The Unanticipated Consequences of
Pandemic Care

Bruce Jancin

May 14, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

The COVID-19 pandemic is fraught with unexpected twists, among them a dramatic plunge in emergency department patient volumes, according to an expert panel on unanticipated consequences of pandemic care hosted by the presidents of the Society of Critical Care Medicine and the American College of Emergency Medicine.

"At the peak of exposure to COVID-19 illness or infection, ED volumes in my system, which are really not much different from others across the country, were cut in half, if not more. And those changes happened across virtually every form of ED presentation, from the highest acuity to the lowest. We're now beyond our highest level of exposure to COVID-19 clinically symptomatic patients in western Pennsylvania, but that recovery in volume hasn't occurred yet, although there are some embers," explained Donald M. Yealy, MD, professor and chair of the department of emergency medicine at the University of Pittsburgh.

Dr Donald Yealy

He and other panelists also addressed some of the other unanticipated developments in the COVID-19 pandemic, including a recently recognized childhood manifestation called for now COVID-associated pediatric multisystem inflammatory syndrome, an anticipated massive second wave of non-COVID patients expected to present late to EDs and primary care clinics after having avoided needed medical care out of fear of infection, and the pandemic's negative impact upon medical education.

Who's Not Showing Up in the ED

Dr. Yealy said that across the country, the number of patients arriving in EDs with acute ST-elevation MI, stroke, trauma, and other highest-acuity presentations is down substantially. But the volume of patients with more routine, bread-and-butter conditions typically seen in EDs is down even more.

"You might say, if I was designing from the insurance side, this is exactly what I'd hope for. I've heard that some people on the insurance-only side of the business really are experiencing a pretty good deal right now: They're collecting premiums and not having to pay out on the ED or hospital side," he said.

Tweaking the Public Health Message on Seeking Medical Care

"One of the unanticipated casualties of the pandemic are the patients who don't have it. It will take a whole lot of work and coordinated effort to re-engage with those patients," predicted SCCM President Lewis J. Kaplan, MD, professor of surgery at the University of Pennsylvania, Philadelphia.

Dr Lewis Kaplan

Evie G. Marcolini, MD, described what she believes is necessary now: "We need to have a big focus on getting the word out to the public that acute MI, stroke, and other acute injuries are still a time-sensitive problem and they warrant at least a call to their physician or consideration of coming in to the ED.

Dr Evie Marcolini

"I think when we started out, we were telling people, 'Don't come in.' Now we're trying to dial it back a little bit and say, 'Listen, there are things you really do need to come in for. And we will keep you safe,'" said Dr. Marcolini, an emergency medicine and neurocritical care specialist at Dartmouth-Hitchcock Medical Center, Hanover, N.H.

"It is safe," Dr. Yealy agreed. "The safest place in the world to be right now is the ED. Everybody's cordoned off. There's way more PPE [personal protective equipment]. There's a level of precision now that should have existed but never did in our previous influenza seasons. So we have something very unique to offer, and we can put people's minds at rest."

He spoke of a coming "tsunami of untreated illness."

"My concern is there is a significant subset of people who are not only eschewing ED care but staying away from their primary care provider. My fear is that we're not as well aware of this," he said. "Together with our primary care partners, we have to figure out ways to reach the people who are ignoring illnesses and injuries that they're making long-term decisions about without realizing it. We have to find a way to reach those people and say it's okay to reach for care."

SCCM Immediate Past President Heatherlee Bailey, MD, also sees a problematic looming wave.

"I'm quite concerned about the coming second wave of non-COVID patients who've sat home with their worsening renal failure that's gone from 2 to 5 because they've been taking a lot of NSAIDs, or the individual who's had several TIAs that self-resolved, and we've missed an opportunity to prevent some significant disease. At some point they're going to come back, and we need to figure out how to get these individuals hooked up with care, either through the ED or with their primary care provider, to prevent these potential bad outcomes," said Dr. Bailey of the Durham (N.C.) Veterans Affairs Medical Center.

Interim Guidance for Pediatricians on an Alarming New Syndrome

Edward E. Conway Jr., MD, recalled that early in the U.S. pandemic, pediatricians felt a sense of relief that children appeared to be spared from severe COVID-19 disease. But, in just the past few weeks, a new syndrome has emerged. New York City has recorded more than 100 cases of what's provisionally being called COVID-associated pediatric multisystem inflammatory syndrome. Dr. Conway and others are working with the Centers for Disease Control and Prevention to develop a case definition for the syndrome, first reported by pediatricians in Italy and the United Kingdom.

"We're trying to get the word out to general pediatricians as to the common signs and symptoms that should prompt parents to bring their children in for medical care," according to Dr. Conway, chief of pediatric critical care medicine and vice-chair of pediatrics at Jacobi Medical Center in New York.

Ninety percent of affected children have abdominal symptoms early on, including abdominal pain, diarrhea, emesis, or enteritis upon imaging. A nondescript rash, headache, conjunctivitis, and irritability are common, cough much less so – under 25%.

"The thought is that if any one of these is associated with a fever lasting more than 4 days, we suggest these children be brought in and seen by a pediatrician. We don't have a formal guideline – we're working on that – but basically the current recommendation is to screen them initially with a CBC with differential, a chem 10, and liver function tests, but also to look for inflammatory markers that we see in our COVID patients. We've been quite surprised: These patients have C-reactive proteins of about 240 mg/L on average, ferritin is quite high at around 1,200 ng/mL, and d-dimers of 2,300 ng/mL. We've also found very high brain natriuretic peptides and troponins in these patients," according to Dr. Conway.

Analogies have been made between this COVID-19 pediatric syndrome and Kawasaki disease. Dr. Conway is unconvinced.

"This is quite different from Kawasaki in that these children are usually thrombocytopenic and usually present with DIC [disseminated intravascular coagulation], and the d-dimers are extraordinarily high, compared to what we're used to seeing in pediatric patients," he said.

Symptomatic children with laboratory red flags should be hospitalized. Most of the affected New York City children have recovered after 5 or 6 days in the pediatric ICU with empiric treatment using intravenous immunoglobulin (IVIG), corticosteroids, and/or interleukin-6 inhibitors. However, five recent deaths are now under study.

Dr. Yealy commented that this new pediatric syndrome is "really interesting," but to date, it affects only a very small percentage of children, and children overall have been much less affected by the pandemic than are adults.

"The populations being disproportionately impacted are the elderly, the elderly, the elderly, and then other vulnerable populations, particularly congregants and the poor," he said. "At my site, three-quarters of the patients coming in are either patients at assisted-living facilities or work at one of those congregant facilities."

The Pandemic's Impact on Medical Education

In many hospitals, grand rounds are being done virtually via videoconferencing, often with attendant challenges in asking and answering questions. Hospital patient volumes are diminished. Medical students aren't coming in to do clinical rotations. Medical students and residents can't travel to interview for future residencies or jobs.

"It's affecting education across all of the components of medicine. It's hard to say how long this pandemic is going to last. We're all trying to be innovative in using online tools, but I believe it's going to have a long-lasting effect on our education system," Dr. Marcolini predicted.

Remote interface while working from home has become frustrating, especially during peak Internet use hours.

"It's staggering how slow my home system has become in comparison to what's wired at work. Now many times when you try to get into your work system from home, you time out while you're waiting for the next piece of information to come across," Dr. Kaplan commented.

All panel participants reported having no financial conflicts of interest.

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