Several doctors put her life at risk with the first death of the coronavirus in Mexico. The patient had not traveled, no one suspected him and therefore they took a test. This is a case that represents the human impact that official definitions can have in a pandemic. It is also a possible explanation behind the number of people with COVID-19 according to the Ministry of Health.
By Gisela Pérez de Acha * / Special Investigations Aristegui News
It was early morning and the emergency room was almost empty. José, 41, (not his real name), had been ill for a week, with a dry cough, he could hardly breathe. At one in the morning, he entered the hospital on the arm of his wife. The lights of the National Institute of Respiratory Diseases (INER) were glowing. Silence. A couple of people waited asleep, each huddled in her chair. It was March 15, Sunday.
José and his wife registered at one of the windows. They filled out the long form: In addition to the symptoms, had José traveled? Maybe not him, but someone with whom he had been in contact? Within minutes, a nurse passed José with the triage doctor, who was in charge of classifying the severity of a patient and deciding whether or not to test for the coronavirus.
So Mexico was still in stage 1 of the emergency. The guidelines of the Ministry of Health said that doctors could only test patients with symptoms for coronavirus, yes, but they must also have traveled or had contact with someone who had traveled, with someone who was sick with COVID-19 or suspected of having have it. In medical parlance, these criteria are called “operational definitions.”
José did not meet the operational definition. Therefore, it was not a “suspicious case” according to the Ministry of Health. For this reason, the doctors were not able to do the swab test, the most common, from the beginning that came to the hospital. It was only two hours before they took a sample of the bronchi to send to the laboratory. But it was not trivial.
For the fourteen doctors from the six different hospitals we interviewed, José’s story represents the problem of narrow criteria for applying tests. The first operational definition may have led the Ministry of Health to underestimate the data on how many people had coronavirus in Mexico in stage 1, the prevention stage.
It was half past one in the morning. José was very ill. I couldn’t breathe. At half past two, the doctors had already intubated him. It was not until then that they took a sample of her bronchi and took her to the laboratory to run a coronavirus test. One of the doctors who treated him, he finished his guard and went home. Within hours, he had “a lot of headache” and a feeling of a cut body. Paracetamol was taken. Twenty-four hours later they spoke to him about the INER to give him the results of his patient: they were positive for sars-Cov-2.
By operational definition, during the two hours before he was given a bronchial coronavirus test, no one gave José a face mask, no one disinfected the areas where he was and where he passed. He was not isolated, he was not a suspect under the definitions of the Ministry of Health.
After three days in the hospital, intubated and under treatment, José died on March 18. José’s death was the first from a coronavirus in Mexico. For four INER doctors related to their case, it was also the first local infection.
“The radiograph showed that the lungs were completely inflamed,” said José’s doctor. “Unfortunately, he entered the group of patients with a poor prognosis.”
According to a report from the World Health Organization [OMS], based on data from China, out of every hundred people who get coronavirus, eighty have symptoms “mild to moderate“Fourteen have severe symptoms: they are short of breath, they need oxygen, a hospital bed and doctors. Six become critical: their lungs, organs and body fail, they are at risk of dying, and more or less three die.
José was part of that 3%. If he had not been in serious condition, unable to breathe, the health personnel would not have tested him for coronavirus, although they would have asked him to isolate himself. After leaving the hospital, he would have returned to work or home, with the possibility of infecting dozens, who could have infected dozens more, and so on.
In a telephone interview with the doctor José Luis Alomy, director general of epidemiology of the Ministry of Health said the change in the operational definition was strategic. This definition “entered in mid-January 2020 and expanded” from China to more countries “until the change came in scenario two, where we turned to try to look for cases in the community.”
For another INER emergency doctor, “in the first stage, most people with mild symptoms of coronavirus were sent home, and that percentage without a test could have been positive, infecting other people.”
José’s wife tested positive for the coronavirus four days after her husband died, according to Ciro Gómez Leyva. We could not contact her due to the confidentiality of the medical data. It is also unclear if anyone asked him to be in solitary confinement during that time.
According to our sources, the case of José is not the only one. On March 21, an emergency doctor of the INER received a 44-year-old patient with fever, cough and pneumonia. He also had not left the country recently nor did he know anyone who had. It was not a suspicious case of coronavirus, although he had the symptoms. The doctor decided to hospitalize him. This time they did isolate him, but according to the doctor “the man voluntarily discharged, and returned at 12 o’clock, he could no longer stand the lack of air.”
When he returned, the doctors intubated him and took a bronchial sample: he tested positive.
“Like those cases there are hundreds here, in Nutrition,” said another different doctor, from the National Institute of Medical Sciences and Nutrition Salvador Zubirán. “I cannot tell you an exact number because in stage 1 we only registered those who took the test. That was the problem with waiting so long to recognize the local contagion. ”
For an infectologist at the GEA González Hospital, that first definition of the Ministry of Health was far from clinical reality. “Some infectious diseases fail to take the operational definition into account,” he told us in an interview, but asked to remain anonymous for fear of retaliation. “I wiped that concept out of my mind two weeks before we officially entered stage 2, when we already had a suspicion that there was local transmission in the country.”
At INER, one of the hospitals that has treated the most coronavirus patients so far, José’s doctor says that if he had known that the patient was suspected of coronavirus, the medical staff would have followed different protection protocols.
“A patient with coronavirus was treated as if he had no coronavirus, ”He said in an interview. He wore goggles, gloves, masks, and disposable pajamas, but that is not enough to intubate a person with this disease. “Doctors, nurses, stretcher-bearers, cleaning personnel, windows and emergencies did not take the provisions that they should have taken,” José’s doctor explained.
In Dr. Alomia he said in an interview that in the official guidelines, the protective measures for influenza and coronavirus “are the same.” When asked why in countries like China, Italy and Spain, doctors wear N95 masks, goggles and special suits, he said that in the case of certain procedures, they are different. “The N95 respirator is only indicated for sampling procedures, Y [para] when a healthcare professional has to be around sampling or cleaning, or [en la] airway intubation, ”said Dr. Alomia over the phone, referring to the Guidelines for Patient Care COVID19.
The INER emergency doctor also exposed herself without adequate protection measures when she treated the second patient, the 44-year-old. “At that time, not all of us had protective measures because there was a team that saw the Covid suspects, and a team that saw the other diseases,” he said in an interview.
The doctor also had to be tested and isolated for 24 hours while waiting for the result. Fortunately, it does not have a coronavirus.
Twenty-five days after the first case of COVID-19 in Mexico, the operational definition changed when President López Obrador announced stage two on March 24, a day after the WHO recognized the local contagion in Mexico. The new definition removed the requirements related to travel abroad. The test is now done for anyone with two of the three main symptoms (cough, headache, fever), shortness of breath (an important finding), and any of the following additional symptoms: joint and muscle pain, pain in the the pharynx when swallowing food, runny nose, conjunctivitis and chest pain, in the last seven days.
According to our sources, the delay in changing it could have caused two problems. One, that the doctors did not detect the local contagion in time to take preventive measures. And two, that the government underestimated the percentage of the infected population.
“We could have increased local contagion because we just focused on travelers,” said the INER doctor. “At that time, there was still no quarantine. People were not isolated. “
Dr. Alejandro Macías is an infectologist and researcher of the National Research System Level III. In 2009, it was the epidemiologist who was in charge of controlling the influenza A (H1N1) pandemic in Mexico. “The operational definition that is being made now in stage two, had to have been done very early to realize what the foci of activity were and isolate them in time,” he said in an interview. “That is to say, trying to find absolutely all the infected and their contacts, to lock them up in their house and not burden the health services.”
The problem is that during at least the first twenty-four days of the coronavirus pandemic in Mexico, “any community transmission (without a travel history) would be neither tested nor detected,” explains Dr. David Romero of the Pro Science Network.
“The issue is the control of the epidemic in the early stages, confirmed Dr. Adrián Camacho, chief of epidemiology at the University Hospital of Monterrey, Nuevo León. “Identify patients very early in order to isolate them and prevent contagion.”
‘Measures were late’
On Sunday afternoon, March 29, one of José’s doctors was preparing to return to the hospital. The 44-year-old patient attended by the emergency doctor is seriously ill in intensive care at the INER. Meanwhile, the Mexican federal government changed its strategy. He began to send a more radical message, calling to reduce activities and avoid the concentration of people in the public space, instead of just promoting the “healthy distance.”
“Stay at home. Stay at home. Stay home ”, López-Gatell repeated on March 28, while President López Obrador shared a video, from Tabasco on March 27:
“I want to talk to you about how we should redouble our delivery. Our sacrifice and our obedience so that together we can stop, confront, and succeed in the coronovirus epidemic … We have to be in our homes, “said the president.
For the eighteen experts and doctors we interviewed, the move is late. At least two weeks earlier, the operational definition should have allowed more cases to be detected to take action and prevent the spread of the virus.
The problem seems to be greater, but we will know in a few weeks: if beds and other supplies, such as ventilators, will be enough for all seriously ill patients.
“The question is when are we going to find out,” said Dr. Romero of the Red Pro Ciencia. “If we are going to find out when they enter hospitals or before they can continue to spread.”
For the doctors who are in the trenches, between the emergency rooms and intensive care beds, the coronavirus wave is coming. José’s doctor, that first fatality of Covid-19, said “there are countless other infected cases, which are not yet known, and which are obviously going to get to the hospital sooner or later.”
It is a matter of time.
* Edited by Sandra Barba With information from Yuriria Ávila