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by Michael Simonson
(cross-posted at Medium)
Fear of Covid has caused some people to forego life saving medical treatment.
“Let’s go to the hospital,” Dalia Ayala told her fiancée, and my friend, Noe Borjas, after he complained to her in mid April of pain on the left side of his body.
A month earlier, while struggling with a liver-related health issue, Borjas reluctantly allowed Ayala to take him to the emergency room near their Northern New Jersey apartment, just across the Hudson River from Manhattan. Since his discharge in mid-March, the coronavirus had rapidly spread across the New York City tri-state area, killing over 9,000 people.
Now, Borjas refused Ayala’s request to go to the hospital. “I’m afraid they are gonna leave me there by myself. You won’t see me,” Ayala remembers him saying. “I’m afraid of this (Covid) stuff going around.”
Four days later, on April 15, Borjas’s condition deteriorated to the point that Ayala had no choice but to call an ambulance to take him to the emergency room*. Due to Covid-related regulations, Ayala had to stay home.
Borjas’ doctors called Ayala early the next morning. “They were waiting for the surgeon to come because he had internal bleeding,” Ayala recounts. “One of his vessels ruptured and that was causing the problem” (the doctors told Ayala that Borjas’ hospitalization was unrelated to Covid).
Ayala called the hospital back a few hours later. She was connected to a nurse named Bethany. “Can you tell him that Dalia loves him?” Ayala asked.
Bethany called Ayala back the same day. “(She) let me know that he was gone,” Ayala says. “When she told me what happened, I asked her, ‘Did you tell him what I ask?’ She said, ‘Yes, thats when he relaxed.’”
Borjas was dead. He was 48.
“If your body is not right,” Ayala advises now, “listen to that and go to the hospital, even if you’re afraid of going.”
The New York Times reported on December 13 that there have been at least 356,000 more deaths in the United States than usual since the start of the coronavirus pandemic.
While the majority of this year’s excess deaths were from Covid-19, more than a quarter were related to other causes, including diabetes, Alzheimer’s disease, high blood pressure and pneumonia, The Times’ noted.
Many of those non-Covid excess deaths, reporter Denise Lu wrote, are most likely indirectly related to the virus and caused by disruptions from the pandemic.
Lu identified three such disruptions, including strains on health care systems and inadequate access to supplies like ventilators.
The third deadly disruption identified by Lu may have cost Noe Boras his life: People avoiding hospitals for fear of exposure to the coronavirus.
The fatal trend emerged soon after the start of the pandemic. In early April, ProPublica reported that at-home death rates had spiked in New York City; parts of Massachusetts, Michigan, and Washington State; and other regions.
While some of those spikes may have been from people infected with Covid-19 who didn’t seek treatment or were instructed to shelter in place, ProPublica observed, “It’s possible that the increase in at-home deaths reflects people dying from other ailments like heart attacks because they couldn’t get to a hospital or refused to go, fearful they’d contract COVID-19.”
That same month, the medical publication STAT provided additional evidence that the at-home death spike was due, in no small part, to a lack of treatment for non-Covid conditions.
Cardiologists across the U.S., STAT reported, had become “worried about a second wave of deaths caused indirectly by Covid-19: patients so afraid to enter hospitals that they are dying at home or waiting so long to seek care that they’re going to suffer massive damage to their hearts or brains. Some call it ‘a virus of fear.’”
STAT referred to an early April survey of nine major hospitals that showed the number of severe heart attacks being treated in U.S. hospitals had dropped by nearly 40% since the coronavirus began spreading widely in March.
“The whole community is discussing this, asking where are all of our patients?” Martha Gulati, the chief of cardiology at the University of Arizona, told STAT. “There’s nothing we’ve done overnight that has cured heart disease.”
Gulati added that patients were coming in so late that they had massively damaged hearts, including heart muscles that have ruptured. “That was something I’d only seen before in textbooks, to study for exam questions,” she said. “Now we’re seeing those cases because people are putting off care.”
Mitchell S.V. Elkind, an attending neurologist at NewYork-Presbyterian, a New York City hospital at the epicenter of the pandemic, revealed to STAT that about half as many patients as normal were in his stroke unit. “People with stroke symptoms really need to know they should come in for treatment” immediately to limit brain damage and the risk of permanent paralysis, he said.
Boykem Bozkurt, the president of the Heart Failure Society of America and professor of medicine at Baylor College of Medicine, echoed Elkind’s concern to STAT. ”If anything, we would expect higher rates,” he said. “We are not seeing the number of patients we should be seeing.”
Many of the “missing” patients from American hospitals “may indeed be dead,” reporter Usha Lee McFarling theorized, pointing to a report by New York City’s EMTs. Between March 30 and April 5, the EMTs fielded 1,429 cardiac arrest house calls in which patients could not be revived, an eight-fold increase from the same period a year earlier.
“While some of the fatalities were likely caused by the novel coronavirus,” McFarling wrote, “others may have been caused by untreated cardiovascular disease or stroke.”
Bozkurt agreed. “I think globally, we are going to see adverse trends in … cardiovascular deaths due to our patients not seeking care because of Covid,” he speculated.
A New York Times report from May offered additional examples of people delaying potentially life saving treatment to avoid contracting Covid.
For “time-sensitive procedures like cardiac catheterizations, cancer surgery and blood tests or CT scans to monitor serious chronic conditions,” reporter Katie Hafner wrote, “doctors now find themselves spending hours on the phone trying to coax terrified patients to come in.”
Hafner cited a review by the insurance company Cigna Corporation of its claim and pre-authorization data for seven acute conditions, including heart attacks, appendicitis and aortic aneurysms. The review found declines ranging from 11 percent for acute coronary syndromes to 35 percent for atrial fibrillation in the rate of hospitalizations over a recent two-month period.
“People are saying: ‘So I’m having a heart attack. I’m going to stay home. I’m not going to die in that hospital,’” Dr. Marlene Millen, a primary care physician at the University of California, San Diego, told Hafner. “I’ve actually heard that a few times.”
Like STAT’s McFarling, Hafner referenced EMT data showing a link between the drop in non-Covid care and the rise in at-home deaths. In Newark, New Jersey, Hafner reported, emergency medical services teams made 239 on-scene death pronouncements in April, a fourfold increase from April 2019.
Fewer than half of those additional deaths could be attributed directly to Covid-19, according to the president and chief executive of Newark’s University Hospital.
In some parts of the country, the increase in at-home deaths continued into the summer.
Between March and August, The Charlotte Observer reported, the number of people found dead in their homes in North Carolina’s Mecklenburg and Orange counties rose 35% and 31%, respectively.
In Orange County, none of the deaths were linked to Covid-19.
“Fear (of contracting COVID-19) absolutely played a major role in (the increase in at-home deaths),” Joey Grover, the county’s medical director for emergency services, told The Observer. “Just because COVID is happening doesn’t mean baseline heart disease has gone away. I think there are fewer people seeking care.”
A sizable portion of Houston and Los Angeles’ summer at-home deaths were also caused by people delaying treatment for non-Covid conditions, according to reports by ProPublica and The Los Angeles Times, respectively (though you have to scroll way down both articles — and literally to the bottom of the LA Times story — to read about it).
“Normally these patients would have called us earlier on, and now they are waiting too long because maybe they don’t want to be transported to a hospital,” Houston Fire Department Senior Capt. Isabel Sky-Eagle told ProPublica. “Now we’re catching them when they’re already in cardiac arrest, and it’s too late.”
In one South Carolina county, the elevated at-home death rate lasted into the fall.
“Call volume to the (Anderson County) county coroner’s office has been ‘through the roof’ (for at-home deaths) since the pandemic began,” according to an October report by local news station WYFF.
“The coroner’s office links the increase in at home deaths,” Devlin added, “to people in need of medical care electing not to visit the hospital due to fears of contracting COVID-19.”
January 2021 Update:
According to C.D.C. data, over 213,000 more Americans died at home in 2020 than in 2019 (see 2020-2021 dataset here and pre-2020 dataset here). Eleven percent of the 213,000+ excess at-home deaths were attributed to Covid-19.The remaining 89% of excess at-home deaths were attributed to non-Covid conditions.
*The paramedics initially told Ayala that Borjas was fine, and left. Ayala called them back a second time, and they still refused to take Borjas to the hospital. They only relented after Ayala continued to pressure them during their second visit. Their reluctance may have been related to orders given to E.M.T.s in nearby Paterson, New Jersey, as reported by The New York Times on April 1: “Don’t go in a home, don’t touch the patient, and don’t take anyone to the hospital, unless absolutely necessary.”
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