We swore an oath: “Primum non nocere” — First, do no harm. When pandemic stress began to bear down on our hospitals, we scrambled to manage the burden of volume and simultaneously mitigate the threat of contagion. In our war efforts, we donned our hazmat suits, and pleaded with everyone to do their part. We stopped most elective procedures and shut our doors to visitors, families, even volunteers. What we couldn’t avoid was the ill-consequence of these actions. Our patients would suffer more than they should, and our staff would bear an unmeasurable burden. The best we could manage was to try and do less harm.
In Italy, which was hit early and hard by the pandemic, hospital admissions for acutely decompensated heart failure (ADHF) declined, according to data pooled from 8 Italian hospitals. But those patients who did present to the hospital had more severe symptoms. This pattern was also seen in London where among new ADHF admits to King’s College Hospital, approximately 20% more had reported NYHA Class 3-4 symptoms and worse peripheral edema. Furthermore, a study at King’s College and Princess Royal University Hospital found hospitalization in 2020 was independently associated with worse in-hospital mortality. In the German Helios system of 67 hospitals, in-hospital mortality increased from 6.0% to 7.3%, compared to control groups from the previous year. In the same system, ICU level care was needed more often during 2020 for ADHF admissions, and in-hospital mortality rates rose to 7.0% (from 5.5%).
Though hospital admissions for CHF were down overall, our sickest patients kept coming through the doors, and for many possible reasons they were even sicker. Were they more sedentary stuck at home and over-indulgent with salt and fluids? Did they wait longer before seeking help? Were they going without medications, avoiding trips out to the pharmacy, or missing their home nurse visits? Did their scheduled follow-up office appointments get canceled since their doctor was too busy at the hospital? Or did they get infected? Our destination LVAD center also absorbed tremendously sick patients from outlying hospitals for advanced heart failure management. As a result, we needed to use more temporary mechanical support devices for cardiogenic shock. And in 2020, we performed more durable LVAD implants than in any preceding year.
But despite our collective heroic efforts, we have been met with new challenges. An honest look at the year in review sees beyond the numbers. We have all borne witness to the ill-effects of hospitalization during pandemic months. We have seen an increase in depression as well as delirium and how it can impair recovery. The lack of family visitation (during COVID-19 restrictions) has led to emotional distress and its domino effects, including decreased appetite and poor nutrition, disinterest and disengagement with medical staff and therapy services, even psychomotor slowing and delayed neuromuscular recovery post-operatively. We have seen poor wound healing and more aspiration events. Subsequently, some patients have had longer hospital stays, creating a vicious cycle of more time isolated from family and friends, captive in a foreign and sterile environment, with the sparse human interactions constrained to hidden faces, muffled voices, and minimal physical contact.
Patients with chronic medical illness are at higher risk for mood and anxiety disorders, sometimes suggested to be as high as twice the risk of the general population. In heart failure patients, the prevalence of clinical depression ranges from 18 to 21%, double rates of major depressive disorder in general community samples. Syndromes involving depressive and anxious symptoms are often more challenging to diagnostically classify since neurovegetative symptoms overlap significantly with constitutional symptoms of disease. Some chronic conditions and the medications used to treat them, such as beta-blockers, directly cause depressive effects. Add on top of all these complexities the descent of a global pandemic of life-threatening, possibly untreatable, and novel infectious disease with “lockdown” quarantine and isolation mandates, and the problems of mood and anxiety can explode.
Many unique features of a pandemic situation layer on depressive and anxious reactions. Looking at standard screening scales for depression and anxiety within U.S. census data, adults in 2020 were more than three times likely to screen positive for depressive disorders, anxiety disorders, or both, compared to 2019 census data, at a rate of more than one-third of the 2020 sample. The prevalence of anxiety was higher in earlier months of the pandemic, with depression increasing significantly in later months. New investigations address the psychological effects suffered by patients and families due to the bans on visitation in hospitals, causing terminally ill patients to die without the presence of their loved ones. COVID has added a layer of distress fueled by fearful social isolation, increasing psychological symptoms in LVAD recipients and other chronically ill populations.
As a multidisciplinary team, we have had to respond – all while dealing with the stress ourselves. Few of us were sidelined by COVID-19 infection, but all of us shared in the hardship of longer work hours. We bore witness to more death and despair and felt the pangs of isolation between shifts when our own potential exposures removed us from the tangible support of loved ones. We have been left physically and emotionally drained. But like soldiers, we rise to the bugle call and press on with marching orders. We find a way to rally, to respond to the attack, to mitigate the damage.
We have all leaned on each other to grapple with the unknowns of this new virus, with still much to learn as we dissect the data from this modern-day plague. Though the pandemic stress has been taxing, we can look back to see the remarkable endurance and resilience of the human spirit. Like the stories of the Titanic, when so many lives were lost to the icy waters of the deep, we remember the lifeboat that risked capsizing in panic and chaos by turning back to rescue just a few more souls. That has been similarly portrayed time and again at health care facilities across the globe. Even when the burden of disease seemed overwhelming, especially in emergency rooms, nursing homes, and intensive care units, health care workers kept showing up – kept turning back. Though the virus has claimed over 2.5 million lives so far, the devastation could have been so much worse if not for the care and compassion, selflessness, dedication, and altruism of frontline workers and health care heroes. Again, we swore an oath. And we meant it. To all of you – indeed all of us, kudos! And thank you.
Thomas M. O’Brien is a cardiologist. Marie E. Rueve is a psychiatrist.
Image credit: Shutterstock.com
