APSF Newsletter: Online-Only

The Hidden Victims: A Case Series of Effects of the Pandemic on Patients without COVID-19

July 8, 2020

Rodney A. Gabriel, MD, MAS; Suraj Trivedi, MD; Christopher R. Tainter, MD; Ulrich H. Schmidt, MD, PhD, MBA, FCCM

Hospital Hallway

Disclaimer: We aim to present letters from our readership that may generate further discussion on managing patients with COVID-19. Given the novelty of COVID-19, best-available clinical evidence is limited and supported from anecdotal reports from China, South Korea, Italy and other sites, and from studies of previous epidemics like SARS and MERS. The opinions expressed are those of the authors and not the APSF. These materials are presented for informational and educational purposes only and do not establish a standard of care or constitute medical or legal advice. The APSF does not support or endorse any specific idea, product, equipment, or trademarked technique. We strongly promote consistency with your governing bodies and organizations such as the CDC, WHO, ASA, AANA, and AAAA. Readers are reminded to consult with their institutions and medical/legal advisors regarding any of the views and opinions expressed by the authors.

Dear Editor,

Since the first COVID-19 diagnosis in the United States in mid-January of 2020, there has been a rapid increase in the incidence of the disease and deaths from it.1 The United States now leads the world with the largest number of confirmed cases.2 With a global mortality rate estimated around 4%, stringent social distancing guidelines were nationally adopted in an effort to limit the exponential spread of the virus.2,3 When referring to care of non-COVID-19 patients, Rosenbaum asked, “While the COVID-19 pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for patients with non COVID-19 related diseases?”4 How do we best maintain the highest degree of healthcare for all patients while also adopting the measures needed to protect our healthcare community from viral spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)?

In many hospital systems, COVID-19 specific guidelines were developed that emphasized protection of healthcare workers and patients and minimizing many types of non-essential procedures in an effort to conserve scare resources in the event of a massive COVID-19 patient surge. Have our efforts on mitigating the spread of COVID-19 resulted in suboptimal patient care in some particular instances? In this letter, we discuss a few examples where the clinical course of a case changed due to systemic process changes or fear secondary to the COVID-19 pandemic.

Case 1: Patient mortality due to delayed patient presentation

A 75-year-old man with a history of coronary artery disease with multiple coronary stents in place and rectal cancer treated with chemotherapy and radiation was scheduled for further surgical resection of his tumor. While awaiting surgery, he was found to have severe multi-vessel coronary artery disease. Given the stability of his rectal cancer, he was first scheduled for a coronary artery bypass grafting. Due to the COVID-19 outbreak, the patient made a decision to delay the cardiac surgery. Soon after, he developed chest pain, but did not return to the hospital for nine days, for fear of viral exposure. When he finally presented, he was diagnosed with an acute myocardial infarction, which rapidly progressed to cardiogenic shock. He was emergently intubated and a left ventricular assist device (LVAD) was placed. He was extubated two days later. The following day, the LVAD was removed, however he developed pulseless ventricular tachycardia, and resuscitation attempts were unsuccessful.

Case 2: Foregoing non-invasive ventilation for mechanical ventilation

A 75-year-old woman with a history of hypertension, diabetes mellitus type 2, and osteoarthritis was brought to the Emergency Department with respiratory distress, generalized weakness, and subjective fevers.

Due to concerns for a possible COVID-19 infection and transmission to others, high flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) were avoided, although recent studies now indicate it is safe to use high flow nasal cannula in patients with COVID-19. She was supported with escalating levels of oxygen supplementation. She was found to have a combined respiratory and metabolic acidosis with an oxygen saturation of 94% while on a non-rebreather mask at 15 liters of flow. As she clinically deteriorated over the next four hours, a decision was made to perform rapid sequence intubation foregoing NIPPV or bag mask ventilation to limit aerosolization of viral particles. Her blood pressure and heart rate prior to induction was 129/75 and 92, respectively. Immediately after induction with etomidate (0.2mg/kg) and rocuronium (1mg/kg), she became hypotensive and bradycardic and suffered a cardiac arrest, from which she was unable to be resuscitated.

Case 3: Foregoing standard treatment for fear of spreading SARS-CoV-2

A 33-year-old woman called emergency medical services (EMS) for acute shortness of breath after running out of her asthma inhalers. Upon EMS arrival, they noted an oxygen saturation of 79%, and provided one metered-dose inhaler treatment and supplemental oxygen via a non-rebreather face mask. In the emergency room, the patient was administered intravenous methylprednisolone, metered dosed albuterol, and intramuscular epinephrine. A one-hour nebulized albuterol treatment was ordered, but not administered because of concern for aerosolization of viral particles if the patient was infected with COVID-19. Her COVID-19 result was negative, and she received her nebulized treatment several hours after presentation. She was admitted to the hospital for continued management.

Discussion

We described three unique cases in which medical management was altered secondary to fear of spreading SARS-CoV-2. The first case represents a direct consequence of delaying surgery due to COVID-19. Delay in treatment led to a subsequent myocardial infarction outside the hospital, which unfortunately led to the patient’s death. It is conceivable that receiving the CABG surgery earlier or seeking treatment sooner may have prevented his death. The second case represents an adverse outcome from quickly proceeding to intubation, a variation from standard institutional practices during respiratory distress. For cases of acute respiratory failure, a trial of NIPPV can often delay or possibly even prevent mechanical ventilation and intubation and the negative aspects associated with those interventions.78 During the early days of the pandemic there were significant concerns of aerosolizing viral particles through the use of HFNC or NIPPV and a push towards early intubation and mechanical ventilation in all patients with both confirmed and suspected COVID-19 to protect healthcare staff from potential COVID-19 exposure. However, global practices have vastly changed over the last several months with an effort being made to avoid intubation and mechanical ventilation for as long as possible with the use of NIPPV or HFNC. Our third case presents a delay of care in a patient with acute asthma exacerbation whose nebulized albuterol treatment was delayed. While the outcome was good, this represented a change of standard care for a patient that could have led to a worse complication and possibly lead to an unnecessary hospital admission.

As demonstrated in the three cases presented, patients may be wary about visiting a hospital for fear of contracting SARS-CoV-2, which may potentially lead to poor outcomes caused by delayed treatment of preventable diseases. For example, there has been a decrease in cardiac catheterization rates during the COVID-19 outbreak. This is potentially secondary to patients being fearful of contracting SARS-CoV-2 with resulting symptomatic ischemia.5 The number of patients presenting with strokes to major New York City hospitals has also decreased. It is difficult to conclude exactly why this is the case, but one hypothesis is that patients fear contracting SARS-CoV-2 in a healthcare facility.6

It is important to ensure that systems are in place to deliver timely and appropriate provision of patient care. When instituting measures aimed at protecting our healthcare workers, we should also continue to examine how it may negatively affect the care of all patients. It is a difficult balance to find and is wrought with moral and ethical dilemmas. Our institution developed various measures that may help reduce treatment issues around non-COVID-19 and COVID-19 positive patients. Some examples include: 1) providing screening questionnaires and temperature checks to visitors, patients, and employees; 2) increase in COVID-19 testing, which includes routine testing all patients scheduled for surgery and most employees; 3) increasing testing availability (up to 1,500 tests per day) with the option of rapid testing if required thus allowing a greater capture of asymptomatic carriers; 4) double-testing symptomatic patients that initially tested negative; 5) increasing availability of rapid tests in the emergency department; 6) providing a helmet bases non-invasive ventilation system for patients to reduce potential aerosolization of viral particles. 7) use a protected box for high flow oxygen needs. Implementation of these measures minimized the concerns of healthcare workers about COVID exposure at the workplace, thereby decreasing the number of cases where usual care processes were not followed. Lastly these measures increased the trust of the population as seen by the increase in non-emergent procedures.

Strong leadership at all levels to ensure adequate resource allocation is paramount. We should encourage patients to seek timely and appropriate care, and provide a safe environment for them to do so. Finally, protocols based on the best available evidence must be created and frequently reviewed to ensure we continue to protect our healthcare workers while minimizing patient adverse events.

 

Rodney A. Gabriel, MD, MAS
Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA

Suraj Trivedi, MD
Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA

Christopher R. Tainter, MD
Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
Department of Emergency Medicine, University of California, San Diego, La Jolla, CA, USA

Ulrich H. Schmidt, MD, PhD, MBA, FCCM
Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA


The authors have no conflicts of interest.


References:

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  6. Hospital admissions for strokes appear to have plummeted, a doctor says, a possible sign people are afraid to seek critical help – The Washington Post. https://www.washingtonpost.com/national/health-science/hospital-admissions-for-strokes-appear-to-have-plummeted-a-doctors-says-a-possible-sign-people-are-afraid-to-seek-critical-help/2020/04/08/2048b886-79ac-11ea-b6ff-597f170df8f8_story.html. Accessed April 25, 2020.
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  8. Weingart SD, Seth Trueger N, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: A prospective observational study. In: Annals of Emergency Medicine. Vol 65. Mosby Inc.; 2015:349-355. doi:10.1016/j.annemergmed.2014.09.025.
  9. Isolation Precautions | Guidelines Library | Infection Control | CDC. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. Accessed April 26, 2020.
  10. Why California Sent Ventilators to New York and Other States – The New York Times. https://www.nytimes.com/2020/04/10/us/california-mail-in-ballot-coronavirus.html.