Inside the down jacket is a "hand brush", which is always worn by emergency doctor Cui Xiaolei recently so that he can get into work at any time.
The condition of critically ill patients with new coronary pneumonia is changing at any time, leaving the doctor with little reaction time.
In Shijiazhuang, the patient in front of him has an exclusive medical team, and his condition is reported 6 times a day. The medical order is jointly formulated by the National Health Commission and a local expert group, including the use of ECMO-Extracorporeal Membrane Oxygenation. The technique of temporarily replacing the heart and lung outside the human body is often regarded as a "life-saving straw."
At the beginning of 2021, there was an outbreak of new crown pneumonia in Shijiazhuang.
The Second Hospital of Hebei Medical University organized a medical team and entered the Hebei Chest Hospital, which is designated to treat patients with new coronary pneumonia. Cui Xiaolei served as the leader of the ECMO team and was responsible for the treatment of critically ill patients.
As of January 23, they have accumulated 4 ECMO cases.
On January 23, the first anniversary of Wuhan’s “closing of the city”, Zhou Chenliang, director of the Department of Critical Care Medicine, Eastern Hospital of Wuhan University People’s Hospital, posted a screenshot on WeChat Moments.
It was a picture of him and his colleagues in the intensive care unit a year ago, with the text "We will hold our ground."
Zhou Chenliang participated in the rescue of the world's first lung transplant patient with new coronary pneumonia, and ECMO bought time for that operation.
Over the past year, he has seen some critically ill patients cured with ECMO "on the machine", and it is inevitable that there will be regrettable moments of powerlessness.
"Scientific workers should have such a realization that all treatment methods and diagnosis and treatment processes need to be continuously reflected, summarized, and discarded." Zhou Chenliang said, "Don't let people think that ECMO technology is the life-saving straw that entrusts all hope. It's just an extracorporeal life support technology."
The most important thing is to see whether the primary disease is reversible
Even though he was wearing protective clothing, Cui Xiaolei heard clearly, and the blood oxygen saturation monitor started to alarm.
He looked up, and the blue numbers flashing on the screen quickly dropped.
The hospital bed was a critically ill patient with new coronary pneumonia. After several days on ECMO, medical staff had to replace consumables for the equipment, including pump heads and membrane lungs.
This is a "stop" operation, during which the instrument cannot draw blood from the patient's body as in a normal state, and after being oxygenated by the artificial oxygenator, it is returned to the human body to support the patient's respiratory system.
The shorter the operation time, the smaller the impact on the patient.
Although familiar with this set of procedures, Cui Xiaolei and the team members practiced several times in advance, "Whoever cuts the pipe, who sees the machine", to ensure "safety".
Before the new coronary pneumonia pandemic, ECMO did not have the level of awareness it is today.
In the Wuhan epidemic, it was once thought to be able to "resurrect the dead."
A paper published in the Journal of the Chinese Medical Association in June 2019 introduced that in 2018, 260 hospitals in China reported 3923 cases of ECMO technology applications.
In different medical institutions, the highest patient survival rate was 51.1% and the lowest was 43.5%.
In 2020, because ECMO has been successfully applied to the critically ill treatment of new coronary pneumonia, medical institutions across the country are vying to apply it.
Cui Xiaolei is familiar with the development history of ECMO. He can start from the embryonic form of this technology in the 1950s, talk about the "machine as big as a gasoline barrel" in the 1970s, talk about the performance of ECMO in China's handling of the SARS epidemic in the early 21st century, and therefore And reduced mortality.
In his opinion, this technology can not only save people, but also has the problems of "high trauma, high consumption and high complications". Whether it can be used, whether it should be used, and how to manage it after use, not only tests the professionalism of the medical team. Standards are also a "social issue".
The current ECMO technology has two main applications. Simply put, VV-ECMO replaces lung function, and VA-ECMO replaces heart and lung function.
But it cannot "cure diseases" by itself.
Take the new coronary pneumonia as an example. When the virus causes the patient’s lungs to lose function and cannot supply oxygen to the red blood cells, ECMO technology can be used to extract the patient’s venous blood, complete the oxygenation in an external instrument, and then inject it back into the body. "It will not be cured; when the patient's heart cannot support blood circulation, ECMO can temporarily take care of it, but it cannot eliminate the cause of the loss of heart function.
"It is just a support method to buy time for the treatment of the primary disease." Cui Xiaolei said that while it maintains the life of the patient, the doctor can treat the disease. "Some diseases can be cured, but the patient's life is required to maintain sufficient time. "
According to him, according to the guidelines and expert consensus issued by the International Extracorporeal Life Support Organization (ELSO), ECMO is indicated for cardiogenic shock caused by various reasons, including acute myocardial infarction, fulminant myocarditis, cardiomyopathy, and extracardiac Surgery and heart transplantation, as well as respiratory failure caused by various reasons, such as severe pneumonia and drowning.
There are indications, but it is only the first step in the evaluation of ECMO. "The most important thing is to see whether the primary disease is reversible."
That is to say, during the life-sustaining period of ECMO, is it possible to cure the primary disease of the patient?
If it is not possible, getting on the machine is meaningless.
In a consensus issued by the Chinese Society of Cardiothoracic Anesthesiology in December 2020, malignant tumors, irreversible brain damage, and severe irreversible multiple organ damage are "absolute contraindications" for ECMO technology.
In January 2020, in response to the then-new crown pneumonia epidemic in Wuhan, the National Health Commission issued a guiding diagnosis and treatment plan.
It has been updated to version 8.
Under "Treatment of Severe and Critical Cases" item, added content to refine the timing of ECMO activation, blood oxygen saturation, respiratory rate, arterial blood pH, combined cardiogenic shock and cardiac arrest when using a ventilator And so on, are all factors that doctors should consider.
The diagnosis and treatment plan also stated that "critically ill patients who meet the ECMO indications and have no contraindications should start ECMO as soon as possible."
"Ventilators are used to the extreme and are ineffective before ECMO is considered." Zhou Chenliang, who has worked in the Department of Critical Care Medicine for many years, explained. "But from the perspective of the 8th version of the plan, the threshold for applying this technology is not high." Wuhan Anti-epidemic in 2020 During the period, the government provided free treatment for patients with new coronary pneumonia.
In a sense, this policy eliminates another threshold for ECMO to be used in critically ill cases of new coronary pneumonia.
There is a saying in the field of critical care medicine: "When ECMO sounds, gold is worth two." In addition to the expensive equipment and consumables, the first time ECMO is operated, a professional medical team needs to manage the whole process.
"It costs 60,000 to 70,000 yuan to start up, and 40,000 to 50,000 yuan to change consumables, and an average of 10,000 to 20,000 yuan a day."
In the daily emergency department and intensive care unit of hospitals, this cost is not affordable for every patient who "fits for the indication".
On this day in January, Cui Xiaolei’s team successfully replaced the consumables for the patient. The old catheter was cut off and replaced with a new catheter pre-flushed with saline.
After restarting the machine, Cui Xiaolei saw black venous blood pouring into the translucent catheter, meeting, rotating, and combining with sufficient oxygen in the instrument, turning it into a bright red, and then infusing it back into the patient through the catheter.
The alarm sound of the blood oxygen saturation monitor stopped.
No matter how much experience you have, you cannot completely avoid the problems that ECMO may bring
"Before getting on the plane, we have to consider how to get off the plane." Zhou Chenliang said that applying ECMO technology to test the comprehensive capabilities of the rescue organization, the most important thing is whether the technical team is adequately staffed and experienced. "After getting on the plane, management is very complicated. If the management conditions are not met, and without considering how to get off the plane, we can’t bite the bullet and get on the plane.”
He recalled that a year ago, the People's Hospital of Wuhan University used ECMO for critically ill patients with new coronary pneumonia because "experts are gathered, the hospital has a strong comprehensive strength and a powerful transplant center."
However, Zhou Chenliang also admitted that even experienced doctors cannot completely avoid the problems that ECMO may bring, such as bleeding, hemolysis, infection, renal failure, thrombosis, terminal limb ischemia, vascular injury, and arterial stenosis.
Some complications will threaten patients' lives in the short term, and some will have long-term effects.
At noon on January 10, Cui Xiaolei received a call as soon as he finished checking the room, requiring him to rush to the hospital immediately to take over a patient whose condition is rapidly deteriorating.
When he walked into the intensive care unit with the newly established ECMO support team, he saw at a glance that the patient’s left leg was dark in color, which is a typical feature of VA-ECMO causing terminal limb ischemia, and he needs to immediately puncture a "distal limb." Perfusion tube" to restore blood flow in the legs.
"If you don't do it, this leg may not be kept." He recalled that the patient had used a lot of drugs to raise blood pressure, and the blood vessels had constricted severely.
The medical team was wearing protective clothing and 3 layers of gloves, and intubation was extremely difficult.
Everything must be done with the aid of visual ultrasound equipment. They must seize the time to rush to get a successful one-time vascular puncture before the protective mask in front of them fogs up.
Zhou Chenliang also experienced such a moment.
A year ago, when he was changing the line for a patient with severe bleeding, the patient's blood oxygen saturation continued to drop.
The mask was covered with mist. While pressing the puncture port after the patient's extubation with gauze, he fumbled with his hand to complete the puncture placement from another puncture point.
That was the first time he completed the ECMO tube replacement operation.
Cui Xiaolei introduced that in the past two years, most of the ECMO applications in Hebei Province have been in the Second Hospital of Hebei Medical University where he works.
In 2020, Hebei Province will carry out a total of 97 ECMO treatments, of which 38 cases are in his emergency department.
When Wuhan closed the city last year, he was driving back to his hometown in Xingtai. “There are very few severely ill patients in Hebei, and I don’t think the epidemic is very close.” 10 days later, he was sent to Tangshan and Cangzhou for support and stayed for more than 70 days.
He remembered that there was a local team that mastered ECMO technology, but as soon as the leader said "100% guarantee the survival of patients", he was "a little bit uncertain" about the operation.
Cui Xiaolei is not afraid.
In 2016, he received ECMO technical training in Beijing. Since then, he has been sent to the scene of the explosion accident and the H7N9 avian influenza epidemic area.
In this round of the Hebei epidemic, as of January 24, 2021, the second hospital of Hebei Medical University has assigned more than 80 medical staff to the chest hospital. In addition to the intensive care department, there are emergency, cardiovascular, endocrinology, obstetrics and gynecology, and neurology. Waiting for members of the department.
Shijiazhuang People's Hospital, also designated as a designated treatment hospital, was also taken over by a Sichuan-Hebei aid medical team composed of more than 60 people.
According to reports, among the famous "Eight Immortals" in the Wuhan epidemic, 5 people arrived in Shijiazhuang as members of the National Health Commission expert group, including Du Bin, director of the ICU of the Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Tong Tong, director of the Department of Critical Care Medicine, Beijing Chaoyang Hospital. Zhaohui, Kang Yan, director of the Department of Critical Care Medicine, West China Hospital of Sichuan University, etc.
Cui Xiaolei said that in the chest hospital, every morning, the national expert group will hold a symposium on the condition of the disease, and in the afternoon it is a national “remote online meeting”.
Du Bin and Tong Zhaohui come to rounds every day, and the hospital implements the treatment strategy of "one person, one team" and "one person, one plan" for severe and critical patients with new coronary pneumonia.
Medicine can be transferred at any time, and experts can be present at any time.
The ECMO team changes shifts every 4 hours, and updates the latest status of the patients in the expert group when the shift is transferred. Discussions on the condition are conducted at any time, and decisions are made together.
In charge of 3 ECMO patients at the same time, Cui Xiaolei feels a lot of pressure, but relying on such a medical team, he has the confidence.
In the critically ill area, Cui Xiaolei met many "friends who fought side by side last year." In fact, according to his observation, even medical staff from various hospitals who have never cooperated had no obstacles to communication. "Our goal is too great. It's consistent".
The only thing the doctor thinks about is to save people
Most severely ill patients with new coronary pneumonia have symptoms of respiratory distress.
In clinical practice, doctors usually make patients adjust to the "prone position" to improve "ventilation".
However, after ECMO is switched to the prone position, the patient has a tracheal intubation and dental pads in his mouth. No matter how careful the operation of the medical staff, it is difficult to prevent these devices from injuring the patient's tongue and oral mucosa and causing bleeding.
The problem is that ECMO usually requires the use of anticoagulant drugs to ensure smooth blood flow. Once the patient is injured, it is difficult to stop the bleeding.
For another example, new coronary pneumonia can cause stress peptic ulcers in patients, and anticoagulant drugs can cause these ulcers to bleed.
Cui Xiaolei could not forget those "horrible" scenes.
The patient lost consciousness, with various catheters inserted in his body, and under long sedation, he experienced a series of catastrophes including bleeding.
A doctor once wrote on the Internet, "I participated in ECMO training that year, and the teacher on the podium said, if I am about to die, please don't give me ECMO, so that I can die more decently."
There are also some people questioning that ECMO is currently widely used in the treatment of critically ill patients with new coronary pneumonia. “Is it really necessary?” “Is it because the statistics are good, the technology is used to extend the life, and the patient’s nucleic acid turns negative before dismissing the machine. Death, don’t count as the number of new coronary pneumonia deaths?"
"I haven't seen such a case so far." Cui Xiaolei said, "The treatment is carried out in strict accordance with medical regulations."
Zhou Chenliang responded, "It is absolutely correct to use this technology."
In his view, "(new coronary pneumonia) critically ill patients cannot die" is indeed a "political task", and medical behavior cannot be simply considered.
We must use the power of the country, spare no effort to reduce mortality, and achieve "life first".
"From the result, it is also right. This (saving lives) is a'big right and wrong' problem. What is right is right, and what is wrong is wrong." According to Zhou Chenliang's comparison, whether in China or abroad, ECMO is on the machine. The requirements for indications are very strict, including age restrictions, "Europe and the United States can only be under 60 years old, and the Chinese standard is raised to 75 years old."
With the experience of emergency handling of the new crown pneumonia epidemic last year, Hebei has relatively abundant medical resources allocation in this round of the epidemic.
In several designated hospitals, the treatment "bayonet" is moved forward, which helps prevent patients from turning mild to severe.
Therefore, Cui Xiaolei said: “For this time, the ECMO in Hebei Province is definitely enough. The age limit can be relaxed a bit, taking into account the patient’s health and prognosis.” He also said, “If it can be used, the doctor will not use it. I think a lot, the only thing I think about is to save people."
During the Wuhan epidemic in 2020, Zhou Chenliang never asked the patient's family whether to give up treatment. On the contrary, some family members would take the initiative because of despair.
It took him two months to cure a critically ill patient.
The family members cried guiltily after hearing the news that the patient was alive, because she felt hopeless before and told the doctor to give up treatment.
Yi Fan, a doctor at Wuhan Central Hospital, had been infected with the new crown virus and was dying of life with a black face.
With the support of ECMO, Academician Wang Chen of Beijing China-Japan Friendship Hospital and Zhan Qingyuan, director of the Department of Critical Care Medicine, who supported Wuhan at the time, jointly rescued him.
122 days later, he specially rushed to Beijing to visit his "comrades."
At this time, his skin was fair and his cheeks were plump, no different from ordinary people.
Zhou Chenliang said that several of the patients he had rescued with ECMO in 2020 were successfully "off the machine", cured and discharged, and became friends with him.
Some have returned to work, and some have joined the charity.
"Seeing these, I still consider whether it should be, is it worth it?"
After returning to daily life, the Department of Critical Care Medicine of the Eastern Hospital of Wuhan University People's Hospital completed the transformation of the "dual closed-loop channel" and built a "combined peacetime and wartime" intensive care unit.
That is the trace left by the "blood battle".
After passing by on weekdays, Zhou Chenliang always thinks of who has lived in this ward and who "left" in that bed.
During this time, he paid close attention to changes in the epidemic situation across the country every day.
The Wuhan doctor carefully compared the data, "It's all'sporadic'. The total number of infected people has not risen. Most of the severely ill patients are the elderly and people with underlying diseases. As long as the number of infections does not increase significantly, the prevention and control situation is still relatively good. optimistic".
However, as far as he knows, the People's Hospital of Wuhan University has formed a team of critical care medicine early, ready to set off at any time to go to other places for support.
China Youth Daily·China Youth Daily reporter Qin Zhenzi