Never forget that the lab leak was a “conspiracy theory” that the New York Times’ head Covid reporter called “racist.” If you think I’ll tire of recalling this, my friends, you are wrong.

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[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (31 children)

As I'm sure you are fully aware, hospitals do not generally make their internal policies public.

So when you say "[H]ospitals were literally forcing patients into ventilators even if they could still breathe without assistance, in order to protect the medical staff from Covid infection, knowing full well that intubation is a very dangerous procedure that will kill many of those patients. (Especially when hospitals failed to treat the secondary bacterial pneumonia when it invariably occurred.) It completely failed to protect the staff, or keep the patients alive, but that was the policy."

So you claim to know about the existence and contents of this policy with respect to at least some hospitals.

How?

But we have whistleblowers and survivors reporting preemptive intubation

That only shows that it occurred in some cases. A sensible assumption that was only shown to be erroneous as data became available would be that intubation would be critical in patients with oxygenation levels that are known to be harmful in other contexts.

doctors publicly resigning because they disagree with that preemptive intubation

That's at least indicative of some issue. Can you link me to some of these public resignations?

There's skepticism, and then there's refusal to believe that the sun exists because you can't lick it.

You've claimed that a policy exists and that hospitals don't make such policies public. What I'm asking for is the evidence that you have to make that claim.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (30 children)

I don't think you're arguing in good faith at this point. I've already linked to evidence of this policy, and I know you've seen it because you replied to that post.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (29 children)

I don't think you're arguing in good faith at this point.

Oh, FFS. If there never was a policy of intubating patients who could breathe normally for the sole purpose of protecting hospital staff, just say so.

There's no need to get all ad hominem.

I've already linked to evidence of this policy, and I know you've seen it because you replied to that post.

I've responded to that post.

I agree that there is evidence that there a change in when and whether intubation was a good idea. However this is all about the outcomes for the patient.

I don't agree that any of your links suggest that people would be intubated if their breathing and oxygenation levels were normal, solely for the protection of hospital staff.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (28 children)

I don't agree that any of your links suggest that people would be intubated if their breathing and oxygenation levels were normal, solely for the protection of hospital staff.

If I said, or gave you the impression, that hospitals were intubating people with normal oxygen levels and no Covid symptoms, then I apologise for misleading you. That's not what I intended to say. Of course they were intubating people in the ICU with reduced oxygen levels. But they were doing it early when patients were showing only slightly reduced oxygen, often not in distress, and often in preference to trying non-invasive ventilation first. And they did this explicitly because they feared that non-invasive ventilation would spread the disease to staff and other patients.

To be clear: there were also many cases were patients had dangerously low oxygen, and were in distress. Even in those cases, invasive mechanical ventilation may not always be appropriate.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (27 children)

But they were doing it early when patients were showing only slightly reduced oxygen, often not in distress, and often in preference to trying non-invasive ventilation first.

Not quite. They were often not in distress, but this was anomalous: Their oxygenation levels were dangerously low.

And they did this explicitly because they feared that non-invasive ventilation would spread the disease to staff and other patients.

I don't agree that any of your links suggest that that was anything more than a minor consideration in the decision to intubate early.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (26 children)

this was anomalous: Their oxygenation levels were dangerously low.

No, it was not dangerously low. 30% oxygen is dangerously low. 70% is not.

I don't agree that any of your links suggest that that was anything more than a minor consideration in the decision to intubate early.

The links explicitly say that that early intubation was done to protect staff. Doctors and nurses who were there on the front lines say that early intubation was done to protect staff. Major media outlets say early intubation was done to protect staff. Articles in scientific journals say early intubation was done to protect staff. Professional medical associations recommended early intubation to protect staff. But you know better.

Denial is not just a river in Egypt.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (25 children)

30% oxygen is dangerously low. 70% is not.

30% or 70% of what?

Normal arterial blood oxygen saturation levels in humans are 97–100 percent. If the level is below 90 percent, it is considered low and called hypoxemia. Arterial blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart, and should be promptly addressed.

If we're talking oxygen saturation, 95% is low. 80% is dangerous. 30% is off the charts rapidly dying.

The links explicitly say that that early intubation was done to protect staff.

Misleading at best.

"Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation."

This is not explicitly to protect staff. It's to avoid emergency intubation (which poses additional risk to staff) and to avoid prolonged use of nasal oxygen or an NIV mask.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (10 children)

If we're talking oxygen saturation, 95% is low. 80% is dangerous. 30% is off the charts rapidly dying.

Yes Doctor ActuallyNot 🙄

As I mentioned earlier, organ damage doesn't normally set in until the SaO2 falls below 40%.

"Blood oxygen level below 40 percent leads to compromise the function of Brain and Heart and Blood oxygen level below 20 percent leads to comma [sic] and ultimately, it causes death."

(I wish journals would supply proof-readers to their writers, especially those whose first language is not English. For the fees they charge they could afford it.)

What I love about debating things with you is that on the rare occasion you quote a source, it never says what you say is says. Nowhere does the Wikipedia page you linked to say what levels are dangerously low. I can only guess you plucked those percentages out of thin air. (Although I agree that 30% is critically low.)

The Wikipedia page on hypoxemia says "Serious hypoxemia typically occurs when the partial pressure of oxygen in blood is less than 60 mmHg" which would be around 80-85% saturation, but "serious" doesn't really have much meaning here. Later in the paragraph it talks about "severe" hypoxemia. What's the difference between serious and severe?

The relationships between oxygen partial pressure in the blood PaO2, oxygen saturation in the blood SaO2, the oxygen level measured by a pulse oximeter SpO2, and what we actually care about, oxygen availability to organs, etc are very complex, but generally a Sa02 of 80% will normally cause the patient to breathe a little bit more heavily, and possibly not even be aware they are doing so.

I already linked to a case study of 70% SaO2 that was treated without intubation and there was no harm done. This person claims that according to a pulse oximeter her blood oxygen level frequently drops to 70% and may sometimes be as low as 35% (the oximeter is probably not very accurate at those low levels, especially if they're only transient readings). She survived long enough to ask her question on the internet 😉 and the only advice she was given was "check with your doctor".

Doctors of course want to treat hypoxemia and get blood oxygen levels as close to normal as possible, as they should. But not every medical condition is an emergency that requires the patient to be rushed into medical surgery instantly. Before the Covid panic set in, doctors had many other tools available for managing hypoxemia before knocking them out with powerful anaesthetics, shoving a tube into their lungs, and forcing high-pressure oxygen into them.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (9 children)

As I mentioned earlier, organ damage doesn't normally set in until the SaO2 falls below 40%.

Is that paper a joke?

(I wish journals would supply proof-readers to their writers, especially those whose first language is not English. For the fees they charge they could afford it.)

Looks like a predatory journal. It has an impact factor of 0.05. And the paper looks like a year nine statistics project.

Is that your best source for you claim that "organ damage doesn't normally set in until the SaO2 falls below 40%"?

Because your other link measured long term cognitive deficits from dropping below 90.

What I love about debating things with you is that on the rare occasion you quote a source, it never says what you say is says.

Do you really want to go into poor citing of sources?

You just linked to a paper on the lack of correlation between liking or disliking tea and oxygenation. Then, on this pinnacle of rigorously peer reviewed cutting edge scientific research you took the single phrase "Blood oxygen level below 40 percent leads to compromise the function of Brain and Heart" and used that to claim that the inversion is true. "Blood oxygen level not below 40% does not lead to 'compromise the function of Brain and Heart'". That doesn't even follow if you accept the fucking premise, does it?

I already linked to a case study of 70% SaO2 that was treated without intubation and there was no harm done.

Are you really trying to claim that the decision around early intubation was not for the benefit of the patient but for the safety of staff with the reasoning: "Because evidence was published later that oxygenation levels would come back up without intubation, and the lack of willingness of medical staff to time travel into the future, find that out time travel back and include that knowledge in the decision, shows that they were merely protecting staff"?

Because there's a number of flaws in that logic.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (5 children)

Looks like a predatory journal.

shrug Maybe so. That would explain the lack of proof-reading and the general shittiness of the paper.

Nevertheless, at least I found a source, even if poor, that supports my position that critically dangerous blood oxygen levels are below 50%. Whereas you seem to have just plucked some figures out of thin air, then used a tertiary source (Wikipedia) that doesn't support your claim. If you have a better source, I'll be happy to be corrected but I want to see the source.

We know that doctors of course want to get people back to high nineties SpO2 if possible. But it's like blood pressure. If your blood pressure is 140/90 mmHg your doctor will say it is seriously high, and want to put you on meds and lifestyle changes immediately. But they won't call the ambulance until it reaches 180/120 and maybe not unless you are also having symptoms of potential organ damage.

And even then, the doctors are being cautious because male athletes can survive short periods of 370/360 mmHg blood pressure with no harm.

In one study, over a period of ten years, SpO2 of under 92% is associated with a doubling of risk of death. But if you read the paper, you will see that the SpO2 was taken from a single reading (so we have no idea whether that was representative of their normal blood oxygen level for a long period of time, or just a one-off bad day), and then a ten year follow up to see if they had died during that period.

What they found is that:

  • low SpO2 was significantly associated with being older, being a smoker, having at least one chronic disease, and being overweight (high BMI);
  • dying early was associated with being older, being a smoker, having multiple chronic diseases, and (counter-intuitively) being underweight (low BMI).

So what they found was that over a ten year period, old sick smokers are more likely to die than younger healthy nonsmokers. Thank goodness for science to tell us these things!

As pointless fascinating as that study is, it tells us nothing about the risk of death or serious injury from acute periods of low SpO2 during illness, or what blood oxygen level risks permanent and immediate organ damage.

I maintain that it simply is not a medical emergency requiring intubation for patients merely because they have low SpO2, not even as low as 70%, and I have much more credible evidence than the tea guy. Can you do better?

your other link measured long term cognitive deficits from dropping below 90.

My "other link"? I've given, what, eight or ten links in this thread?

If you are talking about this one or this one, neither of them say any such thing.

In any case, the emphasis there should be on the long term. I expect that what you are talking about is something like "if you have sleep apnea for multiple years, you can experience cognitive decline equivalent to losing 3 IQ points" where even if the results are true and significant they're talking about months or years of low SpO2. Not a week or three while you're sick.

Read the case study I linked to earlier of the woman presenting with Covid, pre-existing illness, happy hypoxia and an SpO2 of 70%. Did the doctors treat this as a medical emergency requiring immediate intubation? No they did not. With treatment, it took 30 days for her SpO2 to consistently stay above 90%. For 30 days, her SpO2 hovered between 85-90%.

"Blood oxygen level not below 40% does not lead to 'compromise the function of Brain and Heart'". That doesn't even follow if you accept the fucking premise, does it?

I'm not sure what point you are trying to make here. If you feel that the source I gave lacked credibility (okay, fair enough), find a better one. What is the highest SpO2 level (or SaO2, or PaO2) associated with severe and immediate failure of the brain and/or heart?

Whatever that level is, let's say X%, then doesn't it stand to reason that if < X% causes death, then > X% doesn't cause death? Otherwise X isn't the highest level.

Of course we're just talking round numbers. Of course different organs have different tolerances for low oxygen. Of course there is individual variation. Of course there can be long-term organ damage setting in before death occurs. Of course doctors don't want to see patients get within a bull's roar of that X.

I found one poor quality source that puts X at 40% for serious and immediate organ damage to the heart and brain, and maybe that's wrong and maybe it isn't. I don't know what that X is, and I don't think you do either, but I do know it isn't 70%.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (2 children)

Are you really trying to claim that the decision around early intubation was not for the benefit of the patient but for the safety of staff

That's what the doctors and nurses on the front line say. That's what the advice given by medical associations say. Early intubation to prevent infection and protect staff.

Theodore Iwashyna, a critical-care physician at University of Michigan and Department of Veterans Affairs hospitals in Ann Arbor: “We were intubating sick patients very early. Not for the patients’ benefit, but in order to control the epidemic”. (Emphasis added.) The article also says "doctors often pre-emptively put patients on ventilators or gave powerful sedatives largely abandoned in recent years. The aim was to save the seriously ill and protect hospital staff from Covid-19." (Emphasis added.)

with the reasoning: "Because evidence was published later that oxygenation levels would come back up without intubation, and the lack of willingness of medical staff to time travel into the future, find that out time travel back and include that knowledge in the decision, shows that they were merely protecting staff"?

No time travel was needed.

Here's the Wall Street Journal again: "Hospitals Retreat From Early Covid Treatment and Return to Basics". (Emphasis added.) Quote:

Now hospital treatment for the most critically ill looks more like it did before the pandemic. Doctors hold off longer before placing patients on ventilators. Patients get less powerful sedatives, with doctors checking more frequently to see if they can halt the drugs entirely and dialing back how much air ventilators push into patients’ lungs with each breath. “Let us go back to basics,” said Dr. Eduardo Oliveira, executive medical director for critical-care services for AdventHealth Central Florida, which recommends its doctors stick with pre-pandemic guidelines for ventilator use. “The less you deviate from it, the better.”

Hospitals eventually abandoned the Covid protocols for aggressive, preemptive early intubation and went back to pre-Covid standards of care. They didn't need time travel into the future. They just needed to have not thrown out their existing standards of care.

Prone positioning was known about for at least 20 years, and then Covid hit and many doctors forgot all about it. Hospital administrators defined Covid protocols and disciplined or fired doctors and nurses that deviated from them. In other hospitals, where the front line staff had more flexibility, fewer patients died.

The dangers of intubation have been known for decades. I've already provided links to discussion of those dangers. This 2003 paper on the risks and benefits of intubation for SARS patients recommends invasive intubation only if non-invasive ventilation failed but that hard-won knowledge was thrown out in 2020 and then only slowly, grudgingly, returned to, on the corpses of people who didn't need to die, if only the doctors had treated them using what was already known in 2019.

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (13 children)

"Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation."

This is not explicitly to protect staff. It's to avoid emergency intubation (which poses additional risk to staff) and to avoid prolonged use of nasal oxygen or an NIV mask.

It literally says it is to avoid additional risk to staff. Avoiding that risk is protecting the staff, duh.

And the reason they wanted to avoid nasal oxygen and NIV masks was because of fears that they would spread the Covid virus to staff.

Nobody wants to wait for a patient to go into cardiac arrest and only then try to decide whether or not to intubate. But there's a happy medium between the two extreme positions:

  • do nothing at all until the patient has a heart attack, then intubate;
  • intubate every Covid patient with slightly lowered SaO2 immediately on admission.

Before 2020 this was uncontroversial. Then Covid came along and some (but not all) hospitals started to routinely and preemptively intubate Covid patients early as a matter of course, on the assumption that the patients would all need to be intubated eventually (which was untrue) and that by doing so they would protect the staff and other patients from cross-infection (which may or may not actually have been true).

In France, Paris hospital used early intubation, and saw horrific death rates. In Marseille, the major hospitals intubated less and preferred to try other treatments first, and didn't have anywhere near as many deaths. [Citation required]. Same virus. Same population. Only the treatments were different.

Critics have argued that New York hospitals intubated too soon, on patients with blood oxygen levels that did not put them in immediate danger. They based their diagnosis on pulse oximeters which are known to be unreliable at blood oxygen levels below 90% below 70% (they under-report oxygen saturation). They put the decision of who and when to intubate in the hands of inexperienced doctors, or doctors whose speciality was in completely different areas. They forgot or ignored decades of experience with ventilators, running them at too high pressure, neglected to use antibiotics to prevent secondary infection (which had been standard treatment during the first SARS epidemic!) and then, most unforgivable of all, refused to give antibiotics to patients who developed secondary bacterial pneumonia on the basis that "Covid is a virus".

And they did this at a time that the ICUs were never, not for one single day, at full capacity, and the hospitals were no more "overrun" than in any heavy flu season. Despite this, they panicked.

Sometimes panic-driven incompetance is indistinguishable from malice.

Edit: fixed the percentage for pulse oximeters.

Edit:

  • Adults with sleep disordered breathing commonly tolerate SpO2 levels between 80 and 90% for prolonged periods
  • Adults with comorbidities tolerate SpO2 levels between 80 and 90% during long distance flights (Akero et al, 2005)
  • A proportion of adults with coronary artery disease develop anaerobic metabolism indicative of myocardial ischaemia with SaO2 between 70 and 85%

Source

So a SaO2 of 70% is not critically dangerous.

[–]ActuallyNot 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (12 children)

It literally says it is to avoid additional risk to staff. Avoiding that risk is protecting the staff, duh.

They are not intubating patients who don't need it, it order to protect staff. Moreover, if it's unlikely that the patient will need intubation there's no protection for staff of intubating them, because the risk is during emergency intubation.

They are prioritising early intubation, and protection of staff is a minor consideration in that.

So a SaO2 of 70% is not critically dangerous.

Yes it is. You get brain damage "Using serial pulse oximetry measurements, the amount of time spent below normal saturation values (SpO2 <90%, <85%, and <80%) correlated with decreased cognitive performance. 30% of the 55 patietns that completed neuropsychological testing were cognitively impaired at 1 year."- Your own link.

And 30% is out of the fucking question.

A proportion of adults with coronary artery disease develop anaerobic metabolism indicative of myocardial ischaemia with SaO2 between 70 and 85%

Which is part of the danger of coronary artery disease

[–]weavilsatemyface 1 insightful - 1 fun1 insightful - 0 fun2 insightful - 1 fun -  (11 children)

They are not intubating patients who don't need it

Not now. But early on, that's exactly what they were doing, according to the nurses and doctors who where there.

I don't know how many sources that say the same thing it will take to change your mind:

"Intubate your Covid patients early, don't use non-invasive ventilation because it will spread the virus to staff, and it's better than having to do an emergency intubation later."

Those treatment guidelines contradicted pre-Covid guidelines, they went against best practices for SARS, and within months it became obvious to most (but not all) hospitals that they were a disaster and they went back to the pre-Covid guidelines and only intubated when absolutely necessary.

Had hospitals merely followed the treatment guidelines they already had for other respiratory illnesses, including SARS, people would have lived. But they panicked over a disease which even at the time we had good evidence was not much more dangerous than a bad flu for most people. ICUs were no more overwhelmed than they typically get every three or four years.

Our Covid response completely did the wrong thing. New York allowed the disease to run wild through nursing homes, where the people most desperately needed to be protected from Covid, and then shut down almost the whole of society to protect the young, healthy laptop class who were never in any real danger.

30% of the 55 patietns

That's a direct quote is it? Misspelling and all? I've probably give a good dozen links in this thread. I have no idea which one you are referring to.

What about the 70% who suffered no cognitive impairment?

"decreased cognitive performance"

Well duh if you are low on oxygen you're going to suffer decreased performance, but that's not the same as permanent and irreversible brain damage. My wife has lived with periods of "brain fog" for over 30 years, which probably is related to decreased oxygen to the brain (although the doctors don't really understand what causes it). But it comes and goes and when she's not in brain fog she's as sharp as ever.