Several months into the global spread of the COVID-19 pandemic, the world has been impacted in predictable and unpredictable ways. 

Our island nation has been significantly impacted. The nature of work and life has been significantly altered. Our activities of daily living have been severely impacted. Not surprisingly, our health care system has been acutely burdened and is at risk of being overwhelmed if we fail to contain community spread of the virus. What is the impact rate of spread of COVID-19?

Unfortunately, the onerous burden imposed on our health care system by COVID-19 has adversely impacted the ability of patients to access routine care. No doubt many of our readers have had the experience of having their medical appointments cancelled and rescheduled. Some patients, in fact, are avoiding the health care system of their own volition, given perceived risks of exposure to the SARS-CoV-2 virus. This week we will try to discuss some of these issues.

While most people who get infected with the SARS-Cov-2 virus have no or mild systems (81 per cent), 14 per cent of patients will need hospital care and five per cent of the infected population will need care in an intensive care unit.

The number of severely ill patients can pose a significant burden for a health care system. The most direct effect of the COVID-19 epidemic on the health care system relates to the number of people who get severely ill and in need of hospital care within a short time frame, hence the need for every society to flatten the curve of infections and limit the number of persons seeking care at any given time. This is critical to avoid stretching the health system capacity and human capital required to care for these sick patients.

The presence of many infected patients in a hospital also raises the risk of spread of infection to other patients who are in the hospital at the same time, or to the hospital staff. Additionally, high numbers of infected persons within a short time frame impose an enormous economic burden on the society and for a small nation like ours, could limit our ability to mobilise adequate resources to care for those sick with COVID-19 and others with acute or chronic non-COVID-19- related conditions.

Preparing for the ‘surge’

One can think of the impact of COVID-19 on the health care system in terms of need for personnel, hospital beds, operational and clinical resources and responsiveness.

One of the first things that can be done is to appreciate the pattern of COVID-19 infection in other countries, and operationally prepare for the increased numbers of patients or “surge” as it has been described by leading epidemiologists. Even if avoidable, the surge is predictable when we look at the disease pattern in other countries that were ahead of Jamaica in the global spread of the pandemic. In most health care systems in the world, it is difficult to significantly increase bed capacity over a short space of time. Given this reality, one of the measures that can be taken in COVID-19-designated receiving hospitals is to decrease the amount of ongoing clinical care to allow limited resources to be diverted to the expected surge in COVID-19 cases.

In COVID-19-designated receiving hospitals, cancelling clinics allows for physicians and nurses to be available increasing inpatient health care manpower to take care of sick COVID-19 patients. In these facilities, cancelling elective surgeries not only helps with manpower issues, but also reduces the use of medical disposables like gloves, masks, etc, that are already in short supply. Avoiding elective surgeries that have a high rate of ICU utilisation (eg: neurosurgery/cardiac surgery) also will increase the ability of COVID-19-designated facilities to take care of critically ill patients with COVID-19 infection. Generally, there is a process of assessment with the aim being to postpone clinical treatment or visits for patients who do not have urgent/emergent problems.

Managing non-COVID-19 patients during the COVID-19 pandemic

Patients have legitimate reasons to be concerned about catching the COVID-19 infection while seeking care in COVID-19-designated receiving hospitals and so, understandably, avoid or delay seeking care.

Unfortunately, this decision can be detrimental and can place a good number of patients at risk for bad outcome. An unfortunate and undesirable effect of the COVID-19 pandemic that has been noted worldwide is the reluctance of the population to seek urgent medical care. Patients with emergent medical conditions that would in normal times prompt a visit to the hospital or A&E are staying at home and likely accruing increased chances of dying and/or of having complications that could have been prevented with early treatment. The data has been particularly striking for heart attacks, strokes and other heart and neurologic diseases. A study soon to be published in the United States has suggested a 38 per cent fall in the presentation to the emergency room of a particular type of heart attack. Generally, patients with this kind of heart attack need to have their heart arteries opened as an emergency, and delays in treatment increase the risk of death or damage to the muscle of the heart. Doctors in Europe and China have also reported that the numbers of emergency cardiac patients being admitted have significantly reduced.

Stroke centres in the United States and Europe have also noted falls in acute stroke patients presenting to emergency rooms. These centres serve to quickly identify what type of stroke is occurring and the best methods to treat them to reduce the amount of brain tissue that dies. If done successfully, patients can leave hospital with normal neurological function or may have smaller strokes with better prognosis than would have occurred in the absence of treatment. Surgeons have also reported that patients presented to the hospital late with appendicitis and cholecystitis increase the difficulty of operations and the risk for complications and prolonged hospital stays.

It is believed that the major reasons for patients not presenting to hospital emergency rooms is one of fear. Patients anecdotally report fear of being exposed to the SARS-CoV-2 virus and becoming infected with COVID-19 disease. It should be noted that many of the patients who are likely to present with heart attacks and strokes are at increased risk of severe COVID-19 disease should they become infected, so their fears are not totally unfounded. However, symptoms that suggest severe acute disease that usually would prompt an emergency room visit in normal times should not be watched at home, as this may lead to death at home or the occurrence of preventable complications. Symptoms of concern would include chest pain, sudden shortness of breath, severe abdominal pain, abnormal bleeding, the inability to talk or to move a limb, etc.

It is important for us to recognise that medical and surgical emergencies can result in loss of life or result in complications that can significantly reduce quality of life or length of life. During this period of the COVID-19 epidemic, our health care facilities are taking measures to reduce the likelihood of infection occurring in the hospital setting. So, if we find ourselves with symptoms that suggest life and limb may be at risk, it is best to seek emergency care.

The COVID-19 pandemic should not be used as an excuse to delay or avoid seeking medical attention for urgent or emergent medical conditions, as such delays may prove to be catastrophic or deadly. Such care can still be safely obtained in non-COVID-19 receiving hospitals without the fear of contracting the COVID-19 infection. Patients are advised to seek immediate attention for urgent medical conditions like heart attacks, strokes, chest pain, and acute shortness of breath, sudden loss of movement in limbs, loss of consciousness, abnormal bleeding and surgical emergencies.

Depending on the clinical issue being addressed, sometimes telemedicine or virtual care may be a useful option to deliver care, and individuals should explore this option with their doctors or health care providers. Telemedicine or virtual care is appropriate and recommended for patients who have clinical problems that do not necessitate being seen in a clinic/hospital environment. Such care may be useful and helps to keep them safe from potential exposure to COVID-19 infections.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital Correspondence to emadu@caribbeanheart.com or call 876-906-2107