epidemic Response”). Several doctors from Wuhan Central Hospital told Caixin reporters that the internal material was true. The Publicity Department and Public Health Department of Wuhan Central Hospital declined to respond to this matter.
The "Epidemic Disposal Instructions" shows that on the afternoon of December 29, 2019, the emergency department of Houhu Campus of Wuhan Central Hospital received 4 patients from the South China Seafood Market. CT and blood tests were all manifestations of viral pneumonia. . The Public Health Department of the Central Hospital reported these cases to Wang Wenyong, chief of the Transmission Prevention Department of the Jianghan District CDC. Wang Wenyong responded that he had recently received similar reports from other hospitals, but they were sent to the city to check for various pathogens with no results. Regarding the cases in the central hospital, he would report to the leaders before replying.
The Public Health Department of the Central Hospital immediately notified the Medical Office to organize a consultation with experts in the hospital, and notified the hospital’s Infectious Disease Office to carry out disinfection and isolation. At 16:00 that day, after consulting the emergency department, the respiratory medicine expert of the hospital found that there were also several cases in the respiratory medicine department from the Huanan Seafood Market, and the number of cases increased to 7. Half an hour later, the Public Health Department called Wang Wenyong from the Transmission Prevention Section of Jianghan District Center for Disease Control and Prevention and Jin Xiaomao, director of the Emergency Office of Wuhan Center for Disease Control and Prevention again to report the situation. At around 20:00 that night, the District Center for Disease Control and Prevention and the Municipal Emergency Management Office arrived at the Houhu Campus of the Central Hospital, conducted flow analysis and sampling of 7 patients, and sent them to the Municipal Center for Disease Control and Prevention overnight for testing.
The prevention, treatment and reporting process management of infectious diseases may be divided into public health departments, hospital infection management departments or medical offices in different hospitals. Specific to Wuhan Central Hospital, the second duty of the Public Health Department is to conscientiously carry out infectious disease epidemic reporting work in accordance with the "Infectious Disease Prevention and Control Law", strictly implement the prevention and treatment and reporting systems and procedures of infectious diseases, collect and Check the infectious disease report card, promptly urge doctors to complete the report if any omissions or misreports are found, and complete online direct reporting correctly and timely in accordance with regulations. It also includes strengthening early warning and monitoring of infectious diseases, managing key infectious diseases, standardizing the diagnosis and treatment of infectious diseases, and implementing an infectious disease pre-examination and triage system.
According to the "Epidemic Handling Instructions" of the above-mentioned central hospital, after the district CDC completed the flow control and sampling of 7 cases, on December 31, the Public Health Department of Wuhan Central Hospital called Zhang Yan, director of the Jianghan District CDC , asked about the sampling results, Zhang Yan told him to wait for notification. On January 3, the Public Health Department once again called Wang Wenyong, chief of the Transmission Prevention Section of the Jianghan District Center for Disease Control and Prevention, and asked whether the 7 cases of viral pneumonia reported earlier by phone should be reported to the infectious disease report card . Wang Wenyong replied that for such special infectious diseases, we should wait for notification from superiors before reporting, and report the specific disease types and other notifications.
On January 4, the Public Health Department of the Central Hospital received a guidance manual for unexplained viral pneumonia issued by the Wuhan Municipal Health Commission. The manual showed that for suspected cases, expert consultation must be organized within 12 hours in the hospital. If consultation cannot be ruled out, an infectious disease report card should be reported immediately. But on the next day, the 5th, when the Jianghan District Health Bureau organized a meeting of various hospitals, they also said: Suspected cases that cannot be ruled out by the consultation of experts in each hospital should be reported to the District Health Bureau, and the district will organize expert consultations. If the cases cannot be ruled out, Then submit the infectious disease report card.
After the meeting on the 5th, the Public Health Department of the Central Hospital communicated with the Medical Affairs Department of the District Health Bureau to report process matters. The Medical Affairs Department of the District Health Bureau responded: The Central Hospital is a municipal hospital and should be consulted by municipal experts. The District Health Bureau cannot consult municipal hospitals. The Public Health Department of the Central Hospital immediately called the Medical Affairs Office of the Municipal Health Commission. The latter said that the hospital should be under the jurisdiction of the territory and that the district health bureau had a wrong understanding. After coordination by the Medical Affairs Department of the Municipal Health Commission, the Medical Affairs Department of the District Health Commission agreed to organize expert consultations in the district.
According to the "Epidemic Disposal Instructions", from January 8th to 10th, the Public Health Department of the Central Hospital reported 14 reports of pneumonia of unknown cause (9 cases on January 8th, 4 cases on January 9th, and 4 cases on January 10th). 1 case per day), among which on the evening of January 9, the district CDC conducted investigation and sampling of 4 cases reported that day.
On January 11, Hubei Province’s “Two Sessions” opened. The reporting process has changed again.
On January 11, a patient in Houhu District could not rule out pneumonia of unknown cause after in-hospital consultation. After the Medical Office of the Central Hospital submitted the consultation opinions to the Medical Affairs Department of the District Health Bureau according to previous procedures, the Medical Affairs Department of the District Health Bureau requested that the patient The hospital contacted the district Center for Disease Control and Prevention on its own to collect samples and conduct investigation; the Central Hospital immediately contacted Zhang Yan, director of the Jianghan District Center for Disease Control and Prevention, but Zhang Yan said that it needed to wait for notification from the medical administration.
After that, the already complicated reporting process was once again complicated. At 11:30 noon on January 12, a director named Xu from the Law Enforcement Supervision Office of the Hubei Provincial Health Commission led a team to the Houhu District of the Central Hospital to supervise the work related to the fever clinic. Director Xu gave instructions: Infectious Disease Report Card The report needs to be cautious, and it needs to be jointly determined by the province and city before applying for a card - which means that there are more consultations at the municipal and provincial levels than before.
At 9 a.m. on January 13, Director Wu Fengbo of the Disease Control and Prevention Department of Wuhan Municipal Health Commission and a delegation from the Disease Control and Prevention Department of Jiang'an District Health and Health Bureau went to the main hospital of the Central Hospital (Nanjing Road Campus) to convey the latest cases of pneumonia of unknown cause. Report spirit. Consistent with the statement from the Hubei Provincial Health Commission’s Law Enforcement Supervision Office – cases of pneumonia of unknown origin should be reported with caution. Wu Fengbo made more specific requirements: The discovered cases must first complete various tests and related examinations in the hospital. After being diagnosed as pneumonia of unknown cause by the hospital expert group, they should then report to the district health committee for consultation and notify the district disease control and sampling. After consultation by the district and city , provincial level testing, if the case remains pneumonia of unknown cause, case information can only be reported with the consent of the Provincial Health Commission.
At around 9 a.m. on January 13, Wang Wenyong, chief of the Transmission Prevention Section of the Jianghan District Center for Disease Control and Prevention, called the Central Hospital and asked the hospital to correct the unexplained pneumonia patients reported on January 10 to other diseases.
At 15:00 that day, the Public Health Department of the Central Hospital called the Disease Control Department of the Jianghan District Health Bureau to inform the aforementioned cases reported on January 11 that the District Center for Disease Control and Prevention had not been conducting sampling and flow control in the future, making it impossible to report the case. The Medical Affairs Department of the Health Bureau said that the hospital notified the District Center for Disease Control and Prevention on its own. The District Center for Disease Control and Prevention also said that it would wait for notification from the Medical Administration and asked the Disease Control Department of the Health Bureau what to do. The District Health Bureau’s Disease Control and Prevention Department replied: Wait.
After waiting for another three days, the district disease control department never came to take samples, and the cases were still unable to be reported.During this period, the Public Health Department of the Central Hospital asked surrounding hospitals and learned that they had not been able to apply for the card recently.
Until 16:00 on January 16, that is, the afternoon before the closing of the "Two Sessions" in Hubei Province, the Wuhan Center for Disease Control and Prevention finally sent two staff members to the Wuhan Central Hospital to conduct sampling. At this time, the Central Hospital's unknown cause The number of suspected cases of pneumonia has increased to 48. On the evening of January 17, the Hubei Provincial Center for Disease Control and Prevention also came to the Central Hospital to conduct an epidemiological investigation on the cases sampled the previous day and collect relevant clinical data.
In the early morning of January 18, the Wuhan Municipal Health Commission reported 4 new cases of pneumonia infected by the new coronavirus. Previously, from January 12 to January 17, the Wuhan Municipal Health Commission’s daily routine reports stated that “there were no new cases of pneumonia infected by the new coronavirus in the city” the previous day.
The diagnosis and treatment experiences described by many doctors from Wuhan Central Hospital to Caixin reporters are consistent with this record from the hospital’s public health department. In fact, the administrative intervention from the National Health Commission in the reporting of new coronavirus cases, especially the obstacles set up between January 12 and 17 to prevent hospitals from reporting, was not limited to one central hospital in Wuhan, but to many hospitals in Wuhan. Had the same experience.
Unable to diagnose
According to the "National Surveillance, Investigation and Management Plan for Cases of Unexplained Pneumonia" issued by the former Ministry of Health in 2007, medical personnel should report to medical institutions immediately after discovering cases that meet the definition of unexplained pneumonia. Expert consultation and investigation are organized within 12 hours, but if a clear diagnosis still cannot be made, an infectious disease report should be filled in immediately, indicating 'pneumonia of unknown cause' and reported directly online."
However, judging from the above "Epidemic Handling Instructions" within Wuhan Central Hospital and the specific implementation conditions of many hospitals interviewed by Caixin reporters in Wuhan, local medical institutions did not obtain self-completed infectious disease reports before late January. The card has the right to report directly online.
"The infectious disease report card itself is very simple. We can just fill in the infectious disease report card on our own computer for confirmation, but we need to make a diagnosis before filling in the infectious disease report card." A doctor from Wuhan Central Hospital told Caixin reporters , “Before COVID-19, if we were diagnosed with hepatitis B or other serious infectious diseases, we could You can make a diagnosis directly on the computer, and then a window for an infectious disease report card will pop up. After filling it out, click OK to upload. "
But the initial problem that doctors encountered during the new coronavirus epidemic was that they did not know what it was. Disease - Most of them gave a diagnosis of fever pending investigation or possible community-acquired pneumonia, and then admitted them to the hospital. Community-acquired pneumonia is a general term for a type of pneumonia caused by a variety of microorganisms such as bacteria, viruses, chlamydia, and mycoplasma. The main clinical symptoms are cough, with or without sputum, and chest pain.
Soon, doctors discovered that the conditions of some patients were different from the known community-acquired pneumonia. Most community-acquired pneumonia, including influenza A, influenza B, etc., mainly infect the upper respiratory tract, and their lung images The academic characteristics are not obvious. Ground-glass infiltrates are clearly visible in the CT films of these patients, and they often quickly develop visible lesions in both lungs. Antibiotic treatment is ineffective. Seven tests of blood routine, blood biochemistry, and respiratory viruses also prove that the pathogen is not influenza A, B, or influenza. Respiratory syncytial virus, adenovirus, parainfluenza virus, etc.
Professor Zhao Su, chief physician of the Department of Respiratory Medicine at Wuhan Central Hospital, once told Caixin reporters that the hospital often encounters patients with special conditions and difficult diagnosis. A common method in recent years is to spend money to find a gene sequencing company for NGS testing. , hoping to use its metagenomics-based second-generation high-throughput gene sequencing technology (mNGS) to identify pathogens , “Since BGI started using sequencing technology, many gene sequencing companies have appeared in China. At our various medical seminars, second-generation high-throughput gene sequencing technology has been continuously introduced, and these companies have also sent medical representatives. Go to major hospitals to preach, and it has been proven to be effective." Another way is to cooperate with some scientific research institutions and use the scientific research methods of these institutions to find out the cause of the disease.
Both methods have their own pros and cons.There is a charge for testing with a third-party gene sequencing company, which is equivalent to a personalized external testing service. It costs about 3,000 yuan to test 6 million base pairs. The advantage is that it is fast, and the results can usually be obtained in three days, said a doctor from Wuhan Union Medical College Hospital. , "With this 3,000 yuan, we can find out what kind of virus or bacteria the pathogen is, which may save lives." Cooperating with scientific research institutions is equivalent to combining the clinical treatment of doctors with the cutting-edge scientific research topics of research institutions. It is a win-win situation for scientific research and clinical applications, and it is generally free. The disadvantage is that the cycle is relatively long.
Caixin previously reported that on December 15, 2019, a 65-year-old deliveryman named Zhang from the South China Seafood Market began to have a fever. On December 18, he went to the emergency department of Wuhan Central Hospital (Nanjing Road Campus) to see a doctor. , doctors suspected that he had community-acquired pneumonia and admitted him to the hospital for "fever investigation". On December 22, the patient's condition worsened and he was admitted to the respiratory intensive care unit. Doctors After various antibiotic treatments failed, bronchoscopy sampling was performed on the patient on December 24. The patient's alveolar lavage fluid sample was then sent to Guangzhou Weiyuan Gene Technology Co., Ltd. for NGS testing. The results revealed that there was a substance similar to On December 27, Weiyuan Genomics notified Wuhan Central Hospital of the new coronavirus, which is about 81% similar to SARS, and shared the data with the Institute of Pathogens of the Chinese Academy of Medical Sciences.
On December 27, the Emergency Department of Nanjing Road Campus of Wuhan Central Hospital received another 41-year-old patient surnamed Chen. He had fever without obvious cause on December 16. On that day, the patient underwent bronchoscopy in the ICU of the Respiratory Department of the hospital. Samples were taken and sent to Boao Medical Laboratory Co., Ltd. in Beijing. On December 30, Beijing Boao Medical Laboratory reported the patient’s genetic sequencing report to the doctor: after NGS testing, the pathogen was SARS coronavirus.
On the same day, the test report from Beijing Boao Medical Laboratory appeared in the WeChat of Ai Fen, director of the emergency department of Wuhan Central Hospital. She sent the report to her classmates and also spread it to the department group to ask everyone to pay attention to protection. . At 17:48 in the evening, Li Wenliang, an ophthalmologist at Wuhan Central Hospital, forwarded a screenshot of the report to his classmates and issued an early warning message: "Seven cases of SARS have been confirmed in the South China Fruit and Seafood Market and are isolated in the emergency department of our hospital."
However, the early warning caused dissatisfaction, and those who blew the whistle quickly felt the pressure. On the night the screenshots were circulated, that is, at 1:30 a.m. on December 31, Li Wenliang was called by the hospital leaders to the Wuhan Municipal Health Commission to inquire about the situation. After going to work at dawn, he was interviewed by the hospital's inspection department, and after that he wrote a letter as requested. "Reflection and Self-Criticism on False News Rumors". On January 3, Li Wenliang was reprimanded by the police. The day before, on January 2, Ai Fen was also interviewed by the hospital's inspection department, saying that his behavior aggravated social panic and affected the overall development of Wuhan.
On the evening of January 3, Wuhan Central Hospital urgently convened a meeting with the directors of various departments. According to the meeting minutes obtained by Caixin reporters, the meeting first reported that the pathogen detection and cause tracing of unexplained pneumonia are in progress, and the sanitation and disinfection of the South China Seafood City has been completed. 44 cases have occurred, 11 severe cases, and no human beings have been found yet. Human-to-human transmission phenomenon; the meeting revealed that Wuhan’s health system has entered a wartime state, and a command center for pneumonia of unknown causes has been established, requiring all hospitals to enter a wartime state of duty and strictly implement a leave system. In principle, no leave will be arranged, and you must report when you leave Wuhan. The meeting also emphasized the need for strict discipline, "being political, disciplined, and scientific" and not making or spreading rumors. Each unit is optimistic about its own personnel and strictly enforces confidentiality disciplines. It requires medical staff not to disclose confidential information in public, nor to spread rumors. Discuss related conditions through words, pictures, etc. that may retain evidence.
Controls on third-party testing such as genetic companies have also been tightened unprecedentedly. A person from a gene sequencing company revealed to a Caixin reporter that on January 1, 2020, he received a call from an official of the Hubei Provincial Health Commission, informing him that if samples of new coronavirus pneumonia cases in Wuhan were submitted for testing, they could not be tested again; Some case samples must be destroyed, sample information cannot be disclosed to the outside world, and relevant papers and related data cannot be released to the outside world. "If you detect it in the future, you must report it to us."
On January 3, the General Office of the National Health Commission issued the "Notice on Strengthening the Management of Biological Sample Resources and Related Scientific Research Activities in the Prevention and Control of Major Emergent Infectious Diseases", this National Health Office Science and Education Letter (2020) 3 The document states that for recent Wuhan pneumonia case samples, based on the currently available etiological characteristics, transmissibility, pathogenicity, clinical data and other information, until the pathogen information is further clarified, the samples are temporarily classified as highly pathogenic. Pathogenic microorganisms (category II) shall be managed; all relevant institutions shall, in accordance with the requirements of the health administrative department at or above the provincial level, provide biological samples to designated pathogen testing institutions for pathogen testing and complete handover procedures; without approval, no one shall Other institutions and individuals provide biological samples and related information; institutions and individuals that have obtained biological samples of relevant cases from relevant medical and health institutions should immediately destroy the samples on site or send them to a nationally designated preservation institution for safekeeping.
The inability to diagnose has become a new obstacle for hospitals to report the epidemic. "Previously, the hospital used third-party testing companies to conduct virus testing. Even if the city's diagnosis was not available and the card could not be reported, the doctor at least knew what the disease was and could treat it symptomatically and provide protection." A doctor from the Central Hospital told Cai The new reporter said that after the promulgation of Document No. 3, no medical institution dared to send samples to third-party testing agencies for testing, and could only send samples to the regional CDC.
The smallest window is also closed
The infectious disease report card filled out by doctors and reported uniformly by hospitals is undoubtedly a key part of epidemic reporting. According to the "Infectious Disease Information Reporting Management Standards (2015 Edition)", the infectious disease report card is filled in by the first-diagnosing doctor or other personnel performing duties; infectious disease cases discovered during on-site investigations are diagnosed and reported by local medical institutions. Infectious disease report management personnel of medical institutions (generally the public health department of the hospital) must check the information on the paper infectious disease report card or electronic infectious disease report card received, and any questionable report cards must be verified in a timely manner by the person who filled out the card. .
In the above-mentioned document, the responsibilities of the Centers for Disease Control and Prevention are: to review the infectious disease information reported within its jurisdiction, provide timely feedback and verification of doubtful reported information, and delete misreported and rereported information in a timely manner. Reported information on outbreaks of Class A infectious diseases, some Class B infectious diseases, and unexplained disease outbreaks should be investigated and verified immediately, and the third-level confirmation review of the reported information should be completed online within 2 hours. The main responsibility of local health committees is to analyze, utilize and publish reported infectious disease epidemics.
It can be seen that neither the local health commission nor the Centers for Disease Control and Prevention has the right to prevent hospitals or doctors from filling out infectious disease report cards. They can only verify and report the report cards after they are submitted. However, many practices of the Wuhan Municipal Health Commission are different from the "Infectious Disease Information Reporting Management Standards (2015 Edition)".
After cases of pneumonia of unknown origin were reported by Wuhan Central Hospital and Hubei Xinhua Hospital, and the three-level CDCs of Hubei Province, Wuhan City and various districts initiated emergency response workflows, on December 30, the Wuhan Municipal Health Commission issued a notice to all medical institutions The person in charge issued "About doing a good job in handling unexplained reasons" "Emergency Notice on Pneumonia Treatment Work" mentioned that multiple cases of unexplained pneumonia have appeared in many medical institutions in Wuhan and are related to the Wuhan South China Seafood Wholesale Market, requiring all medical institutions to report to the district disease control department and the medical administration department of the National Health Commission. Report patients with pneumonia of unknown origin who have had similar characteristics in the past week. The Municipal Health Commission also convened a meeting with the heads of the city's disease control centers on the same day. Each district is preparing to set up a special emergency response team to investigate and deal with cases. This is equivalent to bringing all epidemic reporting under the control of the local administrative bureaucracy.
On December 31, the first expert team from the National Health Commission arrived in Wuhan. On the same day, the Wuhan Municipal Health Commission released information about unexplained viral pneumonia to the public for the first time: 27 cases have been found so far, of which 7 are in serious condition, the remaining cases are stable and controllable, and 2 cases have improved and are scheduled to be discharged from hospital in the near future.Based on the analysis of the condition, treatment outcome, epidemiological investigation, and preliminary laboratory testing, experts believe that the above-mentioned cases are viral pneumonia. The investigation found no obvious human-to-human transmission and no infection among medical staff was found.
At this time, the Wuhan Municipal Health Commission's "Response to Pneumonia of Unknown Causes" headquarters mentioned in the emergency meeting of Wuhan Central Hospital on January 3 began to function. A deputy chief physician at the Central Hospital said that since December 29, the "command" has successively notified various hospitals to transfer relevant patients to Jinyintan Hospital. As of January 2, the Central Hospital has transferred seven patients. "They are all commanded The ministry issued a notice and then sent ambulances to transfer them, but not all of them were transferred. They only transferred those who had a history of contact with the seafood market. Even those who had almost been cured by us were all transferred to Jinyintan. Those who had no history of contact with the seafood market were transferred. Never.”
He remembered that the hospital had admitted several patients with similar symptoms, but they had no history of contact with the seafood market, so they were not notified of transfer. “When I asked the hospital what to do, the hospital said that the headquarters did not notify the transfer, so it could only find a patient with more than 20 patients. Isolation ward with beds."
This selective transfer by the "Headquarters" of the Wuhan Municipal Health Commission was later confirmed by a "Admission Criteria" investigated by Caixin reporters. A doctor from a Hubei Provincial Hospital told Caixin reporters that before the National Health Commission’s first version of the “COVID-19 Diagnosis and Treatment Plan” was released on January 15, the Wuhan Municipal Health Commission conducted an inspection of local hospitals at Jinyintan Hospital on January 4. A training was held, during which the "Medical Treatment Manual for Unexplained Viral Pneumonia" was issued. The work manual contains a total of ten documents. The first is the "Diagnosis and Treatment Plan for Unexplained Viral Pneumonia (Trial)" (hereinafter referred to as the "Trial Diagnosis and Treatment Plan"), and the second is the "Entry Criteria for Unknown Viral Pneumonia" ” (hereinafter referred to as the “Admission Criteria”). There are significant differences in the clinical diagnostic criteria for "unexplained viral pneumonia" between the two.
"The "Trial Diagnosis and Treatment Plan" should have been compiled by the Hubei Provincial Expert Group and the earliest expert groups of the National Health Commission. The "Entry Standards" were later compiled by the Wuhan Municipal Health Commission. Many hospitals in Wuhan follow the later guidelines. The above-mentioned doctor said that the so-called inclusion and exclusion criteria are the principles and criteria that guide front-line doctors to diagnose and report patients with certain diseases.
A workbook obtained by Caixin reporters shows that in the "Trial Diagnosis and Treatment Plan", there are four case definitions for "unexplained viral pneumonia": fever; imaging characteristics of pneumonia; normal or normal white blood cell count in the early stage of the disease Decreased or lymphocyte count decreased; after 3 days of standardized antibiotic treatment, the condition showed no significant improvement or progressively worsened. The definition states: Pneumonia cases that meet these four conditions and cannot be clearly diagnosed as other diseases are defined as viral pneumonia of unknown cause; if the patient has a history of exposure to the South China Seafood Market or a history of contact with similar patients, the first three conditions are sufficient. The Huanan Seafood Market in Hankou, China is considered to be the main source of the new coronavirus epidemic. In the early days, it was true that most patients had a history of contact with the Huanan Seafood Market.
The Wuhan Municipal Health Commission’s “Entry and Exclusion Standards” are more stringent than the “Trial Diagnosis and Treatment Plan”. The first sentence of its opening stipulates that those with both epidemiological history and clinical manifestations will be included. Among them, the clinical performance requirements are basically consistent with the four items listed in the "National Expert Group Standards" case definition, only one of which is fever is further defined as ≥38 degrees; the bigger change is that one must have an epidemiological history, that is, in December 2019 Since March 1, merchants, employees and staff who have been engaged in trading activities at the South China Seafood Market for a long time may become ill. Those who have been engaged in processing, selling, slaughtering, handling and transporting at the seafood market for more than three hours in the past two weeks, or those who have a clear history of contact with poultry and wild animals in the seafood market within the two weeks before the onset of illness, and those who meet the case definition People who live, live, study, accompany, and share the same ward with others, or medical staff who do not use effective protective measures for diagnosis, treatment, and care.
Case definition is the basis for diagnosis and exclusion of a disease, and generally includes three aspects: epidemiological history, clinical manifestations and etiological evidence.Before the National Health Commission announced on January 9 that the pathogen of unexplained viral pneumonia in Wuhan was a new coronavirus and the full genome sequence of the virus was clarified, clinicians did not know what the pathogen was. Without etiological evidence, clinical diagnosis could only be made. Through both epidemiological history and clinical manifestations. "In hindsight, the case definition given in the "Trial Diagnosis and Treatment Plan" is generally sound. It not only pays attention to the patient's epidemiological history, but does not stick to the seafood market as a possible source of infection. Patients with a history of contact are not simply excluded. If the case definition in this plan is strictly followed, a large number of patients unrelated to the seafood market will not be missed, and the phenomenon of human-to-human transmission will be discovered earlier,” the person said. I don't quite understand why "Into the Platoon" "Standards" should change the epidemiological history related to the seafood market to a necessary condition. "
A person close to the Hubei Provincial Expert Group revealed that members of the national and provincial expert groups saw the "Entry Standards" of the Wuhan Municipal Health Commission. I was very angry at the end and asked the Wuhan Municipal Health Commission to take back the pamphlet and reprint it. The Wuhan Municipal Health Commission later reprinted a set of work manuals with a green cover, removing the "Admission Standards", but the standards implemented by each hospital Diagnosis and reporting criteria have not changed.
"The "Inclusion Standards" include the epidemiological history related to the seafood market. An important consequence is that "recruiters" who spread the virus among people are excluded. Looking back afterwards, many doctors believe that the rapid increase of the epidemic from a few hundred cases at the end of 2019 to thousands around January 20 should have something to do with this.
The work manual issued by the Wuhan Municipal Health Commission also states that for suspected cases, the hospital needs to organize expert consultation within 12 hours. If the consultation cannot be ruled out, an infectious disease report card should be reported immediately. This regulation shows that major hospitals have the right to report infectious disease report cards on their own.
However, just one day later, on January 5, when the Jianghan District Health Bureau organized a meeting for all hospitals in the area, it said: For suspected cases that cannot be ruled out through consultations with in-hospital experts organized by each hospital, they should be reported to the District Health Bureau, and the district will Expert consultations are organized here, and infectious diseases report cards cannot be submitted until the conditions are ruled out.
In this regard, a person from the disease control department explained to Caixin reporters that the reporting of unknown infectious diseases is of great importance. Hospitals are more cautious in diagnosing and generally report the cases step by step. After the circulation and testing are completed, they will be reviewed by the local health commission before proceeding. Complete report cards as required. The local health committee then reports to the next higher level in order to achieve "unanimous progress."
Although reporting an infectious disease report card at this time requires district consultation and approval, the entire reporting process can still be carried out. A document obtained by Caixin reporters showed that as of January 11, Wuhan Union Hospital had reported a total of 11 patients (9 patients were reported unexpectedly on the 11th), Xinhua Hospital had reported a total of 9 patients (6 patients were reported on the 11th), and the Central Hospital had reported a total of 11 patients. 11 people.
Starting from January 12, the reporting process was abruptly suspended. The aforementioned "Epidemic Disposal Instructions" shows that officials from the provincial and municipal health committees pointed out that new coronavirus cases should be reported carefully, and that based on the previous consultations with the district health bureaus, additional testing by the municipal and provincial health committees needs to be carried out , if it is still pneumonia of unknown cause, case information can be reported only with the consent of the Provincial Health Commission.
In fact, this reporting path, which had become cumbersome, was never passed in the next five days. "At that time, we just refused to report it or allow it to be reported." A doctor at Wuhan Central Hospital told Caixin reporters that according to the procedures at the time, when similar cases were encountered, antibiotics were first used for three days of treatment, and after three days of antibiotics ineffective, , it requires consultation by an expert group in the hospital, and then it can be reported to the district. The district expert group will consult and notify the district of disease control sampling, and then invite the city, and then the province... "It needs to go through four levels of consultation and level-by-level testing. After the patient still had pneumonia of unknown cause, the hospital and doctors could fill in the infectious disease report card only after the entire process was approved by the Provincial Health Commission and the diagnosis was completed. "
" "There are many cards in the middle, and many clinicians and hospitals cannot operate it at all. " He said, "The hospital keeps records every day. Those who are sent for sampling are critically ill and cannot be observed. They are screened every day. Those who can carry it are carried out by themselves.”
After January 12, this process became even more impossible, because the district, city, and province had not made a clear diagnosis, and the test results were not fed back. In this way, the hospital could not apply for a card, and even more There was no way to transfer to Jinyintan Hospital, and the patients had no exit at all. “As a result, the isolation wards were quickly filled up, so we had to open three more wards in Houhu and Nanjing Road campuses. The ward was full again, so we could only fetch water in the outpatient department, and there were long queues in the hospital." He believed that the large number of medical staff being infected was related to the fact that the isolation ward was full at that time. "There were more and more patients, and many patients just wanted to be hospitalized for injections. , if your respiratory department and emergency department are full and there are no beds, they will go there Other departments require hospitalization for treatment, and they want to stay in the upper hospital before transferring to other departments, but the medical staff receiving treatment in those departments lack adequate protection."
The doctor's statement is consistent with the aforementioned internal "Epidemic Handling Instructions." A department from the Central Hospital Director's list He said that by mid-January, reports were basically suppressed. He told Caixin reporters that from the beginning, each patient had to go through consultation procedures. Wuhan Central Hospital itself is a municipal hospital. On March 30, a medical treatment expert team was established internally, including There are a total of 12 people including experts from respiratory departments, emergency departments, ICU and other departments. After consultation and diagnosis, the public health department is responsible for reporting and notifying the disease control department for transfer. "At first, there were a few who reported them to Jinyintan, and then they were transferred to Jinyintan. Unable to move, all pathways were paralyzed. "He said that the process after the consultation became far away.
The Wuhan Third Hospital in Wuhan Wuchang District also encountered the same problem. A doctor at the hospital told Caixin reporters that the hospital's first The highly suspected patient is a 91-year-old grandmother who came to see a doctor on January 3. She was infected with her own virus Three daughters, two doctors from the hospital, five nurses, and two other patients in the same ward.
On January 9, the third hospital collected samples from this old woman and reported them to the Medical Affairs Office of the Municipal Health Commission and the city. , district-level CDC. “They were unwilling to come before. We said, if you don’t come for such a serious patient, you will be responsible if something goes wrong. "The doctor said. Later, the Municipal Health Commission and the Municipal Center for Disease Control and Prevention came to the hospital for consultation. Before the results were available, the old woman passed away that night.
Between January 10 and 12, the three hospitals again All the infection status and samples of the family members and medical staff related to this old woman were reported to the Municipal Health Commission and the two urban CDCs. "We conducted a detailed consultation in the hospital. We felt that the situation was very serious at that time. So. Many medical staff were infected. But the expert consultation we applied for at that time never came. "The doctor said, "At that time, the city gave us feedback that the samples needed to be sent to Beijing for testing, which took a long time, so we had to wait for the results to come out before we could consult. "It wasn't until about seven or eight days later that the sample test results were finally available, and they were all negative. So, the hospital organized a second batch of samples to be sent for testing, and then the infected people were diagnosed as COVID-19 patients - and this was already the third batch of experts. It happened after the team came.
The situation at Wuhan University Zhongnan Hospital, a provincial hospital, was not much better. Doctors at the hospital told Caixin reporters that the hospital admitted a highly suspected patient with a history of contact with the South China Seafood Market in early January. Both lungs were severely infected and had become white lungs. Since there were already rumors about the emergence of SARS among doctors at that time, I was very alert and immediately reported it to the hospital leaders. "
On the day of admission, the Medical Administration Office of Zhongnan Hospital reported to the Municipal Health Commission and the Municipal Center for Disease Control and Prevention, asking them to come for sampling and testing. At the same time, the hospital urgently converted the ICU into an isolation ward and set up 16 beds. month 10 , these beds were all filled, and most of the suspected patients admitted later had no history of contact with the South China Seafood Market.
"The wards were all full, and there was no news from the city. We were anxious and reported to the Municipal Health Commission many times, and later to the province. The National Health Commission continues to report. The doctor said that it was not until January 12 that the Municipal Health Commission appointed three experts to the hospital. During the meeting, the experts said that only those with a history of contact with the South China Seafood Market can be reported for nucleic acid testing.This statement has been questioned by some doctors because there will be many cases left with similar symptoms but no history of contact with the seafood market, and the standard is too harsh.
However, experts from the Municipal Health Commission asked Zhongnan Hospital to be careful in applying for tests and control the number of tests, saying, "You applied for too many." In mid-January, the Medical Administration Office of Zhongnan Hospital once again reported the problem to the provincial and municipal health commissions, and received a verbal warning and criticism of Zhongnan Hospital's "low political awareness."
The same is true for Wuhan Fourth Hospital located in Qiaokou District. A person from the hospital told Caixin reporters that around January 10, the hospital also treated similar cases of pneumonia. "At that time, the hospital hoped to apply for a card, and hoped that someone from the district CDC would come to do sampling and flow control, but the district CDC did not send anyone for a long time. Later, because these patients were all mild, we treated them with ordinary pneumonia. Cured. "
" in mid-January. At that time, everyone was covering up, from the province to the city to the hospital. The province did not allow the city to report, the city did not allow the hospital to report, and the hospital did not allow the department to report. It was just covered up layer by layer. , causing the golden prevention and control period to be repeatedly missed,” the above-mentioned doctor from Wuhan Central Hospital lamented to Caixin reporters.
Another doctor recalled that it was probably not until the end of January that the hospital informed the doctors that everyone could register one by one. After making their own diagnosis, they could fill it out on the computer. "But it's too late." He sighed.
The heavy price
During this period, not only were more and more fever patients coming to the outpatient clinic for medical treatment, but also medical staff in Wuhan Central Hospital began to show fever and other symptoms. On January 11, the hospital received news that an emergency department nurse, an ophthalmologist and a gastroenterologist were suspected of infection. One of the ophthalmologists is Li Wenliang. After an elderly female glaucoma patient in his bed was diagnosed with suspected COVID-19 on January 10 and transferred to the isolation ward, Li Wenliang developed a low fever on January 11, with a body temperature of 37.2°C. On January 12, his body temperature suddenly rose to 38.4°C, and on the 13th it was 38.5°C. Seven tests for respiratory viruses and mycoplasma and chlamydia were negative, his blood picture was normal, and CT showed ground-glass patches in both lungs.
Immediately afterwards, on the morning of January 12, a female colleague of Li Wenliang’s ophthalmology department also reported a fever of 37.4°C, which rose to 38.3°C in the evening. On the 13th, she reported a temperature of 38.5°C. She was negative for seven respiratory viruses and mycoplasma and chlamydia, with normal white blood cells and low lymph. CT showed ground glass patchy shadow under the right lung. The two received infusion antiviral treatment in the outpatient clinic.
On January 13th and 14th, Wuhan Central Hospital received reports of three more suspected infections among employees. By the 15th, the number increased significantly to 9 cases of suspected infection among employees, and on the 16th there were 7 more cases. In just six days from January 11, when the first employee infection was discovered, to January 16, the number of suspected cases among employees at Wuhan Central Hospital increased to 26. "The hospital set up a special ward for medical staff on January 13, and later expanded it to a one-story ward, then two wards, then three wards... until more than 100 people were hospitalized in this hospital. " said a department director of the hospital.
Infection among medical staff is important evidence that this new epidemic disease is contagious between humans. However, important information about nosocomial infections among medical personnel on such a large scale was not reported in time due to numerous obstacles, let alone presented in the online direct reporting system.
Until January 24, the National Health Commission visited the Houhu District of Wuhan Central Hospital for an inspection. The hospital truthfully reported the infection situation of medical staff: from the end of December to the present, a total of 175 medical staff had developed fever, including 56 cases. There are 2 critically ill cases receiving treatment in the hospital, but at this time, only one has been confirmed. The other 32 medical staff are waiting for sample test results, and an additional 119 medical staff are under quarantine and observation.
On January 28, the Wuhan Municipal Health Commission announced the further expansion of nucleic acid testing institutions, and Wuhan Central Hospital was allowed to conduct nucleic acid testing. The infection situation of medical staff in the hospital began to really emerge. An internal information obtained by Caixin showed that Wuhan Central Hospital reported 17 confirmed cases among employees that day.As of February 9, Wuhan Central Hospital has reported a total of 68 confirmed cases of COVID-19 among employees, with 142 people hospitalized (138 in the Houhu Branch of the Central Hospital, 3 in the Pulmonary Hospital, and 1 in Jinyintan Hospital). 147 people were observed in the outpatient clinic.
In the early morning of February 7, Dr. Li Wenliang died of illness in the Respiratory Intensive Care Unit of Houhu District of Wuhan Central Hospital at the age of 34. He became the first medical staff member to die of COVID-19 infection at work during the Wuhan epidemic; 3 On March 1, Jiang Xueqing, director of the thyroid and breast surgery department and chief physician of the hospital, died of COVID-19 infection. Wuhan Pulmonary Hospital died at the age of 55 after rescue efforts failed; on March 3, Mei Zhongming, deputy director and chief physician of the hospital’s ophthalmology department, died at the age of 57 after being infected with COVID-19 at Jinyintan Hospital; Zhu Heping, the retired deputy chief physician of the hospital's ophthalmology department, died of COVID-19 in the West District of Wuhan Union Hospital at the age of 66.
According to figures obtained by Caixin reporters, more than 230 medical staff at Wuhan Central Hospital, which has more than 4,000 employees, have been diagnosed with COVID-19, ranking first among all hospitals in Wuhan in terms of infection rate and death toll.
Many doctors at the hospital analyzed that the possible reasons are that firstly, the Central Hospital is one of the hospitals closest to the South China Seafood Market, the main source of the epidemic in the early days, and it received the most patients in the early stage among all hospitals; secondly, The first generation of the new coronavirus may be more virulent, and doctors such as Li Wenliang and Mei Zhongming may have been infected by the same patient; third, there were more and more patients with fever symptoms in early January, and Jinyintan Hospital, the only infectious disease hospital at the time, Only accept pick-up from seafood market A large number of patients with a history of contact with the disease had no exit or beds and were transferred to other departments for treatment and hospitalization. As a result, many medical staff from other departments who had no experience in handling infectious diseases and lacked information about the epidemic were "recruited"; in addition, the main person in charge of the hospital None of them are doctors. The director has been working in an office for a long time. The secretary is the former personnel director of the Municipal Health Commission. He does not know enough about medicine, especially infectious diseases. Not only does he not pay attention to the epidemic, but he also orders all departments and doctors not to pass on epidemic information. Leading to a lack of vigilance on the part of doctors, etc.
