Joseph S. Bushra still wonders whether he could have done more for the woman, who was in her mid-40s. She turned up in his emergency room earlier this month with severe neurological symptoms. Her worried family had pleaded with her to go to the hospital, but she refused. She was too afraid of the coronavirus.

“By the time she came in, it was too late for her, and she died,” said Bushra, an emergency medicine specialist at Lankenau Medical Center in Wynnewood. “There was nothing we could do. It’s tragic. … The virus kept her from coming to the hospital when she should have.”

Bushra said he didn’t know if he could have saved her life had she come in sooner, “but we would have had more of a chance.” He said she died of “a neurologic condition,” but declined to elaborate to protect her family’s privacy.

The woman’s death highlights a disturbing trend seen by emergency doctors and paramedics across the Philadelphia region: a decline in the number of people being rushed to the hospital — with a palpable drop in patients with heart attack and stroke symptoms, like chest pain and numbness.

Temple University Hospital, for instance, reported a 27% drop in heart and stroke patients between March 1 and April 9, compared with the same time last year. Virtua Health has seen a small decline in heart attack and stroke cases, while Penn Medicine and Main Line have not. Most other hospitals in the Philadelphia area say it’s too early to offer solid data, but are worried about this troubling trend gaining steam.

“The reduction in volume is concerning,” said Kraftin Schreyer, an emergency medicine doctor at Temple’s Episcopal Campus. “We have to assume that the disease prevalence for heart attacks and strokes hasn’t changed, which brings me back to the initial concern that patients are trying to manage their complaints at home because they are potentially afraid of getting exposed to virus in a hospital setting."

Megan Stobart-Gallagher, an emergency physician at Thomas Jefferson University Hospital, said doctors are grappling with a two-headed dragon: a flood of severely sick patients with a virus they know little about, and a scary decrease in patients with familiar diseases they’re used to treating.

“In addition to seeing the numbers of COVID-19 patients go up, the other thing that’s worrying a lot of emergency doctors is, where are the patients with the appendicitis? Where are the patients with the bread-and-butter stuff that we are used to seeing on a daily basis?” Stobart-Gallagher said. “We’re worried about those people who may be staying home.”

Non-COVID-19 patients are sicker

Overall, emergency department admissions have dropped at many hospitals, which could be due to many factors, namely that stay-at-home orders prevent people from participating in the types of activities that land them in the hospital. People who come to the ER with minor ailments may instead be turning to urgent care clinics or telemedicine, which has surged in popularity during the pandemic.

But emergency doctors are not referring to those patients. They’re talking about people who are so scared to go to the ER that they’re self-triaging serious conditions, such as patients who arrive at the hospital in near-septic shock from untreated urinary infections, said William Pace, an infectious disease doctor who works in several Philadelphia-area hospitals.

“Patients who come in with non-COVID-19-related stuff are dying at higher rates,” he said, and noted a 35-year-old patient who died of pneumonia within 24 hours of arriving at the hospital — an unusual cause of death for such a young patient.

Patients who have had heart trouble in the past are at greater risk of serious complications from the coronavirus and may be particularly wary of risking exposure by going to the hospital.

Still, when treating heart attacks and strokes, every minute matters. Patients who delay seeking care could end up with more permanent damage to their heart or brain than if doctors had been able to intervene sooner.

“The major message has to be that with a heart attack or heart failure, staying home is not a good place to be,” said William A. Gray, a cardiologist at Main Line Health and president of the American Heart Association’s Philadelphia chapter. “Elective procedures are on hold, but it’s fair to say a heart attack is not elective.”

Reports from cardiologists around the country who have seen a “sudden drop” in heart attack patients in recent weeks spurred the American Heart Association to launch a new media campaign, urging people to call for help at the first signs of heart attack or stroke, which include sudden chest tightness, light-headedness, slurred speech, and limb paralysis. Other warning signs include severe headache, vomiting, and blurred vision.

‘They’re waiting it out’

First responders have noted an overall drop in their hospital trips.

Calls to Narberth Ambulance, whose paramedics respond to 911 calls from five towns with roughly 100,000 residents, is down by about half, said David Zaslow, the squad’s president and assistant chief.

The Philadelphia Fire Department declined to enumerate its ambulance calls, but according to an Inquirer analysis of EMS event totals tweeted by the department daily, volume is down 14% in the first two weeks of April, compared with the same period last year.

After the virus began to spread, ambulance transports by the Second Alarmer’s Association and Rescue Squad in Montgomery County dropped from between 20 and 25 a day to about 15, said Kenneth Davis, assistant chief.

Davis suspects the drop is partly due to fewer people out doing things that land them in the hospital — kids aren’t breaking bones playing baseball because sports are canceled, and there are fewer car accidents because no one has anywhere to go.

At the same time, he said, the people who are calling for an ambulance are “a little sicker than normal.”

“That would go to the theory that they’re waiting it out,” Davis said.

Patrick Glenn, a lieutenant and paramedic with Narberth Ambulance, recalled a 68-year-old Haverford man who recently put off calling 911 because he assumed his symptoms were just a stomach bug. By the time he called 911 two days later, he was so sick that he went into cardiac arrest in the ambulance.

“He was very close to being too late,” Glenn said.

‘The second health crisis’

Doctors stressed that the risk of putting off needed emergency care could be greater than any possible risk of contracting the virus by going to the ER. Hospitals are taking precautions to protect patients from exposure, such as requiring all staff to wear masks, increasing cleanings, and separating patients with symptoms.

Knowing that some patients may still be inclined to put off treatment, cardiologists at Penn Medicine have been checking in with heart patients through telemedicine visits, said Lee R. Goldberg, Penn Medicine’s chief of advanced heart failure and cardiac transplant.

Rates of stroke and severe heart attack cases at Penn Medicine are on par with previous years, which Goldberg said could partially be due to the health system’s efforts to proactively reach out to patients through telemedicine.

Still, doctors worry about the patients they haven’t met yet, who may be experiencing heart or stroke symptoms for the first time, said Jonathan Lee Gleason, Jefferson Health’s chief quality officer.

“The first health crisis of 2020 was COVID-19; the second health crisis of this year will be all the impact of delayed necessary medical care” due to nonurgent procedures being delayed, and, Gleason said, “people who just didn’t come in because they thought it wasn’t safe.”