Waiting too long

In normal times, Tri-City Medical Center hosts a busy emergency department in San Diego County, seeing 60,000 emergency patients annually. But recently, fewer people have been visiting the ER—even though the hospital had only seven COVID-19 patients as of May 4. Tri-City’s ER volume has dropped more than 40 percent from pre-pandemic levels.

Eric White, an ICU nurse at the hospital, says one woman had been suffering from respiratory failure but worried, “I’m afraid I’ll get COVID-19 if I go.” Although she finally did arrive to the ER for treatment, she eventually left the hospital on hospice care.

“If she had come a few days earlier, she would have had longer to live,” White says.

Amid the spread of the coronavirus, medical workers at hospitals and clinics have noticed the disconcerting trend: Fewer patients than normal are showing up in emergency rooms.

Four hospitals in Western New York reported that visits to their emergency rooms were down by 60 percent in April. In Detroit, Mich., Dr. Robert Klever of Detroit Receiving Hospital told the Detroit Free Press his emergency department was seeing an average of 102 patients a day, compared with 192 a day before the state’s stay-at-home order began. (The order does not prohibit ER visits.)

It’s an ironic reality at a time when the coronavirus continues to circulate in communities across the United States, infecting more than 1.2 million Americans since February. Many have become sick to the point they must seek emergency care. In outbreak hot spots like New York City, news reports have described overwhelmed hospital systems, overworked doctors, and intensive care units overflowing with COVID-19 patients.

Yet in many other places, hospitals and clinics have actually seen drastically fewer patients than usual. While hospitals have steeled themselves for an influx of COVID-19 patients, their ER workers often see fewer patients than usual complaining of non-virus-related maladies.

Isn’t that a good thing? Yes, at least in some cases: With millions of Americans staying at home under no-travel orders in recent weeks, for example, traffic accident injuries appear to have dropped significantly. In California, the Road Ecology Center found that vehicle collisions fell by 50 percent under the state’s stay-at-home order, with about 200 crashes per day resulting in injuries or fatalities, down from 400 per day previously.

But ER visits for other life-threatening ailments not directly related to traffic have also dropped significantly. Doctors believe it is largely due to people’s fear of visiting the hospital and catching the coronavirus from medical staff or other patients.

“There’s been so much fear that nobody wants to go to the hospital unless they absolutely need to,” said Laura Chow, a doctor in Austin, Texas, who treats head, neck, and lung cancer patients.

Chow said that early in the pandemic, two very sick cancer patients called her office, but “despite our best efforts to get them to go to the emergency department, they frankly refused.” The patients finally came hours later, but at that point they were so sick that both died.

Other doctors have reported a dearth of heart attack patients—a trend that seems to be occurring in multiple countries.

In Spain, for example, treatments for a serious type of heart attack known as a STEMI have fallen by 40 percent. In Austria, hospital admissions for heart attacks and similar serious heart conditions dropped 39 percent between the first and last weeks of March.

In the United States, the situation is similar. The Journal of the American College of Cardiology logged a 38 percent reduction in STEMI treatments at U.S. hospitals.

Some doctors have speculated reduced pollution (because of fewer cars on the roads) or reduced work-related stress may have reduced the frequency of heart attacks. But fear of visiting the emergency room during a pandemic seems to be a major factor—one that some patients have admitted to.

According to the Detroit Free Press, Klever knew of at least one recent heart attack victim who died after waiting too long to call 911. He said that city ambulance statistics from the past month show at-home deaths have increased fivefold, with 147 people dying at home this year, compared with just 27 such deaths at this time last year.

“That’s the collateral damage of people who are afraid to come to the emergency department,” he told the newspaper.

Early figures indicate at-home deaths have risen elsewhere as well. NBC News reported that in 2019, New York City’s 911 calls for cardiac arrest averaged 69 a day, with 27 deaths. During the same period in 2020, cardiac calls averaged 195 a day, with 129 deaths.

While some at-home deaths may be COVID-19 cases involving people who did not die in a hospital, they do not all appear to be so. They add to concerns that people are dying of not only COVID-19 but other treatable conditions.

Early reviews of mortality data in the United Kingdom and the United States show a significant increase in “excess deaths” during March and April. Excess deaths are those that exceed the total deaths that would be expected in a region based on normal trends from previous years.

The Yale School of Public Health and The Washington Post estimated 15,400 excess U.S. deaths this year between March and early April, only about half of which could be explained as known COVID-19 cases. A similar New York Times analysis counted 23,000 excess deaths in New York City alone since mid-March, with about 4,000 of those not recorded as COVID-19 deaths. It’s not yet clear which of those additional deaths may have been unrecorded COVID-19 cases and which were due to other causes.

Whatever the case, medical groups are urging Americans not to hesitate to seek emergency care, and noting that hospitals have put careful safety measures in place to prevent the coronavirus from being transmitted to ER patients.

The American College of Cardiology ran a recent ad listing heart attack and stroke symptoms—chest pain, difficulty breathing, numbness, confusion. The ad included a stark reminder: “Heart attacks and strokes don’t stop during a pandemic.”

This story has been updated to correct the description of Tri-City Medical Center’s emergency volume in comparison with other hospitals in San Diego County, and to correct the date on which Tri-City Medical Center was caring for seven COVID-19 patients.