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Articles
Big drop in stroke, heart patients at hospitals here
Reasons for national trend are unclear, but severity of cases suggests virus fears cause some to delay care

Omaha-area health systems have seen a dramatic decrease in the number of heart attack and stroke patients coming through their doors since the coronavirus pandemic began.

A review of cases, published last week in the New England Journal of Medicine, found a 39% decrease in patients undergoing stroke imaging from February to a period between late March and early May. And a survey of nine major hospitals last month showed that the number of severe heart attacks being treated in U.S. hospitals had dropped by nearly 40% since the novel coronavirus took hold in March.

Local cardiologists and neurologists say they're seeing similar — in some cases larger — decreases in patients seeking evaluation and care for the two conditions, both of which are leading causes of death and disability. Some also are noticing patients coming in later, hours or even days after their attacks.

The exception so far has been CHI Health, which has seen no decline in strokes overall and since February has seen an increase in big strokes involving large blockages requiring a procedure that involves fishing the clot out of the blood vessel.

Doctors so far don't have a concrete explanation for why many hospitals are seeing fewer patients for strokes and heart attacks. But a leading theory is that people are waiting out their symptoms at home because they're afraid to come to the hospital and risk exposure to the virus.

Doctors are concerned that such delays could mean missing out on time-sensitive treatment and result in long-term damage and disability.

"Everyone is struggling to understand why the drop is happening," said Dr. Pierre Fayad, a neurologist and medical director of the Nebraska Medical Center's stroke center. "But the biggest fear is that patients are missing out because of fear. Fear shouldn't stop them from seeking care."

Health care officials, in fact, are reminding people that it's safe to call 911 if they're experiencing symptoms of either type of attack and safe to come to hospitals for emergency treatment. Some hospitals also are seeing people putting off seeking care for other emergencies, such as appendicitis and gallbladder troubles.

Leaders of the American Heart Association and seven other national heart and stroke groups posted a letter to that effect last month.

Locally, doctors stressed that area hospitals have implemented a number of measures intended to keep staff and patients safe from the virus, including requiring patients and providers to wearmasks and barring visitors in most cases. Patients with suspected COVID-19 typically are evaluated and treated in separate areas.

"You need to take your heart attack seriously and get it managed and let us protect you from the virus," said Dr. Daniel R. Anderson, a Nebraska Medicine cardiologist and chief of cardiovascular medicine at the University of Nebraska Medical Center.

Area hospitals also have the capacity needed to treat patients with conditions other than COVID-19. Hospitals and surgical centers in the Omaha area canceled most elective surgeries and procedures from mid-March to early May in order to prepare for a virus surge.

But since Gov. Pete Ricketts lifted restrictions effective May 4 for those hospitals that had adequate beds and protective gear, they have slowly begun to add those procedures. St. Francis Hospital in Grand Island and Good Samaritan in Kearney, both of which have had surges in COVID-19 patients, reopened for non urgent procedures Tuesday after meeting the mark for capacity.

Fayad said the overall number of people arriving at the Nebraska Medical Center for strokes is down by about 30% on average. Smaller hospitals are seeing declines as well, as evidenced by a 50% reduction in calls through the health system's tele health network. That system connects the health system with 10 sites in Nebraska and Iowa for remote stroke consultations.

Those who are coming in typically have more severe symptoms, he said. And some have waited for hours or even days. Similar reports of such delays have come in from New York, South Carolina and Florida.

Treatments developed in recent years can reverse stroke and heart attack effects. But they need to be administered quickly.

"There's no other explanation for a trend like this," Fayad said. "We've never seen this kind of drop before."

Dr. David Franco, a neurologist and stroke director at Methodist Hospital and Methodist Women's Hospital, said the number of patients coming in for stroke evaluation was down about 50% from March through early May compared with the same period last year.

Pam Stout, stroke program coordinator for Methodist Health System hospitals in Omaha and Council Bluffs, said the hospitals are seeing the stroke patients who do come in show up later. Staff have heard patients say that they didn't want to come in because they thought the hospitals were busy with the virus or because they didn't want to catch it.

Dr. Vishal Jani, medical director for stroke with CHI Health in Nebraska and Iowa, said the health system initially saw a 10% to 15% decline in patients coming in to get checked for stroke. But those numbers now are running head to head with the same months last year.

CHI has seen an increase in the number of patients with large-vessel blockages requiring the vessel-clearing procedure known as mechanical thrombectomy. It's a relatively rare intervention, used in about 5% of stroke patients. Typically, he and his team do four or five a month. Since April, they have been performing nearly twice as many, peaking at 11 in April. That increase is consistent with a trend seen in hard-hit New York City. Both here and there, such patients tend to be younger.

COVID-19 has been associated with increased clotting, thought to be part of the body's infection-fighting response to the virus. But CHI Health hasn't seen many patients diagnosed with COVID-19 experiencing large-vessel clots, Jani said.

Research so far indicates that it can take from eight to 12 days for people who have been exposed to the virus to suffer strokes. Jani said his theory is that some patients may be suffering strokes before they test positive.

"That could be the reason, but we can't be sure," said Jani, an assistant professor of neurology with Creighton University's School of Medicine. He served on an international panel that prepared guidelines for safely treating COVID-19 patients for stroke during the pandemic.

Cardiologists across all three systems are seeing decreases in patients coming in for evaluation of heart symptoms.

Anderson, the Nebraska Medicine cardiologist, said he has seen a 60% decrease in April compared with the first three months of 2020. Methodist has seen declines similar to those it has seen for stroke.

Dr. Jeffrey Carstens, a cardiologist with CHI Health, said the system's heart visit numbers in Omaha and Lincoln are down by as much as 40%.

"You typically don't want to make too much of a blip in a number," he said, comparing it to the stock market. "But it's so consistent with what we're seeing nationally that it has to be real."

It could be that people are having fewer heart attacks because they're less active or facing less social stress while isolating at home, he said. Some also may be misinterpreting their symptoms.

But some are waiting it out at home, which means they arrive when they're sicker and harder to treat.

"If you think you need to come, you just need to come," Carstens said. "It's important to get checked out if you think there's something wrong." julie.anderson@owh.com, 402-444-1066

"The biggest fear is that patients are missing out because of fear. Fear shouldn't stop them from seeking care."

Dr. Pierre Fayad, a neurologist and medical director of the Nebraska Medical Center's stroke center.

WARNING SIGNS FOR HEART ATTACK AND STROKE

Heart attack

» Chest discomfort, lasting more than a few minutes or going away and coming back. It can feel like uncomfortable pressure, squeezing, fullness or pain.

» Pain or discomfort in one or both arms, the back, neck, jaw or stomach.

» Shortness of breath, with or without chest discomfort.

» Other signs may include breaking out in a cold sweat, nausea or lightheadedness.

Stroke (Spot it F.A.S.T.)

» Face drooping: Is one side of the face drooping or numb? Ask the person to smile.

» Arm weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?

» Speech difficulty: Is speech slurred or difficult to understand? Ask the person to repeat a simple sentence.


Articles
25 days in ICU, 15 on ventilator: Omahan, 73, recovers from virus
Retired nursing assistant says much remains hazy from her long battle with COVID-19. But, she says, 'I can still remember the love I got.'

There were flowers and balloons, a few tears, thunderous applause from hospital staff who lined up to see their patient off and — hopefully — a caramel cake waiting at home.

Ruby Jones walked out of CHI Health's Immanuel Rehabilitation Institute on Thursday morning after surviving a battle with the coronavirus that left her weakened but more determined than ever to gain back her strength, gab with her two "old lady" best friends again and hug her family close.

Her month long hospital stay hints at what the 73-year-old Omahan has endured and overcome.

Jones became sick with COVID-19 in early April but doesn't know how she was exposed to the coronavirus.

"I stayed at home in my apartment. Everybody said, 'Stay home, stay home,' " she said She had a dry, itchy cough that she initially chalked up to sinus problems. She also has diabetes and high blood pressure, two conditions that seem to exacerbate COVID-19 complications.

A friend told her she sounded confused over the phone. The next thing she remembers is waking up at the Immanuel Medical Center, disoriented. Where was she? How much time had passed? Jones ended up spending 25 days in the intensive care unit, 15 of those hooked up to a ventilator to help her breathe. After her condition stabilized, she spent another 14 days in rehab, relearning how to sit up, walk, dress and feed herself after weeks of lying still in a hospital bed.

"She has been through it," granddaughter Jennifer Allen said.

Much remains hazy about the period when she first felt ill and the time she spent on the ventilator, sedated and surrounded by beeping machines, tubes and doctors and nurses who all looked alike in long gowns and masks. But some things come back clearly.

"Truthfully, I can still remember the love I got," she said.

Jones retired after a long career as a certified nursing assistant at nursing facilities like Immanuel Fontenelle. She's not used to being on the other side, as the patient in need of care.

"I loved helping people, not people helping me," she said.

When Jones was first admitted to the hospital, Dr. Erik Jacobson said she wasn't doing too badly — she was scared of the contagious virus sweeping across the world but hoped she'd be able to head back home and recover there.

That was not in the cards. Within a day or so, her condition quickly worsened and she had trouble breathing.

"What we are seeing with this is that people can have this period where they're really feeling OK, their body is trying to manage this and then suddenly they can have this change where they will decompensate," he said.

This was still early on in the coronavirus pandemic, and doctors were trying to figure out — as they still are now — what medications and therapies would help patients ward off the frightening new virus.

Jones was given hydroxychloroquine, which was briefly touted as a promising treatment by some, but it didn't do much. Doctors tried to keep her blood pressure from spiking and made sure she got adequate nutrition through a feeding tube.

Jacobson tried some blood thinners and anti-inflammatory drugs toward the end of Jones' stint on the ventilator. Whether it was just timing or the medications, she began to improve.

"If you're having a heart attack, we have a very common pattern of treatment. We know how to do that," Jacobson said. But it's hard for patients and their families to accept that there is no approved treatment for COVID-19, though doctors are trying different combinations of drugs, including trials for remdesivir, and plasma therapy.

"Without a known way to fix this, it's very scary," he said.

Jones improved enough to be removed from breathing support, but her recovery was just beginning.

COVID-19 patients seem to spend more time on ventilators than patients with other respiratory ailments, said Jacobson and Dr. Aishwarya Patil, the associate medical director of the Immanuel Rehabilitation Institute. Having a tube down your throat for a prolonged period of time can make it hard to talk and swallow once it's removed.

Long ICU stays can lead to other problems: muscle weakness, fatigue, depression, anxiety, a form of disorientation called "ICU delirium" and cognitive problems with memory and problem-solving.

Immanuel decided to start rehabilitation even though Jones was still testing positive for the coronavirus.

"The sooner you start the rehab, the better your outcome is," Patil said.

Most, if not all, rehabs are not accepting patients who still have the coronavirus, she said, so therapists visited Jones in the coronavirus unit, taking care to wear protective gear. Once she tested negative, she was moved to the Rehabilitation Institute nearby. She spent three demanding hours each day doing physical, occupational and speech therapy, with plenty of breaks to rest.

"Ruby survived — that is a miracle in itself — and we just had to step it up and help her," Patil said. "Ruby lived up to it and she did everything we asked her to, so that was verymotivating for us."

Jones will continue her recovery at her granddaughter's house. Her great-grandchildren made bedazzled posters thanking the staff at Immanuel for saving their grandma, and the medical teams that cared for her in the ICU and in rehab came down to cheer her as she was discharged, slowly but determinedly pushing a walker.

She's feeling stronger every day, and credits her "sweet and loving and kind and patient" caretakers and her family for pushing her to get well.

"I see myself coming back to me a little bit at a time," she said. Even her appetite is returning — just in time for a slice of that caramel cake her great-granddaughter promised she'd make. eduffy@owh.com, 402-444-1210 twitter.com/eduff88


Livewellnebraska
Glimmers of hope in Grand Island: Officials say coronavirus deaths, hospital stays dropping

Is the coronavirus finally loosening its grip on the hard-hit Grand Island area?

Health officials there say it’s too soon to declare victory, and Grand Island Mayor Roger Steele warned that social gatherings with larger crowds may not be possible until August. Don’t count on the city pool or water park opening this summer, he told residents.

But there are encouraging signs that the virus may have already hit its peak. Fewer people are seeking hospital care. Confirmed coronavirus cases in Hall, Hamilton and Merrick Counties seem to be declining, though delayed results from testing might play into that.

During the week ending April 24, 17 coronavirus-related deaths and 329 cases were reported, Central District Health Department Director Teresa Anderson said at a press conference Thursday.

So far this week, there have been only two recorded deaths and 41 cases reported, although there have been complaints about test results from the TestNebraska initiative that set up last week in Grand Island taking days to be processed.

“I mentioned these things to give us courage to continue going on, but not to let our guard down,” Anderson said. Residents should still stay home whenever possible, stay 6 feet apart, wear masks out in public and frequently wash their hands.

The World-Herald's complete coronavirus coverage

An editorial in the Grand Island Independent on Tuesday said TestNebraska had failed medical providers in that central Nebraska hot spot because the public-private testing collaboration hadn’t shared positive test results with public health officials there since testing began. That left doctors and nurses “flying blind” in battling the virus, the newspaper said.

Nebraska Gov. Pete Ricketts said that glitches with the system are being fixed and that more data had been uploaded into the state’s coronavirus tracking system by Tuesday night.

Anderson said she herself has been frustrated with some of the testing backlog but asked residents for patience.

“Those of us that were partners in TestNebraska need to remember it’s a pilot project, there will be issues, and as partners, we need to work together to fix those issues,” she said. “We’re providing regular feedback to the state on the TestNebraska process, and it will get better, and it will get better quickly.”

It’s not clear how many people in the Grand Island area have been tested over the past week through the TestNebraska effort. Hall County, where Grand Island is, still has one of the highest coronavirus case counts in Nebraska, with 1,368 known cases and 36 deaths as of Thursday. The Health Department has not released data showing how many people have recovered.

KENNETH FERRIERA/ THE WORLD-HERA 

St. Francis Hospital in Grand Island. About a month ago, the hospital was treating more than 50 COVID-19 patients. Now it fewer than a dozen.

Edward Hannon, the president of St. Francis Hospital, said the number of COVID-19 patients being admitted to the Grand Island hospital has been dropping for 10 to 14 days.

“Things are really, really encouraging here in Grand Island, and I hope we can continue to see this trend,” he said during a video conference call on Thursday.

One month ago, the hospital was caring for 50-plus patients with coronavirus, with 14 to 16 people in its intensive care unit. About 10 patients were transferred to hospitals in Omaha to free up beds in the ICU.

Today, there are fewer than a dozen COVID-19 patients at the hospital, and only four in the ICU. Most people are able to recover from the virus at home.

“It’s still out there,” Hannon said of the contagious virus. But “it just seems to be, by all appearances … getting better in our community.”

The coronavirus crisis shows why it’s critical to support local journalism

The hospital took down a tent that had been erected next to its emergency room to prepare for a surge of patients, and the respiratory fast-track area set up to screen patients hasn’t been used in a week. Extra ventilators shipped to St. Francis are heading back to the Omaha metro area, where cases have been rising over the past week or two.

Elective surgeries are starting up again, after being put on hold to make sure the hospital had enough staff, beds, protective gear and ventilators to care for COVID-19 patients.

“People shouldn’t be afraid to come to hospitals,” Hannon said. “We’re dealing with this really well. They shouldn’t put off their diseases and concerns.”

Hannon also put in a good word for TestNebraska, saying he received his test results — negative — about 30 hours after he was tested last Thursday at Fonner Park.

He praised the dedicated doctors, nurses and staff at St. Francis and thanked community members for doing their part to slow the spread of the virus, while also donating masks and meals to hospital employees.

“It brings joy to my heart to see this community continue to rally around St. Francis,” he said.

Photos: Nebraska's coronavirus helpers

State_and_regional
Ricketts says further relaxing of coronavirus limits depends on trends in next couple of weeks

LINCOLN — Gov. Pete Ricketts said Thursday that it’s too early to know whether rodeos can be held, wedding receptions set or the Nebraska State Fair can proceed as scheduled.

The same goes for youth soccer, adult sports, the reopening of bars, and pretty much any other event or business that brings more than 10 people together.

“Stay tuned,” Ricketts said at his daily coronavirus briefing. “We won’t know until we get a little bit more data here in the month of May what June will look like, much less what is going to happen in July or August.”

He said the state is moving step by step to ease up on social distancing restrictions. So far, 73 counties have been allowed to reopen restaurants, hair salons and other close-contact businesses, with restrictions. Another 16 will be able to do so on Monday. Religious services, including weddings and funerals, are being allowed statewide, also within limits.

The most recent step was to allow youth baseball and softball teams to start organized practices on June 1 and games on June 18.

But Ricketts said state officials are watching closely to see what happens under the relaxed restrictions before loosening up any more.

He said it will take about two weeks to see whether the changes lead to more cases. That’s how long it can be before someone starts showing symptoms after being infected. If all goes well through the rest of May, Ricketts said, the state could consider relaxing the 10-person limit on gatherings in June.

“It’s difficult to forecast how big of crowds we will get to until we actually get some experience loosening those restrictions,” he said.

The coronavirus crisis shows why it’s critical to support local journalism

Ricketts said he is watching two key measures: the rate of tests that come back positive for the coronavirus and hospital capacity. The rate of positive tests is one way of judging how widespread the virus is in a community.

Hospital capacity reflects how well the state is doing at slowing the spread of the virus and keeping the health care system from being overwhelmed. Typically, a certain percentage of those with the coronavirus will wind up needing hospital care, with some of them needing intensive care and ventilators.

Part of the decision-making will also depend on the state’s ability to do contact tracing. Ricketts said 277 state employees who have been trained to do contact tracing are now helping local health departments.

“This is an important part of how we tackle the virus head-on,” he said, “so everybody else can lead a more normal life.”

Felicia Quintana-Zinn, a deputy division director at the Nebraska Department of Health and Human Services, said tracers contact people who have tested positive for the coronavirus to find out who they might have exposed to the virus. In most cases, exposure occurs if people are less than 6 feet from one another for 10 minutes or more.

Next, the tracers contact the people who might have been exposed and direct them on whether to self-quarantine or simply monitor for symptoms of the virus. The goal is to prevent those people from spreading the virus further. Quintana-Zinn said people exposed to the virus are advised to talk with their own health care providers or the local health department about whether they need testing.

She said state officials are looking at contracting with private firms to increase the number of contact tracers. The goal is to beef up until the state has 1,000 tracers.


Our best staff photos of May 2020

Photos: Our best staff photos of May 2020