Cardiac care in a pandemic: an unfolding tragedy?
As the debacle over the Department of Health’s handling of the first wave of the coronavirus pandemic has unfolded, several troubling possibilities have been uncovered. Amongst these is the suggestion that patients were discharged prematurely as hospitals were cleared for the first wave. Patients with suspected coronavirus were routinely discharged initially, in the belief that there was little that hospitals could do unless and until they required ventilation, something that may have led not only to delays in diagnosis of other conditions, but also misdiagnoses.
Missed cardiac issues
Coronavirus is a respiratory disease, and can cause connected cardiac issues, particularly pericarditis and myocarditis. Both of these complications involve a build-up of fluid around the heart, causing symptoms akin to those of a heart attack. In order to arrive at a firm diagnosis clinicians have to rule out both possibilities with a variety of tests, so simply discharging such a patient home is not safe.
Patients who may suffer from cardiac conditions should rarely, if ever, be discharged home before they are fully investigated. In the case of some conditions (including coronary artery disease and aortic stenosis), delays in diagnosis and treatment can make the difference between life and death. In at least one case of which we are aware, a developing heart attack was missed, when a patient was discharged home with a misdiagnosis of coronavirus.
As the pandemic unfolded, it also became apparent that coronavirus caused a variety of problems that occurred after the initial onset of symptoms: several reports emerged of patients experiencing cardiac, lung and liver problems after an apparent recovery from acute respiratory illness. The resulting cardiac problems included heart attacks – presumably caused by the extra stress induced by coronavirus upon already diseased coronary arteries – and these required further hospitalisation.
The requirement for re-hospitalisation brings us onto the second type of cardiac misadventure that appears to be emerging from the pandemic.
Delays in emergency response
The ambulance services were frequently at capacity (or beyond it) during the peak of the first and second waves of the pandemic. Under this degree of pressure, it is not surprising that call response times generally increased. However, emergency calls are categorised in order to ensure calls requiring rapid responses are prioritised (for example a conscious patient who is complaining of central chest pain with shortness of breath would be put in category two, with a target response time of less than 20 minutes and certainly no more than 40 minutes).
We are seeing increasing evidence response times by paramedics did not fall within the required timescales – whether for reasons of protracted under-resourcing, a lack of PPE (particularly during the first wave), and/or errors in categorising the call. Whatever the reasons, failure to respond in such circumstances can have catastrophic consequences.
In some cases of which we are aware, the relatives of patients were left quite literally doing CPR whilst waiting for an ambulance to arrive, or having to make the decision as to whether they should take matters into their own hands and drive the patient to hospital themselves.
The pandemic has been an unfolding (and in some aspects, an avoidable) tragedy for the entire nation, as it has for much of the world. Very sadly indeed, its extent is only beginning to be comprehended: the casualties did not all suffer from coronavirus, and a chronically under-resourced and underfunded health service has struggled to cope. Cardiac patients in particular have been badly affected.
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