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ER doctor stresses importance of pulse oximeter program


by Tara Giles
Sports reporter - Coos County Democrat and Berlin Reporter
November 26, 2020
REGION — Littleton Regional Healthcare Emergency Room Dr. Richard Levitan has written about the importance of pulse oximeter monitoring as it relates to COVID-19.

He said, "Before vaccination protects our country there will be tens of thousands who develop COVID pneumonia. We have no national policy on COVID + patient monitoring with pulse oximetry. NHS does. Germans do it better than anybody (1/6 our death rate). Only 2/50 states have it listed on web guidelines including Vermont and Maine."

LRH has adopted the program.

Levitan gained nationwide notoriety after appearing in a New York Times piece as well as appearing live on CNN after leaving the North Country to travel to New York City to offer help, at the start of the pandemic this past spring.

He said, "It was killing me watching what was happening in New York and not being able to be there to help out. I spent my entire life teaching airway management and watching this disease surge in New York while sitting up here watching the snow melt didn't quite sit well with me."

Levitan's priority, and something he'd like to share on a local level is that the public health message should be less driven by fear.

He noted, "There's a lot of anxiety and fear around this disease. What I learned in NYC and something I believe the entire country should learn from New York City, is how we can prepare for this better. I believe the entire country owes a debt to New York and can learn from those healthcare workers and what they have discovered."

According to Levitan, the majority of COVID-19 patients are not reaching out for medical care until it's too late.

"Many people are waiting until they can't breathe, and are toughing it out at home for fear of going to the hospital. What I'm saying, is do not be afraid to come to the hospital to get checked out. It's better to catch this disease on the front end, then on the back end when patients get very sick," he said.

To get into the medical side of things, Levitan put it simply.

He said, "This disease causes pneumonia, which causes your oxygen levels to go very low. Oxygen levels below 92 percent should prompt patients to call into the LRH COVID tele-health line or speak to their doctor."

He went on to explain, "I saw people sitting in waiting rooms on their cell phones with extremely low oxygen, percentages that you would normally see in climbers at 15,000 feet. If you suddenly fell to such low levels you would normally pass out in minutes. We now know that this happens slowly in COVID patients, but many patients don't feel short of breath until their numbers get alarmingly low. Patients with COVID pneumonia present normally about five to 10 days after getting sick. If we knew their oxygen level earlier, and we could start treatment earlier, many fewer patients would need a ventilator."

Levitan says a simple screening tool, a pulse oximeter, can help the public monitor their own levels.

"We have these in every ambulance and in every hospital. They are fairly cheap and attainable to the public and are available in most pharmacies. What I'd like to see across the country is widespread monitoring using this tool. This way we can tell in advance if a person is silently getting sick before more serious symptoms develop," he explained.

"We cannot prevent all bad outcomes. This is a dangerous virus, but people are seeing many stories of sudden death and people being put on ventilators. For the vast majority of patients, we can get ahead of it with proper monitoring. They don't need ventilators, and they shouldn't be scared to come to the hospital," he said.

The Vermont Department of Health recently announced the pulse oximetry program. Since its inception, more than 300 patients have received a pulse oximeter from the VDH. Pulse oximeters are also available at any local drugstore.

The announcement from the Vermont Department of Health states, "Among several deaths in COVID-19 cases (all with laboratory-confirmed SARS-CoV-2 infection, the etiologic agent of COVID-19) in Vermont, hypoxemia appeared to occur prior to the onset of dyspnea. In addition, the concept of 'silent hypoxemia' has been described among COVID-19 cases outside of Vermont."

The program was outlined, "The Vermont Department of Health is embarking on a public health program intended to allow more rapid detection of clinical deterioration of COVID-19 cases through the use of pulse oximeters at home. Earlier detection of hypoxemia in COVID-19 cases could prompt earlier medical evaluation and, as indicated, supportive care such as provision of supplemental oxygen. In turn, it is hoped that more rapid initiation of supportive care for COVID-19 cases will also result in better clinical outcomes, including decreased mortality."

It goes on to say, "Within approximately 24 hours of a positive SARS-CoV-2 test result, newly diagnosed COVID-19 cases are contacted by Vermont Department of Health staff. At that time, COVID-19 cases are interviewed regarding symptomatology. All cases are counseled to seek medical evaluation if they develop dyspnea. Through this new program, cases will be queried in the same interview about whether or not they have a pulse oximeter at home."

If a reading drops below 90 percent oxygen saturation (the norm is 95-100 percent), patients must seek medical attention.

In an editorial Levitan wrote for the Wiley Online Library, he states, "In all areas of emergency medicine, we know that earlier detection and intervention minimizes end‐organ injury and improves outcomes. I believe that this will be shown with COVID‐19 pneumonia too. Last month in AEM, Caputo et al.7 reported that awake proning and positioning maneuvers coupled with noninvasive oxygenation reduced the need for intubation in two of three patients with moderate to advanced COVID‐19 pneumonia."

He went on to state, "Hopefully, such techniques will work even better if we identify pneumonia earlier with only mild hypoxia and before severe lung injury. This month's study by Shah et al.6 supports the growing body of literature that pulse oximetry monitoring should be a standard of care for discharging known or suspected COVID‐19 patients."

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