State urges people not to delay care after 62% hike in out-of-hospital deaths amid pandemic

Beth LeBlanc
The Detroit News

Lansing — As March waned and Michigan's coronavirus caseload grew, Emergency Medical Services Chief Jeff White experienced a change that health care workers across the state least expected during a global pandemic.

Emergency runs plummeted. Hospital transports tanked. And the remaining calls began trending toward increasingly serious medical conditions.

Richmond-Lenox EMS staffers typically respond to a handful of cardiac arrests a month in the 300 square miles they serve in Macomb and St. Clair counties, White said, but between late March and mid-May the numbers jumped. 

"When you're used to seeing maybe four cases a month and then you see two, maybe three in the same day, you start to suspect there’s something more to this," White said. "And what we suspected is maybe it had to do with people putting off medical care." 

From March 15 to May 23, Michigan's out-of-hospital deaths soared 62% from the same time period in 2019 and out-of-hospital cardiac arrests increased 43.3%, according to data provided to the state by Michigan EMS agencies.

Michigan EMS transports during that same time period decreased 17%, heart attack transports declined 10% and stroke transports fell 12%. 

The data confirmed what had so far been anecdotal suspicions that non-COVID-19 patients avoided medical care during the peak of the pandemic. It has Chief Medical Executive Dr. Joneigh Khaldun urging Michigan residents to go to the hospital for medical emergencies.

MDHHS Chief Deputy for Health and Chief Medical Executive Dr. Joneigh Khaldun updates Michigan residents on COVID-19 developments, along with Governor Gretchen Whitmer on Thursday, May 28, 2020.

“It is incredibly important that people not delay care, especially if they are having concerning symptoms like chest pain, difficulty breathing or dizziness,” Khaldun said in Thursday statement. 

While Metro Detroit hospitals struggled with capacity for COVID-19 patients in March and April, their emergency departments experienced decreases similar to those occurring with EMS.

Estimates place the "dramatic decrease" in emergency department visits during that time at 40% or more, said Dr. James Ziadeh, chief of emergency medicine at Beaumont Health, Michigan's largest hospital system. 

"I think a lot of it was honestly fear from the public and the community in terms of contracting COVID if they came to the hospital," Ziadeh said. "What that did was led to a situation where people with true emergencies weren’t getting seen in a timely fashion and led to the data we’re seeing now.”

Nationally, emergency department visits plunged 42% in the 10 weeks following President Donald Trump's declaration of a national emergency related to the pandemic, according to the U.S. Centers for Disease Control and Prevention. 

The phenomenon has been observed in other states, especially those with large urban areas particularly hard hit by the virus, said Dr. Mark Hayward, a professor of sociology at the University of Texas at Austin who has expertise in demography and epidemiology. 

While fear of contracting the virus definitely played a role, he suspects the out-of-hospital deaths and cardiac arrests were likely more prevalent among minority and low-income populations without the same access to health care. 

"In terms of the minority populations and poorer populations, they also have a history and legacy with health care providers that’s not always positive," he said. 

Michigan's percentage of African Americans included among the out-of-hospital deaths and cardiac arrests were 11 to 12 percentage points higher than the proportion of Black individuals in the state's population.

It is similar to the disproportionate impact COVID-19 had on African Americans. Blacks have comprised 31% of Michigan's confirmed coronavirus cases and 40% of confirmed COVID-19 deaths even though they are about 14% of the state's population, according to state data. 

What Michigan's data shows

Overall, the EMS data represent a surge in out-of-hospital deaths from 1,579 in 2019 to 2,824 for that same two-month period this year, according to the Michigan Department of Health and Human Services. The number of out-of-hospital cardiac arrests for the March 15-May 23 period increased from 3,033 in 2019 to 4,346 in 2020.

EMS transports decreased from 224,175 in that time period in 2019 to 187,363 this year, according to the Department of Health and Human Services.

Out-of-hospital deaths are defined as those where EMS personnel have answered a call and found an individual dead at the scene and did not transport the deceased to a hospital. Out-of-hospital cardiac arrests are defined as those occurring before or after EMS arrived. 

African Americans comprised 26% of Michigan's out-of-hospital cardiac arrests and 25% of the out-of-hospital deaths from May 15 to May 23.

The number of Black individuals suffering an out-of-hospital cardiac arrest during that time period increased 102% from 2019, while the number of Black out-of-hospital deaths soared 172% from 2019, according to state data. 

Wayne, Oakland and Macomb counties also experienced the highest prevalence of increased out-of-hospital deaths and cardiac arrests from March to May, just as they did with the COVID-19 cases and deaths.

In Macomb County, out-of-hospital cardiac arrests rose from 170 during March-May 2019 to 280 this year. In Oakland County, the number rose from 354 to 544. In Wayne County, the number exploded from 670 to 1,247. 

The same trend happened with out-of-hospital deaths. In Macomb County, the number soared from 76 in 2019 to 191 during the same period this year. In Oakland County, the number rose from 210 to 412; and in Wayne County, the number skyrocketed from 295 to 785. 

What hospitals saw

At the height of the pandemic in March and April, emergency department visits for other ailments decreased significantly at Beaumont Health hospitals, Ziadeh said. Numbers started to increase in recent weeks but are not yet at the level they were.

"In my career, I’ve never seen anything like that, and I think that speaking with my colleagues in emergency medicine, this is something that they also haven’t seen during their professional career," Ziadeh said.

Likewise, at Henry Ford hospitals, fewer patients were coming to the emergency department with heart attacks, said Dr. Samer Kazziha, chief of the cardiovascular department at Henry Ford Macomb. By the time they got to the hospital, it was too late and the damage was done, he said.

"We were wondering what was happening, and why we weren’t seeing them," Kazziha said. The state data released Thursday, he said, "shows the patients who weren’t presenting were dying at home.

"I have been in practice for more than 35 years as a cardiologist, and I have never experienced anything like this," he said. "It was like the stock market at that time. It just stopped.”

Recent studies out of Italy, also hard-hit by the virus and subject to an intense lockdown, have shown a 50% increase in sudden cardiac deaths from last year to this year, said Dr. Kim Eagle, a director at the Frankel Cardiovascular Center at University of Michigan.

Around the United States, the frequency with which people have gone to the hospital with heart attacks during the pandemic diminished, he said. 

"We told patients the last place we wanted them was the hospital or clinic because we didn’t want them to share the virus," Eagle said. "Every action has a reaction.”

While the decrease in non-COVID patients blindsided Michigan hospitals, other areas of the country benefited from delayed onset of the virus, said Hayward, the University of Texas professor. 

"I don’t think that was even on the radar when the pandemic was blowing through New York City and Michigan and Detroit," he said. "It was a little on the radar here in Austin, but that’s because the virus came here later.”

What caused death spike

Public health professionals are still working to fully understand all the factors influencing the rise of out-of-hospital deaths.

Lack of access to hospitals for minority and low-income populations, financial and insurance-related uncertainty as unemployment bloomed and mitigation measures keeping people at home might have been factors, Hayward said. 

"During the shutdown, people were told to stay in place," he said. "There’s a lot of symptom misinterpretations at that time, and then there’s fear. So you can see why people would be recalcitrant to act on symptoms indicative of cardiac arrest, stroke or diabetes.”

As Richmond-Lenox EMS staff responded to calls throughout their 300-square mile jurisdiction, patients increasingly asked paramedics to assess them at home and avoid the hospital, White said. 

"There was tremendous apprehension on behalf of even those we were called for about not wanting to go to the hospital," he said. "We had to provide continual reassurance that the hospitals were doing a good job of protecting people once they got to the hospital.” 

While delays in care likely contributed largely to cardiovascular issues, the mental stress of the burgeoning pandemic, lost jobs and separation from loved ones likely also played a factor, said Kazziha of Henry Ford Macomb. In recent weeks, he's seen an increase in people in their 50s presenting with cardiovascular issues.

"These are the people that have had the risks but also have been under tremendous stress,” he said.

Some opponents of Gov. Gretchen Whitmer's executive order barring non-essential medical procedures during the COVID-19 pandemic argued in court the order had the effect of deterring those who needed help from seeking it out of fear of violating the governor's edict.

Physicians were given broad discretion regarding what constituted a medical emergency that would bypass the order, but three Michigan medical centers and a patient argued it wasn't enough in federal court. The Michigan Supreme Court agreed this week to review the constitutionality of the governor's emergency powers at the request of a Grand Rapids federal judge.

Without further information on the deaths, it's difficult to say whether the ban on non-essential medical procedures can be solely blamed for the out-of-hospital deaths, said Patrick Wright, vice president for legal affairs for the Mackinac Center for Public Policy, whose legal foundation represents the medical centers.

"But there’s also the full range of other illnesses that we deal with on a day-to-day basis and if we’re not discovering or treating those, those can also lead to death," Wright said.

As warnings of a second possible wave of COVID-19 cases continue, Ziadeh said it's essential that people don't make the same mistake by staying away from the hospital for life-threatening issues. 

If another surge occurs, it's important that "we continue to message to our community that the emergency departments are safe and capable of handling any emergency, whether its COVID or non-COVID related," he said. 

At the peak of the virus in Michigan, some larger hospital systems, particularly those in Metro Detroit, were reporting hundreds of patients with COVID-19 on any given day. The Henry Ford Health System reported on April 7 having 752 coronavirus patients admitted, but that number eventually declined and, as of Monday, the hospital system reported 16 COVID-19 patients admitted. 

Likewise, in recent weeks, the hospitalization rate statewide has continued to decline slowly despite an uptick in coronavirus cases in recent weeks.

Eagle noted hospitals are much better equipped now to handle not only a coronavirus surge but also non-COVID-19 related concerns. 

"It's very unlikely for a patient to get infected with the virus if we handle things in the right way," Eagle said. "All of the lessons that have been painful hopefully will be applied much more effectively if we have to go through this in a deep way again.”