Everything can be COVID-19: As the pandemic progresses, doctors find that the first definitions of the disease were too narrow

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The patient presented to the emergency room with a psychiatric illness. She was delusional and heard voices and her record showed a history of schizophrenia. The triage staff therefore sat her down and asked her to wait for a psychological bed to open.

For a full day, the woman waited in a busy emergency room at a large hospital outside of Seattle. It’s not unusual in the United States or Canada either. There and here, psychiatric patients come to the emergency room every day, and long waits for specialized treatment are the norm.

The woman was therefore not displaced. And it wasn’t until his fever soared that the medical staff realized they had something more disturbing on their hands. “We know that when patients with psychiatric illnesses get sick, it degenerates mentally,” said Dr. Gregg Miller, an emergency room physician at the hospital. “And we realized that the reason his schizophrenia was reactivated was because of COVID-19. “

We treat each patient as a potential COVID patient

Across Canada and the United States, emergency rooms and intensive care units have been divided into two separate worlds, with patients suspected or diagnosed with COVID-19 on one side and those without.

But as the pandemic is on, doctors say, it is increasingly difficult to exclude anyone as a possible carrier of COVID. “We see so many strange presentations of this that basically we are in a state where almost everyone who comes up with something is a potential case of COVID,” said Dr. Brett Belchetz, who practices emergency medicine in Toronto.

For hospitals with limited protective equipment and long delays in testing, this is a problem. This means that there is no easy way to triage patients, keep supplies or give mental health workers a break. “We are taking precautions with everyone now,” said Belchetz. “We treat each patient as a potential COVID patient. “

The range of possible symptoms of COVID has already increased considerably since the early days of the pandemic. A colleague spoke to Belchetz about a patient who entered with a laceration in the head. “Everyone thought it was not a concern,” he said. Head injuries are bread and butter in the emergency room. But after a few detailed questions, the patient revealed how he was cut: he passed out and fell. He has no cough or fever. But he was not getting enough oxygen. He was stamped. The test came back. He had COVID-19.

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“What has become very frightening is that initially we had this very clear case diagnosis,” said Belchetz. “It was traveling, coughing, shortness of breath and fever.” If you had it, or if you were exposed to a known case, doctors could treat you as if you had the disease. “But what we discovered is that almost anything can be a presentation of COVID-19,” said Belchetz. “We have seen patients whose only symptom present is a headache or their only symptom is abdominal pain and we are buffering them and they are positive. “

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

The second COVID case that Levine saw did not qualify at all at the start. She was 70 years old, had recently traveled to the Caribbean and suffered from fatigue and malaise. What she didn’t have was a fever or cough. “Fortunately, I was wearing a mask / visor / dress and gloves by being too careful,” wrote Levine. After an abnormal chest x-ray, he sent her for tests; he also returned positive.

Difficulty locating COVID-19 means there is no easy way to triage patients, keep supplies or give mental health workers a break.

Jonathan Ernst / Reuters

For Miller, the challenges of this situation did not fully settle before having seen his first atypical presentation of the disease. During the first weeks of the pandemic, a woman with an irregular heartbeat came to the emergency room. She had a history of what is called atrial fibrillation. And her heart was beating wildly, almost twice the normal rate.

Miller and his colleagues focused on this; they wanted to control his heart rate. “A few hours later, it raised the fever, and then we realized:” Oh my God, this story is not just about atrial fibrillation, “he said. They sent her for a sample. She had COVID-19.

“Theoretically, you know this is happening,” said Miller. “And this is something we talked about. But to actually see it happen right in front of me was like “Oh my God”. I was fortunate to have taken the appropriate precautions with her. I wore a mask, I wore a dress. But I sort of went through the motions, I did it simply because everyone was doing it. And then when she raised the fever, it became much more internalized. “

Miller and several colleagues recently released a paper on early lessons learned from the pandemic in the Seattle area. He said the message to be drawn from this is not that there is no point in separating COVID patients from non-COVID patients. “You can do it,” he said. You can’t assume that because you did, the rest of your emergency room or clinic is free of COVID.

“Someone said to me,” Oh, this is our clean area, this is our dirty area. “And we said, ‘No, it’s your dirtiest area and it’s your least dirty area,'” said Miller. “There are certainly patients where the risk is high and there are patients where the risk is low. But at this stage, there are no patients where there is no risk. “

This means that, to be as safe as possible, doctors and other front-line staff must be 100% 100% of the time. And it is expensive. “Throughout your shift, you have to watch everything you touch,” said Belchetz. “You should constantly pay attention to the protective clothing you wear, making sure you never accidentally take off your gloves and touch your dress. “It is a lot of stress,” he said. “And going home at the end of your shift is terrifying.”

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