Please Don’t Avoid the Emergency Room
By: Ariela Zebede
Tags: Health, Covid 19, Coronavirus, Hospital, Emergency

Please Don’t Avoid the Emergency Room

Health care workers across the country have been asking: Where are our regular patients?

Credit: aydinmutlu / Getty Images

Amid the Covid-19 pandemic, heart attacks, strokes, and even appendicitis continue to plague thousands of Americans. For many of these, minutes can mean the difference between life and death. Still, as people continue to practice social distancing and hear stories of overwhelmed emergency rooms, many are hesitant to go to the ER despite warning signs.

Jordan Delgadillo of Peoria, Illinois is one of these patients. In March, he was up all night with severe stomach pain. “It felt like knives in my side,” he says. Delgadillo told himself, “It’s gonna go away, it’s gonna pass.” It didn’t. He laid in bed for days until he couldn’t endure the pain any longer. He sought advice from an online forum, hoping someone would “give [him] an excuse not to” go to the hospital.

“Seeing the news constantly, seeing how bad the hospitals have been getting — in my mind, if you’re in the ER, you’re going to catch the coronavirus,” he explained. “That was my biggest fear.” When a flood of commenters told him to go to the hospital immediately, he broke down and cried because he was “so scared” — not of his illness, but of the hospital.

Dr. Christopher Colwell, chief of Emergency Medicine at Zuckerberg San Francisco General Hospital and a Professor of Emergency Medicine at University of California, San Francisco (UCSF) says, “I’ve had several news agencies interview me saying, ‘Now that we can’t go to the emergency department, what should we do if we have chest pain or strokes or those kinds of things?’ and I say: Wait a second! Who said you can’t go to the emergency department?”

Every physician I spoke with said they believe the biggest factor driving the volume decrease is fear.

Health care workers across the country have been asking: Where are our regular patients? The Centers for Disease Control and Prevention (CDC) reports that emergency department visits during late March and early April were down 42% compared to the same period last year. Kaiser Permanente, a major health care delivery system in California, reported a nearly 50% decrease in the number of heart attack hospitalizations during March and early April compared to earlier this year.

There are many explanations for this decrease in emergency department (ED) visits. Stay-at-home orders mean there are fewer cars on the road, fewer motor accidents, injuries, bar fights. The lockdowns could also be slowing the spread of other contagious diseases that typically infect Americans this time of year. Lastly, under normal circumstances, many people use the ED for non-emergencies. Those people are likely staying home or taking advantage of expanded telemedicine services.

But every physician I spoke with said they believe the biggest factor driving the volume decrease is fear. Informal online health forums are flooded with questions and concerns like “Is the ER a good idea right now?” “I’m terrified of the ER right now.” One person with chest pain wrote, “One Google search told me I should have it looked at, but corona and stuff so I can’t.” These patients are fearful for good reason: Is it worth adding to a public health crisis if their problems aren’t serious?

Protocols vary from hospital to hospital, but Dr. Colwell says that they’ve generally taken extreme precautions to prevent Covid-19 transmission. In his ER, patients are immediately masked upon arrival. They’re diligent about hand washing and cleanliness protocols. “Certainly there is Covid at the hospital, but your risk of catching it by coming to the hospital is extremely low,” he says. “I think you could make an argument, in some cases, that the hospital is as safe as any place you could go.”

Often, catching a disease early is the key to treating it. Many ER doctors have noticed that those who are coming in have waited until their conditions are more serious and thus more difficult to treat.

Dr. Colwell says there are many ways to treat a stroke, for example, within 3–5.5 hours. Sometimes, physicians can even reverse strokes entirely. “But we’re getting people three days later, four days later, and at that point, there’s really nothing we can do.”

“Are these patients going to die from things that are treatable?”

Delgadillo got to the ER just in time. He says his appendix was starting to burst as the doctor took it out. Delgadillo went home a few hours later. He says that if he hadn’t gotten a response online, he would’ve waited and then been stuck in the ER for weeks, or worse, he says, “in the morgue.”

Other patients haven’t been as lucky. With heart attacks, Dr. Colwell says, “Time is myocardium.” Most heart attacks are caused by clots that prevent blood flow to cardiac muscle. The longer the muscle goes without blood, the more muscle fibers die. Now, he says, “we have patients coming in that all of a sudden have almost no cardiac function.” A family member who lost a loved one to a heart attack remarked to Dr. Colwell, “I told him to go in earlier.”

Dr. Sofia Vinna in South Florida understands why patients are hesitant to come to the ER. Ultimately, though, she asks, “Are these patients going to die from things that are treatable?”

Dr. Gail D’Onofrio, chair of the Department of Emergency Medicine at Yale School of Medicine and Chief of Emergency Services at Yale-New Haven Hospital, notes that low-income individuals are probably most impacted by this fear. She says that more “plugged in” populations can access telehealth services or triage call centers. Individuals of low socioeconomic status are also more likely to suffer from baseline conditions that make them susceptible to severe cases of Covid-19. Dr. Vinna points out that patients who suffer from pre-existing conditions may be even more afraid to come to the ER because they know they’re at a higher risk for Covid-19 complications.

It’s too early to see the quantifiable effects of this fear, but we’re starting to see some clues. The New York Fire Department saw a nearly 800% increase in cardiac arrest deaths at home in late March and early April. According to CDC death certificate data, since February, there have been between 21,089 and 44,639 “excess deaths” in the U.S. from illnesses other than Covid-19. These are deaths above the expected range for this time of year. In particular, late March and early April saw spikes in death caused by circulatory diseases (hypertension, heart disease, and so on) and diabetes. Many have attributed these excess death numbers to untested Covid-19 cases, but Dr. Colwell says, “It would be a big mistake to attribute it all to that.” He thinks, more likely, many of these deaths are people who should have gone to the hospital and avoided it.

During the 2014–2016 Ebola Crisis in West Africa, people had similar fears about going to the hospital. Studies estimate that preventable deaths from non-Ebola conditions during the outbreak effectively doubled the Ebola mortality rate. Dr. Colwell wants to make sure we don’t make the same mistake in the U.S.

“The critical message is: If you need medical attention we are here for you, and we can safely provide care for you,” he says. “We need to now get back to addressing the regular medical issues that have been going on all along and if we don’t, we’re going to now create a similar crisis for non-Covid related medical problems.”