








key: cord-324345-j43rpvwk
authors: Leong, Hoe Nam; Lim, Hong Huay
title: SARS – My personal battle
date: 2010-11-19
journal: Travel Med Infect Dis
DOI: 10.1016/j.tmaid.2010.10.007
sha: 
doc_id: 324345
cord_uid: j43rpvwk

It isn’t every day that a doctor becomes a patient. It is more peculiar when it occurs with an unknown mysterious epidemic respiratory illness that kills. Severe acute respiratory syndrome (SARS) gripped the world in 2003, spreading via air-links and throwing the global economy into disarray. As a practicing physician in Singapore, one of the first countries affected, I describe my first-hand account of my battle with this illness, how I acquired this illness in Singapore, and eventually quarantine in Frankfurt am Main, Germany.

Summary It isn't every day that a doctor becomes a patient. It is more peculiar when it occurs with an unknown mysterious epidemic respiratory illness that kills. Severe acute respiratory syndrome (SARS) gripped the world in 2003, spreading via air-links and throwing the global economy into disarray. As a practicing physician in Singapore, one of the first countries affected, I describe my first-hand account of my battle with this illness, how I acquired this illness in Singapore, and eventually quarantine in Frankfurt am Main, Germany. ª 2011 Elsevier Ltd. All rights reserved. I vividly remember the time when I first saw the index patient with Severe Acute Respiratory Syndrome (SARS) in Singapore. She had just returned from a shopping trip from Hong Kong. She was unwell on the last day of the trip while her travelling companion had been unwell earlier. Upon return, both eventually sought help at two different major hospitals in Singapore. The index patient was admitted to Tan Tock Seng Hospital (TTSH) on Saturday, (1st March 2003), and an infectious disease consult was sought on the following Monday. I was the infectious disease registrar-oncall that day for TTSH.

Her presentation intrigued me, and with little hesitancy after discussing with my consultant, we assumed the medical management of the patient. The working diagnosis was atypical pneumonia of uncertain etiology. On that day, 3rd March 2003, the entity of SARS-Coronavirus was not even coined. At a much later time, I learnt that there were rumours of an 'infectious agent' in Guangdong province, and various diagnosis were offered included Chlamydia infection to avian influenza. She was nonetheless investigated, and managed as for atypical pneumonia.

As a young enthusiastic registrar, I was determined to find the etiology to her infection. Not wanting to miss any unusual signs, I examined the patient thoroughly twice daily. We explored and liaised with the various clinical laboratories to investigate the cause of her pneumonia. Routine tests from sputum bacterial culture to respiratory viruses immunofluorescence to serology were unyielding. All investigations were fruitless.

On the sixth day of her admission, I was referred another patient with atypical pneumonia. And again, I was presented with the same history of a young Singaporean woman with atypical pneumonia in a returning traveler from Hong Kong after shopping. The incredulous similarity unsettled me as I asked the referring consultant if we were talking about the same patient. With this new referral, both patients were immediately isolated and an alert was issued to the Ministry of Health, Singapore. This was to the credit of my consultant. It was an exceedingly busy day for me as I had to attend to new referrals, run an outpatient clinic, and subsequently draft a clinical summary of these two patients by the early evening. Needless to say, I didn't go home till it was very late that night. It was subsequently elucidated that these two individuals acquired the disease while staying in the same hotel in Hong Kong from an ill visitor from Guangdong Province. 1 The next day was the weekly scheduled infectious disease round in my practicing hospital, TTSH, where infectious disease physicians from the various public hospitals in Singapore would gather. Each public hospital (Singapore General Hospital, National University Hospital, and TTSH) would take turns to host the event that is held on all most Fridays of the month. At this opportunity, we presented our cases, and discussed our findings. As a group of Infectious Diseases Physicians, we had no inkling to the etiological cause. Nonetheless, the patients remained isolated.

Eventually, the patient's fever defervesced on day 14 of illness. I wasn't scheduled to perform the ward round that day, but I returned to visit the patient that Sunday morning. My curiosity had the better of me. On hindsight, I should not have, as I developed fever with chills and severe myalgia that very morning while going to work. That spelled the beginning of my own illness. For once, I appreciated what having chills meant. Despite driving in hot-weather Singapore, with the vehicular heater at its maximum setting, I failed to get any relief.

Coupled with the severe backbreaking myalgia and the absence of respiratory symptoms, I believed I had dengue fever. I drank plenty of fluids and took plenty of rest. The fever broke eventually on the Tuesday morning. This was day three of illness. With this reassurance, I decided to continue on my scheduled trip to New York for a conference. My pregnant wife and my mother-in-law accompanied on this trip. The plans were that we would have a short holiday visiting relatives after the conference. The flight was pleasant but interrupted by the airline staff seeking assistance for a passenger who developed epigastric pain. My paediatrician wife and I rendered assistance. This turned out to be a blessing in disguise later.

The next day I remained well and we toured the New York City prior to the start of the meeting that evening. When the lecture began, I felt extremely unwell, and developed severe chills and myalgia again. On returning to my room, I realised that I had broken out with a faint viral looking-like rash. I had a huge sigh of relief with the firm belief that my diagnosis of dengue fever was further reaffirmed. At that point in time, I had yet to develop any respiratory symptoms. My wife and I telephoned a colleague in Singapore and we concurred to have a full blood count test done at the clinic the next day. The American physician we referred to by the hotel in New York was a board-certified travel physician. His associate examined me initially, and astutely identified crepitations on my right lung. A Chest X Ray demonstrated radiographic features of consolidation and a full blood count showed normal white cell count and platelets. The physician immediately made a diagnosis of atypical pneumonia and I was prescribed levofloxacin. He showed professional courtesy and offered me free samples. On my part, I made a decision to return home on the first flight out that evening. The physician tried to dissuade me as he felt I would recover in a few days.

Just prior to leaving the clinic, I decided to call home to Singapore to update my family and a trusted colleague in Singapore on this new development. It was easily 12 midnight in Singapore time when I woke up my colleague! It turned out that this call was highlighted to the Director of Medical Services, Ministry of Health, Singapore, and a frantic search began for this sick doctor.

I was halfway across the Atlantic Ocean when the Ministry eventually found me. The crew servicing the passengers happened to be the same crew that serviced us on the flight out to Frankfurt from Singapore. Naturally, we were identified out easily, like a sore thumb! We were cordoned off to the rear of the plane with three empty rows ahead of us. It was extremely professional of the aircrew to have treated us with dignity and respect. Perhaps it was ignorance, but I was not treated as if I had a highly infectious agent. My respiratory symptoms of cough began with this flight, and in retrospect, I wish I had stayed in New York.

When we arrived in Frankfurt am Main Germany, the passengers and then the crew were taken off the plane, leaving my pregnant wife, my mother-in-law and myself as the last passengers. Eventually, three Germans boarded the plane in 'spacesuits'. I was full of admiration for my mother-in-law who took all these sudden news and men in full personal protective equipment (PPE, complete with powered air-purifying respirator) in unbelievable calmness. In a matter-of-fact tone, she told me composedly that she had watched television and knew what to expect e exactly! She had developed a cough by now, which she did not blame me for. The Germans were clearly well-prepared for the scenario, having rehearsed this recently for a mock patient at the airport with a viral haemorrhagic fever. The hospital, Klinikum der Johann Wolfgang Goethe-Universität, and its staff, led by Professor Hans-Reinhard Brodt, was exceptional in delivering the best care possible to me. As both my mother-in-law and myself were ill, we were moved to the intensive care unit in this isolation ward. My wife was cordoned off in a separate room.

However, the nightmare with my illness has just begun. I became increasing short of breath with an unabating persistent fever. My respiratory symptoms that were nonexistent initially returned with a vengeance, as I had to cope with haggling bouts of cough that resulted in me desaturating on the oxygen monitor. Every single attempt to change my posture would result in a severe bout of cough that frightened my mother-in-law. It appeared as if my lungs would be spit out at the next cough. At the end of each bout of coughing, there would be haemoptysis. This was a terrifying sight for a mother whose daughter was pregnant with my child. The thought of a fatherless child, no doubt, crossed her mind.

My experience as a patient humbled me. I had no toilet privileges, as I was too unwell to get out of bed. For the love of my life, I was cursed that I couldn't bring myself to empty my bladder supine, but had to stand. It didn't help when it was frequently interspersed with bouts of coughing and haemoptysis every time I tried to position myself! Science thus taught me, in cruel fashion, that I could hold 1 L of urine in my bladder.

My wife eventually joined me when she developed fever at the end of the second day of arrival. The sense of guilt overcame me as I thought of the illness I had exposed my wife to. In this moment of desperation, I cried to God's help, and I offered my life for the safety of my wife and my unborn daughter. My hopes fell to despair when I became extremely breathless one evening despite being on a full-face oxygen mask of 100%. The sensation of breathlessness was extremely terrifying as I tried to take in deeper and deeper breaths to satisfy my air hunger, but to no avail. I felt suffocated as if the air had no oxygen. Incredulously, I retained some sense of logic. I knew I had to avoid mechanical ventilation if I wanted to keep the odds in my favour. I struggled and prayed, and in the silence, I found peace. The night turned to day, and amazingly my recovery started.

My mother-in-law never developed fever. Her respiratory symptoms resolved by the evening of admission, and she was up and about, back to her usual spritely self. In jest, we attributed her health to her younger days when she worked in a farm. My wife miraculously had much milder symptoms. There was a fetal ultrasound assessment, which turned out well. The doctor avoided all chest radiographs of my wife to protect my unborn child. Intravenous erythromycin, a category B drug, was the only drug prescribed for my wife.

The managing physician allowed me to participate in the medical care and we actively discussed the choice of antibiotics. On the first day of admission, there was still no news of SARS or any infectious agent. But the news of a new infectious agent (SARS) broke out on the second day of admission, and I was given a Promed email on this. This was 15th March 2007. With that news, my days as a patient in isolation continued. Regularly thereafter, we were fed information from the Promed by the attending healthcare workers.

In the study of science, my mother-in-law, wife and myself were subjected to various samplings for viral cultures. It almost became a daily routine that we had daily nasopharyngeal and eye swabs. Arterial blood gases (requiring a puncture on the radial artery) were performed regularly. The attending physicians had to do this while in their full PPE in thick industrial grade gloves. To their credit, they managed to perform these tests in those unwieldy suits and gloves. When I was better, I performed the blood sampling for my wife and mother-inlaw instead.

For the benefit of science, I agreed to a bronchoscopic examination. They obtained an old scope and a respiratory physician was flown in for the procedure. The bronchoscopist was accomplished, but the experience was far from pleasant, but it gave me the moral authority to advise my subsequent patients when I submitted them for endoscopic examinations. A computer scan of the chest was performed when I was much better. The record of my stay and the findings was eventually published. 2 We all eventually recovered, and during the obligatory isolation, we had the chance to sample hospital German cuisine, and ordered in Chinese takeaways and pizzas. Indeed, Frankfurt should be the place to eat Frankfurters! The only recreation was the ice figure skating championship that was broadcasted during that period. The doctors were fantastic, and the nurses were unbelievably warm and understanding. We couldn't have received better care from anyone else.

The solitude in isolation was deafening as the days wore on. My initial reading was with the only English book my wife asked from our German caregivers, the Bible. It was through this episode that I first read the whole gospel according to Luke. Our friends and family took turns to call us to keep us entertained. We were regularly updated by colleagues fighting the battle in TTSH. Without these friends, we would have clearly lost our sanity. The best gift came when Dr Asok Kurup, my colleague in the Singapore General Hospital (SGH) came to visit me. He brought well wishes from my department; get well cards and an English novel. I felt 'loved' by my friends. I was a staff of SGH, and was rotated to TTSH as part of the infectious diseases training programme. Despite the fact that I acquired the disease from another hospital, the CEO of Singhealth, the administrative group for SGH, Professor Ser Kiat Tan, announced publicly that he would pay the entire hospital bill. This settled my worries. Some time after my discharge, my employer was billed for my entire stay, including the quarantine charges. It was a large bill that I would never have been able to pay in a lifetime. Professor Tan made calls to me either personally or through his secretary. That offered a lot of hope for this patient. Even Singapore Airlines offered my wife a bouquet of flowers, despite the trouble we created for them. They truly exemplified their motto e "A great way to fly". I am still grateful to their staff till this day.

A lady approached our isolation unit one day, with magazines in English. She introduced herself in spattering bits of English and gesticulations as the matron of the hospital. She represented the hospital and felt for sorry our solitude. We were very grateful for this unusual warmth in the cold early spring in Frankfurt am Main. In return, we gesticulated wildly back at her, acknowledging her kindness.

Eventually we were discharged when our period of isolation was over. We were whisked off in a private car and quietly into the airport. We never went through immigration when we first arrived, and hence, technically, illegal immigrants! The flight back was uneventful. The crew knew of our special status but remained professional. On arrival in Singapore, we were whisked into a waiting taxi and sent home. The journalists never got to me.

We returned home to welcoming family, colleagues and friends, intermixed with hugs, kisses and warm handshakes. They were clearly relieved that we have survived this episode. This came amidst further news of infection and death caused by the virus. For me, it was great to be home. I visited SGH on the Monday after, and greeted my colleagues. This was just when SARS was identified in SGH. I was roped in to help with the transfer of patients from SGH to TTSH. Thereafter, I started working in TTSH, working hand-in-hand with my colleagues in battling SARS. My wife joined me subsequently on secondment from KK Women's and Children's Hospital. Together with other SARS survivors, we formed a team, collecting respiratory samples from individuals suspected to have SARS. My wife and I worked with various doctors. The camaraderie was amazing to say the least, and we made long lasting friendships with many people.

SARS was eventually controlled, and we returned to our previous positions. My daughter, was born in early September, full term with no apparent birth defect. We have survived an epidemic, and in 2009, the world was thrown into another epidemic of swine-origin H1N1 influenza. 3 As a physician, this experience has allowed me to better appreciate what a patient experiences. That solitude and isolation, is a horrific tragedy for both the physician and patient. And yet, as an Infectious Diseases Physician, I have sadly implemented this order on many individuals. Sometimes, these individuals die, alone, in desolation.

The fear of an unknown mysterious illness is overbearing. Coupled with isolation, this becomes defeatist. The impetus is thus with us physicians as we remember the aphorism by Dr Edward Trudeau, "to cure sometimes, to relieve often, to comfort always". 4 We all can always comfort patients, even in isolation.

Since 2003, we have been blessed with two other children, Vivianne and Lucas. Marianne, who is now six years old, is starting first grade this year. Though tumultuous, the SARS experience has taught us valuable lessons as doctors not otherwise taught in medical school.

Outbreak of severe acute respiratory syndrome e worldwide

Identification of a novel coronavirus in patients with severe acute respiratory syndrome

No conflict of interest.

