Thursday, April 30, 2020

The Other Victims of Covid-19

“I just want to run this case by you,” the emergency room doctor at the other hospital told me on the phone. We frequently get these calls from other hospitals. Smaller emergency rooms with fewer resources often don’t know what to do in complex situations. After all, scientific literature in medical subspecialties changes rapidly and for a non-specialist these cases offer difficult conundrums. Moreover, smaller institutions don’t have access to specialists around the clock. Consequently, they turn to other medical centers for help. The physician told me the details of the case. A woman in her sixties with high cholesterol, diabetes, coronary artery disease and lung disease (COPD from years of smoking) developed some weakness on her left side about 1 week prior to arrival. The day before she came in her weakness worsened and she could barely walk and couldn’t lift her left arm. She called 911 to bring her to the hospital.

Her symptoms were consistent with an ischemic stroke – a blood clot lodged itself in a blood vessel cutting off circulation to the right motor cortex in the brain. (In our brains, the right side controls the left body and vice versa.) The emergency medicine physician ordered an MRI of the patient’s brain and intracerebral vessels. The MRI confirmed the diagnosis, showing a stroke with a clot in one of the large arteries known as the middle cerebral artery. Was there anything, the doctor wondered, we could do for this patient?

In the treatment of stroke, we often say “time is brain.” And the scientific literature bears this out. Approximately 1.9 million neurons die every minute the brain is deprived of blood flow. Ergo, strokes require immediate intervention for the best possible outcome. For those who present within four and a half hours of symptom onset, we give them tissue plasminogen activator (tPA). This drug breaks down clots in the body and though it poses a risk for bleeding, multiple trials demonstrate significant efficacy. Beyond four and a half hours, brittle vessels and brain tissue lead to an even higher risk of hemorrhage, outweighing the benefit of the drug. In patients with a clot in a large vessel in the brain (like the patient I was called about) we can use a catheter to pull out the clot from the blood vessel. Remarkably good evidence supports using this procedure up to twenty-four hours after symptom onset. Patients with large clots come in without the ability to walk, see, or speak. Ten to fifteen years ago they would have died in a nursing home. Today, with timely treatment, they can walk out of the hospital 2 days later. But if patients present after 24 hours from symptom-onset we can offer little beyond rehabilitation and secondary stroke prevention.

Though the patient was out of the time window for any acute therapy, I asked the physician to transfer her to our hospital to ensure she didn’t worsen further. After arriving by ambulance, I met the patient in the emergency room. On my exam, she barely lifted her left arm and leg, hopelessly struggling against the necrotic brain tissue. I discussed her condition, what had happened, and how we might help. We would have her do as much rehabilitation as possible to take advantage of neuroplasticity and get her stronger.

“Will I ever be able to live by myself again? Or walk again?” She asked.

Unfortunately, given the size of her stroke, she would likely require help to cook, walk, and drive. At least in the near future, her whole life would be dependent on the help of others. What would come one year down the line was uncertain. I told her not to lose all hope. Rehabilitation after stroke takes months and patients can make significant strides.

“Also,” I asked, forgetting myself, “any reason for waiting to come to the hospital?”

“Yes,” she said. “I was scared about the coronavirus and I wanted to avoid getting sick.”
***
Before Covid-19 hit the United States, I saw many patients who, alas, presented too late for treatment. Occasionally they couldn’t even use their dominant arm, but they waited hours or days to seek help. Some said they thought their deficits would improve, others worried about the hospital bill, or were skeptical of physicians. The data over the past few decades corroborates this experience. In a 1997 study in the Annals of Internal Medicine, physicians examined patients with myocardial infarction, or heart attack, and the delay between the onset of symptoms and hospital presentation. Forty percent delayed their presentation for over six hours. In a 2001 study, one-third of patients with symptoms like abdominal pain, chest pain, and shortness of breath – all potentially serious – delayed seeking care. And over two-thirds of these patients waited because they thought the problem would go away. In a 2019 study, Greek physicians found that of patients presenting to the hospital with acute stroke symptoms nearly one third arrived over four and a half hours after their symptoms started, putting them outside the window for tPA eligibility. In other words, even prior to the pandemic, many patients either chose not to come or physically could not come to the hospital despite life-threatening symptoms.

Covid-19 directly causes physical devastation and in so doing exacerbates the kinds of delays described above. The exact death rate from coronavirus alone is unclear given our lack of widespread testing and our ignorance about how many people actually have it. At one point, the case-fatality rate in China was 2.3%, in Italy at another point 7.2%, while some estimate 1-2% and lower. Whatever it ends up being, it is highly significant and crippling. As of this writing, notwithstanding drastic quarantine measures, the virus has claimed over two hundred thousand lives worldwide, and that number continues to increase. Most of us understand the risk and we seclude ourselves to mitigate the disease’s damage.

However, there are unintended effects of the current mitigation campaigns. There will likely be an increase in morbidity and mortality from other diseases. For instance, other hospitals and our own emergency room call us less frequently. My colleagues are seeing this as well; far fewer stroke patients come to the hospital now. Another colleague recently admitted a patient with a massive heart attack who stayed at home for fear of Covid-19. It’s not that the incidences of stroke or heart attacks are acutely falling – a highly unlikely scenario. Unfortunately, among other possibilities, I suspect patients, afraid of the virus and for their lives, avoid the hospital. They stay home with incapacitating symptoms, as the patient I treated did. Our public health response to the virus, though appropriate, compounds patient hesitancy to seek help.

The most up-to-date data bears out these anecdotes. In a small and imperfect observational study from Hong Kong during late January and early February, patients with bad heart attacks took nearly four times as long to present to the emergency room as others in prior years. Another study in the Journal of the American College of Cardiology collected data indicating a 38% drop in calls for certain types of heart attack emergencies across major hospitals in the country. And it’s not just in vascular disease where these kinds of delays and deficiencies occur. Reportedly, vaccine prescriptions have plummeted during the pandemic, too. Public health experts in England have warned that cancer deaths as an indirect effect from the virus will be higher than those directly caused by the virus. A New England Journal of Medicine article tells multiple stories of patients who were misdiagnosed or experienced a delay in care due to bias in favor of or fears of Covid-19. A full accounting of this kind of delay in or lack of treatment has yet to be done. But these are the other casualties from the Covid-19 pandemic: patients with treatable conditions who do not get treated in time.

How do we communicate urgency to our patients during this bizarre and frightening time? An ideal public health policy advocates staying home but encourages patients to seek treatment if something goes wrong. Unfortunately, in the chaos of a pandemic, myopia reigns and we focus on one disease to the exclusion of others. A deadly disease is deadly and requires treatment regardless of the contagion around us. If we and our leaders cannot modulate our message we may face an even worse, and preventable, tragedy.

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