Why the emergency departments look empty amid a viral outbreak

TORONTO — The sound of Nicole Odermatt's son gasping for air woke her just after midnight.

The Cambridge, Ont., mom immediately recognized an attack of croup, which the six-year-old had faced several times before. But even as his lips turned blue, she admits to hesitating before she ultimately called an ambulance.

"I didn't want to be one of those people filling up the beds at the ER unnecessarily," Odermatt said days later, with Max no longer feverish and on the mend.

"I don't know what the situation's like in the emergency room. I don't want to take him there and expose him to something unnecessarily and I don't want to be taking up a bed that somebody else may need more."

She initially thought, "Can this wait until morning?" But her son was in distress.

"No, he couldn't have waited."

Odermatt's medical scare has a happy ending, but an era of public health directives to social-distance and conserve precious health-care resources for COVID-19 has many people grappling with when it's OK to go to the ER.

Contrary to what one might think, several emergency room doctors report relatively quiet ERs these days — likely due to the fact people have curtailed routine visits that can be addressed by virtual or in-person consults with their family doctor, and the fact widespread isolation has cut opportunities for sports injuries, traffic accidents and other common ER traumas.

Of course many emergencies — heart attacks, anaphylaxis, burns — can occur regardless of whether a person is housebound or not.

While some hospitals are under increased strain from COVID-19 patients, emergency physicians said people should not hesitate going to hospital if they are in medical distress.

Dr. Carolyn Snider, chief of emergency medicine at St. Michael's Hospital, described careful isolation measures that separate COVID-19 patients from others, and pointed to many weeks of planning to ensure adequate care is available for whoever — and whatever — may come.

"You never use the 'Q' word in the emerge because we're all pretty superstitious," said Snider, instead describing a "calm before a storm."

"We just know we have to be ready, and that the more time we have to be more ready is what we're thankful for."

Over at another Toronto hospital, emergency physician and health services researcher Dr. Jennifer Hulme said she fears some overly cautious patients will suffer at home and even die from lack of care.

She described one recent patient who required intubation for a severe respiratory ailment that he later admitted began two weeks before he was rushed to hospital. 

"It was incredibly sad to see this guy so, so sick, who didn't feel that he could access services because he was afraid of COVID-19," said Hulme. 

"We could have had more time to figure out what was going on and to potentially treat his underlying condition before it got that bad."

Like Snider, she stressed the work hospitals have undertaken to ensure emergency patients safely get the attention they need, when they need it.

Hulme also pointed to the danger of not maintaining care for particular cases including pregnant women and infants, whose check-ups should not be skipped.

"Anecdotally, even from my own mom's groups, people are avoiding their pediatrician's office or their family doctor's office to get vaccines because they're worried about the offices being a source of infection," said Hulme, a new mom herself.

"If vaccination is postponed, then we're now putting an entire cohort of people at risk of measles. We could be causing another outbreak."

Odermatt said she feels lucky to live five minutes from an ambulance bay, and that a vehicle was ready and waiting to respond. When they arrived at hospital about 10 minutes later, she was surprised to find the ER "eerily quiet."

And that's a good thing, she added, musing on what the alternative could have looked like.

"The whole (next day) I just couldn't stop thinking about: What if the ambulance wasn't there? What if the situation had progressed further and the ambulance was out on other calls? What if I got to the emergency room and it was inundated with people, just full of people in crisis?"

The chance COVID-19 demands could lead to deaths from other causes is real, said Steven Hoffman, a professor of global health, law, and political science at York University, and the scientific director of the Canadian Institutes of Health Research's Institute of Population & Public Health.

He pointed to a systematic review of studies that examined a surge in health-care demands in West Africa during the Ebola outbreak of 2014 to 2016. It found more people died from lack of health-care access for non-Ebola needs than Ebola itself.

"We can put off some elective surgeries and yes, we can defer preventative dental checkups and we can try to encourage the cancellation of general annual appointments without particular needs. But eventually these things all do add up in causing health consequences," said Hoffman.

Dr. Yanick Beaulieu of Montreal's Sacred Heart Hospital also described a drop in ER visits, but suspected that was more due to people heeding isolation directives and avoiding injury rather than an effort to avoid health-care strain or increased reliance on virtual-care.

There's only so much virtual care can address, added the cardiologist and intensive care physician, noting people should still head to the ER for certain problems.

"Any patient that has any important pain — chest pain, shortness of breath — anything that would require going to the ER judged by the patient or their family, they should just come. We'll take care of them," he said. 

The long-term impact of today's measures is a question that will be closely watched.

ER visits also declined in Ontario during SARS, with as much as a 45 per cent drop seen in Toronto's "infected" facilities at the outbreak's peak in April 2003, according to the Canadian Institute for Health Information.

They remained low for months afterwards, with a drop of more than five per cent persisting in the Greater Toronto Area eight months later. It was 10 months before visits returned to 2002 levels.

Beaulieu noted there are certain people who are generally reluctant to visit the ER "even in normal times."

"I'm sure we may hear in a couple of weeks from now that things happen because people didn't want to go to the ER in fear of catching something," he said.

"For now, I think it's working pretty well and they should come if they need to."

This report by The Canadian Press was first published on March 25, 2020.

Cassandra Szklarski, The Canadian Press