In the first week of April, David Cron, a surgery resident at Massachusetts General Hospital tweeted that “nearly everything I’ve operated on this week was gangrenous. Limbs, gallbladders, appendix, bowel.” He called it “collateral damage” from COVID-19.
Gangrene is when body tissue dies due to either a severe infection or loss of blood flow. It takes time for tissues to become gangrenous; if someone sees a doctor when they first experience symptoms, it’s less likely to occur. But because of the pandemic, some patients have been putting off seeing their doctors.
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“Someone who is, for example, bent over with crippling abdominal pain at home would probably typically come into the emergency department right away or within a day,” Cron said. “And we have patients waiting three or four days to come in. When you’re dealing with appendicitis, cholecystitis, hernias, bad infections in your bone or soft tissues, the longer you wait, the worse it gets.”
Doctors who treat stroke and heart attacks, meanwhile, have found that their patients haven’t just waited, but disappeared. Last week, Harlan M. Krumholz, a professor of medicine at Yale University, wrote an article in the New York Times: Where Have All the Heart Attacks Gone? Krumholz works at Yale New Haven Hospital where, despite an increasing number of COVID-19 patients, they have not reached capacity because their other patients have decreased. “In more normal times, we never have so many empty beds,” he wrote.
There’s no good reason why COVID-19, the illness caused by the new coronavirus, would lead to fewer cases of unrelated health conditions. “You would expect a kind of baseline level of emergency healthcare utilization and then the COVID on top of it,” Ashley Meagher said, a trauma and general surgeon at IU Health Methodist Hospital in Indianapolis.
Doctors have come to the unsettling conclusion that people in need are simply not seeking help, or waiting longer to seek help—either because they’re afraid to go to the hospital for fear of catching the virus, or think hospitals are too overwhelmed with COVID-19 to assist with their non-COVID health issues.
“This is false,” Cron said. “We’re still there for them.”
In New York City, FDNY data showed there were 1,990 house calls for heart attacks between March 30 and April 5—four times the number of house calls from the same time period in 2019. There’s no way to know for sure if those people were intentionally steering clear of the hospital, but the increase is reflected in deaths too. Of those calls, 1,429 people could not be revived—an 800 percent increase from last year, as Angioplasty.org, an online community of cardiologists, reported.
The avoidance of healthcare is just one of ways the COVID-19 pandemic will have ripple effects on health that reach much farther than those who get the virus. Clinicians who treat cancer are concerned about the changes in screening, lab tests, and treatment options offered to cancer patients. Those who manage long-term health conditions like asthma, diabetes, and high blood pressure warn that these health issues may get worse as people have less access to health care and their lifestyles get disrupted. All together, it could lead to complications in surgeries, or creating disease burdens that we’ll be dealing with long after the pandemic is over.
“Everybody is afraid of COVID right now, but people should not be afraid of coming to the hospital if they’re sick enough to need to come to the hospital,” Meagher said.
Since mid-March, the emergency department where Meagher works has been eerily quiet. It is typically bustling with people with urgent medical issues like appendicitis, bowel obstructions, injuries from falls, or gallbladder infections.
“It’s alarming because our emergency general surgery service should be very busy,” Meagher said. “I’ve talked with a number of my colleagues across the country and everybody has seen a similar effect.”
Chris Kwolek, the Chair of Surgery for Newton-Wellesley Hospital in Massachusetts and a vascular surgeon, has also seen an increase in the number of patients who have delayed coming in. When people put off getting care for circulation problems in their feet or legs, instead of being able to restore blood flow, Kwolek has had to resort to removing those limbs.
“We’ve had to literally do amputations, as opposed to being able to save an extremity or a leg,” Kwolek said. “Then these patients are also in the hospital for a longer period of time.”
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In the U.K., a patient near Manchester had a sudden weakness in his left arm and leg, symptoms of a stroke, but persuaded his wife not to call for an ambulance because he was terrified of going into the hospital and catching COVID-19. After 24 hours, his wife overruled him, and the paramedics found him with no movement at all his left limbs.
“Since it was 24 hours later, that meant we couldn’t give any specialized clot-busting treatments,” said Deb Lowe, the national clinical director for stroke at NHS England and Improvement and a consultant stroke physician at Wirral University Teaching Hospital. “He missed that window. That’s the problem with stroke, it’s so time-critical.”
Any treatment delay after having a stroke can lead to more complications and symptoms, Lowe said. Like swallowing problems, which puts people at risk for pneumonia, as well as speech problems and cognitive issues. Lowe said she’s seen data from the biggest stroke centers in the U.K. suggest that there’s almost a 45 to 50 percent reduction in stroke patients in recent weeks.
“That’s our big worry, that we’re going to see a big burden post-COVID, of people that have had common, minor strokes or moderate strokes that never presented to health care professionals,” she said.
Cron and Kwolek pointed out the irony of trying to avoid the hospital: By doing so, a person could end up needing to spend more time there, and have a more complicated case for their doctor to manage later on.
“There’s a real risk now that people’s long-term health and mortality is going to be affected more by the fear of COVID than COVID itself,” Lowe said.
Patients normally find their way to Lee Ocuin, a liver, gallbladder, and pancreas surgeon in North Carolina, when they have vague symptoms—like abdominal discomfort—that don’t go away. Eventually, they make an appointment with a primary care doctor, who does testing and refers them to a specialist. Then they end up in Ocuin’s care, who frequently treats cancer, along with other diseases.
This whole process is now disrupted, Ocuin said. “Every step in this chain is affected. It’s a ripple effect.” He expects to see fewer patients as people go to their primary care doctors less frequently.
A medical oncologist in the U.K. who didn’t want his name used so he could speak openly, agreed that the pandemic has altered “every possible facet of cancer care you could imagine.”
These are necessary adjustments while health institutions move resources to deal with COVID-19. While many elective surgeries have been cancelled, people may miss out on regular appointments, routine screenings, and diagnostics that would catch cancer as well.
“The diagnostic pathway is basically in chaos,” he said. “Chaos is a strong word, but people really are struggling to maintain any normal service.”
He said he thinks many cancer diagnoses will likely be delayed, because the tests used to find the cancers have been delayed, unlike emergencies where people can still get seen right away. He works at a center that sees, roughly, 600 new patients a month with cancer.
“That’s a hell of a lot,” he said. “We’re not [even] seeing a fraction of that. And this has been going on for two months. If it takes longer to make the diagnosis, then there’s the risk that the patients are perhaps less treatable, less curable, more chance for the cancer to grow.”
The pandemic also impacts cancer treatment decisions for people who already have a diagnosis, like what types of chemotherapy or radiation therapy they will receive. Some treatments require people to go to infusion centers weekly or biweekly—those might be replaced with pills, or treatments that require fewer in-person visits.
The consequences of the pandemic are also unknown for people with long-term chronic conditions, like asthma, diabetes, and high blood pressure. Jamie Hartmann-Boyce, a senior researcher at the Center for Evidence Based Medicine at the University of Oxford, recently wrote a paper on how people with chronic illnesses suffer during emergencies, by looking at past data on natural disasters.
In 2017, a global review on 113 studies found that after floods and storms, chronic conditions worsened. Another review from 2005 found that the lack of access to routine health care was a leading cause of death after a disaster. In 2014, during the Ebola epidemic in West Africa, “lack of routine care for other conditions is estimated to have contributed to 10,600 additional deaths in Guinea, Liberia, and Sierra Leone,” Hartmann-Boyce wrote.
Not only might people be unable to see their physicians as often, but their diets can change, their levels of physical activity drop, and their stress can increase.
Hartmann-Boyce has been a Type 1 diabetic since she was 10 years old, and said she’d typically be seeing her doctors on a regular basis, but that those appointments will likely decrease during the pandemic.
“Even though my diabetes is fairly well-controlled and I’m very aware of the disruptions that are coming,” she said. If a person lives through a period of time where their condition isn’t well controlled, it could potentially lead to consequences like blood sugar fluctuations, nerve issues, or eye problems, she said. After the 2002-2004 SARS outbreak, a study found that hospitalizations for diabetes went down during the outbreak, but surged afterwards.
“We might not stop seeing these negative [health] outcomes for quite awhile,” Hartmann-Boyce said. “We could be looking at a long tail of impact, I think.”
All the doctors said that right now it’s crucial for patients to prioritize their own health and safety, even if they don’t have COVID-19 or are afraid of getting it. Talk to a doctor early on if you feel symptoms, and before deciding for yourself if something is or isn’t non-essential.
Kwolek stressed that many health care providers are now relying heavily on telehealth services to talk to their patients and do virtual visits. “We have the ability to reach out to people’s homes and meet them where they are,” he said. “We can triage and reinforce that when people really do need urgent care or emergent care, we’re still here, we’re still available.”
He said it is true that they don’t want people coming in if it’s not urgent. “But at the same time, we want to get the message out that as practitioners, as health care providers, as institutions, we’re here to be able to take care of these problems on top of everything else going on with the respiratory emergencies and [coronavirus] illnesses,” Kwolek said.
Still, government officials, hospitals, doctors, and the public will need to recognize that even if a COVID-19 vaccine or treatment emerges in the coming months, there could be an additional health care surge that follows it.
Kwolek said that soon, major institutions will start thinking about this and their recovery plans. “Just like we’re planning for the recovery for the economy, we need to be very thoughtful about the things that we can do to take care of that backlog of patients,” Kwolek said. “Whether it’s a surgical patient for a cancer problem or whether it’s a patient with a blockage in their artery, or someone who’s had more of a chronic GI problem that can now get fixed.”
Of course, this potential surge of patients will be entering a health care system that is overworked and exhausted from the pandemic.
“You’re going to have had a lot of providers who’ve been involved in a very intense time, both in terms of the ICU and our anesthesia and critical care staff and our nursing staff,” Kwolek said. “We want to make sure that we take care of them as well. We’ll need time for mental health. It’s not like just turning on a switch off and on, but we really have to make sure that we have a thoughtful process.”
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