Working Through L.A.’s COVID Nightmare

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S1: The first thing I need you to understand about Dr. Clayton Kasan is that he’s got this almost alarming pep. That’s what one of our producers called it. Anyway, I think you need PEP to do what he does. He works in emergency services. So if you call nine one one in L.A. County, there’s a pretty good chance you’ll reach someone he manages. The coronavirus means he’s busy, really busy.

S2: From about eight o’clock on, I’m usually in and out of Zoome calls. Sometimes I’ve done what I call the hitting for the cycle where you do like a zoom, a WebEx, a team’s an actual conference call and I’ll hit all the different platforms. And I think my record for a day is like 10 Zim’s.

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S1: Dr. Carson can rattle off the coronavirus statistics in L.A. One covid patient is dying there every ten minutes. But Dr. Carson, he also feels this crisis from a couple of different perspectives. When he works, his emergency room shifts a few times a month. He treats patients who are unlikely to live. And then when he comes back to work at the L.A. County Fire Department, he can plot out the way his firefighters and EMTs are actually part of a community spread.

S3: There is one day at the beginning of this surge where, you know, the numbers come in to me every day. How many new pauses do we have? How many are out sick just in our department? And I’m looking at it. And I started sending out Jif files from Titanic, where the captain is standing at the bridge. As you can see that the ship is going underwater. And I said, this is how I feel at this moment.

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S1: I like this story because I think it explains something important about the doctor. Even when he’s feeling his darkest, he’s still got that energy, that sense of humor. He’s sending out gifts, which at first I thought was a kind of coping mechanism until I asked him to explain it. I got to say, listening to you, you sound almost chipper. Has that gotten harder, sort of maintaining that over the last couple of months?

S2: You know, the interesting thing is I got asked a similar question and I said, well, look, this is a really hard time and it’s the hardest year in my practice for sure. This is my 20th year and it is exhausting. But this is exactly what I trained to do. This is exactly the position I train to be in. And death is in. The emergency department is just part of the job.

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S4: So we get a little bit used to it. I wouldn’t say numb. It’s still it’s definitely it takes a toll on us still. But this is you know, we spent a lot of years training to be in exactly the position that we’re in, but it is tiring.

S5: Today, Dr. Carson is going to take you inside the Los Angeles covid crisis. He’s not going to whitewash what he sees, but he’s also going to do it the best emergency doctors do every day. He’s not going to let you give up hope. I’m Mary Harris. You’re listening to what next? Stick with us.

S1: In order to understand how Dr. Carson does this work, how he faces down death day after day and then gets up in the morning to do it all over again, you’ve got to understand his personal philosophy of mortality, an attitude that is both glaringly obvious in theory, an incredibly profound and application. Death itself, he says, simply isn’t a tragedy.

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S6: The sad part, the tragedy is when people die of preventable death. People die no matter what. People die every day, and death itself is not a tragedy. It’s something that we all are destined to do, preventable death when someone dies, a death that didn’t have to happen. That is where we really have to put our focus.

S1: The hard thing about this moment is that so many of these coronavirus deaths, they should have been preventable. But by the time Dr. Carson gets there, they are not. The magnitude of the problem is hard to imagine. Los Angeles is on the threshold of having one out of 10 residents test positive for covid. Hospitals are reportedly out of capacity. And Dr. Carson says actually it’s worse than that.

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S7: We talk about ICU capacity and they say the ICU capacity is zero. It’s not zero. It’s actually a large negative number, huh? Zero percent capacity means I don’t have any available ICU beds.

S8: It doesn’t account for the fact that I’ve got across our system hundreds and hundreds of patients in ERs and spillover units waiting for an ICU bed. And sometimes the only way that ICU bed comes available is the patient that’s in there dies. They move them out, clean the bed. Now suddenly we get an ICU. But it’s the the only silver lining. When we hear code blue over and over again at the hospital is that at least we may get some movement of our patients.

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S5: Yeah, I mean, you tweeted this photo. It must be an app on your phone of all the hospitals that were, quote unquote on diversion in L.A., what does that mean?

S8: So 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 at the point where we decide a patient needs to go to the hospital, take a look at who which hospitals in our area are on diversion. If there’s one that’s not, will divert the patient to that hospital. But often what we’re seeing right now is every hospital in the area is on diversion. So they just kind of have to take their lumps.

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S1: So you just show up at a hospital that’s full and say sorry. Yep, there needs to be room at the inn for this patient.

S7: Yep. That’s exactly what we do. And how does that go? You know, not always very well. Sometimes we show up and the hospital will come out and they they’ll look at us with that kind of sad eyes, sigh and then go to work, which is what they’re supposed to do. Sometimes when they’re particularly in a moment of exasperation, they look at us and they 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, you know, just to bring in another patient. So we’re finding that increasingly.

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S1: So your patients are like on a stretcher, maybe in a hallway or outside, where do they even go?

S7: So depending on the hospital, sometimes in the hallway, sometimes outside, sometimes sitting in the ambulance for hours. And, yeah, it depends. We’re working on some strategies right now. One we launched last week. We’ve applied it a couple of times, but it’s kind of an ambulance consolidation to have one ambulance crew watch multiple patients so the other ambulances can go back into service because in our bad times, like a babysitting service. Well, yeah, that based on federal law, when a patient arrives at the hospital, even if the hospital doesn’t accept that patient, the patient belongs to the hospital. We actually don’t need the hospital to accept the patient. It’s their patient whether they like it or not. But, yes, 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 100, 100, just waiting outside, waiting outside in hallways, or now with this new plan, we’re going to be consolidating them intense. When you have people 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.

S1: Last week, Los Angeles got a lot of attention because of these new directives that seemed to limit the kind of care emergency workers could give because of covid EMTs were being told to save oxygen for the most severe patients to avoid running low. They were also being reminded not to bring patients in cardiac arrest to the hospital if they had a low likelihood of survival. Dr. Carson says these rules are actually best practices, not a rationing of care. But he also admits the countries in the middle of an emergency, things are going to look different for a little while.

S2: Part of it is we have to shift our mindset. And this is where the hospitals, I think, have really struggled is if a plane crashes or there’s a mass shooting, the standard of care immediately changes. You just train up who you have. You find volunteers. You have to train laypeople to do things to put a tourniquet on or to monitor them. You just do it.

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S6: And in those circumstances, that goes on without question. 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 going to a disaster mindset.

S2: When you go to a disaster mindset, it’s all about triage. So hospitals are very abreast at doing that. They’re just not it’s hard for them to shift to disaster gear. They really liked operating in their comfort zone, which is their standard operating procedures. Once we get them to think with that mindset, then our ambulances turn around faster and they get it. Sometimes we just have to walk the row with them and say, this one’s a red, this one’s a yellow, this one’s a yellow, this one’s a green. This one can go to the lobby and they say, well, but that one should be on a heart monitor. You go, I know, but we also have to have an EMS response. So remember, they’ve been here for forty five minutes on a monitor and nothing has happened. So maybe they’re not as severe as we thought they were and going up and down that road and then usually the light bulb comes on because they’ve all trained to do that. It’s just hard in practice to do it. When it’s not a plane crashing in your backyard, it’s become almost the new normal.

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S1: But that disaster mindset, it does mean that sometimes you leave people behind when his EMTs are having particularly tough conversations. Sometimes they call Dr. Kasan, ask for his advice.

S6: Sometimes he’s telemedicine calls come. And I had one on Friday and it was one of our paramedic squads that was with a patient who’s in hospice. And the family believes that the patient is was having pneumonia and but the patient has home hospice who’d come in giving her some morphine because they thought she was in pain and she began to have more difficulty breathing in the family, panicked. And so the paramedics were trying to talk to them and say, look, she’s she’s a hospice patient. She’s expecting to be end of life. And the family was being very difficult in terms of acceptance. And so they asked me to speak to them. So I spoke to the family and the family’s stance was, well, but what if this isn’t covered? What if it’s just pneumonia? And what if we gave her antibiotics that she might get better? And why don’t we why can’t we do that? And I said so the answer to them was, of course, we could do that. But she exercised her decision to bring in hospice because she didn’t want to go to the hospital. And if she goes to the hospital. Are we at that point going to decide that if she needs a ventilator, we’re going to do that and we’re going to go down that road when she clearly had decided she didn’t want those things and telling them also that unfortunately right now covid is pretty much all the pneumonia we are seeing. So overwhelmingly likely that’s what she has, is she goes to the hospital and we admit her and go down that path. Even if she doesn’t end up on a ventilator, she won’t be at home. She will probably never come home again. She won’t have family around her. And this is kind of the opposite of what she had wished for when she signed in for hospice. So with that, they the daughter in tears, she spoke to her mother and said, do you want to go to the hospital? And the mother looked at her and said, no.

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S7: And so we left her in the care of home hospice and hopefully she’ll pass peacefully with her family around her in her home, which was her wish.

S1: There are some people, though, who would hear the fact that MS needed to leave a patient behind and think that that’s a tragedy and cold.

S6: I think and maybe this is from years of working in the hospital, but I think sometimes people there are two things. One, they have unrealistic expectations of what the hospital can do for a patient. Who is that clearly an end of life? Most people get their information on this from what they see on television and on television. People do make a lot of miraculous recoveries. But the reality is when you have someone at the end of their life, often what medicine offers to them is we can extend the length of their life, but often at the great expense of what quality they have left. And that’s never been more true than it is now. When the people that go off to the hospital to die mostly die alone. And we do our very best to make sure someone can be there with them. And preferably we bring family to be there with them when we can. But often that’s not the case. And often these people go to have a very cold death on their own in the hospital.

S4: If if it were me, I would rather die at home in my bed surrounded by my family than in the hospital, you know, maybe with a nurse in full PPE and a gloved hand holding mine. And that’s the best I’m going to get or maybe face time with my family from outside. So it’s all about setting the expectation level to where it’s realistic and helping people to understand that the decision that they’re making.

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S1: When we come back, how the vaccine rollout, if done right, could make all the difference. Back in March, in the midst of all the darkness and confusion of the early pandemic, Dr. Carson was put in charge of getting L.A. County’s testing infrastructure into shape. He jumped into action, filling in a spreadsheet with contact information for every health official in the area who could possibly contribute to the effort. And it worked. During the month he was in charge, Dr. Carson was able to increase L.A. County’s testing capacity for the coronavirus from a few hundred people a day to more than 10000 now with vaccine distribution in motion. There’s a chance he’ll get tapped again, this time to get people their shots. So are you thinking you may be working with those institutions to give vaccinations, make sure it’s all going the way it needs to?

S2: 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 across the county. So we’re kind of getting those feelers out right now again for what that might look like. We don’t know for sure. We just know that we have been hearing from our colleagues over at public health that they’re having a challenge getting phase one a complete. And so I think that they’re going to be looking at us as that army that they can put the task to get it done.

S1: You sound excited for the challenge. Like I’m picturing you right now being like, OK, going to get out the spreadsheet. Where can I, like, pop open a vaccine center? Here’s how I’m going to staff it. Is that how you think about it?

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S7: So as you can tell, I’m generally a pretty optimistic person. I look at it as we need to get this done because this is how we really turn the corner. I remember hearing President Trump when he was campaigning back in September talking about how we had turned a corner and just kind of shaking my head at it, going, I don’t know what corner he’s talking about because I don’t see it. But when we talk about these vaccines coming out, I’ll give you an example. Within our department, we generally county fire in terms of our number of people out sick with covid. We have trended along with the county. And as much as I wish I could say that we were better because our folks are more educated and medical issues and things are folks are human beings and they have the same flaws as everybody else. But when you look at it, we trended right along with the surge in the county. We shot up our positivity rate, went way up, our number going out sick, went way up. And we followed that curve right along with the county. When you look, we started we got our vaccine allotted to us on December twenty third. We had our first mass vaccination on December twenty fourth we gave I think thirteen hundred and twenty vaccines on day one. And then we did two more days and now we’ve trickled in some other days. So we’re at about twenty nine hundred or so right now. But what we’ve seen is the county’s positivity rate is staying in that fifteen to twenty percent range, but our positivity rate has dropped to six percent. So that is the potential power of a vaccine.

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S1: I noticed you got your vaccine, you posted a picture. Was it? Emotional for you after all you’ve seen over the last year.

S7: I will say so again, I have all the same flaws as every other human being, and as I sat in that chair and watched them draw up the vial and drop my syringe, there was just a little bit of am I sure this is really OK? Am I really giving good advice to people? And I so I thought about it for a split second. I went, nope, I’m in. And the reason I wanted to put it out on social media and there’s a big push on is there’s a hashtag, Ms. VACs, and there are other ones too, is to show are the people that we lead that we lead by example. We would never recommend that they do something that we are not willing to do. So it was it was really important for people to see that that it’s. What was the old saying? I’m not just a hair club for four men owner. I’m a hair club for men member. Yeah. So I’m in. And when they go, I’m worried about the side effects. I’m worried about this. Well, you know, I think about it too. But I’ll tell you what, what scares me far more than the side effects of the vaccine, the side effects of covid.

S1: Hmm. Did your folks, like, universally take the vaccine or did you have to convince anyone the way you convinced yourself, like, hey, we should do this?

S3: We did a full court press, so we did social media, we did departmental advisories, we did videos, went out to fire stations. We did live Q&A. We then published the the the Q&A so everyone could read it. And with that, we have gotten to right around between 70 and seventy five percent adoption, which is right on par with, I think the higher performing health care institutions, which makes me happy, are typical flu shot adoption is somewhere about 60 percent. So given that I was really, really pleased we’re not done yet. And I think there are still some in that twenty five to thirty percent that are vincible, but there are some that are just going to refuse and we just have to accept that and move on and just keep trying. But you’ll never win over everybody other departments.

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S1: What do you do for that? What do you do for that, like 25, 30 percent. Like you go to them and like have one on one conversations.

S3: So in our department, when we did the mass vaccination sites, one thing that I’m convinced we did right is we didn’t let anybody refuse remotely. Everybody had to come in to one of the sites to refuse. So the concern is I’ll use an example of a station near my house that has a three person station, has 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 would be very easy to fall into groupthink and end up just declining. And so we make 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.

S1: I I was watching video of you giving an interview, and I couldn’t help but notice the bags under your eyes, you seem tired. And while you sound really upbeat, I do wonder how you talk to your colleagues who might be feeling this moment in a pretty deep way, especially the fact that they show up at people’s houses and they’re dying and they have to bring people to the hospital and leave them there outside where I feel it the most, I feel it for our folks and I feel it when I worked the E.R. and I spend the entire shift working in ninety five to my nose is bruised.

S3: And that fear, when you’re in the face of someone with covid and you’re examining them and talking to them and you’re knowing it’s right there in front of your face. And I tell our folks for our EMTs and paramedics that my job is hero support, so it’s my job to make sure that they have the tools, the training, the experience, everything that they need. So when there is a life on the line that they have everything that they need to be able to save it. And I think we do a good job of that. I think we put them in a position to be successful. And the last is giving them some form of optimism, sharing messages with them regularly to let them know that what they do matters.

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S8: So now we just have to get that final step, which is I’ve said that because it’s January and we’re in football season, we’re we’re deep in the red zone now. We just have to punch it into the end zone and we have to make sure we don’t fumble it or throw an interception on the way. But if we can just, you know, just hold on tight and push one more time really hard and push it through, then that is where we’re actually going to turn the corner.

S5: Dr. Clayton Khazan, thank you so much for joining me. Thank you, Dr. Clayton Carson is an emergency physician in Torrance, California, and he’s the medical director at the L.A. County Fire Department. And that’s the show What Next is produced by David Land, Schwartz, Daniel Hewitt and Mary Wilson. We get help everyday from Frannie Kelley. We are overseen by Allison Benedikt and Alicia Montgomery. And I am Mary Harris. You can find me on Twitter. I’m at Mary’s desk. In the meantime, I will catch you back here tomorrow.