Tong Zhaohui, chief physician of the respiratory and critical medicine department at Beijing Chaoyang Hospital, Capital Medical University, recently shared his clinical diaries with the public concerning the medical treatment of COVID-19 patients in severe and critical conditions at Jinyintan Hospital in Wuhan.

Tong arrived in Wuhan on Jan. 18 with the first group of experts dispatched to help the city curb the novel coronavirus. Back in 2003, Tong was also on the frontlines treating SARS, leading a team of 43 medical professionals to establish the "top SARS ward" where they managed to achieve a zero-percent mortality rate among the patients received.

"I don't recommend that we put forward treatment plans based on personal experiences," Tong wrote in early February. "I believe that the treatment for novel coronavirus patients should be primarily supportive. We should make sure that they don't have a lack of oxygen supplies, and protect their organs as best we can."

His diary entries before Feb. 3 already noted the biggest difference of clinical manifestation between COVID-19 and SARS. "Patients are contagious during the incubation period, and some cases only develop early symptoms of upper respiratory infections, but no apparent pneumonia," Tong wrote. "This makes it difficult to identify patients in the first place."

Tong also elaborated in his diaries on how to reduce the mortality rate of COVID-19 patients back in early February. "Despite the many randomized controlled trials into acute respiratory distress syndrome (ARDS), there is still a lack of effective methods in reducing their mortality rate. Plus, the ARDS this time is much more severe than previous cases," Tong worried.

"We recommend that invasive mechanical ventilation should be applied immediately to patients with an oxygenation index of lower than 150 after two hours of non-invasive ventilation delivering up to 100% oxygen," Tong concluded in early February. "If their oxygenation index is still under 100 after 24 hours, we should conduct extracorporeal membrane oxygenation immediately."

"However, irreversible damage will appear if there is insufficient oxygen supply to patients' organs for an extended time," he warned.

In addition to medical treatment, Tong shed light on the development process of new medicine. "It's a long and arduous procedure as any new medications must pass three stages of drug discovery, pre-clinical toxicology studies and clinical studies," Tong explained in a diary entry marked Feb. 6.

"As a matter of fact, many of the medications that have proved effective today during stage-III of clinical studies are more of a case of drug-repurposing. As seemingly effective as they are, we still need to figure out whether they are specifically aimed at the novel coronavirus, as well as their effectiveness in treating patients with both mild and critical conditions."

Physical conditions aside, Tong also noticed the delirium experienced by ICU patients. According to Tong, around 30% to 50% of patients in the ICU have experienced delirium, and among patients using mechanical ventilation, that figure reached around 50% to 75%.

"Advanced age, dementia, any previous experiences of coma or trauma, as well as the severity of sickness are possible triggers for delirium," Tong wrote on Feb. 10.

Tong referenced the 2018 PADIS Guidelines for both non-pharmacological interventions and medical treatment for delirium. He noted that early intervention for patients in a critical condition is practical, meanwhile there were still no convincing statistics regarding the use of antipsychotics in delirium prevention and treatment.

"We shouldn't neglect the symptoms of delirium among COVID-19 patients in critical conditions," Tong stressed.

In mid-February, based on his expertise working in the oldest respiratory ICU in China, Tong and his colleague updated in the diary the respiratory therapy and airway management concerning severe COVID-19 patients.

As treatment proceeded and the national treatment plans continued to be renewed later in February, many new topics appeared in Tong's diary, such as the venous thromboembolism of COVID-19 patients, the presence of sputum bolt in patients' bodies, the anti-viral effects of chloroquine, and the decrease in lymphocytes among COVID-19 patients, to name a few.

"My college professors always taught me not to make a final decision based on individual cases or personal experiences, because that's no way to conduct science," Tong recalled, appealing for the treatment of patients in critical conditions to continue being comprehensive, supportive and protective.

"Researchers, scientists and clinical experts need a lot of self-discipline today. Clinical experiments should be designed in a rigorous and scientific manner, and a conflict of interests should be avoided," Tong urged in his diaries, calling on the medical and scientific community to prioritize patients' lives, as well as the pandemic prevention and control.

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