Whumptober 2024 No. 30- Recovery | Hospital Bed | Holding Back Tears
This is another short one, but I hope you like it all the same!
Whumpee coughed themselves awake. They opened bleary eyes to fluorescent lights and a plain room. Something was strapped to their face. In addition, a quiet yet fast beeping came from somewhere nearby. Whumpee reached up to pull the thing- whatever it was- off of their mouth and nose. A gentle hand landed on theirs and moved it back to their side.
“Shh, Whumpee, baby, that has to stay on, okay?”
Whumpee turned their head.
“Caretaker?”
Their voice was muffled, and as they tried to speak, a few more harsh, wet coughs erupted from their chest.
“Shh, shh, it’s okay,” Caretaker said, “don’t try to talk.”
Their eyes were red and puffy, they must have been crying. Why had they been crying? What was wrong?
“You’re in the hospital,” Caretaker went on, “you’ve been very sick, and I tried to take care of you from home, but you got worse, and I had to bring you here.”
Caretaker’s lower lip trembled, and Whumpee watched them swallow. They reached up a hand to their face. Caretaker leaned into the touch, letting out a shaky exhale.
“The doctors are giving you oxygen therapy, that’s what the mask on your face is for. It’s helping you breathe. You’ve- you’ve got an IV in your arm, and that’s giving you medicine. You’re gonna be okay- you-”
Caretaker bit back a sob. Whumpee wiped the tear that rolled down their cheek. They must have been in a really bad way for Caretaker to get so upset like this.
Whumpee opened their mouth to say something, but all that came out was another string of coughs. Their hand dropped back down to their side.
Whumpee weakly reached for Caretaker’s hand. Caretaker obliged and rubbed circles into Whumpee’s with their thumb.
…
Pneumonia, the doctors had said. A severe case. Caretaker was right to act when they did. Whumpee had almost died last night, it was a wonder they had woken up today at all. Caretaker hadn’t slept in twenty-three hours, but they didn’t care. The only thing that mattered was Whumpee and their recovery.
I might be wrong, but on tv and in movies it seems like they put characters on oxygen (by cannula usually but sometimes mask) after surgery a lot for drama purposes even if there aren’t direct physical issues with their lungs. Like, if a character has a fever
What are reasons a writer could use to give supplemental oxygen after a surgery or injury that has nothing to do with a chest injury?
So oxygenation is measured by the percentage of oxygen-carrying molecules in the blood that are carrying oxygen. This is measured with a sensor on the finger (shown below). A normal oxygen saturation is between 95% and 100%.
If a patient's oxygen saturation falls and stays below 95%, they will be put on oxygen. This will start with 2 liters per minute via a nasal cannula and will be increased to 4 liters if the oxygen saturation does not increase. If the patient continues to desaturate, the cannula will be switched to a mask at 5-10 liters. Concentrations of 6 liters per minute or above require humidification.
People desaturate and get put on oxygen for a variety of reasons. Since all patients who are put under general anesthesia for surgery are intubated, some have a hard time keeping their sats up after extubation and are put on oxygen. Or maybe they lost a lot of blood during surgery or from an injury and desat because they have less oxygen-carrying molecules now. Even if a patient is anxious but not necessarily desat-ing, they might get oxygen just to help then calm down. And of course, anyone having trouble breathing is going to get oxygen.
This is a system I built to not only be able to refill my emergency oxygen cylinder I have in my personal trauma bag that lives in my car but also to use as a part of my sim lab. It takes 3 liters per minute of 90-95% oxygen from a inogen at home concentrator that I have in my closet and runs it through a compressor which is the Invacare homefill 2 and compresses it into 2 E cylinders it also automatically shuts off once it’s reached 2000PSI it can be used to fill smaller cylinders such as my D cylinder or smaller. I also added 2 regulators one which is a 50PSI and the other is a 100 PSI. The 50 PSI one is used for low flow applications such as an oxygen mask or BVM while the 100PSI regulator has a hose connected to it that runs to my zoll EMV+ for its high pressure oxygen supply. I essentially have a source of unlimited oxygen as long as the sieve beds in my concentrator put out 90% oxygen. Also all of the connections and parts are absolutely pressure rated.
Something they don’t tell you about starting oxygen/using nasal cannulas is how much they hurt your ears to wear long term. I know I've just started to wear them, but growing calluses on your ears isn't fun. I've tried a lot of the "ear savers" too but they dont work for me sensory wise.
It has been getting better though has I wear them.
Saturday, August 9, 2025: Often, when I make physical efforts, I experience more and more symptoms. For example, that day while cutting vegetables, I began to feel very weak, with the sensation that my brain was receiving less oxygen, then a migraine started. Fortunately, I had my oxygen which relieved me; otherwise, a crisis would have set in for days… A few hours later, I had gone out and, upon returning, I started to feel very weak with a sense of discomfort, sweating, and palpitations. Sometimes I can no longer discern the exact causes of my symptoms. My condition varies so much that I no longer know whether a given action will trigger symptoms or not.
Long COVID continues to baffle scientists and frustrate patients. Many individuals who had mild or moderate COVID-19 report persistent symptoms that affect their daily lives. Among these lingering issues, cognitive problems - often referred to as "brain fog" - are widely reported. This Medical News sheds light on a recent study conducted by researchers from the Montreal Heart Institute and the Montreal Health Innovations Coordinating Center-Canada, in collaboration with Inogen in California-USA, that explores whether oxygen therapy could help alleviate cognitive issues in long COVID sufferers.
The Study: Portable Oxygen Therapy in Focus
The research team investigated if providing additional oxygen to long COVID patients could help them think more clearly and potentially improve cognitive function. The study involved 21 participants who were given oxygen through portable oxygen concentrators for three hours daily over two weeks. For comparison, they also experienced two weeks of standard care without any supplemental oxygen.
Understanding the Methods Behind the Study
Researchers used a variety of tests to assess cognitive function, including the Montreal Cognitive Assessment (MoCA), which evaluates different aspects of cognition like memory, attention, and executive function. They also used tools to measure depressive symptoms, anxiety levels, and functional status. Oxygen levels in the brain and peripheral regions were measured using specialized devices during both rest and treadmill exercise.
Cognitive Test Findings: Improvements in Key Areas
One of the most intriguing findings was that participants using oxygen therapy showed slight improvements in cognitive scores on specific tests. The MoCA results hinted at better performance, particularly in areas related to visuospatial/executive skills and attention. These findings align with common cognitive complaints from long COVID patients, suggesting that oxygen therapy might support improvements in attention and mental clarity. However, the overall impact on memory and other cognitive functions was limited, as many patients were already performing within a normal cognitive range at the study's start.
Mood and Mental Health Benefits of Oxygen Therapy
In addition to cognition, the study explored how oxygen therapy impacted participants' psychological health. Patients using oxygen reported feeling slightly less depressed than those who did not receive supplemental oxygen. This was particularly noticeable in areas tied to enjoyment of daily activities and the ability to concentrate - both of which are significant struggles for long COVID patients. The study found that portable oxygen concentrators could have a subtle yet positive impact on mental health, reducing some depressive symptoms, particularly feelings of detachment or inability to concentrate.
Oxygen Levels During Exe rcise: No Significant Change Noted
The research measured cerebral and peripheral oxygen saturation during both rest and exercise, aiming to see if oxygen levels improved significantly with supplemental therapy. Surprisingly, no substantial changes were observed in these oxygen levels during either period. This suggests that while portable oxygen therapy may help certain cognitive and mental health areas, it does not necessarily boost oxygen levels in the brain or body during physical activity.
Long COVID and Ongoing Mystery of Cognitive Symptoms
Long COVID affects multiple body systems, creating complex issues beyond physical symptoms like fatigue. Cognitive symptoms are particularly troubling for patients and can range from simple forgetfulness to severe difficulty with problem-solving and focusing. Current hypotheses on long COVID suggest that oxygen deprivation in brain tissues might be partly responsible for the cognitive issues. This study points towards the possibility that providing more oxygen, even at a portable level, could help alleviate some cognitive symptoms and improve overall quality of life.
Participant Experience with Portable Oxygen Therapy
Participants reported positive feedback about the oxygen therapy device’s usability, indicating that the portable concentrators were user-friendly and easy to incorporate into daily life. This acceptance is crucial, as any potential treatment for long COVID must be manageable for patients to use consistently. In total, 70% of participants found the device’s size and weight acceptable, and almost all participants agreed that it was easy to operate.
Conclusions and Future Implications
In conclusion, the study highlights the potential for portable oxygen therapy to provide subtle benefits for cognitive function and mental health in individuals struggling with long COVID. While it does not appear to directly impact oxygen saturation levels during physical activity, it may still offer support in specific cognitive and emotional areas. Future research with larger sample sizes and longer follow-up periods is essential to determine the full benefits of oxygen therapy and to confirm these preliminary findings.
The study findings were published in the peer-reviewed journal: PLOS ONE.
journals.plos.org/plosone/article?id=10.1371/journal.pone.0312735
How would pneumonia have been treated in the mid to late 1930s, during the Great Depression?
This actually varies a LOT depending on where the person was, what their socioeconomic status was, whether they were getting hospital care or being cared for at home, etc...
At the highest level of care, someone could be in a hospital paying to be in a private room (which at the time meant paying for a private doctor (not just the hospital resident) and private nurse (not just the student nurses training at the hospital) to care for them, plus either family members or servants to provide basic direct care), on continuous oxygen therapy, getting arterial blood gas readings (super duper high tech), and receiving the most effective antibiotic of the day- sulfanilamide.
At the "lowest" level of care, someone was probably going to be cared for at home by a family member. To be clear, home nursing was still common at this time and there would have still been generational knowledge about how to feed, clean, and otherwise care for an ill person- knowledge that is largely lost today. If someone had access to a medical text aimed at home caregivers, it likely had advice to purge the body by taking medications designed to make the ill person sweat or vomit. This, and placing a mustard plaster against the person's chest.
You can see that these are two extremely different approaches to care, and most people would be somewhere in the middle- potentially able to afford a doctor's visit or prescription for sulfanilamide, but not private hospital care.
Or, if they did need hospital care (usually just those who didn't have someone to care for them at home, or those who needed oxygen), they would be on a public ward, probably cared for mostly by student nurses and the hospital resident (literally a doctor just out of training who lived and worked full time at the hospital for a year or so before setting up their own practice).
Oxygen therapy would have been available in hospitals at this point in pressurized tanks stored near patient beds. Pneumonia was one of the first uses of medical oxygen, which was titrated to the patient's level of cyanosis and level of consciousness.
Oxygen delivery mechanisms were developed in WWI and resembled just about what we have now in the way of cannulas and masks. Interestingly enough, there was a bitter debate at this time about whether continuous or intermittent oxygen was best. Continuous eventually won out, but not until the 1970's.
I have a side hustle as a hyperbaric medicine provider and I am here to give you the down and dirty!
Sometimes referred to as HBO (hyperbaric oxygen), hyperbaric or dive medicine is a specialty that utilizes oxygen at high pressure to treat a variety of conditions, primarily things involving wounds. We place a patient in a chamber, deliver 100% oxygen to them, pressurize the chamber, and keep them in there for about 120 minutes. Since oxygen is the number one thing you need to heal a wound, we use a lot of it to try and speed up the process.
The Basics
Wait - what? HOW? Try not to have PTSD from your days in chemistry, but remember these?
The treatment physiology of hyperbarics relies on gas laws. Recall that it takes a lot of pressure to dissolve a gas into a liquid.
We use pressure to force oxygen into the blood stream at high rates to facilitate wound healing. For reference, most of your oxygen content is bound to hemoglobin (~98%). You do have dissolved oxygen in your blood, represented by your PaO2/PvO2 in a blood gas. However, this makes up a fraction of O2 content (~2%: if you want a clinical soap box, you should hear me talk about blood gases to students lol). A normal ABG would have a PaO2 of 65-100. An ABG acquired during hyperbaric treatment would be well over 2,000.
As an aside, recall that ambient air is 21% oxygen. Also, as a reminder, we exist at 1.0 ATA of pressure (one atmosphere).
How is it done?
Delivering oxygen this way requires delivery of a lot of pressure. We utilize dive chambers for this purpose. There are two types of chambers:
Monoplace: literally looks like a class coffin. Holds one patient and delivers oxygen at pressure through the entire chamber. These are very popular at wound centers.
Multiplace: literally looks like a submarine. Holds 2+ patients and delivers oxygen at pressure to individual patients hooked up to hoods or masks. These are found at tertiary care/academic medical centers.
Literally, the multiplace hoods make you look like a silly space person.
The reason oxygen is delivered this way in a multiplace chamber is to reduce the risk of fire. Oxygen at pressure can go boom. Having an entire chamber full of O2 is a big risk. So, we deliver the gas individually to each patient.
How did it start?
Dinking around with gases at pressure has been a thing for 400 years. However, it didn't become a more focused endeavor until the first dive suits started to be a thing in the 1870s. The specialty itself is relatively new, developed in the 1930s due to advent of decompression illness with divers. Things really progressed in the 1950s.
One pivotal study was "Life without Blood" in 1959. Dr. Boerema proved that he could keep a pig alive with HBO alone. The ethics of this experiment are questionable but he exsanguinated a pig under hyperbaric conditions (3.0 ATA, 100% FiO2). Plasma was left behind. By doing this, he proved that, at pressure, an organism does not need hemoglobin to live. Kind of a radical thing to prove! Don't worry, the pigs did get their blood back and recovered without issue.
What is treated with HBOT? (hyperbaric oxygen therapy)
Anything related to wound healing can be treated with HBOT. We also treat carbon monoxide poisoning, air gas embolism, and decompression sickness with HBOT. I'll start with those since they are (imo), the most clinically interesting. ;-D
Carbon monoxide poisoning: The physiology of using HBOT to treat CO poisoning is based on the binding affinity of CO to hemoglobin. CO has 200 x the binding affinity for hemoglobin than O2 or CO2 does. Because the binding sites are taken up by CO, hemoglobin cannot pick up O2. It also can't offload whatever O2 is already bound. The goal with HBOT is to bombard the blood with massive amounts of O2 to force CO off.
For reference, it would take about 6 hours for CO to offload on its own from hemoglobin on room air. It would take half as long at 100% FiO2 delivered at standard air pressure (1.0 ATA). CO is rapidly forced off within 30 minutes with HBOT. With very severe CO poisoning, particularly in cases of LOC, this is vital for limitation of hypoxia and neurological sequelae of exposure. Treatment is 1-3 "dives" depending on clinical context. The patient is treated at 2.8 ATA (60 feet of sea water) for about 120 minutes.
Air gas embolism: This occurs when gas is accidentally introduced into circulation. It can either be venous or arterial. The venous system has much more flexibility in tolerance for air bubbles. 15 cc or less of gas introduction is probably not going to result in symptoms. Higher volumes go to the lungs and can result in local lung infarction.
The real danger with this is air introduced into arterial circulation. Depending on where it is introduced, it can go directly to the heart causing an MI, or to the brain causing a stroke. Any volume of air introduced into arterial circulation is bad news bears. Treatment is usually 1 "dive" but could be more based on the context. The patient is treated at 2.8 ATA for 30 minutes and then the ascent is extremely slow. The whole dive takes about 5 hours. Why so long? If we ascend too quickly, the air bubble will reform.
Decompression sickness: This occurs primary with scuba divers who ascended too quickly. Scuba divers generally breath mixed gas, most commonly air (21% O2, ~79% N2) or nitrox (35% O2, ~65% N2). As someone is diving, the nitrogen they breath is also dissolved into their blood since they are at a pressure greater than 1.0 ATA. If a diver ascends too quickly, the nitrogen dissolved in the blood will rapidly reform air bubbles in the blood. We just mentioned how that is problematic.
Since air bubbles can go everywhere in circulation, the symptoms are variable ranging from headache, vertigo, nausea, joint pain, chest pain, stroke symptoms, loss of bowel/bladder function, etc. The treatment for this is to recompress the patient and very slowly ascend in the HBO chamber. Treatment is usually 1 dive but could be more based on the context. The patient is treated at 2.8 ATA for 30 minutes and then the ascent is extremely slow. The whole dive takes about 5 hours. Why so long? Again, if we ascend too quickly, the air bubble will reform.
Wound related conditions: there are roughly 15 approved diagnoses for HBO by Medicare in the USA. This is important to mention because if a condition is not covered, paying out of pocket is extremely cost-prohibitive. Insurance is billed $6,000 per treatment! Some of the most common conditions treated are osteoradionecrosis, soft-tissue radionecrosis, irradiation cystitis with hematuria, and refractory chronic osteomyelitis. Wounds created from radiation exposure have the best evidence to support the use of HBOT. These are considered outpatient conditions so patients come to be treated Monday-Friday. We dive to 2.4 ATA for 120 minutes. At minimum, patients are prescribed 20 dives but most treatment protocols for radiation induced injuries is at least 40 dives.
As you can see, this is a HUGE commitment for the patient. One dive is not enough for these wound related conditions. As a hyperbaric provider, I can say that we have patients with such significant symptom relief from HBO. For example, irradiation cystitis with hematuria is extremely debilitating. Patients are fatigued from chronic blood loss, deal with painful bladder spams and pelvic pain, pain with urination, and increased frequency. The blood can clot and obstruct their urethra or foley catheter. Symptoms like this limit quality of life. HBOT makes a huge difference for them.
Benefits
Anyone who has barriers to wound healing can benefit from HBO. Barriers include vascular disease, CKD, COPD, DM, heart failure, and immunocompromised status. The goal is symptom resolution/improvement or healing of the wound. Some patients get approved for far more treatments than we typically do. Usually the maximum insurance will cover is 60. However, in some situations, the clinical benefit of continued treatments is recognized by insurance and treatment is extended.
As a provider, I get to know these patients pretty well. They show up every day that I am staffing in HBO and it is rewarding to see them improve. Compared to my critical care role, this is a nice change of pace.
Adverse Reactions and Risks
There are risks and side effects to HBO. The most common are barotrauma, pneumothorax, seizure, temporary worsening of cataracts/vision, and abdominal distention.
Barotrauma of the ears and sinuses is by the most common issue we face in HBOT. If patients are not able to clear their ears as they descend ("pop" their ears), they can rupture their ear drums. Patients that cannot descend without extreme pain may need myringotomy tubes (ear tubes) to assist with equalizing pressure.
Seizure is a risk of HBOT and that primarily comes from oxygen reducing the seizure threshold. We mitigate this with "air breaks". These are 5 minutes intervals of the treatment where the patient is receiving air rather than 100% O2. Example, we treat at 100% for 30 minutes, have a 5 minute air break, repeat x 2. Obviously the people at highest risk are those with epilepsy or taking seizure threshold reducing medications.
HBOT can worsen cataracts and vision temporarily. The mechanism of this is poorly understood but we know it is reversible. Distance vision is affected the most.
Contraindications
The only absolute contraindication to HBOT is an untreated pneumothorax. There are many relative contraindications that require a risk benefit analysis. An example of this is pregnancy. HBOT has not been thoroughly studied in pregnancy and is not recommended EXCEPT in cases of CO poisoning where we know that the CO concentration is higher in fetal circulation than maternal. Always treat a pregnant person with CO poisoning.
Other potential contraindications include use of certain chemotherapy agents, COPD with blebs/bullae, severe heart failure, epilepsy, sinus/HEENT disease, claustrophobia, certain implanted devices, or active infection.
With certain chemo agents, they can lower the seizure threshold putting patients at higher risk of seizure in the chamber. People with COPD and blebs are at risk of those blebs popping under pressure and causing acute respiratory distress. People with heart failure can experience flash pulmonary edema after an HBO treatment. If people are claustrophobic, obviously spending time in a monoplace chamber can trigger panic attacks. At my center, we sometimes have people referred to our multiplace chamber for exactly that reason.
Most implanted medical devices are HBOT compliant. Generally, pacers and other devices are tested at 4.0 ATA of pressure. We double check with the manufacturer that the device is compliant. If it isn't, we cannot safely treat and have to deny the consult.
Obviously, if someone is sick, we don't want them in the chamber. Particularly colds, severe allergies, fever, or anything that is affecting HEENT. People with acute sinus infection are unable to clear sufficiently to dive. Even if they can clear, they feel miserable. No need to go through that.
Safety Issues
I mentioned that high O2 environments are at risk for explosion. Safety is the number one concern with any chamber. The goal is to reduce risk of fire by removing fabrics that create static (anything synthetic), removing electronic devices that are not HBOT approved, and going through multiple levels of safety checks for patients and for chamber preparation.
At our chamber, only 100% cotton is allowed in the chamber. All patients have special scrubs that they wear during treatment. No electronic devices can be brought in the chamber which includes phones, tablets, laptops, e-readers, watches, pagers, etc. We do have HBOT approved IV pumps and radio headsets that we use. These have been tested at 4.0 ATA. The radio headsets are for the attendant (staff member) who is in the chamber and this is also for safety purposes. Since we have a mulitplace chamber, a staff member is always in the chamber with the patient(s).
One thing I do want to address is that some people are concerned about putting a patient with active cancer into the chamber. There is concern that the high O2 environment will "feed" the cancer. There is simply not data to support this. Active cancer is not a contraindication to HBOT.
And there you have it! The down and dirty of HBOT! Hopefully you learned something cool. If you think you have a patient who would benefit, find your local HBOT provider. We are always happy to talk with you about the process. If you care about a soapbox of how insurance companies suck, see below. :-D
Soapbox: I will say, I have definitely been frustrated with insurance companies. They are the gatekeepers of this treatment. You can have several providers supporting the use of treatment and an insurance company can still say "no". Very frustrating.
A prime example of this are patients who have avascular necrosis that is steroid or chemotherapy induced. These are often younger patients (late teens, early 20s) who have/had leukemia of some kind. They end up having necrosis at a joint, usually the femoral head, that will likely result in complete joint replacement at a young age. No orthopedic surgeon wants to replace joints on a young person. It comes will all kind of problems and always needs revision later in life.
Insurance companies will say "we only cover radiation induced necrosis" because that is what the literature supports. Yes, they are correct that the vast majority of studies support HBOT for radiation induced injury. However, the pathophysiology of the tissue destruction, while a little different, ends up with the SAME problem. There are studies that support HBOT use in these situation but not nearly as many as radiation induced injury. The result is that patients suffer, get a joint replacement they could have avoided (or postponed until they are fully developed), and generally are shafted.
