CHRISTIANE AMANPOUR: Our Next Guest, Dr
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From: Colleen Dowling To: Colleen Dowling Subject: FW: Transcript PBS News Interview with Dr. Richard Levitan Date: Friday, January 8, 2021 10:39:05 AM Full Video and Transcript https://www.pbs.org/wnet/amanpour-and-company/video/why-covid-19-patients-should-be-going- to-hospitals-sooner/ Read Transcript: CHRISTIANE AMANPOUR: Our next guest, Dr. Richard Levitan, has been practicing emergency medicine for three decades. When the virus began to overwhelm New York City at the end of March, he rushed from his home in New Hampshire to volunteer at Bellevue Hospital, where he trained in New York. And he speaks now with our Hari Sreenivasan. (BEGIN VIDEOTAPE) HARI SREENIVASAN: Dr. Levitan, you have been an E.R. doc for 30 years. You specialize in airways. You decide, in this crisis, to volunteer at the hospital that you`re trained at. How do we keep people from having to be on a ventilator? DR. RICHARD LEVITAN, EMERGENCY PHYSICIAN, LITTLETON REGIONAL HEALTHCARE: This is a respiratory virus. It gets into the lungs, and over the period of several days, it causes collapse of the air sacs in the lungs. And as the oxygen goes slowly down, the patients just accommodate. They accommodate by breathing a little bit faster, but they don`t realize that. It is remarkable, throughout medicine, how we see that disease processes that come on slowly are well tolerated by patients. So, what is amazing about this disease is the onset of this pneumonia takes days. And, as that happens, patients don`t feel short of breath. But our public health message has been, don`t go to the hospital unless you`re short of breath. So this disease is remarkable in two respects. Number one, a huge number of patients hit the health care system all at once. And that`s just the nature of a pandemic. But, number two, they all presented with advanced disease. And what I`m saying is that, as we have learned more about this, I believe we can change that presentation window from one of advanced disease to more milder and even very mild disease, and that that is an enormous win for the patients and for the system. SREENIVASAN: You`re saying that our messaging has been inaccurate, at least based on what we knew when we knew it, because by the time someone is coming to the hospital short of breath, it might already be too late to help them. LEVITAN: I don`t think the word too late is the word to use. I think that, by the time they are coming to the hospital with subjective shortness of breath, their pneumonia is very advanced. But what we have learned in New York just over the last month — and I say we — the credit goes to the front-line health care workers who are overwhelmed in Queens and Brooklyn and the Bronx, who realized some very simple things could avoid ventilators, simple things like putting nasal cannula oxygen at high flows onto people, turning them on to their abdomen, so laying on their stomach, that that would boost their oxygen, decrease the work of breathing. And what we found over — and there`s just a recent study published about this. I was the last author. But a fellow by the name of Nick Caputo in the Bronx was the primary author, and Reuben Strayer, who is in Brooklyn, was also on this paper. And what we found was, two out of three patients, even with moderate to advanced pneumonia, were able to avoid a ventilator during their hospitalization. So, I don`t want to tell people that coming to the hospital means you`re too late. But what I am saying is that, if we move, if we change the public education, if we change the messaging, and if we can detect this silently occurring low oxygen level, that we can do so much better for these patients, and I believe we`re going to avoid even more ventilators going forward. SREENIVASAN: Help explain why it`s so important to keep people off ventilators in the first place. LEVITAN: So, in many lung diseases, if we bridge somebody who is having respiratory problems, their body will recover, and they only need it for a few days. And we have learned how to do that in a way not to harm them. But in this disease, it seems that putting people on ventilators triggers a cascade of other problems. Like I said, we can fix the lung stuff, at least by numbers, right away, but the subsequent problems of blood clot, of renal failure, of other issues, and the fact that they require to be on a vent for so long is really just overwhelming the system from a resource perspective. So, just to explain, you get a breathing tube, you also get a tube in your stomach, you get a tube in your bladder, you get a central line, a venous line, you get an arterial line. You then need a team of people to move you twice a day. And you need sedatives, a lot of sedatives. Most of these patients require two and three sedatives, and then another medicine for their blood pressure. So, most of these patients are on four I.V. pumps, all of these tubes, all of these lines, they`re not moving, and — because they`re so sedated. Otherwise, they would buck the vent. And they have to be flipped twice a day. You compare that to a patient who has one I.V. line, monitoring, getting oxygen, who`s awake, who`s turning themselves in different positions, so they open up areas of their lung, proning, and these patient-positioning maneuvers, the resource utilization there is a fraction of the resource utilization that is happening in the ventilated ICU patients. SREENIVASAN: What are the CDC guidelines on when you should go to the hospital? And you`re proposing a different view. LEVITAN: I am proposing a radically different view. And where I live in rural New England, I drive about 15 miles to a convenience store. And on the front door of my 7/Eleven is the sign. And it says, you`re not going to feel well with COVID. You may have fevers. You may have muscle aches. You may have stomach aches. You`re not going to feel well, but don`t go to the emergency department. What they`re telling people is, go to the emergency department if your fingers or your lips turn blue. And what I`m saying is, I think, if we move this window of presentation, if we educate patients to come in earlier, if we can do point-of-care testing in the E.R., and know, OK, you have COVID, and then we monitor their oxygen, we can make a dramatic difference. SREENIVASAN: Doctor, one of the things, though, people are concerned about is, if they weren`t sick already, that going to the E.R., they`re definitely going to be sick, because that`s where all the sick people are, right? There`s still this hesitation about having to go to a place full of sick people to be tested, diagnosed or treated. LEVITAN: So, late last night, I got an e-mail from an emergency physician in Northern Italy. And he explained to me, we are seeing earlier cases of illness, and we`re doing much better. And so I immediately asked him, so, why is that? He says, well, the patients are no longer scared to come in. And so they diagnosed 250 patients with COVID in the emergency department. They sent every one of them home with a tiny little device, a portable, just consumer-grade pulse oximeter. So they sent people home with this tiny little device. One out 20, 5 percent, came back as their oxygen levels started to go down, and they were hospitalized and treated. None of those 250 patients died. If we move this whole management of this disease to earlier identification of who has it, better pulse oximetry monitoring in COVID- positive patients, as well as those at greatest risk for serious illness, I think we can dramatically influence how this country faces this problem, how we deal with it economically, how we deal with it just societally and globally. SREENIVASAN: You`re advocating for the use of a pulse oximeter almost like a thermometer that we have at home. LEVITAN: Yes, I think we would do much better as a country if, in the medicine cabinet of every American was a pulse oximeter and a thermometer. And, ideally, a phone call away is the physician who you can talk to about how you`re feeling and, hey, these are my numbers. If you are extraordinarily wealthy, and you have a concierge physician, this is not a radical concept. This is being done. This has been done with all of these people. And people say, well, that`s going to cause a rush on these, and you`re going to — it`s going to cause a shortage. Well, in the hospital, we use a different one. In the hospital, what we`re using the hospital- grade. But I don`t control the supply of these devices. People on Twitter have said to me, oh, the people who need them aren`t going to get them. Well, I don`t control the world supply. But if I did, what I would say is, overnight, tomorrow, let`s make sure that every assisted living community, every nursing home is checking the elderly with pulse oximetry early and continuously.