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Friday, April 24, 2020

BREAKING NEWS: Death Is an Expected COVID-19 Effect; Covidlateral Damage Is Not

​Death Is an Expected COVID-19 Effect; Covidlateral Damage is Not

BY SETH C HAWKINS, MD;
SARAH FRANCES MCCLURE, DO;
& WOOTEN JONES, MD, MPH


People infected with SARS-CoV-2, dying alone from COVID-19. Tens of millions on unemployment, some with no money to buy food. Patients with chronic diseases who can’t obtain medication, others with no access to their physicians.

A patient with a STEMI who died because he delayed care. A stroke patient arriving too late. A man whose forefoot was amputated because he waited so long to seek care, and then said he knew that would be the consequence and waited anyway.

A patient who was extremely sick but afraid to go to the ED. He developed sepsis. One with a ruptured appendicitis. Another who delayed presentation for hemorrhagic stroke. Suicidal patients progressing to attempted suicide rather than seeking hospital-based help.

Patients with obstructive cholelithiasis enduring pain while they waited to see if IV antibiotics would help so they wouldn’t risk exposure from an ERCP or cholecystectomy. Worsening mental illness, domestic violence, and child abuse. Lots and lots of abuse.

Health care professionals’ psyches damaged by what they have seen, what they have endured by the lack of PPE that puts their lives at risk every day. The toll it takes knowing they may have to tell a family they are giving their loved one’s ventilator to someone who has a better chance at survival, the fallout from the distrust of patients’ families in the health care system. Seeing patient after patient die alone, not being able to hold their hands. Watching a family saying goodbye on video chat. The grocery store clerks, bus drivers, delivery people, and countless others who are scared of getting sick but go to work every day. The physicians, nurses, and others who told us these stories.

All of these people, too numerous to count, all of these stories, too many to report, share more than COVID-19 or their fear of contracting it. They all represent covidlateral damage, a term we coin here and one that you will likely hear over and over as the pandemic forges ahead, indifferent to our feelings and needs and fears.

Fear and Consequences
The COVID-19 pandemic and its management have presented many unforeseen consequences for Americans. Like the collateral damage seen in military operations, the covidlateral damage from this virus and our management of it is causing trauma that no one expected. There are obvious consequences to our social distancing practices—isolation of already vulnerable individuals, loss of jobs in markets where working from home is not possible, tension in defining what essential services and essential workers really are. Yet there are myriad unforeseen consequences as well.

More than three million Americans filed for unemployment last week alone. The health insurance for many of them was tied to their employment status. Stay-at-home orders have left Americans with chronic diseases even more vulnerable because it is a challenge for them to obtain their medications. New York City and other metropolises have plans and services in place for delivery of these medications, but others do not have these resources. Some rely on health care teams that have implemented innovative new social services or leveraged existing partnerships such as community paramedicine to deploy employees or even neighbors to help vulnerable populations obtain their daily medications. This is not feasible for many American cities and towns, leading to exacerbations of otherwise well-managed and well-controlled medical problems.

Even in cities like New York, access to primary care physicians has become almost impossible. At many hospitals there, primary care clinics have become telemedicine centers, which may be appropriate for chronic and well-maintained problems, but many people still have poorly managed problems. This solution is also useless for those patients who are not privileged enough to have computers, internet access, phones, or electrical power. Absence of this normal medical infrastructure is itself systemic covidlateral damage, and the downstream effect is millions of individual episodes of covidlateral damage for patients.

Fear and changing definitions of urgency have also limited health care access. Social media campaigns have linked the imperative for health care workers to stay on the job with a social contract equivalent that calls for patients to stay home (“We are working for you, so you stay home for us”), and this can perversely discourage well-meaning patients from presenting to emergency departments for conditions they don’t deem emergencies. Many are frankly afraid of hospitals and emergency departments, which are portrayed (perhaps correctly) as the epicenters of disease prevalence and potential transmission in a community.

Categorizing these covidlateral damages as a unified syndrome allows us to better consider the side effects of our management of the virus and generate overall risk-benefit analyses.

Illness and Death
One emergency physician in Pittsburgh described a patient with a STEMI who was loaded into an air ambulance and died within a minute of takeoff. He had delayed coming to the ED for 14 hours after his pain started out of fear of COVID-19. Another patient in Pittsburgh had a classic embolic stroke who arrived after it was too late for interventional opportunities. She admitted that she didn’t come to the ED earlier because of fear.

One EP described a patient presenting four weeks after the hospital’s first positive COVID-19 case with osteomyelitis of his toe. Because he had previously had his fifth toe on that foot amputated, his entire forefoot had to be amputated to allow for better balance with a prosthetic. The patient was asked why he had waited so long to seek care, and he said he was afraid of catching the virus if he came to the hospital. When he was told his forefoot would have to be amputated, he calmly stated, “I am aware of that. I knew that would be the consequence.” The patient had weighed his options and chose to lose his foot rather than risk his chances with the virus because he was older and had comorbidities. He was not aware of the telemedicine clinics that could have assisted earlier in his disease.

Another emergency physician described two friends she screened because of their fear of going to the ED. She convinced them to seek ED care—one turned out to have multiple pulmonary emboli, and the other was septic. They were clearly quite ill with evident emergencies, but were reluctant to seek appropriate care until reassured by an emergency physician that their symptoms were more significant than their risk from COVID-19.

Other reports included ruptured appendicitis, delayed presentation for hemorrhagic stroke, and suicidal patients progressing to attempted suicide rather than seeking hospital-based help. The Washington Post noted that “some doctors worry that illness and mortality from unaddressed health problems may rival the carnage produced in regions less affected by covid-19.” (April 19, 2020; https://wapo.st/2xK0ANu.) Much of this is anecdotal, but actual data are growing as well.

An analysis of STEMI activations at nine high-volume cardiac catheterization laboratories found a 38 percent drop in STEMI presentations by comparing March 2020 with each month from January 2019 through February 2020. And that decline occurred despite widespread stress in the general population and known inflammatory myocardial damage in those infected with COVID-19 that should have exacerbated, not alleviated, STEMI volume. (J Am Coll Cardiol. 2020 Apr 9. doi: 10.1016/j.jacc.2020.04.011; https://bit.ly/3eNnnbR.) Similar drops in volume are seen in the number of stroke patients presenting to stroke centers. (April 19, 2020; https://wapo.st/2xK0ANu.)

A recent American College of Emergency Physicians poll found that 29 percent of Americans are avoiding or delaying medical care due to fear of COVID-19. Eighty percent also expressed concern about contracting the virus from others if they go to an ED. (https://bit.ly/2SEwT7F.)

Delays and Violence
Fear isn’t the only factor complicating routine medical care and patient actions. Elective surgeries were canceled when the pandemic was first building steam, and many patients had already been waiting for those elective surgeries for months. New onset renal failure patients decompensated while the scarlet letters of a person under investigation for shortness of breath or cough delayed intervention or awaiting dialysis machines. Ventilator shortages were expected; dialysis shortages were not.
Similarly, acute pulmonary edema patients going straight to intubation to avoid prolonged aerosolization through CPAP or BiPAP, with any ensuing intubation complications being covidlateral damage. Patients with obstructive cholelithiasis likewise sit on surgery wards on IV antibiotics, enduring excruciating pain while waiting to see if they would improve rather than risk the potential exposure from an ERCP or laparoscopic cholecystectomy.

Other conditions and situations that were merely smoldering prior to the pandemic are also being exacerbated. Mental illness has worsened, along with increases in domestic violence and child abuse, and all of these represent covidlateral damage. The Marshall Project noted that the Chicago Police Department has seen a 13 percent increase in domestic violence-related calls compared with this time last year. (April 22, 2020; https://bit.ly/2VAG3DY.) Even more chilling, Chicago has seen a decline in domestic violence police reports, meaning more people than usual are calling with domestic violence incidents but fewer than usual are following through with formal police action. And local reporting in King County, WA, showed an eight percent rise there. (April 19, 2020; https://bit.ly/2XZzbBL.)

Experts there and elsewhere say the coronavirus gives abusers more tools for manipulation. The data that COVID-19 spreads more rapidly in jails, for example, is one way abusers make victims feel sorry for them and not report the incident. The more rapid release of alleged batterers who do go to jail makes it harder for victims to make a safety plan before the abuser returns home. Typical escape options where there was more freedom to make calls or plans like workplaces may now be closed.

Worldwide Damage
Covidlateral damage is not confined to the United States. The United Nations made a plea this month for urgent action to combat a “horrifying global surge in domestic violence,” with the Secretary General tweeting, “I urge all governments to put women’s safety first as they respond to the pandemic.” (UN News. April 6, 2020; https://bit.ly/2yBNeCQ.)

Earlier this month, the New York Times outlined covidlateral damage from increased domestic violence in China, France, Spain, Germany, and other countries, following “the same grim path: First, governments impose lockdowns without making sufficient provisions for domestic abuse victims. About 10 days later, distress calls spike, setting off a public outcry. Only then do the governments scramble to improvise solutions.” (April 6, 2020; https://nyti.ms/2xMj5AT.) Close living quarters for days on end can exacerbate other family stressors.

Health care professionals can be victims of covidlateral damage as well. There is a vast dearth of knowledge about the virus, how it spreads, and the true threat to each individual in contact with a person under investigation. It is well known that the majority of U.S. hospitals have not adequately prepared or stockpiled personal protective equipment (PPE), which led to the policies about PPE use being broken and burgeoning distrust of the hospital administration by hospital employees mandated to wear PPE many times longer than is safe.

Though these changes in usage policies may have stemmed from Centers for Disease Control and Prevention recommendations, the distrust lies with the hospital administrators who listened to an ever-changing and erratic message from the federal government.
This skepticism is detrimental to the employees’ psyches and ability to work effectively. More immediately, the high rate of infection among health care workers may be related to PPE access, as we saw in Italy. It is not difficult to imagine that compromised PPE recommendations led to covidlateral damage among medical staff.

Moral Injury
While employees were forced to worry about their own safety and create campaigns to obtain donations of appropriate PPE for themselves, they also faced other morally injurious covidlateral damage. Our Italian counterparts warned us that we would need ventilators because the virus is mainly respiratory and patients typically present in florid acute hypoxemic respiratory failure. They cautioned us about the inevitable moral injury of determining who gets a ventilator when not enough are available.

Unfortunately, a finite number of ventilators are available at each hospital in each state. Fortunately, there is a federal stockpile of ventilators, and critical care physicians campaigned to mobilize that stockpile early, unfortunately, to no avail. Those in charge of allocating those ventilators did not see the urgency. The governors of the states with stockpiles of ventilators were left to assist each other. This type of grassroots mobilization of life-saving equipment takes a toll on those facing these challenges each day. Physicians knew ventilators would have been available had those in charge listened. The covidlateral damage to them is knowing what it meant when the hospital stopped receiving enough ventilators to maintain life in its community, when they had to call a family to say, “I’m sorry. We need your family member’s ventilator for a patient who has a better chance of survival.”

This covidlateral damage will extend far past these first months of response. It will also harm future responses to health care needs, the future mental health of physicians, and their patients’ trust in the health care system.

During this pandemic, physicians and nurses have been facing the death toll alone. It became clear early on that the hospital had an obligation to limit unnecessary exposure of the virus. Unfortunately, this became a blanket no-visitor policy. To many physicians, this initially sounded like a dream come true—no one to make unattainable demands or present their Google research as superior to the physicians’ knowledge.

Reality struck early. These patients were coming to the hospital in extremis. They were afraid and alone. They had been cared for at home by their families for as long as possible until the patients needed more than they could offer. The patients were sent to the hospital alone, often with the hope that a ventilator would offer a chance at survival. In many cases, the patients were sent to the hospital to die—alone. With physicians and staff limiting their own exposure for fear of ending up in extremis like their patients, they often watched patients die from the other side of a door. No one at the bedside. No one to hold their hand or comfort them as they took their last breath.

Death is expected as a direct COVID-19 effect. Families saying goodbye to their loved one on FaceTime may be one of the most poignant tragedies of this pandemic: not only expected COVID-19 injuries to our patients and society, but also these growing stories of unexpected covidlateral damage.

Dr. Hawkins is a full-time clinical emergency physician at Catawba Valley Health System, an assistant professor at Wake Forest University School of Medicine, and the medical director of Starfish Aquatics Institute, Landmark Learning, Burke County EMS, and North Carolina State Parks. He also serves as the course director of the Carolina Wilderness EMS Externship. Follow him on Twitter at @hawkvox. Dr. McClure is a third-year resident in emergency medicine at Lincoln Medical and Mental Health Hospital in the Bronx, NY, and a 2016 graduate of Carolina Wilderness EMS Externship. Dr. Jones is a second-year resident in the combined emergency medicine, internal medicine, and critical care medicine residency program at East Carolina University, Vidant Medical Center, in Greenville, NC, and a 2017 graduate of the Carolina Wilderness EMS externship.

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