Delayed treatments will likely jolt healthcare system for years – San Bernardino Sun


As the region re-emerges from the staggering omicron surge of the coronavirus, health professionals from the San Fernando Valley to San Bernardino to Long Beach are facing yet another blunt reality: COVID-19’s impacts among those with unchecked underlying conditions.

Physicians are sounding alarms as people with serious non-COVID-19 conditions continue ignoring symptoms and waiting until the last minute to go to emergency rooms, fearful of contracting the virus.

As a result, some are dying unnecessarily, heart disease rates are soaring, advanced and late-stage cancer is growing, diabetes is going unchecked and, consequently, physicians are seeing more patients in emergency rooms, officials said.

“We are now starting to see some of those ramifications in the long term; it’s the tip of the iceberg,” said Dr. Ali Jamehdor, medical director of emergency services with Dignity Health St. Mary Medical Center in Long Beach. “For example, more acute things that flare up, patients who have diabetes in a severe acidosis state are being admitted to the ICU for insulin drips.”

Jamehdor said the delays in treatment have amplified the contrasts between managing health conditions in a timely way and treating them in later stages. The result is that it’s often too late to save a limb, or worse, a life.

“Now we are seeing the longer-term effects with diabetes and wound care,” he said. “Patients with a small wound on their legs, their fingers who would usually come in earlier. Now they are showing up about a year and a half later with very advanced stages … and are having amputations. This happens in healthcare. It’s not an unknown thing or a completely rare thing, but it didn’t happen as much as we are seeing now.”

With the state now pivoting to a post-surge, endemic phase, healthcare professionals are hopeful the worst of the coronavirus is behind us. But after two years of urging testing, vaccinations, masks, and caution over COVID-19, a renewed message — seen before after past surges — is reemerging: Putting off routine doctor’s visits and screenings leave many susceptible to potential vascular disease, heart attacks or strokes, cancer and diabetic conditions, which detected early may be prevented.

Those showing up at hospitals now are showing up mainly because they have reached their threshold for pain, officials said.

They have myriad reasons for not seeing primary care doctors earlier. Fear of contracting COVID was the most common. But there were others, including early in the pandemic, when doctor’s offices and hospitals were forced to shutter.

Then, as things started back to “normal,” the delta variant hit and most recently, omicron.

“There has certainly been a lot of ups and downs with COVID,” Jamehdor said. “Two years ago, there was a huge change in medicine where the hospitals and emergency departments completely emptied out. It was like a ghost town where a few very sick COVID patients came through, everyone was at home, everyone was staying away from ERs and rightfully so, because at that time there was a new virus and it was a very scary and a very dangerous time. We had no idea what was going on.”

Today, doctors and hospital staffs say they know how to keep everyone safe from contracting the deadly virus.

But more awareness is necessary.

“We saw some catastrophic conditions after the first surge, where patients were concerned about coming to the hospital,” said Dr. Jahandar Saleh, a cardiologist and director of Cardiology Telemetry Services at Dignity Health Northridge Hospital. “We had a lot of patients who had already completed their heart attacks or already caused significant damage to their heart and or were at a higher frequency of cardiovascular events lately, in part, because they were not getting their preventive care.”

Still vulnerable

Saleh said the hospital is very busy now — the result of worsened non-COVID conditions that have led to acute emergencies.

“They simply weren’t coming,” Saleh said. “They stayed at home and died. Now we are seeing an overabundance of cardiac events. I surmised it has something to do with the fact they have not seen their primary doctor, they didn’t have their blood sugar treated or blood pressure controlled. Even when they do come now, we are seeing a lot of very uncontrolled risk factors. Also, people now may have had a heart attack and perhaps damage has already been done.”

Saleh is hopeful the worst of the pandemic is over. But he is cautious due to still high viral loads in communities, which make people with underlying cardiac conditions vulnerable.

“The virus can cause an inflammatory state,” he said. “There are so many COVID-positive patients out there setting off cardiovascular events. As far as cardiac disease, I would imagine we will continue to see a steady state of cardiac events and cardiac disease not just that COVID is present, but the population is aging and there needs to be continued emphasis on risk-factor modification and prevention of the disease.”

Early in the pandemic, some patients’ conditions worsened.

They might have been in the middle of a medication adjustment, ran out of medication, or weren’t being seen for simple conditions such as high blood pressure.

“As a cardiologist at the hospital, when patients came in, I would ask what happened and they would tell me they couldn’t see their doctor, it had been six months or a year since they saw one, appointments had to be rescheduled because offices were closed,” said Dr. Prabhdeep Sethi, an interventional cardiologist with St. Bernardine Medical Center in San Bernardino. “We were only doing telehealth (an online doctor visit or telephone call). Medical staffs quickly realized patients didn’t always have the technology or resources to access telehealth in many cases.”

Sethi said telephone calls work best for very stable patients, but not seeing them and having them describe their symptoms and any signs of disease makes it extremely difficult.

“We already have challenges with language and translations, and add the inability to do a physical examination, that severely limits you,” he said. “In those lapses, patients were most vulnerable. Patients like the physical contact, the eye contact, being in a room and speaking with a physician. Patients started to cancel appointments, because they thought (telehealth) wasn’t worth it.”

Delayed cancer screenings: The ‘ripple effect’

According to Dr. Ronald Tang, an oncologist and medical director with the Dorothy Leavy Cancer Center at Dignity Health Northridge Hospital, there has been an unprecedented increase in morbidity from cancer in stage IV patients due to a decrease and lack of early detection practices.

Many patients neglected early symptoms and were upstaged to more advanced cancers that required chemotherapy instead of minor curative surgery.

Mammograms, colonoscopies, pap smears and low-dose CT scan screenings for lung cancer all decreased during the pandemic by 80% during its height.

Racial and ethnic minority groups with low incomes, when their access to medical services decreased at the beginning of the pandemic, showed even steeper declines in screening and thus led to more cancer morbidity, Tang said.

“Since 1990, overall cancer death rate had decreased annually until the pandemic when there was an uptick of 8 percent to 10 percent. Gastroenterologists have seen more advanced colon cancers, urologists have seen more advanced prostate cancers and gynecologists have seen more advanced ovarian, endometrial and cervical cancers across the board,” Tang said.

Tang said the deficit in cancer screening has put a financial strain on the U.S. healthcare system.

Delay diagnoses is estimated to increase cancer spending by $20 to 30 million dollars.

“There is also an emotional toll on the patient and the families including the healthcare providers,” Tang said. “It completely breaks my heart when I have to tell a patient (they have) stage IV terminal cancer and thus there is no chance of cure. If (they) had only been screened six to eight months earlier or had been seen even through a telemedicine follow up, their cancer could be treated and cured.”

Because of a drop in screenings, patients subjected themselves to higher-risk surgeries and suffered from side effects from nausea, vomiting, hair loss, fatigue and appetite loss due to the toxicities of chemotherapy.

“This deficit in screening during the past two to three years … will have a ripple effect that could continue to affect cancer care in America for the next five to six,” Tang said. “Hope is not lost, however, if we can shrink the screening deficit. We can reverse the trend in hopefully two to three years.”

Diabetes in a COVID-19 world

Then there is diabetes and high blood pressure.

Medical experts agree they are silent killers.

Blood sugar can be at dangerous levels for weeks and blood pressure dangerously high without their effects being physically noticed. But with regular checkups, red flags could pop up.

Prevention and catching conditions early are key.

According to the Centers for Disease Control and Prevention, more than 37 million Americans have diabetes and face its potential devastating consequences.

The disease is growing at its own high rate in the United States, according to the American Diabetes Association. Add on the pandemic and financial hardships due to job loss and potential health insurance issues, and that leads to another set of challenges.

Paying rent and buying healthy food and much-needed medications can become a juggling act.

At Dignity Health Northridge Family Medicine, Sheryl Rosenberg Thouin, a registered dietician nutritionist who specializes in diabetes, has seen the after-effects off sedentary adults working remote all day from home and inactive school-aged children eating processed foods.

Those bad habits can lead to obesity and eventually diabetes, doctors say.

“When you think about the U.S. being so hard hit with COVID, …. we are also a nation of obese individuals with pre-existing conditions who tend not to exercise and eat ultra-processed food more so than many other similarly developed countries,” Thouin said.

Thouin sees more young, obese children with type 2 diabetes coming through her clinic.

Normally, type 2 diabetes is an adult condition.

“For years you would rarely see type 2 diabetes in school-aged children,” she said. “Type 2 means you have an insensitivity to your own insulin and it happens because of obesity. It’s genetic and obesity can bring it on. Prior to COVID, kids were eating sugary cereals, fast foods, not getting physical activity or exercise, but the pandemic made the situation even worse. Today many children are living the lifestyle of an overweight adult who is a couch potato at the end of the work day.”

Thouin points to a number of factors contributing to childhood obesity, from genetics to  sedentary time on video screens.

“You put the pandemic on top of it, it’s fast food, it’s comfort food, it’s cheap foods and especially for low-income families who have to go to work and their child is at home maybe being watched by another sibling but there are no rules at home, you can eat what you want, you can watch TV,” Thouin said. “So, that has made it worse and with a customary diet marginal in vegetables, fruit, lots of processed foods and limited physical activity and genetics for type 2 diabetes that’s quite a powerful combination. It was bad before … and now it’s even worse.”

Still, Thouin sees 2022 looking more hopeful.

Health care experts are savvier in treating COVID, vaccines and boosters are playing an important role and she can bring patients into the clinic and protect them by taking precautions. She can also visit them through telehealth and see exactly what foods are in their cabinets and refrigerators.

“It’s all something that is manageable by paying attention to taking medications you need to be taking, trying to eat the type of foods that keep your blood sugar in a good range,” Thouin said, adding that those with food insecurities are especially challenged. “You have to balance food shortages with obtaining sufficient calories even though those calories may not be the best.”

Diabetes is among the number the many factors requiring kidney dialysis, according to Carolyn Lemos-Urquidez, president of the nonprofit San Fernando-based Kidneys Quest Foundation Inc.

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