## Level 4 -- Professionals Take Over

As symptoms get worse and the patient deteriorates, the frequency with which measurements are taken should go up.increase. At this point, your log should contain temperature, respiration, and heart rate every few hours. Be especially alert for rapidly worsening shortness of breath, rapid breathing, and low blood oxygen level, as these can be signs of developing acute respiratory distress syndrome (ARDS), which requires immediate medical attention. 

You should interpret any of the following as a medical emergency:

### Loss of consciousness

There's different levels. When patient loses consciousness, make a note of whether the patient responds when you call their name (Voice), when you pinch the shoulder forcefully (Pain) or whether he/she does not respond at all (Unresponsive)

If loss of consciousness is brief, you might (if patient quickly recovers and is fully awake again!) encourage the patient to eat and drink a bit, and freshly ventilatingventilate the room. But loss of consciousness is serious,serious; get help.

### Cognitive problems / confusion

You probably know the patient, so you should be able to tell without any fancy tests if and when he/she is not with it anymore. Sudden onset of confusion is trouble. Seek medical help.

### Too high or too low respiration rate / shortness of breath

Count respirations per minute by holding your hand close enough to feel the patient's breath, watching his or her chest, and / or watching his or her abdomen, while holding a clock with a second hand or a digital watch / phone stopwatch. Respiration rate (RR) should be between 12 and 20 breaths per minute. 

Immediate home care for respiratory problems may include ventilating the patient's roomroom, and propping him or her up so that he or she can be in an upright but comfortably resting position. It is also a good idea to elevate the head of the bed for sleeping if possible,trying different breathing techniques andthere are some sleeping positions that can make breathing easier, too (see Level 3, Care work).

![](/images/dyspnoe.png)![](/assets/images/dyspnoe.png)

If you or the patient are experiencing shortness of breath / labored breathing, seek medical advice. 

### Low oxygen saturation

If you have an oxymeter (see [shopping page](/shopping)), any oxygen saturation lower than 95% may indicate a respiratory problem. If at any stage the patient's **lips or fingertips turn blue** (or even mildly blue) (calledblue; called cyanosis), call an ambulance! Anything less than 96%, get fresh air into the patient's room,and get him or her warm.warm, and have him or her lie prone (chest down, back up) if he or she can. 

![](/images/cyanosis.png)![](/assets/images/cyanosis.png)

(Also call a doctor if the fingers, toestoes, or lips turn less blue than this...)

If the patient's skin gets a lacy purple overlay (also called livedo reticularis) like below (and that's not normal for the patient), that is also a reason to call for help.

![](/images/livedo-reticularis.png)![](/assets/images/livedo-reticularis.png)

### Very low blood pressure

Blood pressure lower than the bottom of the normal range (90 mmHg systolic, 60 mmHg diastolic) is cause for concern. Note that blood pressure comes as two numbers, the systolic and diastolic pressure. If you have a cheap automatic device it should tell you both these numbers. If you have a device, note the systolic pressure on the [diary form](/images/covid-diary.pdf).form](/assets/images/covid-diary.pdf).

If you do not have a device to measure blood pressure or have trouble getting a reading, then try testing the patient's capillary refill time instead. Check by placing his or her fingers flat on a hard surface. Use your finger to press down on one of his or her fingernails from the top. The fingernail should lose color. Check how long it takes the fingernail to turn its normal color again. It should take 1-2 seconds. Longer than that may indicate low blood pressure.It could also be a symptom of dehydration. 

Dehydration is a common cause of low blood pressure, so immediate home care may include encouraging the patient to eat and drink, especially foods or beverages containing essential electrolytes like potassium and sodium. Dizziness is a common symptom of low blood pressure, so the dizzy patient will want to be careful while changing positions (laying to sitting up, sitting to standing); fainting may occur. But really, once again, if things do not look right somehow --- if blood pressure is very low, or if the patient normally has high blood pressure and it's looking much lower than their normal --- again, get help.

### Too high or too low heart rate

Heart rate is easier to measure than blood pressure, and usually high heart rate (above 100-110 beats per minute for an adult) goes with low blood pressure. Smaller peopleadults and children often have normally higher heart rates. High heart rate alone may not be cause for alarm, as it may indicate anxiety or dehydration. Relaxation techniques and drinking / eating something might be appropriate. But once again, values outside the normal range here should cue you to seek medical help immediately. This is especially true if you see rapid breathing along with low blood pressure orpressure, high heart raterate, and / or confusion. 

### Very high fever that comes (back) suddenly

If you check temperatures regularly, you will want to be aware that the trend can reverse suddenly, even when the patient seemed to be doing better earlier. Regular measurements are important. A fever that is very high (> 39° Celsius)(39.4° Celsius or around 103° Fahrenheit, or higher) is a cue to seek medical help.advice. So is a fever that goes away and then comes back suddenly. 

### Coughing up blood

This one is self-explanatory. If you notice the patient coughing up blood or blood-stained mucus, seek medical advice.

### Call for help

When any of the above symptoms occur, things are serious! If at all possible, this is the point where you should not be taking any decisions based on a guide from the internet anymore. Do not wait for things to get worse. Call a doctor, or call the emergency number and get the patient in an ambulance pronto. Stay calm and report the situation as it is. Your job is done: You have kept a patient out of the medical system while he or she was just sick. Now it's time for professionals to handle it. The data you have been gathering should hopefully help you convince the operator, ambulance people,paramedics / emergency medical technicians, and doctors that you are not merely panicking for no reasonreason, and will likely help get the patient the care he or she needs sooner.