‘Every patient as a potential COVID’

‘STRANGE’ TRIGGERS

The patient presented in the ER with a psychiatric illness. She was delusional and hearing voices and her chart showed a history of schizophrenia. So the triage staff sat her down and asked her to wait for a psych bed to open up.

For a full day the woman waited, in a busy ER at a major hospital outside Seattle. That’s not unusual in the U.S., or in Canada either. There, and here, psychiatric patients show up in emergency every day, and long waits for specialized treatment are the norm.

So the woman wasn’t out of place. And it wasn’t until her fever spiked that the medical staff realized they had something more troubling on their hands. “We know that when patients with psychiatric diseases get sick, it kind of mentally de-compensates,” said Dr. Gregg Miller, an emergency room physician at the hospital. “And we realized that the reason that her schizophrenia reactivated was because of COVID-19.”

All across Canada and the U.S., ERs and ICUs have been split, with patients suspected or diagnosed with COVID-19 on one side and those without on the other.

But as the pandemic has ground on, doctors say, they’ve found it increasingly difficult to rule anyone out as a possible COVID carrier. “We’re just seeing so many strange presentations of this that basically we’re in a state where almost anybody coming in with anything is a potential COVID case,” said Dr. Brett Belchetz, who practises emergency medicine in Toronto.

For hospitals dealing with limited protective equipment and long backlogs for testing, that’s a problem. It means there’s no easy way to triage patients, conserve supplies or give medical staff a mental break. “We’re taking precautions with everybody now,” Belchetz said. “We’re treating every single patient as a potential COVID patient.”

The range of possible COVID symptoms has already expanded dramatically. One colleague told Belchetz about a patient who came in with a head laceration. “Everyone assumed it was nothing to worry about,” he said. Head wounds are bread and butter stuff in the ER. But after some detailed questioning, the patient revealed how he got the cut: He had passed out and fallen. He didn’t have a cough or a fever. But he wasn’t getting enough oxygen. He got swabbed. The test came back. He had COVID-19.

“What’s become very frightening is that, initially we had this very clear case diagnosis,” Belchetz said. “It was travel and a cough and shortness of breath and fever.” If you had those, or exposure to a known case, doctors could treat you like you had the disease. “But what we’ve been finding is almost anything can be a presentation of COVID-19,” Belchetz said. “We’ve seen patients whose only presenting symptom is headache or their only presenting symptom is abdominal pain and we swab them and they’re positive.”

Dr. Zachary Levine, who works in a Montreal-area emergency department, had seen about 20 presumed cases of COVID-19 by early this week. Most had presented with the classic symptoms, he said in an email. But one, a 37-year-old woman, had come in after weeks of bloating and abdominal pain. She only qualified for testing because she had minor chills. But when her test came back, it was positive.

The second COVID case Levine saw didn’t initially qualify for testing at all. She was in her 70s, had recently travelled to the Caribbean, and had fatigue and malaise. What she didn’t have was a fever or a cough. “Luckily I wore a mask/visor/gown and gloves out of an abundance of caution,” Levine wrote. After an abnormal chest X-ray, he sent her for testing; it came back positive too.

For Miller, the stakes of this situation didn’t fully set in until he saw his first atypical presentation of the disease. In the early weeks of the pandemic, a woman with an erratic heartbeat came in to his ER. She had a history of what’s known as atrial fibrillation. And her heart was beating wildly, at almost twice the normal rate.

Miller and his colleagues focused on that; they wanted to get her heart rate under control. “A few hours later she spiked a fever and then we realized, ‘Oh gosh, there’s more to this story than just atrial fibrillation,” he said. They sent her for a swab. She had COVID-19.

“Theoretically, you know that this is going on,” Miller said. “And it’s something we’ve been talking about. But to actually see that happen right in front of me was like, ‘Oh my God’. I was fortunate that I had taken appropriate precautions with her. I was wearing a mask, I was wearing a gown. But I was just kind of going through the motions, just doing it because everybody else was doing it. And then when she spiked a fever, it really became much more internalized.”

Miller and several colleagues recently published a paper on early lessons learned from the pandemic in the Seattle area. He said the message is not that it’s useless to separate COVID from nonCOVID. “You can do it,” he said. “You just can’t assume that because you’ve done that, the rest of your ER or your clinic is COVID-free.”