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Research Analysis: 30% of COVID-19 patients present without fever, respiratory distress or cough

A study from King County, Washington, characterizes COVID-19 patients receiving care from EMS


The majority of individuals included in this study lived in long-term health facilities and required EMS intervention for their symptoms.

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A retrospective cohort study from Seattle, Washington was recently published online in the “Journal of American Medicine.” Researchers examined the characteristics of COVID-19 patients who received EMS care in the Greater Seattle Area. For the study, “Clinical Characteristics of Patients With Coronavirus Disease 2019 (COVID-19) Receiving Emergency Medical Services in King County, Washington,” researchers analyzed 124 patients who required 911 care for COVID-19 from Feb. 1, 2020, through Mar. 18, 2020.

These patients were identified as COVID-19 positive by nasopharyngeal swabs collected 3-9 days after their EMS encounter and were subsequently added to the study group. Age, underlying health conditions, clinical characteristics, symptoms, examination findings, EMS impression and care were all included in the analysis.

The researchers found that EMS responded to 16% of the 775 confirmed COVID-19 cases in King County during the study time period. The mean age was 76 years and the most common underlying health conditions included hypertension (35%), cardiac disease (33%), lung disease (21%), diabetes (20%) and dementia (19%). Only 5 patients had no underlying health conditions. Almost half, (46%) of patients resided in a long-term care facility.

The most common dispatch codes included illness of unknown origin (28%), difficulty breathing (25%), trauma (15%) and infectious disease (13%). Primary EMS impressions included flu-like symptoms (25%) and respiratory distress (20%). The most commonly recorded symptoms were fever (46%), shortness of breath (44%) and fatigue (40%).

During EMS evaluation, 29.3% of patients had no fever, cough or shortness of breath. 33% of patients required oxygen and/or ventilation support while 24 encounters (16%) required advanced care, including intubation or other aerosolizing procedures.

Memorable quotes from “Clinical Characteristics of Patients With Coronavirus Disease 2019”

Here are some points made in the published research:

“Of the 147 EMS encounters, 91 dispatch assessments (62%) and 43 EMS evaluations (29%) for patients with COVID-19 did not present with symptoms of fever, respiratory difficulty or cough.”

“Although there was some evidence of presentation difference based on residence status, nonspecific symptoms and signs were prevalent among those residing outside long-term care facilities.”

“These observations are consistent with reports demonstrating older persons and those with comorbidities have the highest risk of mortality related to COVID-19 and so could be expected to have more severe illness and require EMS and emergency care.”

Top takeaways from King County, Washington EMS encounters with COVID-19 positive patients

Here are 3 takeaways from the study on COVID-19 patients who received EMS care in the Greater Seattle Area.

1. COVID-19 doesn’t always present with a fever and respiratory symptoms

Not every patient presents with the classic fever, cough and shortness of breath that we have associated with COVID-19. About 30% of patients with COVID-19 presented to EMS without any of these three symptoms. Screening for COVID-19 using only these three symptoms may not be adequate for determining whether a patient is likely to be positive.

As COVID-19 becomes more prevalent across the country, EMS providers should have a high suspicion that their patient may be COVID-19 positive and take the necessary precautions to protect themselves and their team despite a lack of fever and respiratory distress.

2. COVID-19 patients can have a variety of symptoms

Fever (46%), shortness of breath (44%) and fatigue (40%) are still the most commonly reported symptoms of COVID-19, but many other symptoms are also reported. These include cough, altered mental status, nausea/vomiting, diarrhea, headache, sore throat, muscle aches and joint pain. Patients may have many different symptoms and EMS should have a high suspicion for COVID-19 on calls that appear to have an infectious etiology.

3. Elderly and those with comorbid conditions are at higher risk

This study reaffirms the belief that the elderly and those with underlying health conditions are more vulnerable to COVID-19. The majority of individuals included in this study lived in long-term health facilities and required EMS intervention for their symptoms. Additionally, individuals who lived in long-term care facilities had a much higher mortality rate, 73%, when compared to those who lived independently, 35%.

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Marianne Meyers, BS, is a third-year medical student at the University of Washington School of Medicine interested in pursuing emergency medicine. Previously, she was a member of the Santa Clara University collegiate EMS squad where she received her B.S. in Public Health Science. Additionally, she has worked with the King County Public Health Department in Seattle, Washington studying EMT naloxone administration.