The lungs are the organ that allows oxygen to enter the body and carbon dioxide to leave the body. They accomplish this by permitting gas to enter small sacs called alveoli. These sacs allow the exchange of gas across their membrane. The alveoli stay open through the use of a surfactant. In an infection, it can travel to the lungs and cause a potentially fatal condition called acute respiratory distress syndrome (ARDS). In ARDS, the alveoli fill with a fluid that is essentially pus, which diminishes the lungs’ ability to provide vital organs with enough oxygen. There are ways that we can fight that.

If the patient is conscious and able to keep their own airway open, we can put them on CPAP or BiPAP, which is a mask that pressurizes the air that the person is breathing. This extra pressure forces the fluid out of the alveoli and back into the bloodstream. If a person can’t maintain their own airway, they will be intubated and placed on a ventilator. That ventilator will provide pressurized oxygen, and this is called PEEP. You can see it at work here, where a mechanical ventilator is working on a set of pig lungs as a demonstration:

As doctors have gained more experience treating patients with COVID-19, they’ve found that many can avoid ventilation—or do better while on ventilators—when they are turned over to lie on their stomachs. This is called prone positioning, or proning. Because of how the lungs are positioned, this lets you use parts of your lungs that aren’t being used when you are on your back, because it reduces pressure from the heart and diaphragm on the lungs, which allows them to inflate more easily.

If we are talking about emergency intubations (IOW not for procedural reasons), the only people who get intubated and placed on a vent are really sick. People colloquially refer to this as “being on life support.” Anyone can tell you that a person who isn’t adequately breathing on their own is pretty sick. So, for starters, anyone who is being intubated is a pretty sick puppy.

The most common complications in COVID-19 infections are bilateral pneumonia which may progressed to ARDS, sepsis and septic shock, acute kidney injury and others such as acute cardiac injury, coagulopathy, hyponatremia (low sodium levels in the blood) and acidosis (blood Ph too low). Complications are more likely in serious sickness versus non-extreme illness.

On top of that, there are risks for mechanical ventilation: overinflating the lungs, oxygen toxicity, and other issues are possible complications. These complications are more likely in people with ARDS, diabetes, high blood pressure, chronic heart or lung disease, and obesity all are at higher risk of complications from mechanical ventilation. You will recall that these same risk factors also make a patient more susceptible to COVID.

If your COVID infection is bad enough that it is collapsing your alveoli, you likely have problems with other organs as well- specifically the liver, heart, and kidneys. Remember- the same cytokine storm that is damaging the lungs is also damaging other organs as well. This can cause the development of something called MODS (multiple organ dysfunction syndrome). What causes about 20% of COVID deaths is MODS, and is not due to the use of a ventilator. Three quarters of the people who developed MODS already had underlying problems like kidney or heart disease, diabetes, or were morbidly obese.

The simple fact is that we in health care are using other methods for treating low blood oxygen caused by COVID, such as high flow devices (up to 60 liters of oxygen per minute) to try and delay or put off the need to mechanically ventilate a patient, but once you are sick enough from COVID to need a ventilator, you are really sick and your likelihood for surviving is low.

Categories: COVID


Steve · October 26, 2023 at 6:42 am

Love the medical stuff. I would like to hear your opinion on tourniquets. On one hand I hear the tacticool guy talking about them being must have while the paramedics I know say they have never used one. I am sure there a cases where they are vital but how common is that in a civilian context.

J · October 26, 2023 at 7:41 am

From the information that I’ve read at various sources, somewhere in the neighborhood of 75% of COVID patients placed on mechanical ventilation did not survive.

    Divemedic · October 26, 2023 at 8:14 am

    That’s correct, 50-90% of patients with COVID who got intubated did not survive. Still, that’s selection bias, because the only patients who are placed on ventilators are the ones who will die without it. They are already in ARDS associated respiratory failure.

      j · October 26, 2023 at 8:41 am

      Is it also true that hospitals received an additional $39K for each COVID patient placed on a respirator?

        Divemedic · October 26, 2023 at 9:06 am

        I honestly don’t think so, let me explain why. I do know that hospitals get paid for the illnesses that they treat. Even COVID. So when the funds for COVID came around, there was extra money for every patient who had it. Hospitals did what any business would do- they started testing every admitted patient for COVID. Admitted for a motorcycle accident? They test you, you are positive for COVID but asymptomatic. The hospital still gets $$ for treating your COVID, even though it wasn’t the reason why you were admitted.

        At least the hospital knows not to put a COVID negative person in the same room with someone who is positive, so there is that.

        Now the way that hospitals get paid is through the use of the International Classification of Diseases (ICD). Each illness and treatment is assigned an ICD code, and insurance companies (including Medicare and Medicaid) pay according to that code.

        The code for COVID is B97.29. That is the diagnosis. Now there can be other diagnoses assigned to a patient:
        • J80 Acute respiratory distress syndrome
        • J22 Unspecified acute lower respiratory infection
        • J988 Other specified respiratory disorders
        • J1289 Other viral pneumonia

        When anyone is intubated and on a ventilator, they will be sent to the ICU. The ICU is expensive. A stay there costs an average of $31K to $43K, with some cases going as high as $100K. Being on a ventilator makes the cost between $4K and $6k per day higher than not.

        Some hospitals charge more than that. A lot more. George Washington University’s average bill for a patient on a ventilator is $115,000, while Providence Hospital’s average charge for the same service is just under $53,000.

        There isn’t a separate charge for COVID on a ventilator. You get billed by where you are and what they do, after the original charge for the COVID ICD. So itemized, there would be a line item for COVID, one for viral pneumonia, one for the ICU, one for being on a ventilator, etc. It’s so expensive because people in the ICU need so much intervention.

        With that said, I do think it’s ridiculous what hospitals and pharmaceutical companies charge. A bag of saline, which is a plastic bag with a liter of water and half a teaspoon of salt that costs $5 online, hospitals charge an average of $100 a liter for it.

          D · October 26, 2023 at 10:27 am

          > They test you, you are positive for COVID but asymptomatic. The hospital still gets $$ for treating your COVID

          Not only that, but it was at a time when every elective surgery and procedure (the money-making part of the hospital) was shut down due to COVID.

          Ethical? Probably not. But the reasons for doing so are easily understandable.

          J · October 26, 2023 at 11:29 am

          Thank you for your candid response.

          While the $13K and $39K numbers were commonly thrown about, and I recall reading them in some credible articles, currently, while I still see them mentioned, I cannot seem to find a credible source for them. What I can easily find is references to the Cares Act and a Medicare and Medicaid special “add on” payment of an additional 20% for all COVID treatments*.

          Since I’m not knowledgeable enough with the payment coding system, I’m not sure whether or not the math equates to the $13K and $39K numbers…but it doesn’t have to. The fact is that there was a “bonus” paid to the hospitals for the treatment of COVID cases. Understand that I’m not claiming that any or all hospital over-claimed the amount of cases or over-treated in order to increase their revenue, but the system certainly made it tempting…especially with the ability to claim COVID based upon observation and without testing. Thank you.

          * “The Centers for Medicare & Medicaid Services (CMS) yesterday released new guidance implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. These provisions include:

          A Medicare add-on payment of 20% for both rural and urban inpatient hospital COVID-19 patients;
          Waiver of the long-term care hospital (LTCH) site-neutral policy for COVID-19 patients;
          Waiver of the LTCH “50% Rule” for COVID-19 patients; and
          Waiver of the inpatient rehabilitation facility (IRF) “3-hour Rule” for COVID-19 patients.”

            Divemedic · October 26, 2023 at 11:46 am

            Oh, I’m not saying that hospitals didn’t take advantage of Fedbucks. I just don’t think there was a $37k bonus specifically for putting COVID patients on vents.
            Where I think the scam was is in testing every single patient for COVID. Why pad the bill of a few patients when you can do it to all of them?
            Now you get 20% more revenue.

              J · October 27, 2023 at 10:42 am

              Another little known fact that further reveals the greedy state of today’s “health care” system is that private doctors were paid vaccination bonuses of approximately $100-$150 per vaccination by the HMOs, most likely reimbursed by the pharma companies. ..Which explains why most pushed, and still push, experimental, unapproved, and liability free, vaccinations to their patients in spite of the fact that they did/do not prevent the infection nor transmission of the virus…and even worse, in the face of VAERS data showing tremendous amounts of serious injuries and deaths.

              Whatever credibility the health care industry had before this travesty has permanently been destroyed for the love of money, IMO.

Brutus · October 26, 2023 at 11:33 pm

A close friend of mine was moved from a ventilator to an ECMO, which I understand to be a type of heart lung machine, when he had covid. Unfortunatey, he didn’t survive.

    Divemedic · October 27, 2023 at 3:55 am

    ECMO is where blood has CO2 removed and oxygen added while the blood is outside of the body. The now oxygenated blood is then returned to the body.

old geezer · October 26, 2023 at 11:34 pm

did you hear about a province in india, uttar pradesh ? population 240 million or so.

they had quite the successful experience during the bat flu nonsense. did you hear about it ?

they used Ivermectin on a mass scale.

it’s good to keep an open mind, as long as your brains don’t fall out : )

Dan D. · October 27, 2023 at 7:45 pm

Ah the surfactant in the alveoli. When it gets washed out the process of drowning begins. There was a great presentation on this by Dr. Sempsrott at WMS a few years ago. Basically if a victim is expelling foam, off to the ED for supplemental oxygen even if he’s back standing on the beach and again playing Beer Pong. You’ll know in 4-8 hours whether the patient is on the path to becoming better or will need more intervention. The mortality chart is pretty unforgiving since oxygenation is so critical to… everything.

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