First Do No Harm With COVID-19: Corona Collateral Damage Syndrome

Author Affiliation
Lawrence Stock, MD Antelope Valley Hospital, Lancaster, California and David Geffen School of Medicine at UCLA
Mark Brown, MD Antelope Valley Hospital, Lancaster, California and David Geffen School of Medicine at UCLA
Georgienne Bradley, MA Sea Save Foundation, Malibu, California


Communication is complex in that what we say is not always what is heard. Communication that is intended to help can sometimes result in doing harm. The COVID-19 pandemic is a public health emergency. While we rapidly learn of the scientific and healthcare aspects of this disease, there is an opportunity to better understand the consequences of well-intentioned communication by experts.

Given the nature of the rapid global spread of the virus and the high fatality rate of those sick enough to require intensive care, public health and elected-leader messaging of “Stay at Home” was appropriate. With no vaccine or cure, the public health tools of social distancing, respiratory and hand hygiene, and stay-at-home orders were both appropriate and effective at flattening the curve and delaying the peak caseload of COVID-19. Most locations in the US were successful in avoiding overwhelming hospital resources including intensive care units.

However, there are increasing reports from the US and other countries that outside of high-demand hot spots like New York City, most emergency departments (ED) and hospitals have experienced a steep decline in their patient census. ED visits declining 50% or more through the end of April have been widely reported.1 Emergency physicians, cardiologists, neurologists, and acute care surgeons wondered, where did all the acute, non-COVID-19 patients go?2,3 While the number of trauma incidents may have dropped off due to stay-at-home orders, it is unlikely that heart attacks, strokes, and acute surgical emergencies had stopped occurring.

Then we started seeing delayed presentations of many diseases with their resulting complications: appendicitis with rupture; completed heart attacks; and strokes with significant deficits, to name a few.4,5 These are time-sensitive conditions in patients who were coming in past the optimal window for treatment. Why did this occur, what role did our messaging play, and how can we correct this in the future?

Corona collateral damage syndrome (CCDS) is the clinical condition resulting from a delay or failure to seek or receive care for acute emergencies for non-COVID-19 medical conditions.3 The key cause of CCDS is the fear of catching the virus by coming for care to hospital EDs or other healthcare facilities. This fear appears to have been principally associated with the strong but important message: “Stay at Home.”

This message was said repeatedly by authority figures and amplified by news networks over the past few months. This barrage of messages was effective in getting the public to social distance and stay home. However, the unanticipated collateral damage was the fear of seeking help for other concerning symptoms.6 We have the opportunity now to course correct and nuance the message:


“If you are having an emergency, go to the Emergency Room. Hospitals have taken dramatic steps to protect emergency patients from contracting COVID-19.


We are reminded that language matters and communication has consequences, some unforeseen. Always best to ask the listener what they heard.


Section Editor: Mark I. Langdorf, MD, MHPE

Full text available through open access at

Disclaimer: Due to the rapidly evolving nature of this outbreak, and in the interests of rapid dissemination of reliable, actionable information, this paper went through expedited peer review. Additionally, information should be considered current only at the time of publication and may evolve as the science develops.

Address for Correspondence: Lawrence Stock, MD, Antelope Valley Hospital, 1600 West Ave J, Lancaster, CA 93534. Email: 7 / 2020; 21:746 – 747

Submission history: Revision received May 3, 2020; Accepted May 4, 2020

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.


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3. Rubin J. Where are the strokes and the heart attacks? Doctors worry as patients avoid the ERs. Available at: Accessed April 30, 2020.

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5. Kolikonda MK, Hussain MS, Uchino K. Invited commentary: acute stroke preparedness during the Covid-19 pandemic. Available at: Accessed April 30, 2020.

6. Rosenbaum L. The untold toll — the pandemic’s effects on patients without Covid-19. N Engl J Med. 2020.