Race against time: The treatment of the first confirmed COVID-19 patient in New Jersey, USA

This year's spring has finally returned to its past state, and many people may have forgotten how fierce the new coronavirus is. In the documentary "80 Days of Real Shooting in Jinyintan", the doctor said, "We can't catch the patients," "Suddenly there is no time for treatment," and "All your efforts are in vain." It took only one month for 34-year-old Dr. Li Wenliang from the onset of symptoms (January 10, 2020) to confirmed infection (January 31) and then death (February 7). Not long after, a Chinese doctor of similar age on the other side of the ocean was unfortunately diagnosed with the infection. His hospital was still in a state of "heard of but not seen" the new coronavirus; at this time, China's new coronavirus diagnosis and treatment plan has been updated to the seventh edition.

Today's article records the survival story of this Chinese survivor. May everyone be healthy and safe, and stay away from the new coronavirus.

Image source: "80 Days of Real Shooting at Jinyintan"

Written by | Kestrel

March 2, 2020 was an ordinary day in Cai Min's life. It was Monday, and he was attending a medical conference at the Times Square Hotel in New York. He left the venue early at noon because of a severe cough. He told his wife that he would stay at his mother's house at night. His mother's house is in New Jersey, separated from Manhattan by the Hudson River, so that if he got the flu, it would not be passed on to his wife and daughter - after all, his daughter was less than two years old and loved to stick to him.

Cai Min is a Chinese assistant physician who works in four medical clinics in the New York metropolitan area, working an average of six days a week. These clinics are mainly located in communities with large Chinese communities, such as Flushing and Chinatown. Cai Min came to the United States at the age of 14 and uses the English name James Cai. Many of his colleagues and friends are medical practitioners who immigrated to the United States.

After staying at his mother's house until 8 p.m., Cai Min thought that the nearby emergency clinics should be relatively free at this time, so he went for a flu test. The result showed that it was not influenza. Should he go home? He put on a mask and hesitated. The doctor who examined him said that his heart rate was high, which was not surprising because he did feel some palpitations.

Cai Min was still worried. How about getting tested for COVID-19? But the doctor said they didn't have that program. The two didn't think too much about it. In early March, COVID-19 was still just a distant threat to many doctors on the East Coast of the United States. Although several elderly people in Washington State had died from complications of COVID-19, it was just a "local outbreak." Only two people on the East Coast tested positive for COVID-19: a medical worker from Iran and a lawyer.

At this time, the doctor who was seeing patients late at night would not have thought that the colleague standing in front of him would be the first patient diagnosed with the new coronavirus in New Jersey.

The doctor also said that although the chest X-ray looked normal, the cough was too severe and did not seem to have started recently. In addition, the heart rate was high, which might be a dangerous pulmonary embolism. He suggested going to the nearby Hackensack University Medical Center (HUMC, northwest of New York City) in Bergen County for a CT scan to see more clearly. So Cai Min drove to HUMC.

Soon after the CT scan, Cai Min was transferred to a small windowless ward, where he began to have a fever and was short of breath. Because of diarrhea, the few steps to the bathroom exhausted him. He took a video and sent it to his wife, in which he was angry and panting, as if he was being chased by something, and that thing was now behind the door.

March 3, Day 2

In the morning, a nurse dressed in full protective gear, from goggles and a respirator to a gown and a cap, came to test Cai Min for COVID-19. The reason he hadn’t been tested the day before was that CDC guidelines recommended giving priority to patients who had recently been to China. Cai Min hadn’t been back to China in years, and, as far as he knew, hadn’t come into contact with anyone who had tested positive. He figured the test was to be sure.

An infectious disease doctor named Bindu Balani came to tell Cai Min that his CT scan results showed that he did not have pulmonary embolism, but because of inflammation in his lungs, he would be given antibiotics. Cai Min noticed the shadow on one side of his lungs in the CT scan results and judged that this was probably the reason why the doctor decided to test him for the new coronavirus.

Balani, also in full protective gear, spoke softly but seemed to know what she was doing as she explained the treatment plan: The doctors just wanted to rule out the possibility of COVID-19.

After the doctor left, Cai Min, lying in bed, began to search the Internet for symptoms of COVID-19 and asked his wife to check it out as well. The results were alarming: cough, palpitations, fever, diarrhea, cold, fatigue, shortness of breath - almost everything fits the bill! But how could a person like him who usually pays attention to exercise, cares for his family, and works diligently become a victim of COVID-19, and possibly the first case in New Jersey?

The night in the emergency room was filled with people groaning and wailing. Cai Min tried not to pay attention to the sounds and tried to concentrate on reading the messages of condolences sent by friends. The high fever of 39 degrees made the isolation even more difficult.

March 4, Day 3

The news on the evening TV pulled him back from a pathological state of numbness. "The infected person, a man in his thirties, is hospitalized in Bergen County." Upon hearing this, Cai Min's already high heart rate went up again, and he broke out in a cold sweat. Soon, an emergency doctor confirmed the news he least wanted to hear.

He took a photo of the television screen with his cellphone and sent it to his friend, Dr. Yili Huang of Mount Sinai Hospital, which showed the governor's Twitter update.

"How is that possible?"

“But the test result was positive.”

Previously, Balani had comforted Cai Min, saying that even if it was COVID-19, the most severe period of infection should have passed, which was the first two days. "Do you think she is lying to me?" Cai Min held on to a glimmer of hope.

"Of course not." Dr. Huang comforted Cai Min, but he was thinking in his heart that no one in HUMC had ever treated COVID-19, and his friend was facing this deadly virus alone in the ward.

Cai and Huang met at a workplace five years ago. Huang also came to the United States as a child, when he was only 11 years old. They both loved the Bund in Shanghai and had similar accents, so they hit it off right away. Huang is the kind of big brother figure that is recognized by friends. Cai calls him brother, and the two are like family. A few weeks ago, they talked about the new coronavirus. Huang is an optimist. Like many of his colleagues, he thinks that SARS did not threaten the United States, Ebola and Middle East Respiratory Syndrome (MERS) did not, and the new coronavirus will not, and the weather will soon get warmer, and the virus should probably disappear.

With Huang's comfort, Cai Min felt more at ease, but he still made some preparations according to his wife's urging. As early as the end of February, when New Yorkers were still flying around the world, Cai went to the supermarket to buy some frozen vegetables, fruits, 20 pounds of rice, protein drinks and other supplies, just in case. Many of his Chinese friends are also stocking up because they usually pay more attention to reports in the Chinese media. If the virus sweeps New York, everyone will definitely have to stay at home for two months.

Cai Min also posted a reminder in the clinic, asking patients with coughs and fevers to wear masks, and patients who had recently been to China to self-isolate for two weeks. He himself also wore a mask and gloves in the clinic. But he still underestimated the new coronavirus and did not take any protection when commuting on the subway. In fact, as early as early January, Cai Min and his Chinese friends began to wear masks in public places, but in early February, everyone saw a video online of an Asian woman wearing a mask being beaten in downtown Manhattan, and they stopped wearing them.

It was as if fate was playing tricks on him - he removed his own protection and tested positive. His family was also panicked. Cai Min's father lives in Shanghai and used his connections to seek help from doctors who had dealt with this disease. Huang also sought help everywhere: "I called my friends who work in the respiratory department, infectious department and ICU. I haven't contacted some of them for almost ten years." Some of the Chinese doctors sent to Wuhan were even desperate about Cai Min's situation - it is true that some people can recover quickly, but some people have mild symptoms at the beginning, but then take a sharp turn for the worse.

Now, the antibiotics the doctor gives Cai Min can only prevent secondary infection and have no effect on the virus.

March 6, Day 5

Anxious Cai Min felt that everything the doctor said to him was comforting. He said that he was still young and healthy before the infection, and that this disease might be like a severe flu to him. However, on the fifth day of hospitalization, his condition no longer resembled the flu. He was transferred to a negative pressure isolation room, where he could see his blood oxygen saturation through the pulse oximeter on his fingertips. It was very unstable, sometimes dropping below 85%, which made people gasp, and then rising again.

"I have trouble breathing now because I have too much phlegm," he told Huang. "Especially when I lie down, my blood oxygen level drops. I can only sit up and take deep breaths."

"It feels like surfacing for air while swimming. You can never get enough air."

Cai Min sometimes felt that he was not treated well in the ward. Once, a nurse came to measure his blood pressure and body temperature. She was in a hurry and asked him to take the thermometer with his back to her. It was obvious that she was afraid that he would infect her. But compared with the attitude of the nurse, he was more worried about the disease itself: he might continue to deteriorate until his lungs were too damaged and he could no longer breathe. If he did not get enough oxygen, his organs would begin to fail. He kept sending messages to Huang, asking Huang to promise not to let him die here. Huang could only reply "I promise" while praying in his heart that he really had a way to guarantee this.

Cai Min's world shrank to the small screen of his mobile phone. He played his daughter's video over and over again, and stared at the photo of himself holding his daughter. Every minute and every second was as long as the night. He thought about calling his daughter on video, but he was worried that his appearance would make his daughter sad, and himself sad. His wife didn't tell their daughter anything either - how could she explain all this to the child? Cai Min, who was deeply confused and in pain, thought that his daughter would probably feel confused and in pain too.

March 7, Day 6

Although he was breathing through a nasal cannula, Cai Min's blood oxygen was still dropping. He found that when he lay flat, his blood oxygen saturation was only 88%, which meant that his lung function was failing. He was worried about developing acute respiratory distress syndrome, which meant that he might have to be intubated soon. But the ICU where the ventilator was located was on another floor of the hospital - if his condition worsened, organ failure would come quickly, so how could the doctors intubate him in time? He had witnessed with his own eyes that a patient went from respiratory failure to death in just ten minutes.

Cai Min's family and friends are also trying to contact domestic resources and convey the advice from Chinese doctors to Cai Min's doctors. According to the experience of Chinese doctors, the ground-glass shadows common in the lungs of COVID-19 patients are easily overlooked on X-rays, and they will perform two CT scans on the patients to observe the development of the disease.

That morning, Cai Min asked the doctor for a second CT scan, which was recommended by the best doctors in China to help them monitor the progression of the disease. But the doctors were reluctant to do so. They would rather judge the progression of the disease based on blood oxygen, because just sending him to the CT room would put medical staff at risk of infection. Moreover, if he used the CT scan, the equipment would have to be disinfected, and others could not use it during the disinfection period. The hospital said that their treatment method was based on the evidence-based treatment plan published by the CDC, which was different from the plan recommended by the Chinese doctor provided by the patient.

At 10 p.m., Dr. Huang called and asked to communicate with Cai Min’s doctor on speakerphone. Huang “formally requested” another CT scan, but the doctor replied that it was “not necessary” because “no matter what the result is, it is unlikely to change the course of treatment.” Huang questioned how sure she was about her treatment plan and what the basis was. She had never treated a COVID-19 patient, so how could she ignore the collective wisdom of Chinese doctors who had treated thousands of cases? Moreover, after taking antibiotics, Cai Min’s blood oxygen did not increase. In short, the doctors at HUMC still did not realize how quickly the condition of COVID-19 patients deteriorated. However, no matter what Dr. Huang said, the doctor only agreed to discuss it with Cai’s attending physician.

Soon, Cai Min's superior, Dr. George Hall, also called in. After some communication, Danit Arad, another resident doctor in Cai Min's medical team, agreed to exchange phone numbers with Hall and communicate privately. The 64-year-old Hall studied at a famous medical school in China. After immigrating to the United States in 1987, he opened four medical institutions in New York. He also has a lot of contact with China, and a nephew has opened an infectious disease hospital in Yangjiang. For Cai Min, Hall is like a father figure.

Hall told Arad that the Chinese National Health Commission has issued the 7th edition of the "New Coronavirus Pneumonia Diagnosis and Treatment Program", and although its content is based more on clinical experience than published research, some methods are worth trying. For example, chloroquine and Kaletra are both anti-infective drugs that can be used after patients experience symptoms of shortness of breath.

Hall said to Arad: "You know that evidence-based medicine is necessary, and I know that too. But this is a matter of life and death. In this case, you can't wait for standard procedures. Besides, Cai Min will bear the risk of using this medicine herself." He promised to provide Arad with a complete English translation of the "Diagnosis and Treatment Plan for New Coronavirus Pneumonia."

Cai Min lay on the hospital bed, afraid to close his eyes, fearing that he would suffocate in his sleep. His blood oxygen level was still dropping, almost to 80%. He sent his situation to the WeChat group, and a Shanghai doctor suggested high-flow nasal cannula oxygen therapy, but the nurse said she did not have the authority to change the treatment plan. Cai Min asked Hall for help, and Hall asked another famous local doctor Henry Chen to find connections, but still failed to get Cai Min oxygen therapy.

Loneliness and fear lingered around Cai Min. He kept calling the nurses, his tone more severe than ever before. "I won't sleep until I see a respiratory doctor!" "I'm a doctor too, I can assess the risks myself!" He dropped Henry Chen's name, even though he knew the nurse would ignore him.

At midnight, a respiratory doctor finally helped him change to a high-flow oxygen-enriched mask, which can provide a higher concentration of oxygen. Although it is not as good as high-flow oxygen therapy, it is worse than before. In addition, the doctor took blood to check liver function.

Cai Min finally fell asleep, a light sleep. In his dream, he stared at the clock in the ward, repeatedly confirming that he was still alive. He also dreamed that the Chinese doctor looked at the test results and felt that his condition was not good. All night long, he drifted between wakefulness and sleep, trying to figure out whether he would survive or die.

March 8, Day 7

In the morning, when he opened his eyes, Cai Min saw the clock on the wall, his cell phone, and heard the constant beeping of the machine above his head. He finally believed that he was still alive. He began to pray frantically. He prayed to God and Buddha, and made a wish that if he could walk out of here alive, he would save so many lives; promised that he would not work so hard again and be a better father. He read the cards sent by his friends over and over again - these were the only things from the outside world that he could touch and make him feel that he was not forgotten.

He kept in touch with Dr. Huang via text messages. At this time, Huang finally became more worried: "What is coming is coming. This will be the next Wuhan, the next Milan."

Hall translated China's COVID-19 treatment plan in his home study. It was not an easy task, but it was very important, and there was no one to help. Symptoms, disease classification, course of disease, oxygen administration, follow-up suggestions... After working for nearly 12 hours in a row, Hall finally sent the translation to Arad before midnight. The sense of urgency was not just from Cai Min's case - if even medical workers like him could not be saved, wouldn't it be even more hopeless for other ordinary people if they were infected with the virus?

At the same time, Cai Min was surprised to find a technician in protective clothing coming to do a second CT scan for him. Two hours later, Dr. Balani brought the scan results. Her previous calmness was gone. She looked terrified and spoke quickly, trying to sound confident - Cai Min even felt that she must have rehearsed these words many times. She said: "It's time to take more radical treatment."

Cai Min finally saw his CT scan results. Six days ago, there was only one white spot in his lungs; now, the white spots were scattered everywhere like dandelions. The new coronavirus was killing people in his body, destroying the alveoli. In just six days, 40% of his lungs had collapsed.

The so-called more radical treatment is remdesivir. On January 21, Washington State confirmed the first COVID-19 patient in the United States. Four days later, Gilead Sciences accepted the application and provided remdesivir as a "compassionate use" drug, saving the patient's life. A few weeks later, the global demand for remdesivir increased, forcing Gilead to stop approving applications for compassionate use drugs - if it is later discovered that the drug has serious side effects, the pharmaceutical company will not be able to bear the responsibility for so many patients. However, Gilead has significantly expanded the scale of clinical trials of remdesivir in major hospitals.

The doctor finally started using chloroquine and Kaletra on Cai Min, and high-flow oxygen therapy. Oxygen therapy can temporarily save patients with respiratory failure from intubation and ventilators. However, when patients on oxygen therapy speak and breathe through their mouths, they may exhale oxygen mixed with viruses in their nasal cavity and respiratory tract into the air. The greater the oxygen pressure, the higher the risk of releasing the virus. Should we prioritize maintaining patient ventilation or protecting medical staff from exposure? Doctors had to make a trade-off. A few weeks after Cai Min was admitted to the hospital, the hospital was flooded with patients in worse conditions and some infected medical staff, all of whom received high-flow oxygen therapy.

The doctors finally changed their stance, which made Cai Min both relieved and sad. But the most worrying thing was his test results. The hospital assigned him a critical care nurse and vacated an ICU as a backup. If Cai Min's condition continued to deteriorate so quickly in the next few days, he would have to be intubated, and the possibility of recovery would be even slimmer.

He asked the nurse for paper and pen. If he didn't survive in the end, he had to let his daughter know everything. With tears in his eyes, he wrote: "I'm sorry I can't be a good father." He knew too well what it felt like to grow up without a father by your side - his own father was in Shanghai - and his poor daughter had to suffer the same fate. How he wished he could watch his daughter playing with her friends, pick her up from school, hand her over to the groom in person at the wedding, and help her solve any problems she encountered in life. He wanted his daughter to understand how much her father loved her. He carefully folded the letter, stuffed it into an envelope, and placed it on the tray beside the bed. The nurse saw it and said to him:

"I'm sorry."

Compassionate use of drugs not only requires FDA approval, but also the consent of the pharmaceutical company. Dr. Huang was worried that Cai Min could not wait for all the procedures to be passed, so he contacted all the Gilead representatives he knew and mobilized all his doctor friends to contact them. His former superior at Mount Sinai Hospital, Paul Lee, had already written to a deputy director of the National Institute of Allergy and Infectious Diseases (NIAID) to request the use of remdesivir for Cai Min, but was unsuccessful.

With Cai Min's consent, Huang sent his CT images to a large WeChat group of cardiologists, including Chinese doctors and Chinese Americans.

"Hi everyone, my name is Yili, sorry I don't usually post in this group, but my friend became the first case in New Jersey. He is also a doctor, only 32 years old. Please help us."

Felix Yang, an electrocardiologist, simply compared the two CT images before and after, made a short video and posted it on Twitter, calling on people to contact Gilead to help this patient with rapidly progressive respiratory failure.

March 9, Day 8

The short video had more than 500,000 views within 12 hours of its release. Michael Gibson, a cardiologist and founder of the open source textbook website WikiDoc, which has 500,000 followers, retweeted Yang's tweet. Hundreds of doctors around the world shared their knowledge in the comments section. A doctor who travels between China and the United States also found Yang to exchange views. In total, there may be hundreds of people who have tagged Gilead on Twitter for Cai Min.

Dr. Balani has also been busy. In fact, as soon as Cai Min was diagnosed with the virus, she started preparing the application materials for compassionate use. Now, Cai Min's condition should have met the requirements. Less than 4 hours after the CT images were posted online, Gilead notified Cai Min's doctor that the drug had been sent out from the company.

Bill Pulte, the grandson of real estate tycoon William Pulte and a Twitter celebrity who calls himself a philanthropist, released a video of his interview with Cai Min the night before. For a time, Cai Min's condition attracted national attention.

"I've been going through hell for the past week."

"Difficulty breathing, chest pain, high fever, tearing, diarrhea, and the CT scan showed that the condition was still worsening."

"At one point my blood oxygen saturation dropped below 80 percent."

Cai in the video had to stop and breathe every time he spoke. He said he would probably have to be put on a ventilator soon. "I don't know how many days I can hold on." He did not forget to complain about the hospital's unprofessionalism, outdated treatment methods, and inhumane treatment of quarantined patients.

March 10, Day 9

The medicine arrived before 3 a.m. Without waiting until morning, the nurse woke Cai Min up, asked him to sign a pile of legal documents, and then started an intravenous drip of remdesivir.

During the day, the fever that had lasted for 9 consecutive days finally subsided. In fact, before I started using remdesivir, my blood oxygen level had been stabilizing, which can be considered a sign that the body is beginning to recover.

In the next few days, Cai Min was still very weak. He coughed every time he opened his mouth, and he was exhausted when he spoke every word. But overall, his condition was gradually improving. About a week later, he was finally able to talk to his wife and walk around the ward relatively freely. He began to imagine the scene of himself being discharged from the hospital and going home. In the past, every time he walked in the door, his daughter would run over in slippers. His wife told him that these days, every time his daughter heard movement at the door, she would run over in slippers, but she would always cry loudly when she couldn't see her father.

March 21, the 20th day, discharged from hospital

Cai Min has tested negative for the virus twice in a row and can be discharged from the hospital. It is hard to say whether it was the anti-infection drugs at the beginning, the passage of time, the support of relatives and friends, or the immediate effect of remdesivir that brought him back from the brink of death.

He put on the sweatshirt and clean socks left by his mother, put on a mask, left a letter to his daughter on the tray next to the bed, and turned to leave. Someone will clear it away soon and make the bed available to other patients. In just one month, the number of confirmed cases in New Jersey has risen from 1 to 1,914.

After returning home, Cai Min still needed supplemental oxygen, especially when sleeping at night. Within a month, he started working online. Two months later, the epidemic in New Jersey began to ease, and he returned to outpatient practice.

Cai Min after recovery

At the end of June, Cai Min's blood oxygen saturation was still below normal, and his energy was not as good as before. "When I'm awake, my blood oxygen is 97%, but after lying down for a few hours or falling asleep, it drops to 90%." He described his condition on Twitter. "I still need supplemental oxygen when I sleep. I get tired easily. I used to work 60 to 70 hours a week, working in the outpatient clinic, nursing home, and surgical clinic, and I could go home to play with my daughter. Now I can only work 30 hours a week in the outpatient clinic, and I can't run like before."

There is no medical consensus on the optimal range of arterial oxygen saturation. There is a standard that if it is lower than 95% at rest or drops by more than 5% during exercise, it is abnormal. However, it is not enough to make the following judgment based on these isolated values. If the patient's resting blood oxygen was 99% before and is only 95% now, it is considered abnormal; and for patients with chronic obstructive pulmonary disease, the normal standard should be set at 88%-92%. Low arterial oxygen saturation can cause tissue hypoxia, change body temperature, pH value and blood flow, and endanger life. Some tissues are particularly sensitive to hypoxia. For example, brain cells will suffer irreversible damage after 4-6 minutes of hypoxic stress, while skeletal muscle cells can still fully recover after 30 minutes of hypoxia.

During this period, Cai Min has been receiving dual anticoagulant therapy, which is taking 2.5 mg of rivaroxaban (trade name Xarelto) and 81 mg of aspirin every day. The former is an inhibitor of coagulation factor Xa; the latter is an inhibitor of cyclooxygenase that synthesizes thromboxane A2 in platelets. General new crown treatment requires evaluation and prevention of thrombosis, because patients may have varying degrees of coagulation abnormalities, forming a basic hypercoagulable state. At present, this pathogenesis has not yet been clarified.

By the end of summer, Cai Min was able to sleep without supplemental oxygen. He updated the chest CT diagnosis results on Twitter: "There are only a few fibrotic lines on the lower left lung. It is a permanent injury, but not a big problem."

In the fall, he often posted some healthy diets on Twitter to record his progress in weight recovery. As a doctor, he "completely understood the old saying that the body is the capital of revolution this time." He also posted some COVID-19 cases he saw, for example, a teenage patient tested positive for the new coronavirus, but only had symptoms of rash and pain.

In December, Cai Min announced that she had tested positive for the new coronavirus again.

On January 7, 2021, Cai Min posted her Moderna COVID-19 vaccination card, "I got the first shot yesterday. I felt dizzy for the first hour, and the lymph nodes in my neck were swollen. Now it's just a little painful at the injection site." "I will take Benadryl when I get the second shot in February, and then take Tylenol after that." Benadryl is for allergies and Tylenol is for pain relief.

"Getting vaccinated is definitely worth it," said Cai Min.

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