Z hits another one out of the ballpark with his interview of a front-line virus warrior. This if fairly technical so you won’t get much out of it unless you’re a hospital nurse, respiratory therapist, or physician. Move along. The basic issue addressed is: what’s the best way to get life-preserving oxygen into a patient with scary-low blood oxygen levels. Who needs to be intubated and mechanically ventilated? Are we doing more harm than good when we intubate?
I’m not sure if Dr Weingart is an emergency medicine physician or intensivist (ICU specialist) or both. He works somewhere on the east coast.
Some personal take-away points for me:
- The concept of the “happy hypoxemic” patient: Despite oxygen saturation 75-85% (scary low), the patient is alert, talking, comfortable, tapping on their phone. Respiratory rate may be 25–35 or even higher (normal is under 20) but they don’t mind. Taking fairly deep breaths, not dog-panting. Don’t rush to intubate!
- Good idea: Intermittent pr0ning of non-intubated patients to improve oxygen levels. Prone position is lying on your stomach.
- The happy hypoxemic patient will have low pCO2 on arterial blood gas. May be acidotic (low pH) early on. But if pCO2 starts to rise to normal levels (or above) while patient is still breathing fast and hypoxemic? Probably not long before intubation needed.
- High-flow nasal cannula oxygen may be OK after all, as long as wearing surgical mask over it. (Some experts say to avoid this oxygen delivery system since it may aerosolize virus into the hospital room, spreading disease to healthcare providers.)
- After intubation, multi-organ failure often ensues. Unclear whether that deterioration is caused by intubation/mechanical ventilation or not. Was the patient headed down that road anyway?
- Most non-U.S. countries don’t allow the patient or responsible party to “force” physicians to provide mechanical ventilation. If such therapy is futile, it’s not discussed or offered as an option. I assume the same applies to resuscitation of cardiac arrest.
- Dr Weingart is seeing unusually high numbers of critically ill young patients with COVID-19. E.g., 35-45 years old. Unclear why.
There is still a huge amount we don’t know about this disease. Any points made in my bullet points or the video may be invalidated tomorrow.
Fortunately, at my hospital in Scottsdale, AZ, the expected COVID-19 surge never materialized, and it probably won’t in the near future. This epidemic is fading. I’m not particularly concerned about an outbreak after the unconstitutional house-arrest is lifted, except for those at high risk for serious illness. Click for my current advice if you’re at risk.
Steve Parker, M.D.