COVID-19 Health System Overload Forecaster

Can't hurt Tyler. I can imagine the response I'd get from a nurse if I suggested that she catch up with a 2014 paper on Cochrane.

This week allied health students in Victoria were being called on to join the Covid testing, tracking, and tele-health teams. When first year osteo, physio, and radiographer students are being called up, it's a bit of a warning sign we are in for a few very shit months.

VL, Same will happen in NSW. As NSW opens and drops restrictions there will be a huge increase in cases in the next few months and increased deaths to go with it.
I don't think the path out will be as easy or manageable as the new Premier says it will be.

Yes Blindboy, great point.

If you did refuse to have a pulse oximeter put on you during an operation or while in ICU (or even the ED) you would be strictly adhering to evidence based medicine as per the Cochrane Review.
At the same time you would get quizzical looks like you are some sort of conspiracy theorist wacko from said nurse or doctor.

Which brings us to Ivermectin.
The Cochrane Review has clearly stated that there is no evidence that Ivermectin improves outcome for Covid, just like it has said that the pulse oximeter does not improve outcomes in surgery or ICU.

This website shows all the known studies on Ivermectin and seems ok to me:

https://ivmmeta.com

It estimates that given the number of studies showing a positive effect of Ivermectin against Covid, even allowing for various levels of bias, the likelihood of Ivermectin not having an effect is 1 in 200 billion.
Lets just say that's a slight overestimation and conclude that maybe something more realistic is 1 in 100 that it has no effect. Or even more conservative, say 1 in 10 that it has no effect.
So given that Ivermectin has such a low side effect rate maybe it might be worth giving it a try after all, despite what the Cochrane Review website says?

You can dispute all that I have said here, I'm sure at the very least you are conflicted.
But if you believe in evidence based medicine and you believe in the Cochrane Review website then unfortunately you have to acknowledge that this country and the whole world has wasted an extraordinary amount of money on the pulse oximeter.

I don't profess to know the answers but it seems like Ivermectin is worth giving a go, don't you agree?

tylerdurden wrote:

"Evidence" based decision making is not straight forward.

Good example is the pulse oximeter, the thing you put on your finger to get an estimate of the percentage oxygen saturation of haemoglobin.
They are in every operating theatre, ED, ICU, ambulance and hospital ward.
This country spends 10's of millions $ maintaining, replacing and upgrading them every year.
This is a direct quote from the Cochrane Review website:

"no evidence suggests that continuous monitoring with pulse oximetry reduced the incidence of postoperative complications or mortality"

They've also assessed outcomes for ICU, same conclusion.
Lots of trends towards early intervention and maybe subsets of patients benefit more than others but alas, no evidence they reduce morbidity or mortality.

What do we do, get rid of them?

OMG where do I start with this. Are you being deliberately obtuse or just trying to obfuscate?
You have obviously read something on a credible website (ie The Cochrane Institute) and then over-reached...

Pulse oximetry is a tool to give you a trend re a patients oxygenation saturations (aka SaO2 or SpO2).
Having taken hundreds of arterial blood gases (ABG's) during my career, I can categorically state there is a direct correlation between SaO2 and PaO2 (the partial pressure of oxygen in the blood). It's well documented so I provide only my anecdotal experience.
A hypoxic patient will have low PaO2 and consequently a low SaO2 and will require increased FiO2 (fraction of inspired oxygen) .
Room air is 21% FiO2.
COVID patients become profoundly hypoxic, because they have severely impaired gas exchange.
By this I mean the patients SaO2 trends downwards as there illness progresses, so we introduce support (increase FiO2 and also flow).

Here is a very basic guide to the escalation procedure and potential trajectory for the deteriorating COVID patient, vis a vis supplemental oxygen :

1. Nasal prongs (2-4lpm O2 flow)
2. High Flow nasal prongs (these are fantastic because they provide extra O2 but most importantly they reduce work of breathing, WOB, by providing flow to flow starved patients). For example, we can provide up to 60 lpm of air/oxygen mixture (titrating FiO2 to achieve an SaO2>92%, in a patient with nil underlying lung pathology prior to COVID)
3. The patient now has decreasing SaO2 and increased WOB and increased FiO2 and flow requirements. We are at the limit of Ward management at 60lpm flow and 60% FiO2, what next?
4. Intubation

You may also note I have not introduced BiPAP/CPAP/VPAP into this, as it gets a bit more technical but also it is not best practice (aerosol generating procedure etc.)

If a drug manufacturer gave millions of doses of Ivermectin to Africa it can't surely be harmful .

Vitamin D is not proved to help covid but I have no problem people taking it . Same with Ivermectin which does seem to have helped in some cases . Saw the facebook headline of Dr Perrie Kory MD MPA . He said that a colleague had treated 100-200 US congress members plus their staff and families with Ivermectin & the I-Mask+ protocol at flccc.net with none going to hospital .

VicLocal - The potential use of Ivermectin would not be even in the top 10 reasons why people don't want to be vaxed . I know you don't let truth get in your way of your stories .NEVER entered my mind .

Hi Sanguine, it certainly is crazy but yes, the Cochrane review website clearly states that the pulse oximeter does not improve outcomes in surgery or ICU, I hope you are not disputing that.

Are you sure Sp02 is an indication for escalation?
When things got bad in the UK and they ran out of ventilators they parked patients in corridors on Hudson masks because there was no better option.
What they found was that some of them did ok. They then realised that the main indication for intubation was evidence of end-organ oxygen deficiency, not necessarily Sp02 per se. Otherwise it was patient request, mainly fatigue or disliking the "air hunger".
They found plenty of people with sats in the 80's or even 70's did ok, even though in the past they would normally be escalated and/or intubated.
So if there is no evidence of end-organ oxygen deficiency then a patient should not be intubated despite whatever the Sp02 says.
They should be closely followed for signs like confusion, metabolic acidosis, liver dysfunction or renal failure but low Sp02 in islolation (in the absence of those factors mentioned) is not an indication for intubation.

Again, believe what you want to believe but if you use a pulse oximeter in ICU or surgery you are acting contary to the evidence as presented on the Cochrane Review website.
Like I said at the start, evidence based medicine is not straight forward

"If you did refuse to have a pulse oximeter put on you during an operation or while in ICU (or even the ED) you would be strictly adhering to evidence based medicine as per the Cochrane Review.
At the same time you would get quizzical looks like you are some sort of conspiracy theorist wacko from said nurse or doctor."

Er no. Your choice. Pulse oximetry(non invasive) or the pain of having a 23g needle stuck into your radial artery. Or we just ignore it and wait till you turn blue
Go for it tiger...

If you believe in the Cochrane evidence Sanguine you will refuse the pulse oximeter. Doesn't mean you'll get an arterial line, will just mean that the anaesthetist can see your skin colour and make sure you are not cyanosed.
Excess 02 in response to lowish Sp02 (94-95%) may actually introduce more harm that do good, that's one of the postulated reasons why the pulse oximeter does not actually have a net benefit.
Again, if you believe in evidenced based medicine then you will not dispute the Cochrane Review findings

"They should be closely followed for signs like confusion, metabolic acidosis, liver dysfunction or renal failure but low Sp02 in islolation (in the absence of those factors mentioned) is not an indication for intubation."

Well yes of course, nobody views SaO2 in isolation that would be moronic. If they have end organ failure they are already well advanced.
SaO2 gives you an early warning...nothing is done in isolation. How stupid do you think clinicians are?

tylerdurden wrote:

If you believe in the Cochrane evidence Sanguine you will refuse the pulse oximeter. Doesn't mean you'll get an arterial line, will just mean that the anaesthetist can see your skin colour and make sure you are not cyanosed.
Excess 02 in response to lowish Sp02 (94-95%) may actually introduce more harm that do good, that's one of the postulated reasons why the pulse oximeter does not actually have a net benefit.
Again, if you believe in evidenced based medicine then you will not dispute the Cochrane Review findings

Are you dealing directly with COVID positive patients?

Up trending CK and ferritin?

UEC/FBE results? CRP? Have you looked at the actual patient?

Anybody recognise this photo ? It’s done the rounds around the world for the past year or more. It’s currently on our own msm tv station’s amongst the importance of getting vaccinated campaign . The doctor in the picture is Dr Joseph Varon a founding member of the FLCCC. Dr Varon uses ivermectin to treat his patients along with other drugs . Just thought it was ironic when his photo was splashed across the tv tonight .
upload image

Supa,
Sorry that's terrible practice right there (for obvious reasons).I wish we could do it especially for the elderly. No doubt it's the right thing to do but the reality is very different.

I find holding hands with my elderly patients (despite the gloves) is really reassuring for them (and makes me feel good too!!)

Yeah san Guine , Varon is fully vaccinated and is always advocating for it , he worked over 450 days straight and even though he contacted covid he kept working , said the adrenaline kept him going . Must be so tough on patients and staff .

Does it make a difference Sanguine if I’m dealing directly with Covid patients or not? If yes, then how?

The point I’m making and which has perhaps been lost on you is that on the one hand the entire medical world in surgery, anaesthetics and ICU acts in contary to the findings of the Cochrane review website in that they use the pulse oximeter on every patient they treat.

Yet at the same time, many clinicians and various experts point to the Cochrane review on Ivermectin and say that there is no evidence that Ivermectin works.

Surely can’t dismiss the findings of the Cochrane review on one hand then accept them on the other?
Wouldn’t that be confirmation bias or something similar?
What I’m saying is that evidence based medicine is an imprecise science. Actual medical practice is not always based on evidence, as seen with the pulse oximeter.
Does Ivermectin help as prophylaxis and/or treatment? Who knows?
But please don’t cite the Cochrane review as evidence against it, otherwise you will be advocating for taking off the pulse oximeter for every patient having an operation or in ICU

"The point I’m making and which has perhaps been lost on you is that on the one hand the entire medical world in surgery, anaesthetics and ICU acts in contary to the findings of the Cochrane review website in that they use the pulse oximeter on every patient they treat."

Obviously I'm a simpleton and I'm lost... let's all rejoice in the loss of pulse oximetry as a clinical indication of anything. Haha.

Do you work in healthcare...I'm broadening the question ?
I haven't once even mentioned Ivermectin

Ok, now we’re getting somewhere Sanguine.

Guess what, I use the pulse oximeter all day every day on every patient I treat, despite what the Cochrane review says. That’s because I put it in context with what I believe is an a axiomatic, inherent value of the device, even if the formal evidence doesn’t show a demonstrable benefit.

Which then brings us back to Ivermectin. My assessment of the pulse oximeter is largely anecdotal. The firm evidence says it provides no benefit. This is exactly what many doctors believe about Ivermectin, except that Ivermectin has many, many randomised controlled trials which show it’s positive effect against Covid.

Some on here are firmly against Ivermectin, quoting various regulatory bodies and/or the Cochrane review as saying there is no evidence for its use against Covid.
Can’t have things both ways.
Evidence is complicated, no black or whites

"I use the pulse oximeter all day every day on every patient I treat, despite what the Cochrane review says".

So why use it ? It's axiomatic, your word

Still don’t get my point?
Evidence based medicine is imprecise, can’t just cite it when it suits you then ignore it when it doesn’t.
I’m not an absolutist for anything but don’t like it when various people sprout on about evidence then selectively ignore evidence when it suits them

How have I ignored evidence? Axiomatic?

Ok, what’s your view about the use of the pulse oximeter during anaesthesia? Agree with the Cohrane review or reject it?
Currently the use of the pulse oximeter during anaesthesia is very near 100% if not 100% despite the Cochrane review showing that it doesn’t improve outcomes

Ok, what’s your view about the use of the pulse oximeter for COVID patients? Reject it?

A discussion of ever diminishing returns

For Covid patients I believe that best practice in regards to Sp02 is to put it in context with evidence of end-organ oxygen deficiency and/or patient request to be intubated. If there is no evidence of end organ oxygen deficiency and the patient is comfortable I couldn’t care what the sats say.

What’s your opinion on the pulse oximeter during anaesthesia, reject the Cochrane review findings or accept them?

Couldn’t agree more Craig. You’ve got Sanguine and Blindboy on here fixated on the belief that the pulse oximeter does some good in anaesthetics and ICU despite concrete evidence to the contrary. And yet these guys also seem to be offering up other opinions on Covid and the like...can’t reason with some people

Closed door single room for COVID patients, unless cohorted. How are you going to immediately assess respiratory status (apart from WOB)? End organ failure? Oh mate... how are your kidneys/ liver going?
This is great, please don't tell me your a treating physician (f@#K maybe you are?). I'll be going to St Elsewhere..

I had no idea.

"Tyler Durden" redirects here.
The Narrator is a fictional character appearing as the central figure of the 1996 Chuck Palahniuk novel Fight Club, its 1999 film adaptation of the same name, and the comic books Fight Club 2 and Fight Club 3. The character is an insomniac with a split personality, and is depicted as an unnamed everyman (credited in the film as "the Narrator") during the day, who becomes the chaotic and charismatic Tyler Durden at night during periods of insomnia."

https://www.lexico.com/definition/sanguine

I kinda like the archaic meaning

Take a step back Sanguine.

I highlighted the pulse oximeter as a great example whereby seemingly good evidence is totally ignored.
Many cite the Cochrane review website as a definitive source of evidence based medicine yet at the same time in regard to the pulse oximeter the entire world ignores it’s findings.
So it begs the question what is good evidence and why is some evidence acted upon and yet other evidence is completely ignored?
You’re guess is as good as mine.
I know you might find it boring Craig but to me it’s fascinating.
So when someone says “there is no good evidence for Ivermectin” hopefully everyone reading this remembers there is no good evidence for the pulse oximeter (if you believe the Cochrane review).
Nothing against you Sanguine (or Blindboy) but hopefully what I say resonates or at least has got you thinking

TD,
Thanks for the robust discussion

I was actually having a bit of a laugh and could see where tyler was going with this when setting a trap for blindboy . san Guine comes across to me as a champion bloke and must’ve been a bit confused with what tyler was playing at and I can confirm he’s never mentioned any opinion on ivermectin . It does give food for thought and Professor Clancy wrote an interesting piece on Evidence based medicine . Must be extremely frustrating for doctors when they see results in front of their own eyes but bureaucrats tell them its no good .

nice work tylerdurden, showing what reasonable and responsible people do every day of the week...

weigh up all the evidence, formal and informal

you're the guy i'd want treating me

the absolutist crap presented by some on here is just not a picture of the real world

it's a a ridiculous tendency, coming from certain media sources and ideologues more widely, it paints a dangrous picture, void of nuance and common sense, and devolves every issue to black and white, us and them, inner / outer, with us / against us...

it's just dumb

Interview re Denmark's decision to abandon all Covid restrictions:

https://www.rnz.co.nz/national/programmes/sunday/audio/2018815753/how-de...

Well played TD, a point well made. (I also could see where it was leading from the first post)
It’s all about the multi layers of safety against covid really isn’t it, this whole ivermectin thing. I’d take it, based on the evidence that already exists against the very minimal risks posed. Anything that helps I’m all for. At the beginning of the pandemic I bought $350 worth of immune strengthening vitamins for myself and my family. I’ve lowered my alcohol intake from below average to way below average (one mini session in the last two months) and I practice all the social distancing measures.
Of course I also jumped at the opportunity for vaccination, which is the best line of defence. But the whole point of ivermectin is you are better off with multiple layers of defence.

Aviation works in this way as well, using the Swiss cheese model. Picture an aircraft flying through a two dimensional piece of Swiss cheese on the way to disaster, if it gets through the hole filled layer of cheese then you have another layer of cheese but the holes are in different random positions. If it flys on through that layer then you need another and so on, until one of the imperfect layers of cheese safety net catches the aircraft from its doom.

Saying you’re vaxxed so don’t need any further protection is a bit like saying if you’re wearing your seatbelt then you don’t need airbags, have your brakes checked or to stay under the speed limit.
More is more when it comes to protection from covid so that’s why I’m interested in ivermectin or any other similar drug that becomes available.

Another thing is the fact we are heading for 90% National vaccine coverage is significant in regards to hospitalisations (obviously)
Professor George Milne from the university of WA suggests at this rate we will have a hospitalisation rate in the high 600’s per million based on his modelling. If he’s close to being right, then we are looking at under 6000 covid hospitalisations for NSW if we all contracted it in one year. That’s 3000 less than 2017’s flu season.
Of course the cases will be more likely to be more severe, and they are on top of existing influenza patients, but that is also offset by the reality that we won’t all get it in one year. Doherty institute suggests NSW will have just under a mil cases in the first six months (out of a population of 8.2 mil)

So there’s lots to be positive about I think, going forward.

One last thing, and it’ll cause tantrums because plenty of people won’t be able to accept this. But think of covid as the difficult home reno job you put off at your house for years, and then finally you realised it won’t renovate itself so you got stuck into it.
It’s time to think about “wanting” to get covid. The facts are the vaccines are not perfect, and the only way to move forward in the suppression of the virus is for the bulk of us to go through the process and get the better natural immunity. Ideally you’ll be vaccinated so you don’t clog up hospitals. Waiting longer just means more time living in its shadow while your vaccine protection slowly diminishes.

Stu, I read what you said the other day, man I feel for you having that whole other layer of concern over what every parent already feels. I have to agree with Bonza I think who said they sound like survivors, and you’ve got to trust that kids are pretty safe with this virus. Ive no doubt they’ve got dads strong ticker too.

Best of luck everyone, Blowin is largely correct in that a lot of people need to work on their covid fixation anxiety

sypkan said: “you’re the guy i'd want treating me”

Yeah and at the change of shift I’d be more than pleased if san guine took over

tyler, I made two points. The first was that since the paper preceded the pandemic and oxygen levels can drop rapidly with covid, now might not be the time to get rid of pulse oximeters. The second was that it was not something I would get into an argument with a nurse about if she wanted to put one on me. In neither did I reject the evidence.

You have a point about the use of of evidence. It is often difficult to get people to change long standing practice when new evidence comes along. Your point about Cochrane being a definitive source thpugh is misleading. It presents the best available evidence and updates it when that changes. Then your final statement reveals a deep ignorance of the fundamental issue about comparing the evidence around ivermectin to that around the use of the pulse oximeter. The use of the pulse oximeter may be pointless but it is not harmful. The unregulated use of ivermectin does cause harm. It can have serious side effects, it delays the entry of those using it into the medical system, which has resulted in numerous deaths and it misleads people to believe that as covid can be easily treated they do not need to worry about catching it.

So I hope you enjoyed your little joke. And no you did not make some profound point about the use of evidence, you just muddied the waters about a serious issue, with potential to cause harm. No offence taken but your credibility has taken a near fatal hit.

Blindboy no one wants unregulated ivermectin use, and the vaccine also delays people using it entry into the hospital system causing death

’It was found that hypoxaemia was reduced in the pulse oximetry group both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5-3 times less.’

The discussion has probably moved non, but from the extract this seems (to my untrained eye) to give a nod to the pulse oximeters. I’m not disregarding that the outcomes are the same, but isn’t the oximeter just a tool to make the job more efficient?

If so then using something that makes the job easier and less stressful would be the best practice. If an oximeter isn’t used for assessment then what is the alternative and is it quicker, more efficient, less stressful etc, shouldn’t that be the question if the outcomes are the same?

shoredump, unregulated ivermectin use is what is occurring, so what we want is irrelevant. And you seem to have forgotten the most relevant statistic....

Vaccination reduces hospitalisation by 96%.

Blindboy, with respect, this comment is a bit troubling:

"The use of the pulse oximeter may be pointless but it is not harmful. The unregulated use of ivermectin does cause harm. It can have serious side effects, it delays the entry of those using it into the medical system, which has resulted in numerous deaths and it misleads people to believe that as covid can be easily treated they do not need to worry about catching it."

I'll get to the pulse oximeter thing in a minute but Ivermectin, even in very large doses has minuscule side effects (percentage wise) and very occasional idiosyncratic side effects independent of dose, which all drugs have.
And given your into citations, why don't you put up a link which quantifies both the delay to presentation to hospital and worse outcome in general of Ivermectin users? And also a link showing a statistical link between Ivermectin users and refusal to get vaccinated?

Re the pulse oximeter, yes it can potentially cause harm from a number of reasons.
Have a read of this 3 part series:

https://pubmed.ncbi.nlm.nih.gov/2014898/

Never heard of this journal but put in a 5 second searched found it, gives you all you need to know:
https://www.hindawi.com/journals/nrp/2011/260482/

One of the postulated reasons why pulse oximetry does not have a clear benefit on outcomes is because clinicians treat moderate hypoxia (as seen on the pulse oximeter) with too much oxygen, causing the problems outlined in the article. Particularly a problem for longer term administration of oxygen, that's why you need an arterial line.
What you should be doing is assessing end organ oxygen delivery, not fixing the number you see on the pulse oximeter. So therefore, sorry to say it but the pulse oximeter is not without harm.
Additionally, pressure areas and burns have been reported with them as have software malfunctions which have showed higher numbers than reality.

I've got home schooling, got to go.

But Craig, both Sanguine and I will use the pulse oximeter on you, who knows I might actually be a nicer guy in real life than what you think?
I treat the Cochrane review evidence on pulse oximeters exactly the same way I do the Cochrane review evidence on Ivermectin: consider it just one part of my decision making in forming my opinions....otherwise I would have stopped using the pulse oximeter 20 years ago

While mass media article after article attacks ivermectin as horse medication of anti-vaxxers, in the meantime, the National Institutes of Health (NIH) have more formally embraced the drug, including in the government-funded ACTIV-6 clinical trial. Many naysayers in the media declare that the drug is dangerous or not fit for human consumption, yet nearly 4 billion doses of the drug have been donated via the Mectizan program alone—one that has eradicated river blindness. Of the 64 studies completed involving ivermectin, a couple dozen randomized controlled trials evidence some real promise.

Now the NIH offers the world even more evidence as to the seriousness of this potential treatment. Under a table titled “Table 2e Characteristics of Antiviral Agents that Are Approved or Under Evaluation for the Treatment of COVID-19,” the NIH includes Remdesivir, Ivermectin, and Nitazoxanide.

The COVID-OUT trial is another major ivermectin study ongoing led by the University of Minnesota. Funded with over $100 million by the National Institutes of Health, ACTIV-6 is led by Duke University’s Clinical Research Institute. https://www.covid19treatmentguidelines.nih.gov/tables/table-2e/ @blindboy , ivermectin should only be given under guidance by your GP who knows your medical history. Ivermectin interacts well with most drugs but there are some like warfarin that don’t and can be harmful . Doctor patient relationship is so important in any treatment . At the moment the government is stepping in and making those decisions .

96% is excellent

but I think we can do better

"Re the pulse oximeter, yes it can potentially cause harm from a number of reasons.
Have a read of this 3 part series:

https://pubmed.ncbi.nlm.nih.gov/2014898/

Never heard of this journal but put in a 5 second searched found it, gives you all you need to know:
https://www.hindawi.com/journals/nrp/2011/260482/"

TD,
Your first cited paper is from 1991.

Here is one from 2021 from the BMJ:

https://www.bmj.com/content/372/bmj.n677

"Many patients hospitalised with acute covid-19 have severe hypoxia.478
"Hypoxia, silent hypoxia, and the need for supplementary oxygen are all independent predictors of worse outcomes in covid-19.8910111213141516 Novel prognostic tools such as the 4C score have shown the importance of identifying hypoxia early,917 and there are physiological reasons for managing the complication promptly and actively.118

For all these reasons, UK guidelines recommend that assessment and monitoring of breathless, unwell, or high risk patients with suspected covid-19 should include pulse oximetry.1920 Guidance published in January 2021 by the World Health Organization includes a provisional recommendation for “use of pulse oximetry monitoring at home as part of a package of care, including patient and provider education and appropriate follow-up.21"

Pulse oximetry undoubtedly has limitations but is a front line, simple, effective tool it gives clinicians early warning sign into the deteriorating patient.

And yes, of course, oxygen toxicity is a real thing.

Let's also not forget all our CO2 retaining patients (COPD,PF and ILD), whose respiratory drive is facilitated by decreasing PaO2 not increasing CO2 (which is the opposite to the patient with no underlying lung pathology). Apart from an ABG how can we simply and effectively measure this cohorts' oxygenation...pulse oximetry.

And don't get me started on the efficacy of VBG's , useful for Hb, electrolytes and BSL, but should not be driving clinical decisions in respiratory compromised patients