Citrus International Telemedicine Helpline
24/7 Free Medical Advice during the Pandemic
Care Beyond Borders
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Ever heard of an oximeter? If you have a lung or heart condition, you may use one periodically at home to monitor your condition. Or, maybe you've had one clipped to your finger during a trip the ER or while in the hospital.
Regardless of your past familiarity with them, you may have noticed lately that pulse oximeters are popping up in the news and your social feeds, in conversation with friends and family and, if you're like me, your CVS receipt full of coupons — all because of COVID-19.
Dr. Connolly: A pulse oximeter is a painless and reliable way for clinicians to measure a person's blood oxygen levels.
When you breathe, oxygen enters your lungs, passes through thin membranes and enters your blood stream — where it's then picked up by red blood cells and carried around the body to various organs.
A pulse oximeter is a tiny device that usually slides over your fingertip or clips on your ear lobe and uses infrared light refraction to measure how well oxygen is binding to your red blood cells. Oximeters report blood oxygen levels via an oxygen saturation measurement called peripheral capillary oxygen saturation, or SpO2.
Dr. Connolly: The new coronavirus that causes COVID-19 enters the body through the respiratory system, causing direct injury to a person's lungs via inflammation and pneumonia — both of which can negatively impact how well oxygen is transferred into the bloodstream. This oxygen impairment can occur at multiple stages of COVID-19, and not simply for critically ill patients placed on ventilators.
In fact, there's a phenomenon we've observed clinically where a person with COVID-19 can have very low oxygen levels but otherwise appear well, termed "happy hypoxia." It's concerning because these patients may be more significantly ill than they feel, certainly warranting closer attention in a medical setting.
It's why you may be wondering if an oximeter can help detect COVID-19 early.
However, not everyone who tests positive for COVID-19 will develop low oxygen levels. There are people who may have a very uncomfortable bout with fever, muscle aches and GI upset at home, but never demonstrate low oxygen levels.
Ultimately, people should not think of a pulse oximeter as a screening test for COVID-19. Having a normal oxygen level does not mean that you are free of infection. If you are concerned regarding exposure, formal testing is still required.
Dr. Connolly: If a person has a mild case of COVID-19 and is self-treating at home, an oximeter can be a helpful tool for checking oxygen levels so that low oxygen levels can be caught early. In general, the people who are theoretically more at risk for oxygen issues are those with pre-existing lung disease, heart disease and/or obesity, as well as active smokers.
In addition, since "happy hypoxia" can be present in people who might otherwise be regarded as asymptomatic, a pulse oximeter can help ensure that this clinically silent early warning sign is not missed.
If you have tested positive for COVID-19 and are concerned about any developing symptoms, check immediately with your health care provider. From a lung health standpoint, aside from the objective pulse oximeter measurements, I suggest to my patients that if they're having any labored breathing, severe chest pain, uncontrollable coughing or dusky lips or fingers, it's time to go to the ER.
Dr. Connolly: There is not one, universal SpO2 number indicating that a person's oxygen levels are healthy and ideal.
For an oximeter to be an effective tool, you'll first need to know your baseline SpO2, and keep in mind that your baseline reading can be impacted by pre-existing COPD, heart failure or obesity.
Next, it's important to know when a change in your SpO2 reading becomes significant. An SpO2 of 100% has effectively zero clinical difference to a 96% reading.
As a good rule of thumb, a person with COVID-19 monitoring his or her clinical status at home will want to ensure that the SpO2 reading stays consistently at or above 90 to 92%. If the number consistently drops below this threshold, timely medical evaluation is warranted.
Dr. Connolly: Pulse oximeters can have falsely low readings if a person has circulatory issues with poor blood flow to the extremities, such as very cold hands, intrinsic vascular disease or Raynaud's phenomenon. In addition, fake nails or certain darkly colored nail polish, such as black or blue, can distort the readings.
I always recommend that people measure at least one finger per hand to confirm the number.
VERY USEFUL MSG. I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.
Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.
81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this *** has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.
Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.
Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.
A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.
We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.
Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.
worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.
Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.
We are also using Azithromycin, but are intermittently running out of IV.
Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.
Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.
The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.
Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.
We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.
One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.
I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.
Wash your hands frequently
Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water.
Washing your hands with soap and water or using alcohol-based hand rub kills viruses that may be on your hands.
Maintain social distancing
Maintain at least 1 meter (3 feet) distance between yourself and anyone who is coughing or sneezing.
When someone coughs or sneezes they spray small liquid droplets from their nose or mouth which may contain virus. If you are too close, you can breathe in the droplets, including the COVID-19 virus if the person coughing has the disease.
Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the virus to your eyes, nose or mouth. From there, the virus can enter your body and can make you sick.
Make sure you, and the people around you, follow good respiratory hygiene. This means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately.
Droplets spread virus. By following good respiratory hygiene you protect the people around you from viruses such as cold, flu and COVID-19.
Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention and call in advance. Follow the directions of your local health authority.
National and local authorities will have the most up to date information on the situation in your area. Calling in advance will allow your health care provider to quickly direct you to the right health facility. This will also protect you and help prevent spread of viruses and other infections.
From the evidence so far, the COVID-19 virus can be transmitted in ALL AREAS, including areas with hot and humid weather. Regardless of climate, adopt protective measures if you live in, or travel to an area reporting COVID-19. The best way to protect yourself against COVID-19 is by frequently cleaning your hands. By doing this you eliminate viruses that may be on your hands and avoid infection that could occur by then touching your eyes, mouth, and nose.
There is no reason to believe that cold weather can kill the new Covid-19 or other diseases. The normal human body temperature remains around 36.5°C to 37°C, regardless of the external temperature or weather. The most effective way to protect yourself against the new Covid-19 is by frequently cleaning your hands with alcohol-based hand rub or washing them with soap and water.
Taking a hot bath will not prevent you from catching COVID-19. Your normal body temperature remains around 36.5°C to 37°C, regardless of the temperature of your bath or shower. Actually, taking a hot bath with extremely hot water can be harmful, as it can burn you. The best way to protect yourself against COVID-19 is by frequently cleaning your hands. By doing this you eliminate viruses that may be on your hands and avoid infection that could occur by then touching your eyes, mouth, and nose.
To date there has been neither information nor evidence to suggest that the new Covid-19 could be transmitted by mosquitoes. The new Covid-19 is a respiratory virus which spreads primarily through droplets generated when an infected person coughs or sneezes, or through droplets of saliva or discharge from the nose. To protect yourself, clean your hands frequently with an alcohol-based hand rub or wash them with soap and water. Also, avoid close contact with anyone who is coughing and sneezing.
No. Hand dryers are not effective in killing the 2019-nCoV. To protect yourself against the new Covid-19, you should frequently clean your hands with an alcohol-based hand rub or wash them with soap and water. Once your hands are cleaned, you should dry them thoroughly by using paper towels or a warm air dryer.
UV lamps should not be used to sterilize hands or other areas of skin as UV radiation can cause skin irritation
Thermal scanners are effective in detecting people who have developed a fever (i.e. have a higher than normal body temperature) because of infection with the new Covid-19.
However, they cannot detect people who are infected but are not yet sick with fever. This is because it takes between 2 and 10 days before people who are infected become sick and develop a fever.
No. Spraying alcohol or chlorine all over your body will not kill viruses that have already entered your body. Spraying such substances can be harmful to clothes or mucous membranes (i.e. eyes, mouth). Be aware that both alcohol and chlorine can be useful to disinfect surfaces, but they need to be used under appropriate recommendations.
No. Vaccines against pneumonia, such as pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, do not provide protection against the new Covid-19.
The virus is so new and different that it needs its own vaccine. Researchers are trying to develop a vaccine against 2019-nCoV, and WHO is supporting their efforts.
Although these vaccines are not effective against 2019-nCoV, vaccination against respiratory illnesses is highly recommended to protect your health.
No. There is no evidence that regularly rinsing the nose with saline has protected people from infection with the new Covid-19.
There is some limited evidence that regularly rinsing nose with saline can help people recover more quickly from the common cold. However, regularly rinsing the nose has not been shown to prevent respiratory infections.
Garlic is a healthy food that may have some antimicrobial properties. However, there is no evidence from the current outbreak that eating garlic has protected people from the new Covid-19.
People of all ages can be infected by the new Covid-19 (2019-nCoV). Older people and people with pre-existing medical conditions (such as asthma, diabetes, and heart disease) appear to be more vulnerable to becoming severely ill with the virus.
WHO advises people of all ages to take steps to protect themselves from the virus, for example by following good hand hygiene and good respiratory hygiene?
No, antibiotics do not work against viruses, only bacteria.
The new Covid-19 (2019-nCoV) is a virus and, therefore, antibiotics should not be used as a means of prevention or treatment.
However, if you are hospitalized for the 2019-nCoV, you may receive antibiotics because bacterial co-infection is possible.
To date, there is no specific medicine recommended to prevent or treat the new Covid-19 (2019-nCoV). However, those infected with the virus should receive appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care. Some specific treatments are under investigation, and will be tested through clinical trials. WHO is helping to accelerate research and development efforts with a range or partners?
According to Islamic Ideology Council of Pakistan No you should NOT go to mosque if you have symptoms of cough, sneezing, fever, sore throat because you will infect others.
Fever, dry cough, sore throat are the most common symptoms of Covid-19 infection. Some people will have no symptoms at all. Some people may have severe body aches, nausea, vomiting and diarrhea.
If you have high fever, sore throat and painful glands in the throat, it means you most likely have bacterial core throat and will need antibiotics. In Covid-19 patients have cough which is absent in bacterial sore throat.
Runny nose, productive cough and sneezing may be signs of common cold, not Covid-19 infection. But there is no need to worry about differentiating common cold from Covid-19 during an outbreak because treatment and prevention of both conditions is same. So practically both patients will receive symptomatic care a home with precautions
It is best to call laboratory person to come to your home and collect sample from home. Government testing service at 1166 also provide home based Test for Covid-19
One should be very careful in going to hospital if one develops symptoms of Covid-19 or common cold because in hospital they can spread infection to others and may also get other hospital acquired infections. It is better to call 1190 or Edhi Ambulance to take the patient to hospital designated for Covid-19 infection. One should not just walk in to any general hospital.
The best services in Covid-19 outbreak are the Telemedicine services which are either through Telephone or through Internet. In mild cases one should stay at home.
If condition is severe, then one should call 1190 ambulance service to take you to the Hospital designated o Covid-19 infecion.
If you want to go to your Family Doctor, then inform him on phone about your symptoms, take an appointment to minimize waiting time, go with mask on, wash your hands before entering the clinic and do not touch anything in the clinic. Sit at least one meter (3 feet) away from the doctor
Masks and sanitizers are available a Medical Stores and General Stores. Unfortunately due to shortage, these may not be available. You can make mask from cloth at home. You can use three layers of normal tissue paper as mask. You can use soap and water to wash your hands.
Mask is essential for those people who have symptoms. Mask is essential if there is a patient at home. Mask is essential if you are taking care of any patient with Covid-19 infection.
For those who do not have symptoms mask is not essential but a good step.
The general advice and the Islamic advice in any outbreak are to avoid all unnecessary travelling till the outbreak ends. But if there is no choice and travel is essential then all the preventive measures must be observed during travel and ravel details must be shared with the health authorities. If you are quarantined on arrival, you should cooperate and observe all precautions during quarantine.
Only call Ambulance service on 1190 or Edhi Ambulance service if you have severe disease. Severe symptoms means that you have severe shortness of breath, you can’t complete one sentence, you are drowsy, have chest pain, severe vomiting, decreased urine etc, then call Ambulance service to pick you from home.
Travel history to China in the last 2-4 weeks is important. Chinese staffs who have not travelled to China after August 2019 are just like Pakistani people. Chinese products other than meet products are safe unless the product’s surface is contaminated by respiratory droplets of an infected person in Pakistan.
This is alarming to have mixed messages from different sources. You should know that there is no treatment available for Covid-19 infection even if you go to hospital. You also know that most people will safely recover from Covid-19 infection. But you can stop the spread of infection if you say at home. So message is clear that if it is mild stay at home and protect others and if it is severe, go to hospital for admission.
No one knows the exact numbers of cases in your area and there is no method to know this. This concern is not important, because we have to take all he precautions regardless of numbers of cases in the area.
It is understandable that one can be scared in an outbreak like Covid-19. It is the talk of the town everywhere. There is no point in being scared if we know that Covid-19 is mild disease in most cases and most people will recover safely from it. All the hue and cry is to stop the spread of Covid-19 and we all have a role to play i.e., to take precautions and advise precautions, not to be scared
At least 1 meter (3 feet) from a person who is coughing or sneezing if the contact is brief and if you have to say there for longer period than 2 meters (6 feet) is recommended
Any hand sanitizer which contains at least 60-70 % alcohol is good enough to kill Covid-19 virus
Yes, if hand sanitizers and soaps and not available, spirit swabs may be used to clean hands. Since it causes dryness of skin, then you need to use a clean skin moisturizer or cream
All soaps are equally good if used properly with plenty of water for at least 20 seconds
Real Time Polymerase Chain Reaction (RT-PCR) is the test of choice to diagnose Covid-19 infection
All major laboratories in Pakistan provide Covid-19 tests. Governments provide free testing a designated hospital. For home based testing Government of Punjab has provided a dedicated number of 1166. For further details one can call 1133, 1166, 1190
The cost of test varies from laboratory to laboratory ranging from 3000 PKR to 6000 PKR. Governments are providing free testing
Prognosis depends on age and health status of the infected person. People younger than 60 years of age and those without chronic medical conditions have excellent prognosis with mortality less than 2%. Morality increases with advancing age and poor health status of the infected person
When a healthy person develops symptoms of Covid-19 infection or symptoms of common cold, he voluntarily distances himself from other and says a home to protect others.
Yes, self-isolation is recommended treatment for all mild cases of Covid-19 infection. It should by no means be considered as “denial” of health care services to people, instead it is the best thing for the patients and the population at large.
It prevents the spread of infection to others. It also prevents getting of other hospital acquired infections if someone goes to hospital. It curtails infection from spreading. It is the proven method of controlling C0vid-19 infection
No special arrangement is required. Only the standard respiratory precautions, social distancing and surface cleanings are required just like for any other infected person
Overcrowding and family gatherings should be avoided. Patients should not be stigmatized. No dietary restrictions should be advised. No self medication should be done accept taking Paracetamol and safe herbal home remedies.
When danger signs of serious infection develop in any person in self-isolation like severe shortness of breath, blue discoloration of fingers or lips, chest pain, decreased urine, drowsiness, vomiting, generalized swelling or sick look
Here is no special dietary advice for Covid-19 infection. One can take normal healthy diet according to one’s taste
Role of vitamins is not proven but based on available data vitamin C present in fresh fruits seems beneficial. Multivitamins will not harm even if they do not help
No need to worry about children as Covid-19 has very low mortality and morbidity in children
This is a genuine concern. One should immediately distance from elderly and observe strict precautions to protect the elderly
This is a genuine concern. One should immediately distance from heart patients and observe strict precautions to protect the cardiac patients
There is no specific treatment for Covid-19 infection. Care is mainly supportive based on the condition of patients. This makes the prevention even more important
According to Islamic Ideology Council of Pakistan Yes, you can go to mosque for only Farz prayer if you “DO NOT” have symptoms, but must observe respiratory precautions and should not shake hands. Before going to mosque and after coming back must wash hands for a leas 30 seconds
Show empathy to the patient by keeping yourself on his place a lay person
Address the concerns of the patients
Demonstrate kind and caring attitude
Respecting the patient’s autonomy
Guide according to the circumstances of patients and assure continuity of your support
There are no specific clinical features that can yet reliably distinguish Covid-19 from other viral respiratory infections.
Yes, it is the time to quit smoking as smoking may increase the risk of severe Corona virus infection
Wear face mask, wear gloves before examining a patient, use hand sanitizer, keep a distance of 3 feet from a patient, clean the high touch surfaces with bleach solution or other recommended cleaning agents, keep equipment clean. If dealing with Covid-19 patient along with the above measures doctor should also wear protective gown and goggles.
At least 1 meter (3 feet) if the contact is brief and if you have to say there for longer period then 2 meters (6 feet) is recommended.
Respiratory aerosols and droplets spread after coughing, sneezing, blowing nose by an infected person.
No special Personal Protective Equipment is needed at community level. Only masks and Washing hands with soap, or hand sanitizer with 60% alcohol and bleach to clean surfaces are needed
Gowns, gloves, goggles or eye shields (not personal eyeglasses or contacts), N95 or a face mask
The infectious period of Covid-19 starts from incubation period till complete recovery of the patient (up to 14 days incubation period and up to 6 weeks recovery period)
International travel to any country in the last 14 days is relevant in Covid-19 evaluation; with local spread in Sindh travel to Sindh is also important.
Corona viruses are a large family of viruses which may cause illnesses in animals or humans. Some important diseases caused by Corona viruses are SARS, MERS and Covid-19
Covid-19 virus is a type of corona virus which causes respiratory illness; it was officially named Covid-19 by WHO after causing the outbreak in Wuhan province of China in Dec 2019
An epidemic that spreads in different continents of the globe is a pandemic.
It started when infected people returning to Pakistan from countries with outbreaks of Covid-19 brought infection to Pakistan. Most cases came from Iran and others from Middle east and Europe.
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