Many emergency rooms have seen a sharp decline in patients—but that's not necessarily a good thing.

Just a few short months ago, the John Muir Health Emergency Departments in the San Francisco Bay Area were bustling with activity on a daily basis. Between two hospital campuses, doctors were caring for around 370 patients each day. “Our patients ran the gamut from minor medical issues and orthopedics, to medical and surgical emergencies, including strokes, heart attacks and major traumas,” Russell Rodriguez, MD, medical director at John Muir Health's Concord and Walnut Creek Medical Centers' emergency departments, tells Health. “Today, it is a very different picture.” 

Dr. Rodriguez says he expected to see a decline in patient volumes with the COVID-19 pandemic and social distancing orders—mainly fewer minor medical complaints and traumas from motor vehicle collisions—but the actual decline the emergency departments saw was far greater. "The precipitous and concerning drop has raised alarms around many health systems," he says, sharing that both emergency departments have seen about a 50% decrease in volume compared to the same time last year. But it's not just Dr. Rodriguez's hospitals—emergency departments around the country have seen similar declines, including those in New York City's Health + Hospitals and Seattle's Providence St. Joseph Health networks, according to CNBC.

While many of those suffering from COVID-19 symptoms are still flocking to emergency rooms around the country for treatment, it seems others—even those who are in need of immediate medical attention—are drastically stalling treatment or avoiding the hospital at all costs, as they are afraid of exposing themselves to the virus. Dr. Rodriguez says his emergency departments have witnessed many patients waiting several days to seek treatment after having a stroke. “By that point, there is no immediate treatment that can be provided,” he admits. Patients have also opted to stay at home, even while suffering from crushing chest pain. “When these patients finally decide to seek care, they have been diagnosed with a heart attack, often resulting in outcomes like permanent cardiac damage.”

George Fallieras, MD, medical director of BioCorRx and an emergency physician working at Los Angeles Surge Hospital has also seen a dramatic decline in ER visits for conditions other than COVID-19. "It is good for people to not get exposed unnecessarily, if the care they seek is not truly emergent," he says. "But we as caregivers are certainly concerned that some individuals are avoiding the emergency room despite truly requiring emergent evaluation and attention.”

And unfortunately, just because there's been a drop in emergency department visits doesn't mean there's also been a drop in conditions that warrant those visits. "People still have heart attacks, car accidents, strokes, and [severe] abdominal pain, which all need to be treated acutely” points out Shannon Sovdnal, MD, author of Fragile, a board-certified doctor in both emergency medicine and emergency medical services, who serves as a physician and medical director for multiple EMS agencies and fire departments.

The good news: "Even with COVID-19, hospitals are prepared to treat people who need care,” says Dr. Sovdnal. “Hospital systems all over the US are putting additional measures in place to ensure proper handling and care of COVID-19 and non COVID-19 patients," adds Dr. Rodriguez. In addition to having “nearly 100% negative pressure rooms”—which use lower air pressure to allow outside air into the segregated environment, therefore discouraging the spread of infection—he explains that most hospitals segregate diagnosed or suspected COVID-19 patients from the rest of the population, staff and patients are required to wear masks, and the staff is temperature-screened before shifts. 

“It’s most important for everyone to understand the risk of suffering significant pain, short- or long-term disability, or death from an untreated medical or surgical condition is likely much higher than possible exposure to COVD-19. Patients should be reassured they can be safe seeking needed medical care now,” he says. But what exactly constitutes "needed medical care"? Emergency department physicians shared the 10 symptoms or conditions that absolutely warrant an ER visit—versus a visit to urgent care or a telemedicine phone call—even during the coronavirus pandemic. 

1. You're experiencing the symptoms of a heart attack.

Dr. Rodriguez says he's seen a 40% decrease in heart attack patients seeking care in the emergency room, despite the symptoms of a heart attack signaling a medical emergency.

According to the American Heart Association, heart attack symptoms in both men and women include pressure, fullness, squeezing, or pain in the center of the chest; pain or discomfort in one or both arms, the back, jaw, neck, or stomach; shortness of breath; nausea; sweating; or lightheadedness. It should be noted, however, that men typically experience the standard chest pain or discomfort, while women more often experience other, sometimes more flu-like symptoms

2. You're experiencing the symptoms of a stroke.

The John Muir Emergency Departments have also seen a 30% decrease in stroke patients, says Dr. Rodriguez. Per the American Stroke Association (ASA), the acronym FAST can help identify stroke warning signs: face drooping, arm weakness, and slurred speech (the T stands for "time to call 911").

Dr. Fallieras adds that other common stroke symptoms include numbness or tingling, drooling, confusion, leaning to one side, and nausea and vomiting. The ASA says trouble seeing and a sever headache may also signal a stroke. 

3. You broke a bone—and it looks really bad.

"A lot of broken bones can be handled at urgent care, but if there is a deformity it'd be important for an ER doc to set it, since most of these will require elective surgery down the road and these surgeries are currently unavailable,” explains Brandon Lawrence, MD, an Arizona ER doctor. 

According to the Mayo Clinic, broken bones that require emergency medical treatment may also include heavy bleeding, a bone that has pierced the skin, or a bluish color on the affected extremity. If the broken bone is in the head, neck, back, or chest, that will warrant an ER visit, as well.

4. You experienced a major trauma or injury.

While people are out and about less than usual lately because of social distancing, accidents can still happen. All doctors agreed that if you have been in a bad car accident, had a major fall, or sustained a gunshot wound, you should always visit the emergency room immediately. 

5. You have symptoms of a blood clot.

The American Society of Hematology (ASH) says that while blood clotting is a normal bodily process, sometimes clots can form inside of blood vessels and not dissolve naturally, which can become a dangerous situation.

When an abnormal blood clot forms in a vein, it can restrict the flow of blood to the heart and cause pain and swelling as blood becomes blocked behind the clot. This is called deep vein thrombosis (DVT) and typically occurs in a major vein in the legs, and less commonly in the arms, pelvis, or other large veins. In some cases those abnormal clots can dislodge and make their way to the lungs, called a pulmonary embolism, where they get lodged again and block blood flow.

Clotting that occurs in the arteries, on the other hand, is usually caused by atherosclerosis, or a hardening of the arteries due to plaque deposits. When clots show up in the arteries, they can restrict blood flow to the brain or heart, leading to a stroke or heart attack.

Dr. Fallieras says blood clot symptoms aren't always obvious, but often include unilateral leg swelling pain, sometimes with chest pain, cough, or shortness of breath if it spreads to the lungs. According to the ASH, other symptoms of blood clots can depend on where the clot is located (in the heart, it may cause chest heaviness, sweating, lightheadedness, or nausea; in the brain, it may show up as facial weakness, difficulty speaking, or a sudden, severe headache).

6. You're experiencing symptoms of meningitis.

Meningitis—which can be caused by a virus or bacteria—is inflammation of the thin tissue that surrounds the brain and spinal cord, called the meninges, according to the US National Library of Medicine's MedlinePlus. Viral meningitis is more common; and while it can happen to anyone, meningitis is more common in those with weakened immune systems.

Meningitis can turn serious very quickly, so if you experience symptoms like a sudden high fever, severe headache, stiff neck, and nausea and vomiting, you should seek medical attention ASAP.

7. You have symptoms of appendicitis.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), appendicitis is inflammation of the appendix, and it's the most common cause of acute abdominal pain requiring surgery in the US.

The most common symptom of appendicitis is a specific type of worsening abdominal pain. "Often it is a general pain in the middle abdomen, near the belly button, then it localizes to the right lower quadrant," says Dr. Fallieras. The abdominal pain often gets worse when you move around, take deep breaths, cough, or sneeze.

The NIDDK says abdominal pain comes first, but can also be accompanied by loss of appetite, nausea, vomiting, diarrhea, constipation, a low-grade fever, or abdominal swelling.

8. Your heartbeat 

An arrhythmia is an issue with your regular heartbeat—when it beats too fast (tachycardia), too slow (bradycardia), or has an irregular pattern (atrial fibrillation), according to MedlinePlus. Others symptoms include lightheadedness, chest pain shortness of breath, passing out, or sweating, says Dr. Fallieras, and warrant an ER visit.

9. You're having a severe allergic reaction.

While many allergic reactions can be mild or controlled through medication at home, some can be severe and life-threatening, per MedlinePlus. The most severe allergic reaction is known as anaphylaxis or anaphylactic shock, and mainly occurs seconds or minutes after exposure to the allergen. If the allergen has been eaten, however, it can cause a reaction hours after ingestion. 

Symptoms of a severe allergic reaction include abdominal pain, abnormal or high-pitched breathing sounds, difficulty breathing or swallowing, heart palpitations, severe swelling, and even unconsciousness, among others.

10. You were sexually assaulted.

According to a news release from the New York State Department of Health, dated April 7, "treatment of patients for a post-sexual assault medical forensic exam is an essential service in all New York State (NYS) hospital emergency departments." That's because, depending on consent from the victim, medical professionals can gather a forensic history, perform a medical examination and coordinate treatment, and document findings. Patients can consent to involvement by law enforcement at that time, as well. Hospital staff can also offer sexual assault victims information on sexually transmitted infections, pregnancy, suicidal ideation, and alcohol and substance abuse, and provide recommendations for additional treatment and services. While hospitals may have to make changes to their current policies due to COVID-19—like relocation of sexual assault services within the hospital—treatment will not be compromised.

11. You're experiencing severe COVID-19 symptoms.

First: Most mild cases of COVID-19 do not warrant a trip to the ER, though they can still benefit from a telemedicine consult or call to your doctor—especially if you want to be tested for COVID-19.

But if you're having more severe symptoms, you should seek help ASAP. “If you have a bad cough, chest pains, shortness of breath, and are unable to walk much without needing breaks; or if you have comorbidities [COPD, diabetes, heart disease] and have symptoms of COVID 19, I would absolutely recommend coming to the ER,” says Dr. Lawrence.

The CDC also underlines the importance of seeking emergency medical care for severe COVID-19 symptoms, urging people to go to the ER if they experience trouble breathing, persistent pain or pressure, new confusion or inability to arouse, or bluish lips or face. Of course, the CDC says that this is not an inclusive list, and that anyone experiencing any severe symptoms that are concerning to them should seek medical care—a good rule of thumb for any of the above conditions or symptoms as well.

The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDCWHO, and their local public health department as resources.

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