'People are dying at home': virus fears deter seriously ill from hospitals
As New York City was splintering under the weight of the coronavirus, four men were shot in a Brooklyn attack. At about the same time, another was stabbed.
Gang violence is still common in some neighborhoods of the borough, and despite the lower crime rate across the city, the pandemic hadn’t stopped it entirely. The wounded men were rushed to Kings County hospital.
The hospital, however, was grappling with the peak of the pandemic. The trauma unit was filled with Covid-19 patients, there was a shortage of intensive care beds. Doctors and nurses found space for the men wherever they could – hallways, pediatric units – and treated them amid the virus patients on tubes and ventilators, changing gloves in between.
“We were completely overrun,” said a physician who treated the gunshot victims in early April, and who asked to remain anonymous. “The whole department was filled with intubated patients in respiratory failure.”
Coronavirus has flooded health systems across the US since the beginning of March – cramming emergency departments and pushing staff and resources to capacity. But Americans have continued to suffer heart attacks, strokes and traumatic injuries. Mothers have continued to deliver babies.
Some of these patients are contracting Covid-19 while being treated for a different ailment. Others are avoiding clinics and hospitals altogether and dying, unnecessarily, as a result.
“People are staying home, people are dying at home, it’s an absolute travesty,” said Dr Casey Clements, an emergency physician and infectious disease researcher at the Mayo Clinic in Rochester, Minnesota.
The impact is especially clear when it comes to chronic disease. Heart attacks and strokes are among the top reasons that people visit the emergency department. And heart failure patients accounted for almost a million hospitalizations in 2014.
That’s not the case right now. A Bellevue hospital physician, who asked to remain anonymous, said patients with heart issues or gastrointestinal (GI) bleeds are usually some of the most common cases at the hospital. Nowadays, he sees them rarely. “I’m worried people are decompensating at home,” he said.
Clements said the hospital was proactively telling patients they need to come in for severe issues. “They have a higher risk of that killing them than even if they got the [Covid] infection,” he said.
While no reliable statistics are available on how many Americans with nonCovid-related illnesses are avoiding the health system, doctors responding to an informal Twitter poll reported a 40% reduction in heart attack patients. Cigna, the insurance company, said patients were not actively seeking care for urgent health needs, citing significant reductions in hospitalizations for GI bleeds, seizures and appendicitis.
Though it is not known how many people with chronic disease have died in recent weeks, some may be driving up the number of suspected Covid deaths – a grey area of the data that includes people who have died of related health issues.
Meanwhile, another segment of the population is caught in the fray: pregnant women. Every year, about 3.7 million children are born in the US, the vast majority of them in hospital settings.
In a New England Medical Journal study this month, researchers found that 33 of the 215 pregnant women delivering babies at a New York hospital during a one-month span tested positive for Covid-19. Only four showed symptoms.
The fear of contracting Covid-19 has led a small number of pregnant women to avoid medical facilities altogether – opting for home births and midwives. But that comes with its own risks, experts say, which can be more dangerous
than the virus.
“We don’t think it’s safe to deliver at home because we don’t have the emergency system set up to make that transition smooth,” said Dr Robert Smith, an obstetrician-gynecologist at the Michigan Medicine Von Voigtlander women’s hospital.
Meanwhile, trauma victims – those suffering from accidents, falls or violence that account for at least 200,000 hospitalizations a year – have fewer options. These patients are usually taken in an ambulance to hospital and treated, whether or not they want to be exposed to coronavirus.
But coming to the hospital can also lead to a diagnosis. The Kings County physician said he has found respiratory issues related to Covid-19 in Cat scans of older patients while looking for broken bones or internal bleeding from falls.
Assessing the risk of contracting Covid-19 in a medical facility is difficult, and without that data, it can be hard for sick people to make decisions.
A meta-analysis of China’s Covid-19 studies found that infections contracted in hospitals accounted for 44% of the total cases. This included patients admitted to the hospital, but also health workers, who can both contract the virus and spread it to other people if not properly protected.
Without national guidelines, the situation can vary drastically by facility. Michael Klompas, an infectious disease specialist at Brigham and Women’s Hospital and Harvard Medical School professor, said he and his colleagues have been tracking each Covid-19 infection in the Harvard Pilgrim hospital system by date of diagnosis and exposure. So far, he said, hospital-acquired cases are “few and far between”.
Klompas said this success could be attributed to the strict hospital measures: universally masking patients and health workers, testing employees regularly, banning almost all visitors and screening patients. “The package seems to be working,” he said.
Many of those protocols are being followed across the country. While the US does not have designated Covid and non-Covid hospitals, as countries like China implemented, hospitals have devised their own methods to avoid the spread. Telemedicine emergency room visits help triage patients without contact, Clements said, insisting that the Mayo Clinic and the regional clinics it runs across the midwest remain largely safe.
“I feel much safer in my ER and hospital going to work than I feel in a public place,” Clements said. “That’s a universally felt sentiment among the doctors I know.”
At Bellevue hospital in New York City, the largest public hospital in the country, emergency department workers try to group patients together based on their diagnosis, and have two separate ICUs for Covid and non-Covid patients, the physician there said.
But some patients do fall through the cracks. “The transmission to these patients is sometimes unavoidable,” the physician said. “Sometimes we ask ourselves what’s the risk of our patient coming up?”
In Michigan, Smith said the hospital reduced the number of in-house prenatal care visits, and recommended testing delivering mothers for Covid-19. Symptomatic mothers with the virus are put in negative pressure rooms to avoid contagion.
As spring turns to summer, new Covid-19 hotspots have cropped up in cities such as Gallup, New Mexico, and Marion, Ohio, where access to healthcare is already strained.
But physicians are clear: Covid-19 is not the only way that Americans are getting sick or dying.
“It may not have been safe to be a non-Covid patient in the ER for a week or two,” said a New York area doctor. “Now it’s safe but that perception remains.”