SAN DIEGO — A 54-year-old man recently arrived at a Scripps hospital in respiratory distress and died after physicians were unable to break up the massive blood clot in his lungs.
His emergency team quickly learned that the man had been experiencing shortness of breath for several days, but concern that he might pick up a novel coronavirus infection at the hospital kept him from coming in sooner, said Dr. Ghazala Sharieff, chief medical officer of clinical excellence and experience at Scripps Health.
“You wonder, had he come in with initial shortness of breath, could we have intervened and had a better outcome? My thought would be yes,” Sharieff said. “To me, this is probably the best example we can give of what we are trying to avoid.”
Dr. Theodore Chan, chair of the Department of Emergency Medicine at UC San Diego Health, said he also has recently seen an increase in patients who have waited to come in after experiencing symptoms such as chest pain, arm or leg weakness, confusion, fainting, weakness, light-headedness or fever.
“Instead of saying, ‘I just started having the chest pain yesterday,’ sometimes we’re hearing, ‘I’ve been feeling it on and off for the past week or so,’” Chan said.
The consequences: lasting organ damage, or neurological setbacks for those experiencing strokes, or worsening chronic diseases such as diabetes.
It is clear that what medical professionals are observing on a case-by-case basis is part of a larger trend visible in county data, which show that the total number of daily emergency visits for all local hospitals since mid-March, when stay-at-home orders took effect, has dropped 40% on average when compared to rates for the same time frame last year.
Though it is unclear exactly how many are paying the price, a recent spike in death-related emergency calls in San Diego County, despite the overall death rate appearing to hold steady, suggests that the individual reports emerging from the front lines, not just in San Diego but nationwide, are important warning signs that people are delaying needed medical care during the pandemic.
No one in public health seems to disagree. Just last week, Dr. Eric McDonald, the county’s epidemiology director, made a heartfelt plea during a daily COVID-19 briefing for patients not to ignore worrying symptoms. Similar pleas have been made by other public health officials, including Dr. Nick Yphantides, the county’s chief medical officer, and by individual hospitals and health care systems.
County data show that, from March 15 through April 26, hospitals throughout the county handled an average of 1,129 fewer emergency cases per day compared to 2019. It adds up to more than 48,000 fewer emergency visits than were seen across all local hospitals during the same span in 2018 and 2019.
Why aren’t people coming in? Hospital experts note there are at least three different possibilities, all likely contributing simultaneously.
Some who used to use emergency departments for routine care likely are not coming in as much as they used to while others are probably staying away due to public health orders that have asked people to remain home when they can to avoid consuming resources, especially personal protective equipment, needed to care for COVID-19 patients. Many also seem to believe that they’re likely to become infected if they step foot in a hospital that has admitted pandemic patients.
It is unclear how these three possibilities break down. County officials who track data patterns in all San Diego County hospitals in near real time were not available last week to shed light on the situation.
But it’s clear that contagion fear is a big driver.
“I’ve had a couple patients say, ‘I was worried about coming to the emergency department because I was worried about COVID,” Chan said.
A recent visit to Scripps Mercy Hospital Chula Vista illustrated that observation. Though half of the hospital’s 24-bed emergency department was dedicated to non-COVID-19 patients, it was largely empty, while the other half of the department, which is serving those with suspected novel coronavirus infections, was brimming with patients.
Many think that they will be waiting in line with possible COVID-19 patients if they come to the emergency department for care, said Dr. Juan Tovar, an emergency medicine specialist and administrator at Scripps Chula Vista.
“That’s based on an assumption that’s just not true,” Tovar said. “We separate our patients immediately, before we even let them in the emergency entrance. Patients who are at a low risk of COVID-19 get placed in an entirely separate area of the hospital. It’s a completely different path.”
Getting to the front door at Scripps Chula Vista is currently impossible without first being stopped by a masked security guard who, along with a triage nurse, asks patients a quick series of questions about all known symptoms of novel coronavirus infection, as well as about recent travel history, before patients are allowed to proceed. Those with severe viral symptoms are quickly directed down a sidewalk that connects to a side door that is never used by patients without symptoms.
Visits to other hospitals throughout the region in recent weeks, including Palomar Medical Center Escondido, Sharp Chula Vista Medical Center, Jacobs Medical Center at UC San Diego, Scripps Memorial Hospital La Jolla and Sharp Memorial Hospital in Kearny Mesa, all revealed the same approach. All have reconfigured their entry procedures to stop anyone from just walking in and providing separate entry paths for those with potential symptoms and those without.
Another key infection-control measure, Chan adds, has to do with masking. These days, all patients are required to be masked, as are all caregivers, before they’re allowed to enter an emergency department. Having everyone masked, combined with attention to hand washing and just avoiding touching surfaces, drops infection risk like a rock.
“I’m not sure if people who are staying home realize it or not, but everybody, the patients and the providers, in emergency departments are wearing masks at all times,” Chan said. “If everybody is wearing a mask, then your risk of contracting anything drops dramatically.”
UC San Diego Health has recently been testing all of its roughly 300 emergency workers for coronavirus infection using both molecular methods that are best for finding active infections and newly released blood tests that can spot the viral antibodies in the blood that linger after an infection clears up.
After testing everyone, only one worker had an active infection, and they were still involved in new-employee orientation when the test came back positive. None, a hospital official said Friday, had a positive test for novel coronavirus antibodies, strongly suggesting that workers who have been literally on the front lines for more than a month now are not getting sick despite being at significantly higher infection risk than the general public.
As Sharieff’s example so starkly illustrates, emergency room reluctance, even during a pandemic, can have fatal consequences. But how often are such scenarios occurring in the community?
All local deaths are reported to the California Department of Public Health, which maintains the state’s Comprehensive Death File, a repository that is updated regularly, providing monthly aggregated totals at the county level. The file shows 6,198 deaths in San Diego County from Jan. 1 to March 31, just 32 more than were counted during the same span in 2019. Going back to 2015, the total has hovered a few hundred deaths above or below the 6,000 mark for the first three months of the year.
But the pandemic, while it was definitely generating cases and deaths in March, really picked up steam in April, and state death data is not yet available for that month. Breakdowns by age and cause of death for January through March also were not immediately available.
A more current, though less comprehensive, view can be obtained by looking at calls reporting deaths to City of San Diego 911 dispatchers. An analysis of such calls shows that, between January and April, dispatchers handled 137 more death reports than they did in the same four months in 2019. From January through April of 2020, there were 852 such calls compared to 715 in 2019 — a 19% increase. Between 2016 and 2019, death calls generally saw year-over-year increases of less than a percent, if there was an increase at all.
Is this spike caused by emergency department avoidance? That’s a question that will not be answered without further study.
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