Medical Examiner

Los Angeles’ Intensifying COVID Nightmare

Patients left to wait in hospital hallways. A horrifying death rate. A desperate need for mass vaccination.

A hand injects a vaccine into an arm.
A dose of the Moderna COVID-19 vaccine is administered to a staff member at the Ararat Nursing Facility in the Mission Hills neighborhood of Los Angeles on Jan. 7. Mario Tama/Getty Images

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The coronavirus pandemic is still affecting Los Angeles in a frightening way: The city is on the threshold of having 1 out of 10 residents test positive for COVID, and on average, one virus-positive patient is dying there every 10 to 15 minutes. Dr. Clayton Kazan has seen the virus’s effect up close, through his ER shifts, when he treats patients who may be unlikely to live, and his work with the L.A. County Fire Department, where he tracks how firefighters and EMTs may be a part of community spread. Despite witnessing these tragedies firsthand, Kazan hasn’t given up hope. Back in March, Kazan helped increase the L.A. County’s testing capacity from a few hundred people a day to more than 10,000 a day, and he may get tapped again to help the entire region get immunized. I spoke with Kazan on Wednesday’s episode of What Next to get a personal view of L.A.’s COVID crisis. Our conversation has been edited and condensed for clarity.

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Mary Harris: The hard thing about this moment is that so many of these coronavirus deaths should have been preventable, but by the time you reach patients in the ER, they are not. And hospitals are reportedly out of capacity.

Dr. Clayton Kazan: They say the ICU capacity is zero. It’s not zero. It’s actually a large negative number. Zero percent capacity doesn’t account for the fact that I’ve got, across our system, hundreds and hundreds of patients waiting for ICU beds. And sometimes the only way an ICU bed comes available is if the patient in there dies.

Many L.A. hospitals are “on diversion.” What does that mean?

Ambulance diversion means that the hospital makes a request that they not receive ambulance patients for usually for an hour. It’s actually been increased now to the point that when we decide a patient needs to go to the hospital, we take a look at which hospitals in our area are on diversion. If there’s one that’s not, we will divert the patient to that hospital. But often what we’re seeing right now is that every hospital in the area is on diversion, and they kind of have to take our patients nonetheless.

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How does that go?

Not always very well. Sometimes we show up and the doctors will come out and they’ll look at us with sad eyes, sigh, and then go to work. Sometimes when they’re particularly in a moment of exasperation, they look at us then look away and go back to work, and our patients get ignored for extended periods of time because they just don’t have the capacity mentally or institutionally. We’re finding that’s increasingly the case.

So your patients are on a stretcher maybe in a hallway or outside? Where do they even go?

Depending on the hospital, sometimes in the hallway, sometimes outside, sometimes sitting in the ambulance for hours.

We’re working on some strategies right now, including one we launched last week and applied couple of times. It’s kind of an ambulance consolidation, to have one ambulance crew watch multiple patients so the other ambulances can go back into service. That’s based on federal law: When a patient arrives at the hospital, the patient belongs to the hospital, even if the hospital doesn’t accept them. But ultimately we end up providing care for the patients and keeping an eye on them, trying to put as many ambulances back in service as we can and then trying to alert the hospital if anybody begins to deteriorate, which does happen at any given time across our system. We could easily have 100 ambulances waiting outside. But with this new plan, we’re going to be consolidating them in tents. When you have patients in the back of an ambulance, you can’t have one crew watching multiple ambulances. But if you put them in an area where the crew can easily see all of them, it’s much, much easier to accomplish.

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Last week, L.A. got a lot of attention because of new directives that seemed to limit the kind of care emergency workers could give. EMTs were being told to save oxygen for the most severe patients, to avoid running out. And they were also being reminded not to bring patients in cardiac arrest to the hospital if they had a low likelihood of resuscitation. You’ve said these rules are actually best practices, not necessarily rationing of care. And because the country’s in the middle of emergency, things are going to look different for a little while.

Part of it is we have to shift our mindset. If a plane crashes or there’s a mass shooting, the standard of care immediately changes. You just train up whom you have. You find volunteers. You have to train laypeople to do things like put a tourniquet on or monitor patients. In those circumstances, that goes on without question. But in this type of environment where you have this slow-rolling, severe disaster, there’s been a hesitancy to do that. People tend to try to manage things within their normal operating procedures, only just stretching it and stretching it and stretching it rather than changing and getting into a disaster mindset.

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When you get into a disaster mindset, it’s all about triage. Once we get caregivers to think with that mindset, then our ambulances turn around faster and they get it. Sometimes we just have to walk at patients and say, this person can go to the lobby, but that one should be on a heart monitor. It’s just hard in practice to do it.

Are you thinking you may be working with health institutions to give vaccinations, make sure it’s all going the way it needs to?

I know that the city fire department for L.A. is being tasked with helping to launch a massive vaccine site, and we’re anticipating that we’re going to be asked to help ramp up this effort across the county. We don’t know for sure. We just know that we have been hearing from our public health colleagues that they’re having trouble getting Phase 1A complete. I think that they’re going to be looking at us as an army that they can put to the task to get it done.

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I look at it as we need to get this done because this is how we really turn the corner. In terms of our number of people out sick with COVID, we have trended right along with the surge in the county. Our positivity rate went way up. We got our vaccine first allotted to us on Dec. 23, and we had our first mass vaccination the next day. We gave I think 1,320 vaccines on day one, and we’re at about 2,900 or so right now.

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Did your firefighters universally take the vaccine, or did you have to convince anyone?

We did social media, we did departmental advisories, we did videos, we went out to fire stations, we did a live Q&A, and we published that Q&A so everyone could read it. With that, we have gotten to right around between 70 and 75 percent adoption, which is right on par with the higher-performing health care institutions. And I think there are still some in that 25 to 30 percent whom it will be possible to convince, but there are some who are going to refuse and we have to just keep trying.

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Do you go to them and have one-on-one conversations?

In our department, when we did the mass vaccination sites, one thing I’m convinced we did right is we didn’t let anybody refuse it remotely. Everybody had to come in to one of the sites to refuse. I’ll use an example of an outpost near my house that has a three-person station, a fire engine, and that’s it. If one of the people is, say, a probationary new firefighter and his captain is an older captain, it is entirely possible that that captain will have very strong feelings against the vaccine, and it be very easy to fall into groupthink and end up just declining. So we have rotated our apparatus around the county to ensure every person has an opportunity to come in, accept or decline for themselves, and have their questions answered.

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