
Eerie emptiness of ERs worries doctors: where are the heart attacks and strokes? - harambaebae69
https://www.npr.org/sections/health-shots/2020/05/06/850454989/eerie-emptiness-of-ers-worries-doctors-where-are-the-heart-attacks-and-strokes
======
guscost
Dying at home, many of them. Excess mortality is way up, and it’s not all
COVID-19:

[https://www.washingtonpost.com/health/patients-with-heart-
at...](https://www.washingtonpost.com/health/patients-with-heart-attacks-
strokes-and-even-appendicitis-vanish-from-
hospitals/2020/04/19/9ca3ef24-7eb4-11ea-9040-68981f488eed_story.html)

> The possibility that patients may be suffering — and even dying — at home
> rather than going to a hospital led the American College of Cardiology to
> launch a “Cardiosmart” campaign last week, attempting to reassure a wary
> population and encourage those with symptoms to call 911 for urgent care and
> to continue routine appointments, through telemedicine when practical:
> “Hospitals have safety measures to protect you from infection,” it reads.

> “The emphasis here is safety,” said Harlan Krumholz, a cardiologist and
> health care researcher at Yale University and Yale New Haven Hospital, who
> advised on the campaign. “We want to make sure preventable deaths aren’t
> happening.”

> There is no pill, no action, no behavior, he said, that could account for
> the almost 40 percent drop in STEMI patients. “We don’t have a means to cut
> your risk in half,” he said. “Not even primary angioplasty or stopping
> smoking.”

~~~
seibelj
Could relaxing still home and cooking your own meals reduce activity-causing
heart attacks? It’s a trope in the North-East that middle aged men die
shoveling snow.

~~~
munk-a
Possibly in the short term - in the long term the quarantine is likely going
to increase heart disease due to people having more sedentary life styles...
It's quite likely this is just a result of the math of going to a hospital
shifting - a lot of folks decide not to go to the hospital with minor chest
pain due to other obligations[1] and the addition of the outbreak likely adds
to the reasons not to go to the hospital.

1\. Don't do this, go to the hospital if you feel something different in your
chest.

~~~
benburleson
This is anecdotal, but I've never seen more people out walking around town
than the last couple months.

Is there research showing people are more sedentary now?

~~~
indecisive_user
Crime is down, while domestic violence is up. That's evidence people are
staying inside more.

[https://www.bbc.com/news/world-us-
canada-52416330](https://www.bbc.com/news/world-us-canada-52416330)

As a counter anecdote, I know many people that only leave their house a few
times per week, including for walks. They are definitely more sedentary now.

~~~
guscost
And you'd think deaths from auto accidents would be way down, but apparently
not in Boston: [https://boston.cbslocal.com/2020/05/04/coronavirus-
covid-19-...](https://boston.cbslocal.com/2020/05/04/coronavirus-
covid-19-massachusetts-fatal-crashes-rate-doubled-april-massdot/)

~~~
wafn
Anecdotally, around my town the lower number of drivers on the road seems to
be causing those who remain to feel like traffic laws don't matter. I can't
even count how many times I have seen blatant "it's red but there's no traffic
so I'll just go" behaviors, along with ridiculous speeding and lane changing.
Doesn't help that the police essentially announced that they won't be looking
for crime anymore.

------
aluminussoma
There is also another opinion: that many people go to the ER who don't really
need to go there.

I had to visit the ER recently. I did not want to go but my doctor insisted. A
family member who is also a doctor also insisted I go.

The ER was eerily empty. The ER doctor saw me immediately. There were only a
couple of other patients that I could see. This contrasts to prior experiences
in the ER where there is a long wait as I get triaged, with lots of people
waiting to be seen.

Fortunately my situation was nothing serious. When I returned home and told my
relative, he said his hospital's emergency department was also very light. In
his opinion, there were a lot of people going to the ER who didn't need to go
in the first place.

Edit: I am referring to non-trauma related admissions to the ER. E.g. I have a
headache and I am going to the ER to be seen now.

~~~
brianwawok
A lot of people don’t have insurance. You can’t go to a doctor for a $150
appointment without insurance. But you can go to the ER when it gets really
bad for a $2000 appointment (which you don’t pay. May go to court against you
but if you are poor, they won’t collect)

~~~
partiallypro
That's what walk-in clinics (Urgent Care) are for. You can visit those often
without insurance.

~~~
brianwawok
What?

At every one I have been to (not a lot I admit, maybe 4 in my life), I had to
both provide insurance card AND pay my copay before a doctor would see me.
Without payment, they send you to go to the ER.

~~~
partiallypro
How do you know they would send you to the ER? Did you not have insurance? Did
they actually send you to the ER for not having it? Honestly, sounds like you
simply had insurance, filled out a form and just assumed it was required. I've
been to multiple walk-ins, and you can visit without insurance. They will ask
for insurance up front, but you can simply say you don't have any. Then you
will offer payment options. The average Urgent Care visit is under $200. The
point of Urgent Care is literally to handle things that don't need ER visits,
and at a much lower rate. I don't know why I've been down voted above, you can
simply Google/Bing/Duck "no insurance Urgent Care" and find tons. The CVS
MinuteClinic, which is everywhere, doesn't require insurance for instance.

[https://www.cvs.com/minuteclinic/insurance-and-
billing](https://www.cvs.com/minuteclinic/insurance-and-billing)

~~~
true_religion
The OP said without payment they will send you to the ER, which is true. If
you can pay, as you said, then they will see you.

------
jungletime
Doctors in California went on strike and mortality dropped.

One reason for the drop may be due to elective surgeries not being performed.
And since more people at staying at home in a safe environment, due to COVID
there will be fewer accidents. And far fewer medical mistakes too, not COVID
related.

"The third-leading cause of death in US most doctors don’t want you to know
about"

[https://www.cnbc.com/2018/02/22/medical-errors-third-
leading...](https://www.cnbc.com/2018/02/22/medical-errors-third-leading-
cause-of-death-in-america.html)

"Why Do Patients Stop Dying When Doctors Go on Strike?"

[https://www.psychologytoday.com/ca/blog/slightly-
blighty/201...](https://www.psychologytoday.com/ca/blog/slightly-
blighty/201510/why-do-patients-stop-dying-when-doctors-go-strike)

My personal take on this based on statistics and observation is that many
medical procedures are not very effective.

Or trade short term risk, for long term benefit. Eg. Those that survive a
bypass surgery may live longer. But it will shorten the life of those that it
kills. Chemo therapy can kill you immediately, but if you survive the
procedure, it may have also killed the cancer that then will increase your
life expectancy.

I also think many medical procedures are not really changing the course of the
disease. And being in a hospital is inherently risky. You are exposing
yourself to other very sick people, and possible human errors in treatment.

ITs easy to fool yourself into thinking that what you are doing is having an
effect. Consider the thousands of football fans in stadiums thinking they are
changing the course of the game with cheering or booing.

~~~
furyofantares
Most interventions are for something that's not going to kill you right away,
so I would guess that seeking intervention for a medical problem I'm having
would increase my odds of dying right now (due to a mistake, or exposure to
other wick people) while increasing my long term odds. I would not expect an
increase in mortality when non-emergency doctors go on strike.

And I hope to someday live in a world where medical error is the #1 cause of
death. I hope we also focus on quality of life and not just quantity -- but if
medicine seeks to continue extending life then the success case is that error
is essentially the only cause of death. Those articles, and especially their
headlines, are sensational and misleading.

~~~
jungletime
There is also another possibility. If you kill of the weak, the remaining
strong will show better health outcomes. And if you are a drug company, you
can tout that as proof of the success of the treatment.

And I suspect that is exactly what is happening with some of these medical
treatments. They take out the weakest patients (with for example chemo
therapy) and the remaining stronger ones will do better. But really its a
statistical effect.

Same way you can improve test scores in a class, by getting rid of students
with low IQ and work ethic. All of sudden, the average test taking ability
will go up.

~~~
tdeck
Survivor effects like you're describing are controlled for in clinical trials
for chemo and other drugs by comparing outcomes for the entire control and
treatment groups.

------
subsubzero
This is really frustrating, as we were told over and over again from the media
of this huge surge of cases that would overload hospitals. Stay away from the
hospital we were told over and over, the "worried well" are overloading our
medical system and its professionals. Well guess what, people did just that,
they avoided the hospitals to allow for a surge. That's why these hospitals
are ghost towns now. I had a tele-visit with my physician and he said both
covid cases and visits themselves in his location have dropped off a cliff in
recent weeks(sfbay area location). The tents they erected in the hospital
parking lot to treat the legions of sick are being taken down at another
hospital in San Jose. A friend who worked in radiology is now on partial
furlough due to such low patient counts(Stanford, Palo Alto) so I guess this
avalanche of cases never materialized at least not in the bay area(NY is a
different story).

------
umvi
Are _just_ the ERs empty? Or the whole hospital as well? If hospitals are
empty, it's time to stop sheltering in place, because it means it's working
_too well_. What's the endgame? We can't just keep the country shut down
indefinitely. Life must move on. Even though there's still a lot of fear, I
think reopening the country is the best option (while still maintaining social
distancing, etc).

~~~
pmiller2
No, it doesn't mean "stop sheltering in place," unless cases of COVID-19 have
peaked. In order to tell whether they've peaked, you need testing in place, as
well. Even if they have peaked, it could mean "relax some of the restrictions,
but not fully end SIP, while monitoring cases." Opening things back up
prematurely, without sufficient testing, is just going to get people killed.

~~~
manigandham
Why do cases matter? It should be the death rate that peaks, and that's
measurable without testing. In fact it seems to be over-attributed since many
deaths are now being classified to Covid even if there are many other factors.

~~~
pmiller2
Death rate is the proxy for cases. What matters when attempting to contain the
disease is prevalence of the disease.

~~~
jfnixon
I think this is backwards. We have been using infection rates as a proxy for
death rates, since deaths are a lagging indicator. It is certain we are
missing a huge percentage of cases, and expanding testing will uncover those.
It is completely unclear that uncovering more mild and asymptomatic cases will
result in more deaths, so new cases are a bad proxy for future deaths.

~~~
pmiller2
Maybe in an ideal world, but we're not actually _measuring_ infection rates.
Dead is pretty objective, and easy to measure, and, we know that the number of
deaths will roughly track the number of infections. That's why things like
deaths and hospitalizations are what the state of California is watching
closely.

------
trhway
[IANAD] Diabetes, hypertension and cardiovascular issues are among the
frequent issues in serious covid cases. If covid is that widespread as some
studies suggests, may it be that covid triggers the hospitalization earlier
than the heart attack/stroke/etc. would have happened to that person
otherwise. US heart attack rate is 2K/day, ie. on a scale of covid deaths and
significantly less than covid hospitalizations.

Some other factors to consider - much cleaner air these days, no
traffic/noise/rush and associated stress, and you can even hear birds singing
through the day. Personally i find it very relaxing to not spend the days in
our tightly packed badly air-conditioned to the point of serious sweating (our
BigCo. is very big about its "green" energy saving chops) horrendously lit
(those lights burn the eyes and make bright spot reflections on monitor, and
the half-transparent blinds kill when afternoon Sun gets into those windows)
"collaboration and communication stimulating" (read - very stressful) very
modern open floor office.

~~~
koffiezet
I would assume indeed that your first point is the most important-one: people
already in bad health, susceptible to heart attacks and strokes also have a
much higher chance of getting seriously affected by covid with fatal
consequences in the first place.

This is also something you see in statistics, that after any large flu
epidemic, the general population mortality figure drops to something
significantly below average, especially for people in the 65+ age group.

You can see this very well on EuroMOMO [1] - check out the numbers for the
Netherlands in 2018 from week 10 throughout 13. This is a flu epidemic there,
and the aftermath.

[1] [https://www.euromomo.eu/graphs-and-maps/](https://www.euromomo.eu/graphs-
and-maps/)

------
Animats
Yes, Stanford Hospitals actually sent about 20% of their staff home.[1]

Stanford was prepared for a huge influx of coronavirus patients, but they only
have 20-30 in the hospital. This despite a steadily climbing death toll. My
own GP says, if you get it, go to Stanford; they have the investigational
drugs, and they're not overloaded.

Nationally, the US death toll continues to climb. Currently somewhere between
69,000 and 74,000, depending on the source. The SF Bay Area's shelter-in-place
thing seems to have helped. We need to get more people wearing masks, though.
Seeing too many people without masks. More of the good masks, too. You really
need N95 or ASTM Level 3 masks to protect yourself; the cheapies only protect
other people. That only works if almost everybody wears the things.

What's happening outside the US? The Financial Times tracker, which has been
updated every day for months, shows the US death rate flat. Most other
countries have peaked and decreased substantially.[2]

[1]
[https://www.mercurynews.com/2020/04/27/coronavirus-14000-sta...](https://www.mercurynews.com/2020/04/27/coronavirus-14000-stanford-
health-care-workers-hit-with-furloughs-pay-cuts/)

[2] [https://ig.ft.com/coronavirus-
chart/?areas=usa&areas=gbr&cum...](https://ig.ft.com/coronavirus-
chart/?areas=usa&areas=gbr&cumulative=0&logScale=0&perMillion=1&values=deaths)

------
drtillberg
Don't discount the impact of reduction of air pollution on all causes of
mortality. It's not often discussed, but every so often someone makes the
connection between small particulates and heart attacks, etc.

~~~
_bxg1
Pretty sure any impact from that would be a very long-term thing. A lifetime
without particulates might have an effect; a month seems pretty far-fetched.

~~~
pmorici
Why do you think that the effect is only long term exposure?

~~~
_bxg1
Seems like a pretty subtle and non-acute thing. Maybe even analogous to
smoking: something that gradually erodes your health, not something that
suddenly kills you.

~~~
loopz
[https://www.cancer.org/cancer/cancer-causes/tobacco-and-
canc...](https://www.cancer.org/cancer/cancer-causes/tobacco-and-
cancer/health-risks-of-smoking-tobacco.html)

Risks are generally thought to be immediate, but very low.

------
dade_
Cars kill us: Far fewer car crashes, more sleep as no need to commute so early
in the morning, no horrible drive into the office screaming and honking at the
idiot driver, no horrible drive home while texting. Alcohol kills us: no drunk
fights at bars, drunk driving, falling in front of moving vehicles. Not saying
it explains it, but a lot of people get hurt and die for stupid reasons.

~~~
chapium
I don't know if you are in on this, but...

[https://www.theladders.com/career-advice/38-of-new-
yorkers-a...](https://www.theladders.com/career-advice/38-of-new-yorkers-are-
drinking-while-working-remotely)

~~~
drdeadringer
Then they're "just" pickling their liver at home instead of also getting into
fights at bars, driving drunk, and falling down in front of moving vehicles on
top of that.

------
sacks2k
People are staying home and dying. This is one of the major trade offs no
government official is talking about regarding re-opening the economy.

~~~
newacct583
How is that related to the lockdown? Hospitals are open. People are staying
home because they're scared of getting sick, that's not something that can be
fixed by public policy.

~~~
sacks2k
"fixed by public policy"

Public policy right now is to stay home or die of Covid 19. Many people are
scared to even go outside or go to a hospital if they don't have the virus.

Starting to open businesses again and requiring social distancing would
definitely help with the fear and more people would actually go to the
hospital for non-covid health issues.

~~~
newacct583
I don't follow that. Can you walk me through how making people go to work is
going to make them _less_ afraid? You make people less afraid by reducing the
risk they'll get sick, not increasing it. Releasing lockdowns before the
pandemic is controlled increases risk, by definition.

This is the big flaw with the "open up" notion: it fundamentally won't work
anyway. How is "opening up" the economy going to help Jet Blue when no one is
willing to fly? Who is expected to fill those movie theaters and sports
arenas? Who's going to sit in a crowded restaurant?

At best, opening up will get us a half-alive economy. And at the price of a
_much_ longer time until a true recovery starts.

Stay home. We can beat this. The regions that started lockdowns early (c.f.
Europe, New York, the west coast) are well on their way to containment. It's
the "open up" regions and the ones with partial lockdowns[1] that are the
stragglers.

[1] I make this point every time it comes up: but _for goodness sake something
needs to happen in Nebraska_. It's right on the cusp of exploding into a
worst-than-NY disaster and no one is talking about it.

~~~
roca
What does "well on the way to containment" mean?

The new cases/deaths stats in California, for example, are not showing any
long-term decreasing trend: [https://www.latimes.com/projects/california-
coronavirus-case...](https://www.latimes.com/projects/california-coronavirus-
cases-tracking-outbreak/)

~~~
newacct583
California is split. The Bay Area is past peak, socal is still growing.
Washington and Oregon are well past peak, around half of their peak new
infection rate. New York is crossing under 1/3 now. Likewise New England and a
few other smaller states are clearly over the hump.

This stuff works. All these places could have easily blown right through
health care capacity like Milan, but they didn't. The really frustrating thing
is watching it work, then watching everyone figure things aren't so bad and
demand that we "open up", when the only reason things aren't so bad is because
we didn't.

Another month for these early states. Just be patient. As for everyone else,
it's going to be much longer than if they had just followed the lead of the
lockdown set.

~~~
roca
That doesn't really answer what containment means or what the long-term
strategy is.

If you relax lockdowns while you still have a significant number of active
cases then expect outbreaks to reoccur. So is the plan to stay locked down
until active cases in the applicable area are essentially zero, i.e.
eradication? If so, how long will that take? If not, what is the plan?

I know there's no easy solution here but even my well-informed California
friends don't seem to know what the plan is.

~~~
newacct583
This stuff has been written about ad nauseum. Every think tank has some
variant they've published. Here's Ezra Klein's review of a bunch of them (he's
pretty bearish on whether they'll work):
[https://www.vox.com/2020/4/10/21215494/coronavirus-plans-
soc...](https://www.vox.com/2020/4/10/21215494/coronavirus-plans-social-
distancing-economy-recession-depression-unemployment)

The basic idea is that you stay locked down until the outbreak size is small
enough that you can test every contact of every positive case to catch them
before they spread.

This takes _a lot_ of testing. And unfortunately the one body in the USA with
the financial resources to foot that bill is conspicuously silent on a plan
for rolling out expanded testing. But this is how it has to work. The
alternative is, as everyone here loves to scream, more expensive.

But there's no magic wand where people just decide to start working again.
That won't happen, either becuase they're scared or because the outbreaks run
out of control again (which is to say: people won't exit lockdown voluntarily
without containment ever, either they're scared now or they'll be scared of
the results they see).

So call your representatives and get testing funded and scaled. Really there
is no other option.

~~~
roca
Yes, lots of experts have plans. But it's not clear what the California
_state_ strategy is, nor most of those other countries you mentioned earlier,
and they're the ones who make the rules.

I agree with everything else you say. Except calling my representative won't
help because I'm not American and I already know what the NZ strategy is...

------
34679
"Air pollution, of which whose small particulate matter are the most toxic,
contributes to about one-third of the global burden of stroke."

[https://www.sciencedirect.com/science/article/pii/S003537871...](https://www.sciencedirect.com/science/article/pii/S0035378718309767)

"In 2004, the American Heart Association issued a scientific statement
concluding that exposure to air pollution contributes to cardiovascular
illness and mortality. A 2010 update elaborated on those risks.

Short-term exposure can increase the risk of heart attack, stroke, arrhythmias
and heart failure in susceptible people, such as the elderly or those with
pre-existing medical conditions, according to the statement."

[https://www.heart.org/en/health-topics/consumer-
healthcare/w...](https://www.heart.org/en/health-topics/consumer-
healthcare/what-is-cardiovascular-disease/air-pollution-and-heart-disease-
stroke)

------
xenonite
Of course, people hesitate to go to the doctor. But I see a second factor:
Maybe it’s because of a slowing down in many regards. Hence, less stress, and
less heart attacks?

~~~
sdan
Fairly sure the country as a whole is more stressed. Economy and media at
least portray that.

~~~
social_quotient
But fewer externalities like bars, parties, stupid accidents with friends,
rushing to meetings, traffic, physical work env stress, in some cases work
altogether. Not to minimize the mental torment some people feel but I think o
there is a huge reduction in certain kinds of stress.

~~~
sdan
Here's some context: both you, me and a majority of HN readers have decent
lives and cushy tech jobs (I'm a student and have the luxury of coding all
day).

Think of everyone else: those relatively regular/average people in America,
the average Joe. They have bills to pay for, but living paycheck to paycheck,
they can't pay any of it. So now they're seeing whats the best way to get
income. Unemployment check? Website is down. Where to get food? Food banks are
barely sustaining.

Yes, there's definitely a reduction of stress in some areas, but I believe
that thinking of everyone, I mean everyone not just in tech, makes you realize
that as a whole, a lot of people are stressed out of their minds when this can
end.

~~~
dividedbyzero
My mental stress level is wayyy up – but I think I still feel less stressed
overall, because I get more and better exercise, I cook a lot more and that
means cheaper but somewhat healthier food on a schedule that better suits me
in portion sizes that I choose myself (as opposed to the guy at the cafeteria
counter), I have a lot less work-related stress due to remote work (everything
feels somewhat more distant), no stressful commute, more flexibility with
bedtimes (which suits me as a total owl) ... there might be lots other things,
lots other external stressors, hard to tell. It's at the same time nerve-
shredding and very relaxing. I wouldn't be totally surprised if a lot of
people were living lives so unhealthy and harmful that the current situation
would end up being a net improvement in that one way, terrible as it is in
lots of others.

~~~
JackFr
You sound a lot like a person who’s never been evicted.

~~~
dividedbyzero
That's true, I live in Europe, eviction is something that the social safety
net in our country protects people against very well. That may mean the
overall stress levels over here are lower, can't say. ER doctors are making
the same observation here though – heart attacks have plummetted. I guess
personally I'm better off than many, since my job can be done from home; what
I currently do is very much a nice-to-have for the people who pay me though,
other options to pivot to are few, and I wouldn't last long in a bad recession
if I were out of a job, with rent that would quickly become a problem even
with the security net we have here, so that's definitely something that
stresses me. Whether that's enough for the argument I'm making, can't say.

------
scarmig
It'd be interesting if the quarantine from the coronavirus has also
quarantined us from the ravages and stresses of day to day life, leading to
improved cardiovascular outcomes.

I'd be curious about suicide statistics as well--would they be going up or
down right now?

~~~
Trasmatta
Anecdotally, I feel like stress has gone way up for most people, not down. Not
sure it's that's true or not on the larger scale, but it definitely seems true
for me and most of the people I know.

~~~
scarmig
Interesting. For me, it's involved a sharp decrease in stress, though that's
overlapped with quitting my job and having a substantial financial cushion.

~~~
6nf
Millions of people are out of a job and nobody is hiring. You have to
recognise that your situation is much more fortunate than most.

------
diN0bot
if you go to the ER, is it still the case you could up alone in the hospital
without ever seeing a family member? and possibly die alone?

i wonder if a “bad death” is also a deterrent if you thought you were dying.
or if emergencies don’t come with those kinds of calculations. not sure if/why
covid calculation would be any more likely, though.

------
olalonde
This pandemic will surely produce a lot of material for economists and social
scientists who study the law of unintended consequences.

~~~
thinkingemote
And documentaries with titles such as The Power of Nightmares

------
irrational
Maybe working from home is just less stressful. Or, maybe they are finally
getting time to exercise, thus putting of the strokes (I don't know if
exercise will put off a stroke, but maybe). I know I see a magnitude more
people around my neighborhood out walking, jogging, etc. than I ever saw
before.

------
lsaac
Best quote:

> "They still want patients to avoid hospitals yet not hesitate to go if there
> are signs of an emergency"

------
doggydogs94
In other words, all of the Covid emergency is not happening.

------
arkh
> That's really one of the tragedies of COVID-19

More like one of the tragedies of fearmongering.

------
anonAndOn
If CoViD-19 turns out to primarily be a pathogen that most negatively affects
people with CardioVascular Disease then the short answer is, they're probably
already dead. (CVD - CVD, uncanny coincidence?)

