COVID-19: A Los Angeles-based physician discusses challenges now, and ahead

" . . . these are conversations we wish we all had yesterday, or three months ago . . ."

Dr.Jennifer Chang is a family medicine physician and an HIV specialist, working in the infectious disease department at Kaiser Permanente, at the Los Angeles Medical Center, and is a member of the board of directors for the HIV Medicine Association, which, with the Infectious Diseases Society of America, produces this blog. Here she discusses the questions raised by the spread of COVID-19 in the community she serves.

Are there shortages of basic medical equipment for hospitals to face the COVID-19 pandemic?

What I am hearing from frontline providers in hospitals that are seeing a rise in cases of confirmed or suspected COVID-19, are the possible anticipated shortages of necessary equipment – viral culture swabs, gloves, masks – across major medical centers in California and Washington. I am hopeful that back-ordered supplies will arrive soon, however, in the short term, resource conservation is of critical importance. For research institutions, are there tools – gloves, masks, reagents - that can be borrowed from research laboratories? Are there other sectors outside medicine that can provide more masks? Are there alternatives to nasopharyngeal swabs, if there’s a shortage of plastic swabs and culture media for diagnostic testing? How many sputum cups do we have? These are the kinds of operational questions we are asking ourselves – and dilemmas that American clinicians are not used to considering -- due to supply chain issues across the board.

What are the challenges facing you in the weeks to months ahead?

One of my biggest concerns is what will happen to our most vulnerable populations – elderly patients who have little social support, immunocompromised patients living with HIV/AIDS, and the homeless. I’m based in Los Angeles, where we have 36,000 people who are homeless. I care for patients who are living with HIV, and more than half of my patients are older than 50 years old, and many are either transitionally housed or homeless. A lot of the dialogue at the moment is focused on mortality, and the challenges of diagnostics and treatment – but what happens when patients get better, and no longer require hospital-level care? Inevitably, those who recover will need to be discharged. For patients who can return to their apartments, or houses, they will be expected to self-isolate in the safety and comfort of their homes.

But for patients without stable housing, or for whom home may not be ideal due to frailty and mobility issues, how can we envision spaces where patients can be safely received and cared for, in a way that protects the general public but also respects individual needs? How can self-isolation procedures be followed if social services and institutions that many patients may rely on, are also spaces where crowding and congregation naturally occur?

I don’t have the right answers to this, but being able to turn over hospital beds quickly is of utmost importance in coming weeks in order to treat as many people as possible. Establishing safe discharge procedures may be one of the biggest public health challenges that physicians, case managers, and public health agencies are struggling with – and these are conversations we wish we all had yesterday, or three months ago. For those areas around the country that are just starting to see a few cases, and are a few days or weeks earlier in the epidemic – it is never too early to formulate contingency plans.