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From: "Astraea Kelly" To: "AC" Subject: RE: CHECK OUT THIS Intro and Origin Theory/SARS
Date: Tue, 13 May 2003 05:37:32 -0700 
----- Original Message -----
Sent: 5/13/2003 2:13:18 AM
Subject: SARS-Like pattern/N. California

Angie Carlson requested that I speak with you about a pattern we are seeing in our patients at Kaiser Hospital, Vallejo, CA. I am a respiratory therapist (20 years in the field) and I have been working for the past 30 days, almost exclusively, with our "atypical" pneumonia patients.  Ninety to ninety-five percent of the patients I have had since March 9th on my documentation records, have had the following patterns of presentation and outcomes:

Sudden Shortness of Breath, fevers of 100.4 to 102.2 documentable. Pneumonia with ARDS developing in most.  Many have gone into liver and kidney failures, have pleural effusions or cardiac effusions, have had unknown etiology of sepsis arising more often in the last 2 weeks and have needed ventilator support (both invasive and
non invasive) for hypoxia.

Some of my staff members say the pattern was visible to them in ICU as long as 6 weeks ago.   I was aware of it 4 weeks to 5 weeks ago.   At first the patients presented with a viral pneumonia pattern. Their WBC were low 4,000 to 2,000.   We started seeing adults with RSV in their sputums.  Those were placed in isolation, but NOT necessarily negative pressure isolation, immediately and our hospital staff was
exposed to them without isolation while diagnosis and sputums were made and gathered.   Then we saw a bacterial presentation coming.  The bacterial pneumonias were frequently gram negative rods, but not pseudomonas.   Some were Maxilla pneumonia in the sputum.  There were no Influenza A or B in the sputums.   RBC were all over the board on the patients from high to low and we had clotting factors lowered.
ABG's showed mostly metabolic acidosis with hypoxia of moderate to severe in the ICU cases.

At first the patients were able to ambulate in for care, then they came Code 2, then in last three weeks many are coming respiratory or full arrest and intubated in the ER or transferred from other facilities after arrest in ER.  The ARDS patterns develop quickly, within 8-14 hours.  The Xrays are nodule in patterns and grainy. Then we had a rash of intestinal bleeding developing the patterns. Then we had intestinal necrosis.  Many of our patients started going into pulmonary edema or liver failure on the surgery tables.
Our mortality rate has become very high now with these patients.  We are needing more tracheotomies done.  They require paralyzing agents on the ventilators and large amounts of morphine for sedation or we can't control their high respiratory rates.  Sometimes up to 20mg bolus to sedate.

At first we were weaning successfully in high numbers and only losing,  by my estimate, of 4-6 percent of the mechanically ventilated patients. Then it got longer to wean, our success to death ratio started going 50/50.  It may be worse now.  Then our weaned and improving patients started to rapidly deteriorate and die after we thought they were doing better and had transferred some ICU patients to TCU and floor care.  They started returning within 8-12 hours in arrest suddenly.  We have lost 20 patients in the last 30 days on one shift alone, that we can track as respiratory therapists trying to watch our patterns. We have lost count of the total deaths in one month.  It has become VERY disturbing.  I have  never seen a pneumonia season like this in 20 years in the field.  It is a  very late season for flu.  We usually end our flu season in March, not increase it.

 We do have abnormally high amounts of rain and wet weather this year in our area.  However,   we are not seeing yeast or asprigillias in the sputums or "balls or fluff" on Xray.  Our physicians have ruled all of these patients as NOT SARS.  Most were not in any isolation until just recently as mortality increased and we then moved to more contact isolation ....usually with the diarrhea patients.  Those showed a pattern of C Diff.  in the stools, but not all of them.

Our nurses and respiratory therapists (especially) have reported feeling very abnormally tired after working with these patients.  It is difficult and exhausting in 8 hours and many of us have cut our extra hours or overtime  because we just don't feel that well ourselves after a shift.

At first, the patients were older in their 60-80's. Then they got younger and now we have had a teenager and someone in their 20's severely ill.  They were compromised with other illnesses underlying.  It looks like whatever organ was weak to begin with, was the cause of death or ultimate failure. HIV did the worst.  TB history was also a high mortality. Cancers were hit hard, even with a 5 year free of cancer history.  We had a lot of people with history of chronic fatigue syndrome and muscular sclerosis.  Cardiac patients usually died. We started having recently DIC in patients with unknown origin sepsis. We have had several nights in the last two weeks where we are losing 3 or 4
ICU patients per 8 shift at a time with this same pattern.
Our hospital does have suspected SARS from their criteria, of outside of the US travel.  It has only been in the last week that we have opened that isolation criteria up to the U.S. for SARS diagnosis without KNOWN contact with a SARS patient or a health care worker directly inside an isolation room becoming sick.  This has ignored secretion spreads possible.
I am going to forward my personal numbers of patients that I worked with that had this SARS-LIKE, but non SARS diagnosed pattern that I have my notes for.
Symptoms of above description "odd pattern".

58 since March 9th (these are just mine).  This  is far from all  the patients that I have seen with this, but those I can verify by record and name if needed.  I would call them "SARS-LIKE."  We only have 3 SARS suspects listed in Napa/Solono county, although our SARS isolation rooms have been quit I don't who is in there taking up the space.  I personally know of 20 deaths in the last 30 days of this pattern. We have NO deaths listed anywhere in the U.S.  as SARS  deaths. We have a journalist who is working with 4 other health care workers reporting the same patterns in their patients in the Bay Area.  They are unknown to me and I to them.

I don't know which hospitals they are from; they wish to remain non
disclosed. One is working in a hospital that has children as patients and says that
their mortality is matching.   They have also lost 20 patients MANY who are
children to this same pattern in the last month.  I can not personally confirm that
report ..but I can refer you to the journalist who has that report to them and is holding the health  care worker as  a confidential source at this time.
I am afraid I have also gotten sick with the pattern and become  document on this Saturday as a "confidential" diagnosis ...confidential even to me I was not given my diagnosis, it is listed only by screening physician name. And I was required to sign that I had a diagnosis, but that was it....."screening physician name".   My symptoms were diarrhea for 3 days, severe right lower quadrant abdominal pain, stools more than 7 times a day for 3 days, fever (not shown to me at the clinic) but 100 degrees during the day and up to 101 at night for a day and a half, (now normal).  Hypertension of BP 149/89 sitting and 169/98 immediately standing.  Thready pulse.  And mild hypoxia by pulse oximetry of 90 to 87 percent sat at rest. and 93 percent while standing.

My normal saturation is 98 percent.  My peak flows were only 250l/min at my best effort........I have been 550l/min that's half.  My lungs were dry sign of pneumonia on auscultation.  I had a mostly dry hacking cough and abnormally more frequent sneezing times a week with occasional white thick sputum.  No labs or Xrays were taken in my screening.  My ears and throat were checked.......but I do not  know what was seen by the physician.

So it appears to be a "clinical" diagnosis of "confidential" without  supporting labs.  I was referred to follow up with my regular physician and told the symptoms of distress were usually lasting 3 days to a week.  I was not instructed to self quarantine, but I have tried to do so  anyway.  My travel history was taken and I was questioned on who I live with ( a non issue) who would have had these symptoms.  The only people who have had them that I have been in contact with, have been my patients.

I hope this is helpful to you.

If you would like to speak with me, my phone number is 707-747-9206 and I live in Benicia, CA.

The demographics of the patients were that they were mostly  defense contractors or retired, engineers, chemical engineers, veterans (retired) or their spouses.  Not all ..but the majority of the patients fit this social/working class group.

One was an embassy diplomat, and was one was a scientist in defense.  One was an RN, but she was on disability and had recent surgery and was in the outpatient clinics often.  No doctors that I am aware of.  No staff members dying that I am aware of.   I don't know if any other of our staff members have had a "confidential" diagnosis or not for this symptom pattern. For 2 weeks in March and early April all of our ICU physicians were not present for the whole weekend and took calls at home only.  I suspected they had placed themselves in a home quarantine situation, but I have no confirmation of that.
We seem to be abnormally reluctant to discuss from physician to staff that we have ANY pattern and the physicians or administration or managers have been most
unhappy when I or  any other staff attempts to broach this subject with them.

Most of this SARS-LIKE pattern was not in any isolation, contact isolation at best. We have this same presenting pattern throughout our community in the North Bay is my understanding from my manager and  from  our physicians who confirm that concept.   The two other cases of Suspected SARS patients that I have read their chart on, were heath care workers also from different facilities in this area.  They are both doing well.  It is our NON-sars patients who are dying.

         Astraea Kelly
         Respiratory Therapist
         Kaiser Hospital, Vallejo, California
         707-651-1000 general operator switchboard for inquiry
         Home Phone 707-747-9206

Theory of SARS Origins:

I developed a theory while watching our SARS-LIKE presentation  develop at Kaiser Hospital Vallejo, California and believe it has merit.

We had two health care workers travel to Thailand for the sexual tourism attractions in Southern Thailand in 2002.  They left around Thanksgiving and came back just before or after Christmas.  They flew through Hong Kong both in and out of Thailand.  While in Hong Kong or Bangkok, and early in their trips, they both got what we thought then was the Hong Kong Flu.  They said it was the worst flu they  had ever had and both reported feeling as if they had very high temperatures.  They recovered and went on to Southern Thailand to Patong.  They both made many memories with the prostitutes there, who have HIV of 20% or more in their community.

Most of the Thai men do not wear condoms.  Caucasian men, usually do,  but the condoms are noted to break or leak heavily due to the moist heat in the tropics and from the physical stress of a larger organ going into a much smaller organ with rapid friction.  Patong and Southern Thailand are noted for their child prostitution and some illegal child imported female sexual slavery. Patong is on a coast with an old history of sea travel to Malaysia and China.

They are in the middle of the "golden triangle".  Drugs are very prevalent and easily obtained, regardless of Thai government policy.  The police are very liberal in law enforcement for non nations and wish to keep the situation friendly for the tourism industry.
Gibbons, a monkey, is especially noted in Patong and surrounding night club areas for being used and mistreated in sexual acts with humans for cheap entertainment and "live" pornography acts.   There is an animal shelter in Patong that rehabilitates the Gibbons from such practices and releases them back into the wild.  In SARS. we are looking for a human to animal contact where the virus may have jumped species and mutated.  We haven't found the animal in China.  I think we should investigate Thailand Gibbons. They have caves and tropical heat, which are wonderful breeding dens for
tropical fever viruses.  We have an animal to woman's sexual vaginal areas, which is a structure being examined for the SARS mutational sequences. We have high international travel routes, primarily by air routes into Thailand.

We have secretion mixing with sexual practices.  The men report 50 to 60 hits per day from prostitutes wanting to show the men their favors.  In other words, we have a lot action going on and interactions.  Thailand is a communist government with easy and close access to China.  Businessmen and government agents and diplomatic liaisons from all over the world come to enjoy the natural beauty, low prices, and male "Disneyland" pleasures.   And we have frequent monkey to human sexual contacts, released back into the wild.  The women from these monkey acts probably then also sleep with human men afterwards.
 I don't believe Thailand allowed WHO physicians in to see their atypical pneumonia patients.  But there was a reported Italian physician hospitalized in Thailand in November with SARS.  I am trying to find the information on what hospital he was in.  If you know that information, please forward it to me.
Our health care workers who were in Thailand in November to December, both males in their 20's and Caucasian, had an encounter with a prostitute from a local bar.  One of the men went with the prostitute on a late night ride to see her family member who was sick and hospitalized in a Patong hospital.   Then this worker came home to the U.S.
in late December and was sick on his way back to the U.S. However, he immediately went back  to work at Kaiser Vallejo Hospital, and worked with compromised patients for 39 days in a row.  His travel partner worked as many days ,also, but at many facilities in the North Bay  Area, along with Kaiser Vallejo.  Then we started seeing a mild pneumonia pattern in January with our patients, but we really didn't think it odd, it was pneumonia season then.  Then these same pneumonia patients are coming back now, with our strange "atypical pneumonia" picture and they are severely ill. They report they never got feeling better after discharge and have never felt "normal" since January hospitalizations. Some have died. Some have recovered on second admission.

Then in March we saw this whole wave of patterns, as I described in my last email to you of "SARS-LIKE" patterns leading to higher mortality than we have ever consistently seen at our hospital, or any of us can remember.

Now in Cambodia, a SARS-LIKE outbreak has been reported in the last week with 300 infected and 7 deaths.  Cambodia boarders Thailand. Our "Thailand boys" have also been with the tourist markets again.  Also of note, is that our HIV started here in the U.S. in 1980 in San Francisco.  This is also the same year that Thailand began it's "tourism" business trade for international travelers.

And then we have an HIV outbreak in 1980, at the same time as we have international sexual tourism starting in Thailand.   I think we have infected Gibbons being released back into the wild after some viral mutation from human to sexual contacts for "entertainment" on a regular and ongoing basis.  I think we should go to Thailand and track Gibbons for  a possible source contamination to both HIV and SARS investigation.
Of further note, our health worker men from November just returned to Thailand for vacation again in March.  They left on March 27th approximately 1 am from thought to be SF International airport.   They flew into Taiwan with date time change late the 25th or early the 26th.   They went from Taiwan to Thailand, probably landing in Phuket.  They were said to be going to Patong again.  Both left our hospital, after being in the ICU around the areas of the atypical but NON isolation patients.  One was in a Suspect SARS isolation room before he left for the airport. Neither of the men changed their clothes before boarding the airplane, and I seriously doubt they accurately disclosed their SARS contact before entering Thailand, or they would have been in quarantine for their entire vacation.  They emailed back that they had been re-routed through Taiwan instead of Hong Kong and they were fine and having a good time. They should have
returned or are just returning now to the United States from a probable reverse route
through Taiwan.

I was the watching the WHO numbers suddenly inflate on SARS during the 25-26th of March onward.  It was suspected a contaminated plane off loaded in Taiwan.  I thought that timing was very interesting with our male travelers and their unchanged clothes after SARS and SARS-LIKE contact going through an international airport in Taiwan.  Now we have an outbreak of SARS-LIKE in Cambodia, which boarders Thailand.  I do not
know if these men were ever screened for SARS this year.  Every time I attempt to address the issue I am disciplinary threatened at our hospital.  Several of us wanted them  quarantined for 14 days before coming back to work.  Our corporate infectious disease physician stated to me he would only quarantine them if they ran a fever.  That rather ignores the purpose of  a quarantine, which is that someone can be infectious without overt symptoms for a period of time after exposure.  I think it would be interesting to interview the young men on who and where their contacts were and what their travel itinerary was on both trips.

           Astraea Kelly
           Kaiser Hospital Vallejo, CA. 
Astraea Kelly
[email protected]
Astraea Kelly
[email protected]

 [Original Message]
 From: AC  To:  Date: 5/12/2003 10:07:21 PM
 Subject: CHECK OUT THIS SITE: - Hype-free SARS Information