The Invisible Gift

I never thought I’d grow up young.

But, in the 21st century, that’s not unusual. I’m just one of many people   who are 60, 70, 80 or more on the outside, but sprouts of 20 on the inside. This is the era of young older people— vintage youth — a contradiction, but a truth, an ordinary miracle.

On the outside we may be a bit crinkled, but inside it’s still dewdrops and roses. That leads us vintage people  to big surprises: The faces we see in our mirrors. We ask: Who’s that in my mirror? How could that face possibly belong to me? Looks like my mom. Or dad.

What we see in a mirror, the outside us, doesn’t match our inside selves and because we don’t feel old, we imagine age has happened to others, but not to us.

“My friends look old, but I’m just in disguise.”

Me, I’m accidently old — hit and run by the passing years — and I’m thinking of making this bumpersticker for my car: MY OTHER AGE IS TWENTY. Age takes many of us by surprise. Now that’s really funny. Where did we think those birthdays were going? Backwards?

Anyhow, way back, at the threshold year of 60, I finally realized I was on the outskirts of age. There could be a huge run of longevity ahead of me and all I knew about it could be put in a nutshell. I just knew that a stretched-out future in retirement was a new thing under the sun, nothing like my grandma’s life — which was tatting, tapioca and tending to her canary until she died younger than I am now. With today’s medical rescues from conditions that used to kill people, some of us could live to be 100. And if that isn’t a demographic miracle or dumb luck pouring down on our heads, what is?

Think about it: Around 1900, people in the U.S. died at the average age of 48. But we’ve been given a reprieve from extinction. Don’t have to die. Not yet. A forty-year gift of life.

This is unprecedented in the long history of human existence. In fact, it’s an immense gift, but many are blind to it. People look at their older bodies and they don’t see the gift because their packaging is wrinkled.

The gift is invisible. They see the package, not the gift.

So here’s my advice. Take it twice a day. Say this aloud to yourself:

Age is a gift, an invisible gift. Thank you. I’m still alive.

With that perspective you will find an instant cure for wrinkles: You will no longer care about them… it’s just the package, not the gift.

Please add your experience in the Reply section below. This column is an edited version of  one I wrote for the Huffington Post. Thanks, Mel Walsh.

Foot Talk….When Your Feet Begin to Complain

Well, blame it on shoes that aren’t the right size. Or blame it on high heels, pointy-toed shoes, bad genes or aging (which wears out the protective pads at the bottom of the feet). You can even blame the problems on over-zealous shoe salespeople who assure you…with the look of an angel… that the shoes pinching in the store will stretch out when you get home. That is some stretch — the classic shoe store lie women may believe if the shoes are “cute”.

And you can’t just blame us women for being a little silly about shoe choices. Men who go gaga over high heels encourage women to end up with shortened leg ligaments and misshapen feet. (It’s our version of Chinese foot-binding and why men should be quiet about the allure of stilettos. I wouldn’t wear them for Robert Redford.)

So what to do?

Except for special occasions, forget high heels. (The Duchess of Cambridge is going to be footsore when she’s 55.) And get your feet re-measured. They can get longer and wider over time. Buy shoes that are in the actual shape of your footprint, that feel good in the store. Buy nothing that’s a maybe. Wear new shoes around the house for a while and if they don’t fit, bring them back and try again. If you order shoes online at Zappos, they will take them back, no questions asked, and they pay the return postage, so no risk there. Almost all of the brands below are sold at Zappos.

Believe it: Dress shoes can be comfortable

If you have hard to fit feet, but need a flat dress shoe — listen up mothers-of-the bride — try Ros Hommerson’s flats or other brands that combine style with comfort. BZees are on the less expensive side. Stuart Weitzman comes in with comfort at the upper end of your wallet.  Ballet flats and skimmers are the things to look for. Maybe kitten heels if you need some height.

Much more informal for workplace and weekend wear are these brands, beloved of many and stars in my own closet: Merrell Encore, Clarks, SAS, Easy Spirit Traveltime, Hallux Fidelio sandals from Austria and, I confess, UGG’s classic short boots and Ugg’s Coquette slippers. Tourists and other people on their feet all day also love Keen, Teva, Mephisto All-Rounders, Hush Puppies, Aersoles, Crocs and Birkenstocks, Birks still here after all these years.

Clogs are the friends of nurses, chefs, dog walkers and others on their feet all day. Dansko, Sanita, Klogs and Clarks are among the best choices and the place to go if you can’t navigate without clogs. Clogs have gotten less clunky and now come in colors, prints and patterned leathers.
Sport shoes are a cinch when it comes to comfort. Front runners here are Asics, New Balance and Brooks. Other people love the rocker shoes: their backs don’t quite hit the floor. Me, I hate the rocker shoes — like walking through an earthquake. But some are big fans. Different strokes for different feet.

Sock it to you

Now, comfort shoes, if they have enough room in the toebox, can be made even more comfortable with socks that are padded. Thorlo started the padded sock trend and was so successful that other manufacturers got on the bandwagon. You can always find the basic padded sport sock, but now padded socks come in black dressier versions. (Thorlo socks are worth every penny and last a long time — if your mate doesn’t make off with them.)

Drug store relief

A visit to the foot care section of the drug store may help with your walking comfort. Today, there are all kinds of foot gizmos designed to provide relief — from extra padding for the soles to protection for corns and bunions, those lovely bumps that arrive when your feet decide to grow sideways. Many more options at

Professional help

If home remedies and well-selected shoes don’t help your feet, get thee to a professional. No, not a pedestrian. The word is podiatrist. A good podiatrist can help with problems of misbehaving feet. They may have products that drugstores don’t carry and though they will not go all kissy-kissy over your tootsies the way your mom did, they may keep you on the road.

And that’s the point — keep on keeping on — passing through the valley of corns and hammertoes and forward into life on the open road.

Mel Walsh is a gerontologist, author and columnist. Her book, HOT GRANNY, is available online at This column first appeared in the Huffington Post. 

Growing Down: What To Do About Height Loss

 Just call us the incredible shrinking species. Humans are not pre-shrunk. They do it by living a long time. One study of more than 2,000 older adults concluded that women lost an average of two inches between ages 30 and 70, ending up with a total loss of about three inches by 80. Men lost a little over one inch between 30 and 70 and about two inches by 80 — in height that is. No other male parts were measured.

Yep, most of us knew this without reading a study. We just had to look at our grannies as we grew up and they grew down, but it is nice to know that we are not likely to melt into the ground like the Wicked Witch of the West. And if I end up three inches shorter in my 80’s, well, I was always short near the end of the month, so it makes sense to be short near the end of the lifespan.

So where do the inches go? First and most important: The disks between the vertebrae in the spine flatten out over the years. Also, tummy muscles weaken and bulge out, leading to rotten posture and the shortening of the human in question. Also, feet can flatten and the pads of the feet may get thinner which will make us ever so slightly shorter and ever so interested in shoes with thick protective soles. We walk around town looking like mountaineers who lost their way to Whitney. But me, I never met a polyurethane outsole I couldn’t love and take home.

Are there ways to fight gravity?

Yes, regular weight-bearing exercises help preserve height, meaning exercise on your bedroom trapeze won’t count. Israeli researchers, studying more than 2,000 subjects, found that men and women who engaged in vigorous aerobic activity lost only about half as many inches in height as those who adopted the couch slouch life in middle age or who never exercised at all. It will be interesting to see how the texting generation ends up at 80 with only thumb-bearing exercise. They may be small enough to fit in a shoebox.

Other ways to preserve height: Spinal surgeon Dr. Roger Hartl suggests doing all one can to preserve the disks between the vertebrae. That means improving microcirculation to the disks by avoiding obesity, smoking and diabetes, a trio I’ve come to regard as the three horseman of the health apocalypse.

Of course there are also the usual recommendations to promote bone health by adequate calcium and vitamin D. Any height loss that is more extreme, painful or faster than is common — see the stats above — should be investigated by a health professional. A bone density test may be ordered. And, just to cover your bases, it may be wise to bring up the issue of shrinkage next time at the doc’s so the fact of your disappearance gets on the chart.

If you have a primary care doc who is recording your height as well as your weight, give him or her a gold star. If that isn’t happening, use the old pencil mark on the door frame approach. It worked for your kids as they grew up. It can work for you as you grow down.

But don’t get into a funk over predictable height loss that is not associated with serious health issues. Humans in earlier ages didn’t live long enough to have these problems. The longer we live, the shorter we get. It’s a trade-off: life for height.

Who wouldn’t take it?

Summer for Dummies: How To Beat the Heat When You’re 60 Plus

Take off your clothes

That’s a no-brainer for teens, who strip down to short shorts and midriff thingies as soon as school is out. But for older people, each passing decade  brings a desire to cover more of ourselves. In our culture, the sags and other signs of aging are to be hidden, so we wear long sleeves and long pants when it’s 100 degrees out. (Ever see beach pics of older people in other cultures? They just don their swimsuits like everybody else. None of this burqa-esgue hiding.) So take off your clothes. Most of them, anyhow.

There are women…no name here…who abandon their bras in the summer, not wanting to be wired into an extra layer. A sleeveless tank or cami under a light cotton top takes care of the too-revealing issue. Around the house, panties and a tank are adequate for women and certainly get the seal of approval of Cranky Pants, my mate, who walks around in nothing much himself. Capris (also known as pedal pushers among the older set) are great for going out in the world. Kmart has a range of cotton capris for women that are just $7.98.

Neck coolers

These look like rolled bandana scarves and will keep a person comfortable in the heat. They have little beads inside that plump up when wet. First you soak the neck cooler in water to get the beads soaked and expanded. Then you put the scarf on and let the evaporation work to keep you cool. It’s like having your own personal evaporative cooler. Turn the scarf around when the side against the skin gets warm. I keep my extras plumped up and ready to go in a plastic bag in the refrigerator. Look online or in local sports stores for neck coolers. (Yes, neck coolers are a bit dorky, but better dorky than in the ER for heat exhaustion.)

Hand fans

I can’t figure out why we in the U.S. have abandoned these. I carry a folding paper fan in my handbag all summer long and will keep them aflutter when it’s hot outside. Try Amazon, $8.98 for 5. Free shipping for Prime members. These are great gifts for friends with hot flashes.

Managing the hot days

Think Italian or Spanish when it comes to living in a hot clime. They take the afternoons off for siestas and are active in the cooler parts of the day and evening. So, take a hint from them if you want to hike, run errands or garden. Do these things in the early morning. Take a nap in the afternoon.  Then stay up late and enjoy the starry nights. Even cooking dinner ahead of time in the cool mornings makes sense. Then the main food folderol is already in the bag for the day.

Keeping the house cool

Portable electric fans and air conditioning help out many, but so do simple window shades. Also, opening the house when it’s cool at night and closing it up when it starts to get hot in the late morning will manage the temps. You can go greener by not using the AC 24 hours a day and by setting it to 75 or above. As for electric fans, local hardware stores have some great sales. If you have the budget and the talent, ceiling fans are saviors.  A short PS here: In this time of summer fires, it’s smart to have an air purifier at hand too. We have one in the bedroom and one in the living area. As for what face masks are cooler than others….whether worn for fires or Covid….please share  your experience in the comment section. They all seem hot to me.


It seems silly to remind people to drink water, but the older you get, the more your thirst mechanism goes awry. Keeping a big bottle of water in sight is a good reminder. In sight, in mind.

So stay cool, will ya? That is unless you live where I do now, which is coastal California near Monterey Bay. If you are visiting, bring sweaters because the natural air conditioning from the Pacific can freeze your bumbershay off.

Mel Walsh is a gerontologist, author, columnist, spokesperson. Her book, Hot Granny, is available at Amazon. Visit Mel at

Meet Your Future Geezer

Wonder what you’ll be like as an older person?

Well, researchers at the University of Chicago can polish your crystal ball. Their study of people aged 57-85…the National Social Life, Health and Aging Project…goes into people’s homes and asks about their health, relationships and sex lives, though how they get honest answers about sexual behavior in face-to-face interviews with a spouse in the next room is a mystery. Their walls must be thicker than mine.

Health Findings: Parfum de Tiger Balm

In the health department, arthritis is one thing these older adults had in common. In the 75+ group, 62.8 % had arthritis, which explains the sweet smell of Tiger Balm in the morning in the homes of older folks — that and our snappy copper bracelets. Among that same older group, though, only 16.8 % reported a heart attack. Is this good news, or have those with heart problems already passed into the Great Beyond, beyond the questions of researchers? It’s a mystery.

Statistically, hypertension may also be in your future in that 60% of the same older group — 75 to 85 — have high blood pressure, which may be related to the fact that 55.2 % of them are also obese. And the younger group is even more rotund — 61.2 % of the 57-64 year olds are obese. (I am beginning to feel very self-conscious about the cupcakes I made last night.)

About Relationships

I hope this won’t ruin your day, but not all older people said they like to spend time with their partners. Only about 50% of men said they like to spend time with their partners and by the time partnered women got to be over 75, only 47.7 % said they liked to spend time with their honey buns.

If these results aren’t misprints, we have a problem. Retirement means two people alone in a house all day. So do Covid lockdowns. Lordy, if you don’t enjoy that, your days are toast.

But here’s the mystery: The vast majority of people in the study said they were happy in their relationships. Maybe the contradiction just translates into what has become a retirement mantra: I married you for life, dear, but not for lunch. Get the heck out of the house.

Now… The Sex Thing

The younger ones in the study had more lifetime sex partners than the people 75+. Forty-seven percent of women 57-64 had more than two lifetime sex partners, while only 20% of the oldest women had more than two sex partners in their lifetimes.

Well, no surprise here. The fast-lane Boomers among the group had reliable contraceptives and Woodstock. The older ones — well, they were pre-pill and pre-rock and probably lived more in the Tony Bennett lane.

Last, when it comes to sex, men stay true to form. While most women 75 and older said sex is NOT an important part of life, 75% of men over 75 said sex is still important.

So go ahead. Put that picture in your crystal ball — it’s going to be marriage counseling in our walkers.

This column originally appeared in the Huffington Post. It has been updated.

Sunshine Vitamin May Help Older People With Chronic Pain

Though experts currently have differing opinions about sun exposure, one thing is clear and can be acted upon: If you have unexplained or unrelieved muscle or bone pain, you may want to talk to your doc about testing your vitamin D level.

Is vitamin D an action hero painkiller? It sounds silly — pain old vitamin D as a possible reliever of pain. We know vitamin D as the Clark Kent of supplements, found in ordinary grocery stores, easily available from sunlight, available in fortified foods, egg yolks and fish, good for bones, but certainly not as a super hero painkiller.


However, if you have generalized muscle and bone pain, you will want to know what was uncovered by researchers at the Mayo Clinic: People with low vitamin D levels take nearly twice as much narcotic medication for pain as people whose vitamin D levels are normal. So far it’s just a correlation between the level of meds people require and their vitamin D levels, not a proven cause and effect.

But if groups of people who are low on D require almost twice as much morphine, fentanyl or oxycodone as those with a good D level, maybe they are in twice as much pain because they have half as much of what might turn out to be a natural pain preventer or reliever. That’s the theory that has grabbed the attention of medical investigators.

“Vitamin D is known to promote both bone and muscle strength. Conversely, deficiency is an under-recognized source of diffuse pain and impaired neuromuscular functioning. By recognizing it, physicians can significantly improve their patient’s life.”

Body Fat Steals Your D

Dr. Turner adds that people who are overweight are prone to have pain caused by low vitamin D because vitamin D likes to reside in fat. So when any of us have inviting layers of fat, the vitamin takes up residence in Fat City rather than circulating throughout the body the way it’s supposed to, bathing muscles and bones in a nice D bath. Dr. Turner also adds that checking D levels requires just a simple blood test that can be ordered by your doctor.

Can Low D Happen to You?

Yes, especially if you are older. Scientists say that about 50 to 60 percent of older people in North America do not have satisfactory vitamin D levels. Articles in The New England Journal of Medicine, The Journal of the American Medical Association and other reputable sources state that many adults are deficient in Vitamin D. Why? We older people are not outdoors as much as we were when young. We are office-bound or at home cocooning, especially now with Covid isolation. And fearing skin cancer or wrinkles, when outside we cover up and use sunscreen, so the sun can’t get through to work its D magic on the skin.

Dermatologists, naturally invested in preventing skin cancer and wrinkles, say we can get all the D we need through supplements, but there are other experts who advise also getting a little sunshine, not only for pain, but for depression and other ills. Dr. Christiane Northrup, women’s menopause health guru, recommends daily brief exposure to the sun. Her specific recommendations — the dos and don’ts of safe solar exposure — can be found at Now, however you decide to obtain vitamin D, you should know the current optimum level. The National Institutes of Health recommend that women age 51 to 70 get 600 IU’s a day.

Bottom line? Though experts currently have differing opinions about sun exposure, one thing is clear and can be acted upon: If you have unexplained or unrelieved muscle or bone pain, you may want to talk to your doc about testing your vitamin D level.

If vitamin D works to treat your pain, great — then Clark Kent has turned into Superman. And if it doesn’t take away the pain, at least you won’t have rickets.

Mel Walsh is a gerontologist, author and columnist. Her book, HOT GRANNY, Chronicle Books, is available at Amazon. 


Is That All There Is? No, Here’s More

Oh, we have worn out Netflix, seen reruns of Gray’s Anatomy down to the last smashed leg, learned every movie on Amazon Prime and found ourselves watching old Doris Day movies until we began to turn blond and smiley. But there is more at-home sheltering to do, if not this spring, maybe this fall and winter. Anyhow, so sayeth the virus experts.

So are you frozen  to one viewing spot, a permanent dent in the couch, one where generations to come will say: And that is where an ancestor endured the Great Pandemic of 2020? But truly, is this kind of couch muffin entertainment all there is? Netflix, Amazon Prime and popcorn?

Well,  you know there is more, but where to find it?  Here are some choices beyond the usual TV series and movies, choices where you can deepen and refresh  your brain with new ideas, images and pleasures.

For all round results, no matter what your interests are, move on over to 

If you are uptight…who is not?…put relaxing music into the YouTube search box at the top of the page. The choices are amazing and provide hours of soft music, nature sounds, music to sleep by, even chants with nice visuals…whatever works.

And whatever your interest is, you can find a video about it on YouTube. Bridge, birdwatching, vegetarian cooking, heart health, watercolors, pet turtles, closet organization, even animal scat…which is how I found out there was a bear in the yard at our last house.

Plus some of these videos will get you off the couch. Even if you are 90 and a bit frail around the edges, there will be a YouTube exercise video that can get the body…the one you used to acknowledge as yours…moving. If you have trouble standing…feet, knees, ankles and hips on the fritz…search chair exercises for seniors. That will get you into a section that also offers yoga for seniors and pilates standing up…that’s in case you have trouble getting up and down from the floor, an occupational hazard of age.

If you want exercise for your brain, search on YouTube for TED.  TED offers short talks that are worth while…their motto is Ideas Worth Spreading…and right now they are focusing on ideas worth spreading in a time of pandemic. You can also go straight to Your brains and possibly antique opinions will thank you.

If you’ve ever loved a flower, you can’t leave YouTube without doing some gardening. My love of the moment is Monty Don, the BBC hunk who, despite his good looks and talent as a TV presenter,  actually knows more about gardening than any expert I know. But he is not rigid in his rules. He says not to worry too much about pruning roses “the right way”. This is music to the ears of a wayward chopper like me.

Monty Don has done many series over the years. Seniors living in tight quarters might like the series, Big Ideas Small Spaces. I wore that one out and am now into his series, Gardener’s World. Big caveat: watching will mesmerize  people into spending big bucks at the local gardening center.

So love flowers this week. Maybe get outside, away from tired TV shows and CNN and do a little gardening, a little flower worship. I already spent a half hour today staring at the rambling roses in my patio. My Native American name should be: Staring At Roses.

Better than Staring at Headlines.

Moms in Lockdown…on Earth or in Heaven

Ok, this is not like any other Mother’s Day since you first gave birth several centuries ago. That change might have some advantage. There are no restaurant brunches where the service is bad, the eggs cold and the prices hiked. There is no breakfast in bed for us sheltered seniors….a meal where the crumbs in the night remind one of the burnt toast in the morning.

Some of those child-made meals were high on good will, but low on skill. At five years of age, with nobody in the house but mom and me and with nothing much in the house because of war rationing, I served my mom a meal of lettuce leaves decorated with Necco Wafers. I looked upon the plate and thought it was good. What my mom thought was not recorded.

Then there are the thoughts that always come this day about our dear departed moms. How to honor them? Cranky Pants and I found a way after I read that some ancient Greeks used to set a place for one of the Olympus gods even though they knew Zeus or Hera  would not show up. So we set a place at the table for his mom and mine. After toasting them, we spend the meal trading stories about our mothers. It’s something you can do today to honor your own. And tell your kids you have not lost it, but found a new way to honor your mom. It’s Greek. It’s classic. Just like you.

So today, your kids, if your area is still in lockdown, will not show up. The flowers might not make it to the front door. But there may come an invitation to Zoom, Skype, Face Time or phone. Whatever works. You can enjoy the love in whatever form it arrives. And you can set that place at your table for absent mom. Is it possible to imagine a pleasant conversation where you re-live the best moments of her momhood? After a glass of champagne, yes. And ask forgiveness for some of the worst things you ever did as a child.

Mom, I have to talk to you about those Necco wafers.

Three Things Everybody Needs

Nineteen. What did you need at that age? Depends on gender. Male: A fake ID, wheels and a condom in your wallet. Female: A fake ID, lipstick, comb. Forward 50 years. Age 79. What do you need? A blood pressure monitor, a thermometer and a oximeter, a little fingertip device that measures your oxygen, your hot air, though friends can also tell you about that. I’d add in that all of us at the dewy dawn of old age need night lights,  so we do not stumble and tumble on the way to the small room in the middle of the night. (The older one gets, the more frequent trips. Maybe celebrate by getting two night lights. I know. I am a wild, wild woman.)

Clearly, I am lying about the number three as there is still another thing we older people need and that is sleep, right now. What I am hearing from my peers is that people are having constant trouble sleeping. Side effect of Covid news: insomnia.

I’m pretty sure you’ve read all the remedies: Stay away from late day caffeine,  get off the computer, take a relaxing bath, keep your room quiet and yes, no TV in the bedroom. Ha. Whoever writes these is not on my planet.

I know people who cannot sleep without their TV on. It lulls and comforts them. James Garner in the room cheers one off to dreamland. So yes, TV if it suits you. But no to chocolate. If you don’t want the caffeine in chocolate to disturb, eat it early in the day. Breakfast would be really safe. And many older people can’t get in and out of their tubs and it takes too long anyhow. Take a shower. Put on those sleepy time sweats. Watch something incredibly old fashioned on your bed iPad. No violence. Bosch will keep you awake and incidentally raise your BP. Mine went up to 170 over trouble after the last murder. So try the 90 reruns of the series All Creatures Great and Small about a veterinarian in Yorkshire in the 1940’s. It’s relaxing to watch cows get their teats fixed by our hero.

(Masterpiece Theater is now shooting a new version of All Creatures for PBS.)

Also know that there are many relaxing music videos on YouTube. Do not let the presence of another human in the bed deter you from watching old shows on your iPad or listening to music videos. Earphones solve the problem. And then there is bedtime Kindle reading. Last night, thanks to author Robert Harris,  I was present at the murder of Cicero and Cranky Pants slept right through it.

Which gets me to the midnight snatching of the covers. Shivering wakes. If you sleep with someone else, it is going to happen as he or she rolls over and hogs the covers. We here in Shelter Prison have finally solved it: Bought a quilt on Overstock that was so humongous that no rollover could snatch the covers from anyone. Moral: Go big or go freeze.

You probably have your own idea about what a person absolutely should have these days at this age. Please write it in the public comment section below. What keeps me humble is that the comment section after a column is often better than the column.

Go for it and get some sleep.


New Info About Covid You Need to Know Now

This is a first. I have been writing columns for many years, syndicated by King Features and appearing weekly in the Mercury News, but never have I substituted someone else’s column for my own. This piece below by E.R. physician Richard Levitan appeared this afternoon on the front page of the New York Times. It will tell you about early oxygen deprivation as a silent symptom of Covid. With Covid, people can be very low on oxygen and not know it and thus do not seek treatment.

This column on silent hypoxia or oxygen deprivation may get you on Amazon to buy a simple fingertip oximeter, a painless little device to measure your blood oxygen. Just looked online: Prices are rising on oximeters and some deliveries are not until early May. I bought one years ago for $20. Some are now in the $30’s and up to the $60’s.

But let Dr. Levitan tell you about it below and also consider subscribing to the New York Times. They deserve our support for bringing information like this.


The Infection That’s Silently Killing Coronavirus Patients

This is what I learned during 10 days of treating Covid pneumonia at Bellevue Hospital.


Dr. Levitan is an emergency doctor.

I have been practicing emergency medicine for 30 years. In 1994 I invented an imaging system for teaching intubation, the procedure of inserting breathing tubes. This led me to perform research into this procedure, and subsequently teach airway procedure courses to physicians worldwide for the last two decades.

So at the end of March, as a crush of Covid-19 patients began overwhelming hospitals in New York City, I volunteered to spend 10 days at Bellevue, helping at the hospital where I trained. Over those days, I realized that we are not detecting the deadly pneumonia the virus causes early enough and that we could be doing more to keep patients off ventilators — and alive.

On the long drive to New York from my home in New Hampshire, I called my friend Nick Caputo, an emergency physician in the Bronx, who was already in the thick of it. I wanted to know what I was facing, how to stay safe and about his insights into airway management with this disease. “Rich,” he said, “it’s like nothing I’ve ever seen before.”

He was right. Pneumonia caused by the coronavirus has had a stunning impact on the city’s hospital system. Normally an E.R. has a mix of patients with conditions ranging from the serious, such as heart attacks, strokes and traumatic injuries, to the nonlife-threatening, such as minor lacerations, intoxication, orthopedic injuries and migraine headaches.

During my recent time at Bellevue, though, almost all the E.R. patients had Covid pneumonia. Within the first hour of my first shift I inserted breathing tubes into two patients.

Even patients without respiratory complaints had Covid pneumonia. The patient stabbed in the shoulder, whom we X-rayed because we worried he had a collapsed lung, actually had Covid pneumonia. In patients on whom we did CT scans because they were injured in falls, we coincidentally found Covid pneumonia. Elderly patients who had passed out for unknown reasons and a number of diabetic patients were found to have it.

And here is what really surprised us: These patients did not report any sensation of breathing problems, even though their chest X-rays showed diffuse pneumonia and their oxygen was below normal. How could this be?

We are just beginning to recognize that Covid pneumonia initially causes a form of oxygen deprivation we call “silent hypoxia” — “silent” because of its insidious, hard-to-detect nature.

Pneumonia is an infection of the lungs in which the air sacs fill with fluid or pus. Normally, patients develop chest discomfort, pain with breathing and other breathing problems. But when Covid pneumonia first strikes, patients don’t feel short of breath, even as their oxygen levels fall. And by the time they do, they have alarmingly low oxygen levels and moderate-to-severe pneumonia (as seen on chest X-rays). Normal oxygen saturation for most persons at sea level is 94 percent to 100 percent; Covid pneumonia patients I saw had oxygen saturations as low as 50 percent.

To my amazement, most patients I saw said they had been sick for a week or so with fever, cough, upset stomach and fatigue, but they only became short of breath the day they came to the hospital. Their pneumonia had clearly been going on for days, but by the time they felt they had to go to the hospital, they were often already in critical condition.

In emergency departments we insert breathing tubes in critically ill patients for a variety of reasons. In my 30 years of practice, however, most patients requiring emergency intubation are in shock, have altered mental status or are grunting to breathe. Patients requiring intubation because of acute hypoxia are often unconscious or using every muscle they can to take a breath. They are in extreme duress. Covid pneumonia cases are very different.

A vast majority of Covid pneumonia patients I met had remarkably low oxygen saturations at triage — seemingly incompatible with life — but they were using their cellphones as we put them on monitors. Although breathing fast, they had relatively minimal apparent distress, despite dangerously low oxygen levels and terrible pneumonia on chest X-rays.

We are only just beginning to understand why this is so. The coronavirus attacks lung cells that make surfactant. This substance helps keep the air sacs in the lungs stay open between breaths and is critical to normal lung function. As the inflammation from Covid pneumonia starts, it causes the air sacs to collapse, and oxygen levels fall. Yet the lungs initially remain “compliant,” not yet stiff or heavy with fluid. This means patients can still expel carbon dioxide — and without a buildup of carbon dioxide, patients do not feel short of breath.

Patients compensate for the low oxygen in their blood by breathing faster and deeper — and this happens without their realizing it. This silent hypoxia, and the patient’s physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until their oxygen levels plummet. In effect, the patient is injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.

By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator.

Silent hypoxia progressing rapidly to respiratory failure explains cases of Covid-19 patients dying suddenly after not feeling short of breath. (It appears that most Covid-19 patients experience relatively mild symptoms and get over the illness in a week or two without treatment.)

A major reason this pandemic is straining our health system is the alarming severity of lung injury patients have when they arrive in emergency rooms. Covid-19 overwhelmingly kills through the lungs. And because so many patients are not going to the hospital until their pneumonia is already well advanced, many wind up on ventilators, causing shortages of the machines. And once on ventilators, many die.

Avoiding the use of a ventilator is a huge win for both patient and the health care system. The resources needed for patients on ventilators are staggering. Vented patients require multiple sedatives so that they don’t buck the vent or accidentally remove their breathing tubes; they need intravenous and arterial lines, IV medicines and IV pumps. In addition to a tube in the trachea, they have tubes in their stomach and bladder. Teams of people are required to move each patient, turning them on their stomach and then their back, twice a day to improve lung function.

There is a way we could identify more patients who have Covid pneumonia sooner and treat them more effectively — and it would not require waiting for a coronavirus test at a hospital or doctor’s office. It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter.

Pulse oximetry is no more complicated than using a thermometer. These small devices turn on with one button and are placed on a fingertip. In a few seconds, two numbers are displayed: oxygen saturation and pulse rate. Pulse oximeters are extremely reliable in detecting oxygenation problems and elevated heart rates.

Pulse oximeters helped save the lives of two emergency physicians I know, alerting them early on to the need for treatment. When they noticed their oxygen levels declining, both went to the hospital and recovered (though one waited longer and required more treatment). Detection of hypoxia, early treatment and close monitoring apparently also worked for Boris Johnson, the British prime minister.

Widespread pulse oximetry screening for Covid pneumonia — whether people check themselves on home devices or go to clinics or doctors’ offices — could provide an early warning system for the kinds of breathing problems associated with Covid pneumonia.

People using the devices at home would want to consult with their doctors to reduce the number of people who come to the E.R. unnecessarily because they misinterpret their device. There also may be some patients who have unrecognized chronic lung problems and have borderline or slightly low oxygen saturations unrelated to Covid-19.

All patients who have tested positive for the coronavirus should have pulse oximetry monitoring for two weeks, the period during which Covid pneumonia typically develops. All persons with cough, fatigue and fevers should also have pulse oximeter monitoring even if they have not had virus testing, or even if their swab test was negative, because those tests are only about 70 percent accurate. A vast majority of Americans who have been exposed to the virus don’t know it.


There are other things we can do as well to avoid immediately resorting to intubation and a ventilator. Patient positioning maneuvers (having patients lie on their stomach and sides) opens up the lower and posterior lungs most affected in Covid pneumonia. Oxygenation and positioning helped patients breathe easier and seemed to prevent progression of the disease in many cases. In a preliminary study by Dr. Caputo, this strategy helped keep three out of four patients with advanced Covid pneumonia from needing a ventilator in the first 24 hours.

To date, Covid-19 has killed more than 40,600 people nationwide — more than 10,000 in New York State alone. Oximeters are not 100 percent accurate, and they are not a panacea. There will be deaths and bad outcomes that are not preventable. We don’t fully understand why certain patients get so sick, or why some go on to develop multi-organ failure. Many elderly people, already weak with chronic illness, and those with underlying lung disease do very poorly with Covid pneumonia, despite aggressive treatment.

But we can do better. Right now, many emergency rooms are either being crushed by this one disease or waiting for it to hit. We must direct resources to identifying and treating the initial phase of Covid pneumonia earlier by screening for silent hypoxia.

It’s time to get ahead of this virus instead of chasing it.

Richard Levitan, an emergency physician in Littleton, N.H., is president of Airway Cam Technologies, a company that teaches courses in intubation and airway management.