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‘Strokes and heart attacks don’t take a vacation.’ So why have emergency department visits sharply declined?

The Shapiro Building at the Boston Medical Center. Across the country and the city of Boston, hospitals are reporting precipitous declines in emergency department visits, even as coronavirus cases climb.
The Shapiro Building at the Boston Medical Center. Across the country and the city of Boston, hospitals are reporting precipitous declines in emergency department visits, even as coronavirus cases climb.Stan Grossfeld/ Globe Staff

The emergency department at Boston Medical Center — the region’s largest and busiest provider of trauma services — typically logs about 400 patient interactions in a single day. Nowadays, since the coronavirus pandemic swept through the city, visits to BMC’s emergency department have dropped nearly in half.

“We still have days where we encounter about 250 [patients], but we have had several days where we were in the low 200s and even some days in the high 100s,” said Dr. Evan Berg, vice chair of clinical operations in emergency medicine at BMC.

Across Boston and the country, hospitals are reporting precipitous declines in emergency department visits, even as coronavirus cases climb. The phenomenon is as perplexing as it is alarming — at least as it concerns medical emergencies like appendicitis, heart attacks, strokes, and even acute psychiatric problems, for which there is no intuitive way to explain the staggering drops. Some doctors worry that patients are ignoring their symptoms and delaying life-saving treatment over fears they may contract the coronavirus in hospitals.

“Strokes and heart attacks don’t take a vacation just because there’s a pandemic,” said Dr. David Brown, chief of emergency medicine at Massachusetts General Hospital. “They’re still happening. They just aren’t happening as much inside the hospital, which is a major concern to me.”

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Governor Charlie Baker acknowledged the trend Thursday, urging residents to go to the hospital or call their doctor in the event of a medical emergency.

“We don’t want people getting sicker or exacerbating an illness or an injury, and it’s important people are cared for when they’re sick, whether that’s for COVID-19 or for something else," he said.

At Mass. General, emergency medicine doctors are seeing about 60 percent of their usual patient volume, Brown said, with the steepest declines among pediatric patients and patients suffering from non-life-threatening conditions and traumatic injuries.

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Those reductions show that Boston-area residents have taken social distancing seriously, he said. Most pediatric emergency visits are for noncritical issues, like sore throats and rashes, and parents may not want to risk exposing their children to COVID-19 patients at the hospital. Adult patients with similarly less acute conditions,such as urinary tract infections or ankle sprains, may be seeking treatment through telemedicine or at urgent care clinics.

Meanwhile, the spate of business closures and work-from-home mandates has resulted in fewer drivers on the road, and fewer car accidents. With more people avoiding public places and large groups, violent injuries have also plummeted.

“Traumatic injuries can be explained by [the fact that] people aren’t out and about, not in cars, not congregating,” said Dr. Brien Barnewolt, chairman and chief of emergency medicine at Tufts Medical Center, where emergency patient volume has decreased 40 to 50 percent. “But there is certainly a baseline of appendicitis, heart disease, bowel obstruction, and stroke, and we really aren’t seeing those cases as much, either.”

Doctors believe fear of contracting the coronavirus is driving the reductions in emergency department visits. In a Gallup survey conducted March 28 to April 2, more than 80 percent of respondents said they would be “very” or “moderately concerned” about visiting a hospital or doctor’s office if they needed urgent medical treatment, for fear of exposure to the virus. But that fear, doctors argue, is misplaced, given all the precautions hospitals have taken to reduce the likelihood of infection among both patients and providers.

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“I literally track every single COVID patient that comes into our department,” said Dr. Richard Wolfe, who oversees eight emergency departments within Beth Israel Deaconess Medical Center’s network and affiliated hospitals. He said he’s not aware of any patients who contracted the disease in a health care setting. Only a handful of BIDMC medical providers have gotten sick on the job, he added, and those infections occurred before hospitals implemented aggressive policies requiring the use of personal protective equipment.

“It’s been weeks and weeks since we’ve had anyone contract the disease at work, so in some ways, the hospitals and health care facilities — because we have gotten smart about this — are some of the safest places right now,” Wolfe said.

Doctors warn there are serious health ramifications to avoiding necessary and timely medical interventions. They say patients are now arriving in emergency departments with non-coronavirus illnesses later in the course of their diseases and with more severe symptoms that are harder to treat. Patients who choose to ride out heart attacks and strokes because they’re afraid of going to the hospital may also be dying at home.

Wolfe, for instance, said BIDMC emergency physicians are seeing more ruptured appendixes and other life-threatening conditions in patients with diabetes and heart problems who would have suffered far less had they gone to the hospital earlier.

Likewise, Dr. Michael VanRooyen, chair of emergency medicine at Brigham and Women’s Hospital, said he treated a woman in her 60s who had experienced sudden weakness in her arm and leg — clear symptoms of a stroke. But she had decided not to immediately seek care. A few days later, she was in his emergency department, but her stroke had progressed, so she couldn’t be treated with a drug that would have reversed her symptoms and restored her function. The damage, he said, had already been done.

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“Literally, today I had a patient who has been diagnosed with a brain tumor who said they would rather not get it treated and stay at home because they were afraid of being at the hospital alone with COVID,” VanRooyen said.

“I’ve never seen anything drop like this, so this is quite unusual,” he added. “People, I think, are really scared.”

At Mass. General and much to Brown’s surprise, even emergency psychiatric visits by patients with chronic mental health conditions, like depression, bipolar disorder, and schizophrenia, have plunged. As the pandemic recedes, Brown expects pent-up demand for emergency psychiatric treatment to jump.

“I suppose that same population of patients is similarly concerned about exposing themselves to COVID, perhaps. But I can’t entirely explain that because the stress of pandemic — one might hypothesize — might bring out more behavioral health and psychiatric exacerbations, not less,” he said.

Among those already infected with the coronavirus, the fear of suffering alone in the hospital — perhaps the most gut-wrenching consequence of the disease — is enough to keep them away, even if it means risking their lives. And it’s why Berg, at BMC, has struggled to convince some COVID-19 patients to seek treatment.

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“I’ve spoken personally with patients who have declined to be transported by ambulance to the hospital because they don’t want to die alone," he said. “They would rather be sick in their home surrounded by family, than to be cut off at the hospital. It is a really, really heartbreaking thing.”


Deanna Pan can be reached at deanna.pan@globe.com. Follow her on Twitter @DDpan.