February 1, 2003
Zhongshan Number Three Hospital, Zhongshan, China
268 Infected, 28 Dead
JIAN YAN HAD WHAT CHINESE CALLED A LOOK OF GOOD FORTUNE: A fleshy face, wide, round eyes, and black hair with silver streaks. But on February 1, when his wife checked him in to Zhongshan Number Three Hospital, physicians there immediately detected in his labored breathing a distinctly unfortunate sound: a crackle as he inhaled, which indicated severe damage to his right lung. He was already on the verge of delirium, one of the physicians, Cao Hong, the chief respiratory specialist, would note on Jian’s intake form.
IN GUANGZHOU, HOSPITALS WERE BY NOW BECOMING FAMILIAR WITH these cases: patients in their thirties or even younger suddenly stricken with a breathlessness so debilitating that they were reduced to gasping hulks within twenty-four hours of first feeling feverish. Local hospitals lacking respirators or infectious-disease specialists were transferring these patients by the dozen up the medical establishment to larger hospitals. It was exactly the scenario that the team returning from Heyuan had feared weeks earlier: a stealth outbreak was under way, with hundreds of patients already clogging a system that was not aware it was crashing.
Had the doctors at Zhongshan Number Three Hospital, for example, known what the investigative team had uncovered—or been privy to the reports that had been prepared on those early cases in Heyuan and Zhongshan—then they might have taken greater precautions. As it was, they quickly deduced that this patient was already in acute respiratory distress. “I gave him twenty-four hours to live,” recalls Dr. Cao Hong. The decision was made to intubate the patient.
Orotracheal intubation, as the process is known, required that Dr. Cao insert into Jian’s mouth a flashlightlike device called a laryngoscope, which also serves to suppress the tongue. Dr. Cao bent over the patient and strained to see down the oral cavity to the glottis, the flap of skin covering the larynx, as a nurse massaged Jian’s fleshy neck to suppress the involuntary vomiting that often accompanies the gag reflex. After Dr. Cao established that he could see the glottis, he inserted a long, flexible, clear plastic endotracheal tube and slid it down the throat until it reached the base of the tongue. There, the glottis, which normally serves as a protective mechanism to prevent exactly this type of intrusion, had to be finessed and then forced aside so that the eye of the tube and the accompanying inflatable cuff could slide through the windpipe, or trachea, and into the lungs just above the carnia, the point at which the main stems branch off into the right and left lungs. Though there is a blunt, almost pleasing logic to the simplicity of this procedure—bring air to the lungs—in practice it is fraught and often frustrating for physicians, who usually have to make several attempts before safely inserting the tube. It is also one of those medical procedures, like breaking an improperly healed bone to reset it, that can’t be refined into something more delicate; the process is violent, brutally simple, and practically the definition of an invasive procedure—foreign matter is shoved deeply inside the chest cavity. The rudiments of the treatment were first described in the eleventh century, in The Canon of Medicine, by the Arab medical chronicler Avicenna. There was “no harm from inserting a long reed or anything similar around which a piece of cotton-wool is attached…. Perhaps also insert a tube made of gold or silver into the pharynx to assist breathing,” he suggested. In 1869, a German physician, Franz Kuhn, looking to administer anesthesia more safely and efficiently, would push the process further, so to speak, by inserting the tube all the way into the lungs themselves. Between 1880 and 1887, Cleveland-born physician Joseph O’Dwyer would devise a series of tubes that could be pressed into the throat of a child suffering from diphtheria—the disease causes a membrane to form that can completely occlude the larynx, suffocating the patient. The tubes were of great value to patients suffering from what was then a common childhood killer and to some syphilis patients, who suffered from strictures in the breathing passages. However, with the advent of antibiotics, this symptomatic relief became less frequently necessary. It wouldn’t be until after World War II that O’Dwyer’s tubes, combined with the external pumps developed by Kuhn, would become standard procedure in emergency rooms and trauma wards around the world for patients in acute respiratory distress. To this day, orotracheal intubation remains perhaps the most dangerous procedure that could be described as common, and it is considered among the most complicated that any emergency medical technician will ever have to perform. No one keeps accurate numbers on intubation fatalities, but in the United States, about two hundred people a year die from this basic procedure going wrong. In China, according to one physician, the number is certainly in the thousands.
Numerous complications can ensue during an intubation. Even anesthetized or delirious patients possess enough involuntary muscle response to gag, cough, spit, and convulse at this intrusion. Often, by the time a patient has reached the point where he requires intubation, his throat may already be bruised, scarred, or swollen from coughing, infection, or trauma, making locating the glottis and identifying the vocal cords, as opposed to the esophagus, where the food goes down, especially difficult. If a doctor repeatedly tries and fails to pry open the epiglottis, then this might add to the swelling and complicate subsequent attempts. Patients have died or suffered from brain damage because doctors could not find their breathing tubes in time or mistakenly intubated their digestive systems instead of their lungs. Inevitably, successful or not, the process causes massive gagging and coughing, producing phlegm and mucus in abundance.
Because Jian had been previously intubated while at a local hospital, his throat and glottis were already scarred and slightly swollen, making identifying the proper opening that much more difficult. On his first try, Cao couldn’t get the tube under the glottis and had to start the process over again, first suctioning out a considerable amount of blood and mucus and then ventilating the patient with a heavy dose of high-concentration oxygen to keep up blood oxygen levels. He told the nurse to remove the patient’s oxygen mask after a dozen pumps of the ventilator bag, and then he suctioned out the throat again and slid the flashlight back into the patient’s mouth. This time, he managed to hitch the breathing tube under the glottis, mainly by prodding until he felt some give, then suctioning blood out again and peering down the oral cavity for visual confirmation.
Jian Yan started bucking and retching, his barrel chest rising up from the bed so that when he landed on the mattress, it shook the IV tubes and monitors around the operating theater. Was he convulsing? Dr. Cao opened both the patient’s eyes to see if they were rolling back. No. Jian was simply reacting to the foreign matter in his throat. Still, Dr. Cao could not see if the tube was in or not. Two nurses held Jian down as the doctor pulled hard on Jian’s jaw and peered down his throat.
At that instant, Jian coughed up a massive amount of bloody mucus that, according to Cao, “was like a fountain of virus.” Both nurses felt mucus land on their cheeks. Dr. Cao’s shirt was covered with the goo. He wiped the mucus from his forehead and eyes with a gauze pad that was at hand and bent over the patient’s mouth again.
“It’s in!” he shouted. He inflated the cuff with five milliliters of air and then attached the respirator hose and nipple to the adapter end of the tube as air with a high concentration of oxygen was sent coursing into Jian’s lungs. Upon completing the procedure, the whole team scrubbed down and quickly moved on to the next patient, another sufferer from this new ailment.
Dr. Cao eventually stabilized Jian Yan, pumping in antifebrile medication and starting a dose of corticosteroids to keep the autoimmune system from overresponding and exacerbating the symptoms. Besides the explosion of mucus he had fired out during the intubation, Jian was otherwise, as far as Dr. Cao could tell, simply another victim of this dreadful new disease that was causing panic throughout the province. Breath Taker, or Breath Stalker, as some were calling it, had reached the status of provincial legend. Several specialists had ventured down from Guangzhou to help with treatment or to observe these new cases. They ranged from the usual respiratory specialists and infectious-disease experts to acupuncturists, herbalists, and even a Qi Gong practitioner—all of them drawn by the medical curiosity and eager to offer their own treatments. Among those who visited was a nephrologist—kidney specialist—named Liu Jianlun, a taciturn man with wire-frame glasses, combed-over gray hair, and a cherubic smile. He conferred with Dr. Cao on how to increase the lymphocyte count of the patients, and read the charts of several patients, including Jian Yan.
Even more worrying to Liu and other medical professionals was the increasing occurrence of this disease among medical staff. Three nurses in the hospital had already fallen sick, and at least one physician had taken sick leave with something that seemed very similar to what was afflicting these patients. Already, Dr. Cao had ordered all members of his department to sleep in their offices or in local hotels, and to avoid contact with their families.
Newspaper reporters from City Weekend, Southern Express Daily, and other Guangzhou newspapers had called repeatedly asking for information about this new disease and what could be done to prevent it. “At that point, we weren’t told not to talk about it,” says a doctor at Guangzhou Number Three Hospital. “But we really didn’t have that much to say about it either. Because we didn’t know what it was. There was a sense that the less said about this the better, at least until we heard something from the provincial authorities.” Newspaper editors, for their part, still didn’t dare publish anything about the disease. What is certain is that Zhang Dejiang, Politburo member and general secretary of the Guangdong Communist Party—effectively the real ruler of Guangdong—knew about the disease by late December, when the special investigation was launched in Heyuan. No Western journalist has ever interviewed Zhang, and the few Xinhua reporters who speak with him do so only in platitudes. His own CDC officials say that they briefed him about the outbreak. But even they were still unsure about what exactly was going on or how widespread the outbreak really was. A few high-ranking health officials, including the mediagenic Zhong Nanshan, were already convinced that they were not dealing with an influenza outbreak, and they were scoffing at the notion that this was a bacterial disease. Yet until the party line was established, the provincial government was unwilling to make any sort of public statement confessing its own ignorance.
For Dr. Cao, this meant a gradual increase in his ward’s population, until he had two dozen patients and no more empty beds. Finally, he received word that all the patients with mysterious respiratory ailments were to be sent to four hospitals in Guangzhou. At last, the central government was responding.
Cao filled out the transfer document for Jian Yan and gave it to a nurse to slide into the transparent plastic sheets that accompany patients throughout the Chinese hospital system. The patient they were to wheel out would eventually become famous as the Poison King, the first known superspreader of this new disease. He was now on his way to Guangzhou.