By Dr Ernest Madu & Dr Paul Edwards
One of the surprising findings of the current Covid-19 pandemic has been the reduction in number of patients without Covid-19 disease presenting to hospitals and urgent care facilities worldwide.
Hospitals around the globe are reporting an overwhelming number of patient admissions due to a heavy influx of Covid-19 patients. Surprisingly, clinicians are reportedly seeing fewer patients with symptoms of heart attack or stroke in emergency departments. Several reports from many countries indicate that patients are delaying seeking treatment for non-Covid-19-related symptoms because they are afraid of being exposed to Covid-19 patients.
Of particular concern is the reduction in patients who are presenting with medical urgencies or emergencies, as one would not expect that the Covid-19 pandemic would reduce these patient numbers. In fact, for certain conditions such as heart attack and stroke we might have anticipated that these numbers would increase. Prior experience with severe respiratory viral illnesses (flu pandemics and SARS) has suggested an increased risk of heart attack and stroke, related to widespread inflammation in the body.
The reduction in patient numbers presenting to hospitals during this pandemic appears to relate to most diseases. Strata Decision Technologies, a US-based company which concentrates on financial data, has found that for a two-week period in March and April of this year, there was a 54.4 per cent decrease in the number of patients seeking hospital care across the United States as a whole. The University of Wisconsin hospital reported that there was a 50 per cent reduction in patients presenting to their emergency room.
A consortium of heart hospitals in the United States has reported a 36 per cent decline in patients presenting to cardiac catheterisation laboratories for acute heart attacks, despite an expected likely increase in the actual number of persons getting heart attacks during this time. The medical community has noted reductions in patients presenting with surgical emergencies, strokes, infections, and injuries such as broken bones.
Data from Italy have suggested that this is not only an issue for adults but the paediatric population as well, with paediatric emergency room visits falling 73-88 per cent. The only medical non-Covid-19 condition that does not appear to be affected by the steep declines is delivery of infants and Caesarean sections. Locally, arrivals at hospitals for acute non-Covid-19 emergencies appear to have declined as well. Anecdotal reports suggest that this decline is in the order of 20-40 per cent, varying regarding hospitals, health conditions and parishes.
There appear to be several factors that account for the fall in the numbers of patients who are accessing the medical system. When considering the patients who have emergency conditions, the primary reasons appear to be related to fear and lack of knowledge during this epidemic.
To suppress the spread of the SARS-CoV-2 virus, many countries have adopted a policy of staying at home and social distancing; there has been strong emphasis on the need to isolate. However, lost in this message may have been advice on what a patient should do if he is experiencing new and unexplained or worsening symptoms of a chronic illness.
Another, and most likely the primary reason, for patients failing to present early for treatment is related to fear of being in a health care facility at the current time, given the risk of getting Covid-19 disease. A Gallup Poll performed in the United States at the end of March revealed that of patients with heart disease, 86 per cent said they would be either very or moderately concerned about exposure to the SARS-CoV-2 virus if they needed care at a hospital or physician’s office. Another issue, particularly for the elderly, is the lack of family support that is available to them when admitted to hospital. Many facilities are restricting all visitors to reduce the spread of Covid-19 disease. The media has many stories of patients who undergo emergent procedures or who die in hospital, with the only contact with their relative having been by phone.
In recent weeks in Jamaica, several high-profile deaths at home have been reported, presumably from major heart attacks. Some of these deaths, unfortunately, may be linked to delays in seeking care because of fear of contracting Covid-19.
Cardiovascular diseases remain the number one cause of death and disability in Jamaica and unfortunately, they do not take a break because we are in the middle of a pandemic. It is likely that the incidence of heart attacks and strokes will rise in the middle of the pandemic due to the increased stress imposed on individuals who are already at risk, compounded by delays in seeking appropriate care.
For many emergent medical and surgical conditions, delay in medical care results in an increased risk of dying, having long-term damage (which might have been avoided by early treatment), or having a prolonged and complicated hospital course. In many types of heart attacks for example, during which a blood vessel has been occluded, timely restoration of blood flow to the muscle of the heart reduces the risk of dying and the amount of heart muscle that is lost. In the case of late treatment, patients can be left with heart failure and poor quality of life, with inability to carry out many of their day-to-day activities.
For patients presenting with certain types of acute stroke, early presentation allows the administration of “clot-busting” medication which can allow the restoration of blood flow to the brain and preserve the use of the arms and legs. Delayed surgical emergencies may result in more complicated operations, higher risk of infection, longer hospitals stays, and death.
How then can we encourage patients to seek medical attention in an emergency?
Our health care system must tackle this on several fronts. The first step is to validate the very real concerns of our patients regarding the possibility of acquiring Covid-19 disease in a health facility. In response to this concern we need to organise our hospitals and urgent care facilities to minimise this risk as far as it is possible. The strategies are well known and include avoiding patient crowding, the use of masks in health care facilities (patients and staff), thorough regular cleaning of patient care areas, temperature checks for patients entering facilities, and physical separation of known Covid-19 patients from others. The Heart Institute of the Caribbean (HIC) and HIC Heart Hospital have instituted Covid-19 prevention policies that incorporate all these strategies, including a commitment that emergency cases are seen immediately without delay, and that waiting time will be kept to less than 15 minutes in urgent cases. This approach significantly minimises the duration of potential exposure to other patients. Furthermore, HIC employs social distancing measures in the seating arrangements in our A&E.
“Because of fears of contracting Covid-19, patients experiencing a heart attack may unwisely be delaying their cardiac care,” said director of clinical services at HIC and HIC Heart Hospital, Dr Edwin Tulloch-Reid. “The faster a patient is treated, the more likely he is to survive and lower the risk for complications. Patients should not, under any circumstances, delay seeking treatment. It would be unwise to do so.”
For patients who have established medical providers, the ability to communicate with their physicians and to get advice on the best course of action for new or worsening symptoms is important. If care can be provided away from a busy emergency room or A&E, this certainly is advantageous when appropriate. Employing telemedicine can be quite useful in this context, and indeed at the Heart Institute of the Caribbean we have used telemedicine as a care delivery option for more than 12 years – but we have recently seen a 200 per cent increase in the demand and utilisation of telemedicine consultations by our patients, both new and existing. This communication need not be for emergencies only as we should remember that patients continue to have chronic medical conditions that need ongoing management, with the potential to become urgent or emergent situations if early warning signs are missed. Examples of these conditions include congestive heart failure, diabetes, hypertension, asthma etc.
In addition to the above relatively specific measures, we need to educate our population about what constitutes a medical emergency and the need to seek timely medical care. Symptoms such as prolonged and severe chest pain or discomfort, difficulty breathing, prolonged racing of the heart, dizziness, difficulty speaking, twisting of the face, weakness of the hand and legs, fainting or passing out spells, severe abdominal pain, significant bleeding or significant injuries at home are all valid reasons to seek immediate or urgent medical care.
In the same way that our society understands that even though we are socially distancing we do go to the supermarket for groceries, we also need to understand that we need to seek early health care attention when we are feeling unwell. If this understanding is not present then delays in care will continue to produce increased risk of death, medical complications, increased cost of care and relatively poor outcomes. (Jamaica Observer)
Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.
Thoughts and views expressed in guest editorials do not necessarily reflect the opinion of Observer NewsCo, its management or staff.