Clinical Conversations

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Cardiovascular consults are way down. Is the threat of COVID-19 infection scaring people away from EDs?

We caught up with Dr. Comilla Sasson, the American Heart Association’s VP for science and innovation. She’s an emergency physician who teaches at the University of Colorado. She’d traveled to New York City to “help with the response,” and she talked with us from a field hospital that had been set up on a tennis court in Central Park.

She had lots to say about what’s driving patients away from emergency departments these days and what’s likely to happen in medicine (hello, telemedicine!) once the pandemic abates.

Running time: 15 minutes

Links (courtesy of the American Heart Association):

1. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
2. Oxygenation and Ventilation of COVID-19 Patients
3. New COVID-19 patient data registry will provide insights to care and adverse cardiovascular outcomes
4. COVID-19 Compendium for health care providers
5. Coronavirus (COVID-19) Resources for CPR Training & Resuscitation

Links to other interviews in this series:

1. Dr. Anthony Fauci
2. Dr. Susan Sadoughi
3. Dr. Matthew Young
4. Dr. Julian Flores
5. Dr. Kristi Koenig
6. Dr. Renee Salas
7. Drs. Andre Sofair and William Chavey

Transcript 

Joe Elia:     Welcome to Clinical Conversations. I’m your host, Joe Elia.

There is talk that COVID-19 is apparently scaring myocardial infarctions and other bothersome conditions away from emergency departments. Harlan Krumholz wrote about the phenomenon earlier this month in The New York Times. He pointed to studies suggesting that cardiovascular consultations have dropped by about 50 percent in the days of COVID.

My cohost, Dr. Ali Raja and I have asked Dr. Comilla Sasson to talk about this with us. You know Dr. Raja of the Mass. General and Harvard Medial School already. Dr. Sasson is an emergency physician and associate professor at the University of Colorado School of Medicine. She is also vice president for science and innovation at the American Heart Association.

When we scheduled this interview, she was on her way to New York City to, as she put it, “help with the response.”

Welcome to Clinical Conversations, Dr. Sasson.

Dr. Comilla Sasson:     Thank you for having me.

Joe Elia:     I’d like to ask you what the Heart Association thinks about this phenomenon of evaporating visits for cardiovascular diseases. Have you convened a panel to study it? What are you telling people who inquire about it?

Dr. Comilla Sasson:     You know, I think we’re all a little bit shocked and taken aback by just how quickly and precipitously we’ve seen such a huge drop in our volumes in our emergency department. Specifically, and I think it would be naïve to think that that’s just because we’re not having heart attacks anymore or strokes or other time-sensitive conditions. I think what it really boils down to — and I’ve personally experienced this with my own patients — is that people are afraid.

They are afraid that if they go to the emergency department they will get COVID. Even though we have separate areas for them, different places for them to be taken care of. I think what we’re realizing is that because we’ve done such a good job of getting the word out about make sure you’re appropriately utilizing the emergency department, I think the unintended consequence is maybe we’ve actually scared off some people who actually need to be there.

Dr. Ali Raja:     That’s interesting. Dr. Sasson, let me ask you, I’ve followed your research for years, and it really focuses on resuscitation, especially on educating non-clinicians and bystanders to begin resuscitation. You mentioned that people are scared. Are you concerned at all that that might actually translate to resuscitations and CPR? Do you think that people are going to be reluctant to actually go near and potentially help other in distress?

Dr. Comilla Sasson:     Yes. I think that’s actually something that we’re very, very both fearful of and mindful of, and I think what we’re trying to do, both as an organization as the American Heart Association, is get the word out about just how important it is to still go to the emergency department if you need to, call 911 if you have any kind of signs or symptoms of a heart attack. Then if you do see somebody drop, it’s okay to even do CPR. I think there’s so much fear right now of being even near people, touching people, let alone trying to actually do compressions — maybe even with breaths if it’s a household member. So I think we’re trying to get the word out.

I think we’re trying to also work with our partners in the community because we know there are huge health inequities as well. So can we use our reach as an organization, as the AHA who works in churches and schools and has a really big breadth and depth of work that we do in the community. How do we use our relationships to get that message out? I think we have to work in collaboration with all partners to do that.

Joe Elia:     Are you still in New York, Dr. Sasson? Can you tell us a bit about that experience?

Dr. Comilla Sasson:     It’s amazing. It’s wild. It’s something like I’ve never seen before. So I’m literally sitting right now in one of the field hospitals that have popped up. It was created just less than three weeks ago from scratch from a tennis court, literally.

So I think it’s been fascinating to see how a city responds. How do you coordinate care when you have to build a hospital from scratch; and then how do you bring people in and out of the system in a surge time; and then — even now as we’re plateauing here in New York — when do appropriately transfer folks here so that you can open up more hospital beds? And then how do you think about this in the next wave? So what happens when you hit surge two? What happens when you hit surge three? Is the field hospital the answer that could maybe help with all of those overwhelming videos and stories that we are hearing in New York City when the surge happened? How do you sort of think about this not only for the current COVID crisis but then for all the next waves that we know are going to happen?

Joe Elia:     So how long are you planning to be there to help out, as you put it?

Dr. Comilla Sasson:     For a month.

Dr. Ali Raja:     Wow.

Joe Elia:     So the people listening can’t see what we see. It looks like you’re sitting in kind of a tent-like facility. So do you have patients now in that facility?

Dr. Comilla Sasson:     We do. We’ve been ramping up for the last few days, and we’re continuing to ramp up and increase both our capacity to take care of patients but also to increase our acuity as well. So I think, again, as you’re building a hospital, I mean again from scratch, it’s about thinking about how to ramp up appropriately so that you can also make sure that your lab works, that your x-ray works, that you’ve got oxygen, that you’ve got the things that we take for granted in a real hospital, if you will, that has been there for years. You have to make sure everything works first and then I think that’s when you can start to really increase that acuity.

Dr. Ali Raja:     Dr. Sasson, let me ask you, right now we’re in the response phase. You’re setting up a hospital in a tennis court but we’re also generating a lot of data all over the world and this is happening everywhere at once. It’s not like the Boston Marathon where it happened in one city. This is happening all over the world and there’s a ton of data being generated not just around the world but also in the country. So let me ask you, this is obviously going to prompt a lot of data analysis and research at some point. Is the American Heart Association planning to collect and speak on the lessons learned?  Obviously they are — that’s what they do. But do you have any projects that you can talk about now about what’s going to come out of this from the AHA?

Dr. Comilla Sasson:     So I think our first responses that we had right away to this surge that we started to see in the global pandemic was to really increase our research funding. So we’ve allocated 2.5 million dollars of new research dollars specifically towards COVID research, and that’s generated a huge volume of applications, which just means that there’s a lot of people who have a lot of questions, right. We created a COVID data registry as well so that we can start tracking this and utilizing our expertise as an organization in terms of data collection.

We’ve had Get With The Guidelines for many, many years and so I think now we’ve got the ability to leverage that expertise that we had with Get With The Guidelines, precision medicine platform to build this data registry. So we can look at heart conditions specifically over the course of not just years but actually months and days, which is something different than what we normally do because most data analysis is a year later and then as an organization we are the biggest trainer of ACLS and BLS across the world.

So we just released our new interim CPR guidance for patients who are suspected or known COVID for both BLS and ACLS and PALS as well so that people can understand what are the caveats for resuscitation with those patients. Then we also released, just recently, our oxygenation and ventilation just-in-time training. So when you’ve go your medical student or maybe your ward nurse who’s now reassigned to the ICU, how do I learn how to manage a vent or a vented patient quickly? So really just trying to think about how do we build those educational building blocks that we’re really good at. How do we put those into place now so that people have what they need when the surge comes to their city, which we know it will.

Dr. Ali Raja:     If you don’t mind sending us the links to those, the new ACLS / BLS guidelines and the education that you just talked about we can actually put those in the website. [Done!]

Dr. Comilla Sasson:     And we had a huge, even in less than a week, we had over 38 thousand hits to that oxygenation / ventilation module. I can tell you, being here in the rapid response team for COVID, I’ve had a lot of people who are like I just don’t remember how to do a vent. It’s been a while for most of us, right. I can do 30 minutes of it. I don’t know if I could do six days. I can tell you, I took on a patient yesterday who was taken care of by a dentistry resident. You know, so if you think about what happens in a surge or when you have frontline workers who now have to very quickly increase capacity, that’s a real thing where you’ve got people who are very much outside of their clinical expertise who are just helping manage that surge so that’s what this is really all about.

Joe Elia:     The changes in referrals and ED visits that we’re seeing seem to be part of a larger phenomenon that’s happening in healthcare generally. The question is, would you agree that COVID-19 will be a kind of trigger for serious changes in how health gets taken care of in this country?

Dr. Comilla Sasson:     Yes. I think if we want to think about what are the positive things that have happened because of the COVID pandemic, the number one most important thing that we have done that will absolutely change the way in which we function as a healthcare system is to increase our utilization in telemedicine. It’s so funny because I think for the last 10 years we’ve kind of been struggling trying to get people to get excited about it, getting payers to pay for it, trying to get physicians and advanced care providers to sign on for it to say, yes, this is a valuable tool. I think overnight we kind of flipped the switch, just like they did in Wuhan, China, and moved so much of our care to telemedicine that I don’t think we’re going to go back.

I have a five-year-old son who got strep throat a week-and-a-half ago, even though we were on quarantine, so it happens. But we did two telemedicine visits from my house. I’ll be honest, I don’t think I ever want to go back unless we absolutely have to go see my pediatrician. It was amazing. We had everything that we needed at home. I think that’s one of the biggest innovations that I see both not just for the COVID post era but hopefully into perpetuity.

I did have a personal story of a patient who I took care of on telehealth. It was mind-boggling to me — absolutely mind-boggling. A woman who had multiple comorbid conditions with chest pain, who I was literally chatting with online first, because it started out as just a very normal interaction. It escalated into “Oh, my gosh, I’m really worried about you. You need to go to the emergency department right now.” She said no. I said, “Can I talk to your family member?” So then we had escalated up to her family member and yet her family remember said, “She refuses. She said she would rather die than go to the emergency department right now because she does not want to get COVID.”

I kept telling her there’s different sections. If you’ve got a non-COVID respiratory complaint you’ll be fine. We can keep you separate and she refused, absolutely refused, and said she’d rather die. So those are the people that keep me up at night, because you kind of wonder how many other folks never even bother to call or check in or even say that they have these symptoms. How much EMS volume has gone down for 911 calls because people are just afraid. So I think the more we can do to get the message out that “If you have to call 911, if you have to go to the hospital we can keep you safe.” I think that’s going to be key.

Dr. Ali Raja:     Many of us are starting to plan our health system’s response after we start opening society back up, and one of the things that I and many others — including potentially you — are worried about is that we’ll see a surge in patients with delayed presentations or we’ll see more patients rebounding from non-COVID diseases, the diabetic that hasn’t been well managed for the past few months, the patient whose high blood pressure hasn’t been well taken care of because they didn’t take advantage of the telemedicine that you just talked about. What should we be doing now to prepare for a potential surge in patients with cardiovascular disease presentations coming in when we finally do open things back up?

Dr. Comilla Sasson:     I think that’s a great question. I think you might actually have a better answer than I do, but I think everyone’s vantage point is a little bit different. I think what’s been interesting to me is that we’ve been in a very reactionary mode I think for most…most of medicine has always been about sort of treating the condition. So we wait until you develop heart disease to really plug you into the system and take care of you. So I think hopefully we get back to the idea of prevention and hopefully we go out and actually start being proactive about people’s care. To me, that seems like that’s such an important piece that has always been missing because we’re always just trying to put out the latest fire rather than really thinking about there is a CHF patient right now who’s sitting at home who is probably on the verge of having an exacerbation and may be frightened to come into the hospital. So what are health systems really doing to think about those very vulnerable patients right now to say what can we do while you’re at home, while you’re in the middle of your shutdown? What can we do to make you better so that we don’t have those unintended consequences of the flood gates open on whatever day it is, April 26 in Colorado and all of a sudden all these patients who’ve been waiting to be let out because now all of a sudden they think it’s safe to be let out because we’ve said there’s no shutdown anymore.

We’re going to see all those patients and April 26 for the CHFer may be too late. So I think we have to be much more proactive, and I worry that we’re not as proactive as we could be about reaching out to those folks. We know who they are in our healthcare systems, right.

Joe Elia:     I want to thank you very much, Dr. Sasson, for talking with us today about this.

Dr. Comilla Sasson:     Thank you, guys, for having me. This is really important work, and I’m very fortunate to be part of the Heart Association in that we’ve always looked at the sort of great opportunity both to be within the professional sector but then also with the general public in trying to increase everybody’s knowledge and getting everybody on the same page. So I’m hopeful, again, that through all of this what we’re learning, we can actually work with all of our different partner organizations, especially in the community to get the message out that it’s okay. It’s okay to go to the emergency department. It’s okay to use healthcare. Just because you’re in a shutdown doesn’t mean that you need to ignore your health condition until you’re not in a shutdown, and I think we all need to work together to get that message out.

Joe Elia:     That was our 264th episode. All the previous episodes are searchable and available free at Podcasts.JWatch.org. We come to you from the NEJM Group. The executive producer is Kristin Kelley. I’m Joe Elia.

Dr. Ali Raja:     And I’m Ali Raja. Thanks for listening.