On a morning in mid-April, Andrea Ratliff, a south suburban Hazel Crest mother, was struggling to breathe. She had a persistent cough and a nagging fever — both signs of COVID-19.
But she feared what she might encounter if she went to the hospital, imagining a war zone of people sick with the lethal respiratory virus.
"I thought I was going to walk in there and I was going to see people practically dying all around me," said Ratliff, 42.
The parents of Erik Barrera, a Brighton Park 16-year-old, recalled how the right side of his abdomen ached as he video-chatted with a pediatrician from home. His parents worried about taking him to an ER, and who could be lingering with the coronavirus there.
These fears of going to the hospital for even serious symptoms possibly not related to COVID-19 reflect a larger problem. For months, hospitals across the country have told patients to stay away as the new coronavirus raged. They needed every bed they could spare for the sickest patients.
But that message may have caused unintended side effects: Fearful patients who are now told they can start returning to hospitals still aren't showing up, at least not in droves.
In Cook County, there are signs that people have been delaying care since the coronavirus started crippling Illinois in March, potentially contributing to the climbing death toll during the pandemic.
A WBEZ analysis of 911 calls, medical examiners' records and interviews with hospitals, neighborhood clinics and patients has revealed a dramatic drop in people seeking care. The number of people who would typically show up in emergency rooms for heart attacks and strokes, for example, are down significantly. And the number of deaths with unidentified causes, and deaths tied to heart disease, have been on the rise since the pandemic began.
NorthShore University HealthSystem cardiologist Dr. Mark Ricciardi has seen a drop in patients, and believes that in some cases, people are ignoring their symptoms, like chest pain, and dying at home.
"Why would this pandemic 'cure deaths' from heart disease?" Ricchiadi wondered. "Why would we see fewer [heart attacks]?"
On average, up to 10 people a week, arrive in a NorthShore hospital ER with heart attack symptoms and need to have their blocked arteries opened up with a stent. In all of April, only four patients showed up, according to NorthShore.
Petra Peralta (left) and Joel Barrera (right) embrace their 16-year-old son Erik. Erik returned home from the hospital on April 9 after receiving an emergency appendectomy.
Who stopped calling 911 during COVID-19?
From January to April, the number of monthly calls to 911 dispatchers in Chicago dropped by nearly 3,000, according to data obtained by WBEZ. April was the most lethal month of confirmed COVID-19 cases so far, when the new coronavirus killed more than 2,000 people throughout Illinois. In Chicago, two-thirds of people who have died of the virus so far are African American or Latino, underscoring generations of disparities in these communities.
There were fewer calls for emergency help from January to April for several life-threatening conditions, including heart and asthma attacks, chest pain and strokes, according to the WBEZ analysis. The data show that calls from O'Hare and the Loop decreased significantly as air travel dropped and some downtown employees began working from home. But calls from neighborhoods began to drop as well, including from the Near North Side, Austin on the West Side and others.
But here's what was on the rise: calls for difficulty breathing. Shortness of breath is a key symptom of COVID-19. About 4,100 people called 911 in April because they struggled to breathe, up nearly 800 calls since January.
Calls reporting suspected heart attacks declined slightly, but calls for "chest pain" declined by hundreds of cases each month heading into May.
Emergency room physicians at Rush University Medical Center just west of the Loop have witnessed the decline in 911 calls. They normally get 20 to 30 ambulances a day bringing sick patients to the ED.
"We're lucky if we get 10," said Dr. Yanina Purim-Shem-Tov, vice chairwoman of Rush's emergency department.
Patients who arrive by ambulance are mostly coming from nursing homes and homeless shelters, two hotspots for COVID-19 outbreaks.
Overall, there are fewer patients coming to Rush's emergency department. Last year, in April, there were nearly 200 visits. This year in April, there were just over 140.
"They have never ever — and I've been here for a very long time, 18 years — been this low," Purim-Shem-Tov said.
And many of those who are coming to the emergency department are coming later than usual, Purim-Shem-Tov said. She described one patient who fell and hit her head, put up with a persistent headache for a week before heading to Rush, then showed up with significant bleeding around her brain.
Purim-Shem-Tov is part of a Facebook group with emergency department physicians nationwide, a place where they typically discuss interesting cases. Lately, the conversation has turned to their empty emergency departments.
"I'm worried that these patients are getting sicker and sicker, and then COVID will be gone," Purim-Shem-Tov said. "These patients are suffering and they may be too far along to be able to help at that point."
She said there are signs some patients are slowly returning. On May 11, 205 patients visited Rush's ED, surpassing 200 for the first time since the second week in March. Still, the rest of this week, patient visits remained lower than usual, Purim-Shem-Tov said.
There are caveats — and silver linings — in the 911 data in Chicago: Fewer people are being injured or dying from car accidents, falls, and other accidents, which were all down by nearly half.
Experts say this could be a ripple effect of Gov. JB Pritzker's stay-at-home order, in place since March. There's no more dining out, crowded concerts or sporting events for now. In other words, more people are staying indoors, reducing their chances of getting hurt.
A rising death rate on Chicago's West Side
Even primary care doctors embedded in communities, who are often the first providers patients turn to when they don't feel well, are seeing signs that people are putting off dealing with life-threatening illnesses as the pandemic drags on.
At Esperanza Health Centers, a group of clinics on the Southwest and West Sides, in the heart of some of the highest rates of COVID-19 in Chicago, the death rate for their typically low-income and uninsured patients has tripled, said the clinics' chief medical officer, Dr. Andrew Van Wieren.
He acknowledged it's a small sample size, but Van Wieren said of the clinics' roughly 30,000 patients, usually about three die a month. That number tripled to nine in April.
"Certainly we have people on the list who passed away with confirmed COVID, people passing away with suspected COVID and either passed away at home or for whatever reason were in the system and didn't ever get tested, and then passing away from other causes," said Van Wieren.
In some cases these days, people have been delaying medical care because doctors during the pandemic have encouraged them to put off some routine tests and procedures that might have helped identify serious conditions before they got worse. For example, they've delayed procedures to fix their damaged hearts, and blood work that would show rising blood sugars and poor kidney function for diabetics.
Without widespread testing and an unknown number of people who have COVID-19 but don't show symptoms, slowing the spread of the virus has meant less in-person medical care. The idea is to reduce everyone's risk of exposure — patients and doctors alike.
Heart attack patients disappearing from ERs might be among the dead
Even as calls for suspected heart attacks have gone down, the number of people dying of heart disease in Cook County has gone up, according to a WBEZ analysis of county medical examiner's office data.
Heart disease can lead people to have heart attacks, the very patients who started disappearing from Chicago area hospital emergency rooms when the pandemic began.
Heart disease was a leading cause of death in Cook County before the new coronavirus struck, and it's a top killer throughout Illinois. Even still, the number of heart disease deaths in Cook County jumped 28% from January to April, medical examiner's office data show.
There could be even more of these cases within the morgue's deep backlog. The county medical examiner's office is handling an unprecedented number of cases. As a result, the cause of death for hundreds of cases remains "pending." That's a designation given to deaths in which pathologists need more information, such as lab results, before they can determine how someone died. The number of pending cases is now more than a staggering 550 cases.
This year's total number of deaths recorded by the medical examiner is so far more than 5,600 — about 2,800 are due to COVID-19, or half of all deaths in the county.
Many of the pending cases are likely people who died of drug overdoses, said Cook County Chief Medical Examiner Dr. Ponni Arunkumar.
Among the people who died of heart disease, some could have actually died from COVID-19, but just weren't diagnosed, she said.
Most people known to have died of the virus had underlying conditions, such as heart disease. In other cases, people with COVID-19 have had blood clots that caused heart attacks, Arunkumar said.
"When this pandemic ends and you've seen the excess mortality compared to the same time period last year, it will give a true idea of what the increase in deaths is due to the COVID-19 virus," Arunkumar said.
To make sure the county isn't undercounting coronavirus deaths, the medical examiner's office plans to get tissue samples tested for COVID-19 for about 35 people who died between Nov. 1 and mid-April of heart attacks or pneumonia, as well as potentially hundreds of people who died with flu-like symptoms.
Still, the full picture of how people in Cook County are dying during a pandemic may remain woefully incomplete for now. The medical examiner's office only investigates about 16% of the 40,000 people who typically die in Cook County every year, primarily people who die unexpectedly, violently, or now, who are being investigated for COVID-19. People who die at home, for example, may not necessarily be autopsied by the medical examiner.
Hospitals' new message to patients: Come back
COVID-19 cases in Illinois continue to rise, in part, because more people are getting tested. More than 90,000 people statewide have been diagnosed with the virus. More than 4,000 people have died.
But Gov. Pritzker has unveiled a roadmap for how Illinois can start to reopen its economy. That includes allowing hospitals to start welcoming back some patients, like those who need heart procedures. So hospital leaders are pushing a new message, that their facilities are safe, and open for business.
Ratliff, the Hazel Crest mom who struggled with COVID-19 symptoms, eventually tested positive for the coronavirus.
What pushed her to go to the hospital? She couldn't breathe.
"The last two days is when the cough became unbearable," Ratliff said.
She spent several weeks in the hospital, including time spent on a ventilator and on a special bypass machine for the most critically-ill patients.
Barrera, the Brighton Park teen, ended up having appendicitis. His father, Joel, said he was initially concerned about his son catching COVID-19 at a hospital. On the drive to Lurie Children's Hospital in Streeterville near downtown, where his son would have surgery, he envisioned people coughing and otherwise sick once they arrived.
"I did think, 'Maybe we shouldn't go,'" Joel Barrera said in Spanish. "But after seeing my son sick, I knew we couldn't wait."
They took precautions, wearing masks and gloves. When they got to Lurie, there were barely any other patients there. A hospital employee took everyone's temperatures.
And that put Joel Barrera at ease.
Kristen Schorsch covers public health on WBEZ's government and politics team. Follow her @kschorsch. Elliott Ramos is WBEZ's data editor. Follow him @ChicagoEl. WBEZ immigration reporter Maria Ines Zamudio contributed. Follow her @mizamudio.