The Register Citizen (Torrington, CT)
The fifth vital sign in the time of COVID-19
COVID-19 has changed health care delivery and management, inarguably forever. As an internal medicine physician, the way I deliver care has transformed.
I have always loved seeing patients in office. Patient visit starts with checking and reviewing four primary vital signs: body temperature, heart rate, blood pressure, respiratory rate. The measurement of vital signs is followed by a detailed history review and physical examination. Each step adds tremendously to narrowing down my differential diagnosis and thus avoiding excessive unnecessary lab work, while clinching the medical diagnosis. The whole process also allows me to anticipate what may occur over the next few days. But to anticipate, you need robust data available at that point in time. When this data collection is incomplete, the thought process is constrained, and patient care is suboptimal.
Having worked in over three different geographic regions of the world during my career and encountering infectious diseases unique to each area, including malaria, cholera, typhoid, tuberculosis, dengue fever and MERS outbreak, I have seen firsthand how timely intervention saves lives. With COVID-19, I see a spectrum of presentation from fever, cough and shortness of breath to abdominal pain, diarrhea or a rash. However, the sickest patients are those where the organ systems are failing and the first one to take the hit is our lungs. The earlier we recognize this, the better are chances of saving lives.
When I call back a patient with their positive COVID-19 test results, the conversation centers heavily on what would prompt a hospital visit. My biggest fear is my patients not anticipating clearly when to go to the hospital due to lack of actionable information on their hands.
Some patients may have a BP monitor at home and a thermometer, they will be able to give me their BP, body temperature, and most BP monitors will also give a heart rate. If I instruct them on how to measure the respiratory rate that adds more information. But a vital piece that is missing is oxygen saturation — the percentage of how much oxygen one’s blood is carrying.
For some time, pain has been advocated as the fifth vital sign. In the current climate, I would argue with that. I believe that the fifth vital sign is our oxygen level and this fifth vital sign is here to stay and people need more understanding of its significance.
The most life-threatening complication of COVID-19 is hypoxic respiratory failure and acute respiratory distress syndrome, or ARDS. While a person with COVID-19 will start feeling short of breath when the oxygen levels start running low, there is increasing concern that the symptoms may not be apparent till oxygen levels have already fallen to dangerously low levels. There seems to be a lag in the time when oxygen saturation falls and the symptoms of breathlessness present. Oxygen levels less than 90 to 92 percent are very concerning. If patients are able to check their oxygen levels at home, this information alone will save lives by getting people the timely help that is needed.
Measuring oxygen levels is not complicated. A device called pulse oximeter can do that with ease at home. These devices are user friendly. Ideally, I would love to have a pulse oximeter that I can send out to my patients with COVID-19 diagnosis so when I check-in on them, I can get my fifth vital sign — the lifesaving fifth vital sign.
The other day, when I followed-up on my patient with COVID-19 and diabetes, he stated that aside from fever and body aches and pain he felt fine, no breathing difficulties, only to learn 24 hours later that he deteriorated and required mechanical ventilation. It makes you wonder if his oxygen levels were running low and his symptoms had not caught up to deteriorating levels of oxygen till it was late. This silent hypoxia is not to be missed in our evaluation of COVID-19 patients being monitored at home. Outpatient guidelines for management of COVID-19 need to be streamlined and pulse oximetry needs to be essential part of this algorithm.
The success of telemedicine will rely heavily on accurate reporting of patient data. We need to equip our patients with this ability. Health insurance can play a vital role by covering cost for pulse oximeter for anyone with a diagnosis of COVID-19 and medical device companies can step up to make sure these devices are available to everyone who may need them.