The rising number of COVID-19 cases prompted me to create this explainer video on how to use the pulse oximeter correctly. The normal oxygen saturation (SpO2) of a healthy person is between 95 - 100%. It is important to monitor the SpO2 at least daily, better several times a day, for Category 1-2 patients undergoing home quarantine.
The normal oxygen saturation or SpO2 of a healthy person is 95 – 100 %. These numbers generally stay unchanged during moderate intensity exercises and may even increase a little, because one is breathing faster and deeper, resulting in better lung ventilation.
During vigorous short-term exercise, like
in soccer, you may notice a small drop in blood oxygen saturation of about 1 –
2 %. When you stop exercising, the SpO2 will return to your baseline reading quickly.
When a
person complains of shortness of breath, the doctor will take down a medical
history, perform a physical examination and may order some tests. Diseases of the heart, lungs, kidneys or
liver may present with shortness of breath.
The most common functional impairment in patients with lung
disease is impaired gas exchange. In the early stages of many lung diseases, the
oxygen saturation is maintained or is normal at rest, but when the lung is
challenged with increasing demand, like during exercise, the oxygen saturation
may drop.
The 6MWT is used to assess the functional capacity of a
person. The 6MWT is also a simple test
to evaluate gas exchange impairment during exercise. It is widely used, and is considered the gold
standard, to evaluate patients with chronic respiratory disorders like COPD and
ILD. However, it is not feasible to
perform the 6MWT in many office-based practices, which generally, do not have
the flat, straight 30-m corridor required for the test.
There is evidence in the literature, suggesting that the 1MSTST
be used as an alternative to the 6MWT for measuring a person’s functional
capacity and in detecting exercise induced gas exchange impairment. Both tests have a good correlation, and the
advantage of the 1MSTST is that it causes less hemodynamic stress for patients
than the 6MWT. The 1MSTST is well tolerated, easy to perform, understood, and
interpreted; and does not require special hardware.
The mean number of 1MSTST repetitions reported in the literature
achieved ranged from 8 repetitions (patients with stroke) to 50 repetitions (young
men).
The 1MSTST has been validated for use in COPD and ILD of
various aetiologies.
There are many uses for the 1MSTST:
The 1MSTST is used to identify subjects with low exercise
capacity or preserved exercise capacity.
The 1MSTST is used to detect exercise-induced gas exchange
impairment early in the course of ILD, before changes in resting DLco and PaO2,
hence making the early clinical diagnosis of ILD possible. The resting DLco is a specific but an
insensitive predictor of abnormal gas exchange during exercise. The DLco is the
diffusing capacity of lung for carbon monoxide is a measure of the efficiency
of lung gas transfer.
The 1MSTST is used to measure the effectiveness of a
pulmonary rehabilitation programme as an improvement of three repetitions is
consistent with physical benefits.
To perform the 1MSTST place a chair of standard height
(46 cm), without arm rests, against a wall to prevent the chair moving and person
falling during the test. Seat the person upright on the chair with knees and
hips flexed at 90°, feet placed flat on the floor and a hip-wide apart, with
arms held stationary by placing the hands on the hips. The person is asked to
perform repetitions of standing upright and then sitting down in the same
position at a self-paced speed, safely and comfortably, as many times as
possible for 1 minute. The person should not use the arms for support while
rising or sitting. The person is permitted to rest during the one-minute
period.
The patient is given the following instructions:
“The purpose of the test is to assess your exercise capacity
and leg muscle strength. The movement required is to get up from this chair
with the legs straight and sit back continuing the repetitions as fast as
possible within one minute. I will give you the countdown ‘3, 2, 1 Go’ as an
indication to start and I will tell you when we are at the 15 remaining
seconds. If required, you can make a break and resume the test as soon as
possible”.
The patient should be able to perform a minimum of 5
repetitions.
The SpO2 and heart rate are noted before and immediately after
the 1-minute test. The SpO2 and hear
rate are noted for a further 1 minute following the test, during recovery, as oxygen
desaturation can continue for up to a minute after stopping the test. The number of sit-stand repetitions are
recorded for the first 1 minute of the test.
In early lung disease, a person at rest, may have a normal
SpO2 of 95 – 100 %. However, during
exercise the SpO2 may drop because of increased oxygen demand and the presence
of impaired gas exchange in the diseased lungs.
POSITIVE TEST. A SpO2
drop of 3% or more is considered a positive test. A positive test may indicate the presence of
lung disease which requires medical attention.
DO NOT perform the 1MSTST in the following situations.
1. When the resting SpO2 is already abnormal at 94% or less.
2. When the person is immobile or using walking aids.
3. During advanced pregnancy.
4. Following recent abdominal surgery or heart attack.Fo
F STOP the 1MSTST when you notice the following:
1. Feeling faint or giddy.
2. Vision becoming dim or blur.
3. SpO2 falling more than 3% from baseline. (Calculate the value before starting the test. Example: when the resting SpO2 is 96%, stop
the test when the SpO2 fall to 93% or lower.)
4. Sensation of breathlessness which is severe or unbearable.
5. Occurrence of chest pain
You MUST CONSULT a doctor when the test is positive.
The 1MSTST is currently being evaluated for use in
respiratory illnesses other than COPD and ILD.
The IMSTST is being used in some EDs or emergency departments to quickly identify exercise induced oxygen desaturation caused by lung disease, so a decision can be made regarding patient discharge, with or without enhanced monitoring, or hospitalisation.
Is There Life after Death?
Hello. I am Dr Leong a consultant
chest physician.
Is there life after death? This is a very pertinent question, as death
is the only thing that is guaranteed in life.
Many of my patients are concerned but will not bring up the matter to
discuss.
Investigating this subject often
leads to the discovery of spiritual truths.
I found my answer in the Bible and the answer is unique.
Today I wish to share with you my
answer.
Let’s begin.
IS THERE LIFE AFTER
DEATH?
The answer is Yes.
HOW DO I KNOW?
I have seen people in trance. I have seen a person in his 50’s dance, summersault and behave like a monkey. I have seen people walk on fire. I have seen people having their mouths, bodies pierced by sharp objects. While in trance, a person is influenced and empowered by spirits.
I have heard of ghost stories from close friends who had seen and heard the voices of spirits.
There are published photos of ghosts which had been scrutinised and certified authentic.
There are people who had near-death experiences describing out of body experiences. They recall hearing and seeing doctors and nurses doing resuscitation on them.
There are clairvoyants who are able to communicate with spirits.
While in school, I experienced the ouija board where invited spirits can move objects on the board and answer questions.
I hear of exorcism by priests. I have heard how a person’s life has been turned around after the departure of evil spirits.
The supernatural exists whether we want to believe it or not. Medical science has difficulty disproving it. The Bible says spirits exist.
WHAT IS LIFE AND WHAT IS
DEATH?
A person is alive when he is breathing and has a heartbeat. And a person is considered dead when the heart has stopped beating and he is no longer breathing.
HOW DID LIFE COME ABOUT? DID SOMEONE CREATE LIFE?
I am inclined to believe that man is created by a superior being.
The Big Bang theory attempts to explain the creation of the universe and evolution. But the theory is not able to explain how humans get their first DNA sequence and how the first living cell came about.
I believe man is created by God for eternity. Yes, created for eternity.
WHAT IS THE PURPOSE OF
LIFE ON EARTH?
Most of us journey through life with the purpose of sustaining our own lives. We work hard, make money to purchase what we need like shelter, food, security and health. With extra money we purchase what we want too.
My purpose in life is to worship and maintain a relationship with God while also caring for the earth and fellow human beings by using my talents and gifts. In turn, God will provide the ways and means of sustaining my life.
God loves us. We need not worry too much about the future as He is in control of our final destiny.
IS LIFE BOTH PHYSICAL AND
SPIRITUAL?
I have both a physical body and a spirit living inside me. When I die it is my physical body that goes into decay, whereas the spirit lives on. When Jesus, my saviour, comes the second time my spirit will inherit a new resurrected body.
2000 plus years ago, Jesus was crucified on a cross and died. On the 3rd day he rose from the dead. Jesus conquered death. He was seen with a resurrected body that can go through walls. He was on earth for 40 days before his ascension to heaven.
Jesus sets the eternal hope for believers. A future without pain, sorrow and disease.
WHAT WILL HAPPEN AT THE
MOMENT OF DEATH?
My body will fail and stop working one day from illness, a fatal accident or old age. My soul and spirit will separate from my body and live on. They will be lodged in a place known as the “realm of the dead” which is neither heaven nor hell. While at this place the experiences between Jesus believers and non-believers are different. One is pleasant, like in paradise, while the other is not. My spirit will await the Rapture or the Second Coming of Christ when I shall be restored with a glorified resurrected body.
HOW IS SIN AND SPIRITUAL DEATH RELATED?
Sin came about because the first man disobeyed God by eating the forbidden fruit from the Tree of Knowledge of good and evil. When a man with unforgiven sin dies, his spirit is destined to die. However, hell was initially created by God for Satan and the fallen angels and not for man.
God loves us so much that he continues to try all possible ways to win us back to him. His way of saving us is spelt out in the Gospel message. Jesus conquered death and gives the hope of eternal life to all who believes in Him.
My sins are forgiven when I accepted Jesus Christ as my Lord and Saviour. This gift of love, grace and mercy from God is made possible through faith in Jesus Christ. This gift is free. Salvation is not a reward earned by doing good or charitable works.
IS ETERNAL LIFE A CHOICE
THEN?
Man’s eternal destination is either heaven or hell. This destination decision is made while we are physically alive on earth. There is no second chance for the spirit to change its mind after physical death.
God seeks justice for all the wrongs I have done in my life. However, He is graceful and merciful and allows me to choose my destiny when I am alive. By putting my faith in Jesus, he forgave my sins, and justified me into righteousness. He redeemed me from spiritual death.
His work of redemption for believers was completed at the Cross. He carried our sins, sacrificed himself at the Cross and cleansed us of sins. He has justified us into righteousness, freeing our spirits from death.
HOW WILL SOMEONE BE
JUDGED AT THE END?
Bodily resurrection will occur for both believers and non-believers of Jesus some time in future. Then the final judgement follows.
The believers in Christ will have their names written in the Book of Life. Their judgement will be on good works and rewards but not spiritual death. The new heaven and new earth will be revealed.
Those whose names are not in the Book of Life will undergo the Great White Throne judgement when the Second Death will be announced. Hell is envisioned like a lake of fire.
WHAT DID I DO TO FOLLOW
CHRIST?
I first studied intently about
Jesus, looking at the evidence of his death and resurrection. When it became
clear that the Gospel story is true, I did the following:
Acknowledge myself as a sinner
deserving to go to hell.
Believe that Jesus Christ, the Son
of God, came to die for my sins.
Confess my sins and believe that
Jesus Christ is the only saviour.
Understand I am saved by His grace
and not by works.
Believe by faith in the
resurrection of Jesus Christ who is alive today.
And receive him into my life and
let him be my Lord and Saviour.
WHAT SHALL I DO BEFORE I DIE?
Be sure I am saved by continuing to
believe in Jesus Christ
Obey God and be ready and live a
holy life.
Worship God and accept His
salvation with gratitude.
Proclaim the Gospel of Jesus Christ
to the world.
Carry out God’s will by serving others in need.
WHAT IS THE ADVICE FOR ANY
PERSON PREPARING FOR THE FINAL EVENT?
Make sure one is saved for eternity
and not fear death.
Do away with anything that promotes
mental images of scary things e.g. horror movies, occult practices, etc.
If fear persists, get professional
help.
Draw up a will.
Consider advance planning and have
advance directives.
Meet up with family members and friends.
The saved have the Holy Spirit, comforter, in their hearts. God has assuring words and is faithful. Understand that God is sovereign and in control of everything.
THANK YOU.
This is how I view life and death as
a doctor after discovering my faith in Jesus.
Thank you.
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Bible References:
COVID-19 Quick Facts
Video Script:
Hello I'm Dr
Leong. Today's talk will be on COVID-19.
A Suspected
Case of COVID-19 needs to fulfil 2 criteria. One is the Clinical Criteria and
the other is the Epidemiological Criteria.
In the clinical criteria one has to have an acute fever and cough OR an
acute illness with two or more of the following: fever, cough, general malaise, fatique,
headache, myalgia, sore throat, coryza, dyspnea, anorexia, nausea, vomiting,
diarrhea or altered mental status.
In the Epidemiological
Criteria the suspected case needs to have been in the following places within
the last 14 days prior to symptoms and signs.
The case needs to have 1. stayed or worked in an area of high risk of transmission
like in a close residentials example a nursing home or institutions like prison
or immigration detention depot 2. stayed or travelled in an area with community
transition or 3. worked in any healthcare setting.
A confirmed
case is one who is tested positive RTK- Ag in areas of prevalence greater than
10% or cases tested positive with a molecular test, namely RT-PCR or a rapid
molecular test.
This graph
shows the probability of detection of SARS CoV2 over time. The incubation period
of SARS Co V2 is about 5 days. Most infected persons will show symptoms or
signs within 11 days of infection. During the onset of symptoms, RT- PCR
testing will usually be positive. Before symptoms onset, RT-PCR testing can be
negative even though the person is infective because of viral shedding. After the onset of symptoms, the RT-PCR test
can be positive for up to 3 weeks.
Commonly the infected person will no longer be infective to others after
14 days of symptom onset, even though the RT-PCR is still positive as the nasopharyngeal
swabs contain detectable non-viable viral material. The infected person begins
to develop antibodies to the virus after a week of symptom onset and the
antibodies will be detectable at about the 2nd week. RT-PCR will likely be negative after the 3rd
week of symptom onset.
SARs CoV2
mutation and variants. This chart shows the variants of concern. The Alpha, Beta, and Delta variants are
present in Malaysia. The delta variant is of special concern as there is
information suggesting increased transmissibility of the virus. There is also
some suggestion of reduced neutralization of the virus by antibodies produced in
our bodies by vaccination. But it is too
early to say if vaccines are compromised.
Dr Noor
Hisham reported in the Malay Mail that the variants of concern like beta and delta
are already present in Malaysia.
Clinical
stages of COVID-19 infection. There are five categories. Category 1 – asymptomatic.
Category 2 - symptomatic but no pneumonia. Category3 - symptomatic with
pneumonia. Category 4 - symptomatic with pneumonia and requiring oxygen. Category
5 – the critically ill with multi-organ involvement. Persons in Category 1 and 2
maybe opt for home quarantine. Whereas persons in Category 3 to 5 will need hospital
admission.
Category 2 can be divided into mild and moderate. The moderate cases who have RED FLAG symptoms may need to be admitted to hospital for observation. The RED FLAG symptoms are - persistent or new onset fever, exertional dyspnea, chest pain, unable to tolerate orally, worsening lethargy, unable to ambulate without assistance, worsening or persistent symptoms such as cough, nausea, vomiting, or diarrhea, reduce level of consciousness. or reduced urine output in the last 24 hours.
Confirmed cases of COVID-19 can undergo home quarantine or be admitted to hospital for observation. Persons in Category 1 and 2, with mild symptoms, can undergo home quarantine. However should the Category 2 status change with RED FLAG symptoms they better be observed in hospital. Persons in Category 3 - 5 should be admitted to hospitals.
A person
may undergo home quarantine if he fulfills the following criteria: For adults the
person should be less than 40 years and without comorbidities; like diabetes,
cardiovascular disease, chronic lung disease, chronic kidney disease,
hypertension, or obesity. The person
needs to be able to ambulate without any assistance and also be able to self-administer
medication. The person should have no ongoing
clinical needs, like hemodialysis, not pregnant and is not immunocompromised.
For
pediatric patients, who are in Category 1, they should not have any comorbidity
and with a suitable caregiver. Children in
Category 2 with mild symptoms should be more than two years old, with no
comorbidities and with suitable caregivers.
The home
condition should be suitable and the person must be able to adhere strictly to SOP.
Caregivers
who are suitable should not be more than 60 years old, are not pregnant,
without comorbidities, are not immunocompromised and with no disease considered
high risk by health personnel.
The home
should be suitable. A telephone should
be available at all times. The isolation
room should preferably have an attached bathroom. The other occupants in the house are not
immunocompromised and appropriate caregivers should be present in the house.
The person
should be able to adhere strictly to SOP.
The person should stay at home, maintain physical distance with other
household members and there should be no visitors. The person must wear a mask, wash hands
regularly and practice cough etiquette.
The person must be able to report health status to health care providers
through MySejahtera App. The eating
utensils, tableware should be used exclusively for the person.
Vaccination
The national COVID-19 immunization program is on a voluntary basis, is free for all Malaysians and non-Malaysian residing in the country. It is for everyone of age 18 years and above. Currently the age has been extended to cover 12 years and above using the Pfizer vaccine. The immunization target is to cover 80% of the Malaysian population. We are currently in Phase 3 of the program. The immunization program will be completing sometime at the end of this year.
Portfolio of Vaccine in Malaysia are from the following manufacturers: Pfizer, SinoVac, Astra Zeneca, Johnson and Johnson and CanSino.
The Pfizer vaccine uses the mRNA technology. The Astra Zeneca, Jansen, CanSino vaccines use the viral vector technology. SinoVac is of the inactivated virus technology.
As of June the registration for immunization has reached almost 60% of the population in Malaysia. From the graph you can see the accelerated growth for vaccination. There is an increase in demand by the population and vaccine roll out by the government.
Selangor, Sarawak, Kuala Lumpur and Putrajaya will reach vaccination target in August. Labuan will reach vaccination target earlier in July. Perak will reach the 50% target in September and full target by year end.
Vaccine adverse events are very uncommon. Of note with mRNA vaccines is heart inflammation (myocarditis and pericarditis) This adverse event occurs several days after vaccination. It mostly affect males, adolescent and young adults of 16 years and above. The presenting symptoms are chest pain, difficulty breathing and palpitation. The Pfizer vaccine is a mRNA vaccine. The occurrence of the adverse event is about 2 per 100,000 population, aged between 16- 39 years.
Another adverse event of concern is Thrombosis with Thrombocytopenia Syndrome. (TTS). It occurs 4 to 30 days post vaccination. TTS may present as cerebral venous sinus thrombosis. The illness presents with severe headache, worse by lying down or bending over, and is associated with blurred vision, nausea and vomiting, difficulty with speech, weakness, drowsiness, or even seizures.
There may
even be unexplained bruising or bleeding.
Some may experience shortness of
breath, chest pain, leg swelling or persistent abdominal pain.
The Astra Zeneca
and Jansen vaccines are viral vector vaccines.
These adverse events are very rare with 2 - 4 events per million vaccinated.
Recovery Plan
The national recovery plan has 4 Phases. There are 3 conditions to be met under each phase. The conditions include 1. the number of daily cases 2. ICU bed availability and 3. The percentage of population vaccinated.
In Phase 1 only
essential services are allowed. In Phase
2, some economic sectors to reopen while the social sector remains closed. In Phase 3, more economic sectors to reopened,
the social sector is reopened gradually, Parliament and schools to reopened as
well. In Phase 4, there is full
reopening of the economy. Phase 4 is
projected to occur sometime in November and December this year.
This chart shows the number of observed and forecast cases in the month of April and June. R0 is the basic reproduction number of an infection. The rate of infection rises when the R0 is greater than 1 and declines when the R0 is less than 1. We currently have a R0 of less than 1 with declining number of cases.
As you can see from this chart, there has been an increasing number of hospitals managing COVID-19 cases. The number of ICU beds and ventilators have also increased.
As such,
with deceasing number of cases and increased number of ICU beds we can expect
ICU bed utilization will decrease.
More than 10% of the population is already vaccinated. We shall soon reach our 40% and 60% target soon and will help speed up our National Recovery Plan.
There is a very low risk of viral transmission from surfaces and outdoor activities. However there is a very high risk of viral transmission from gatherings in enclosed spaces, like in offices, religious places, cinema halls, gyms and theaters.
Infection
The COVID virus is mainly transmitted via droplets and contact routes. However airborne transmission is possible for example while performing aerosol generating procedures. There has been no report of faecal- oral transmission to date.
A viral dose of about 1000 virus particles is needed before a person becomes infected. During normal breathing about 20 vp are shed in a minute. While speaking about 200 vp. Coughing and sneezing expel about 200 million vp into the air and these vp can remains in the air for hours in poorly ventilated environments.
The infectious dose is dependent on the number of virus particles multiplied by time.
