Parking Lot Medicine
“If she was my mom, I would take her to the hospital.”
I said in the parking lot, to a refugee family from South Asia, through their car window. The patient in the back looked like my mom. She was comfortable, but had a sat of 84% and heart rate of 110. I also knew she had diabetes and lived in a dense apartment. She and her extended family had been my patients for years, since they arrived in the country.
The patient’s daughter was in the front, and grandson was driving. What I didn’t tell them was “Spend an hour with her before you go in, because as soon as she is checked in, they won’t allow you in the room to see her. You won’t see each other again, even if she dies from this. This parking lot may be the last you see of her.”
My clinic has tested almost a couple hundred patients. At first, 60% were positive, but as more worried well came in, our total positive rate has decreased to about 45%. That still seems high to me, although I don’t know how it compares to other practices. I work with resettled refugees in an urban setting, and have never worked elsewhere.
Of those positives, we have a dozen who got admitted to the hospital. Some get admitted but we don’t find out, so the real number is probably two dozen, which goes along with published ratios of positive to admits. Of those in the hospital, most have spent some time in the ICU, which means they had significant breathing problems and needed a machine to breathe for them. Some are there today. One improved out of the ICU but then went back in. Most make it out of the ICU and out of the hospital. At least one died.
“The test is free, but since you are visiting from another country, it will cost you $110.” I said in the parking lot, to a Burmese woman who was having problems breathing for a few days. I also told her I wouldn’t waste the money, and just assume she has Coronavirus and stay home anyway.
The government (Medicaid) now pays for Corona testing for all uninsured patients as long as they have a Social Security number. That is too bad, because visitors and undocumented people also contribute to the disease prevalence and hospital burden. How much better are our statistics than China’s?
“Look that way. I am going to put this in your nose for 3 seconds,” I say in the parking lot. I try to stand on the upwind side, because the test induces the patient to sneeze or cough. I feel like a sitting duck, complete with duck costume. I’m not sure if swabbing through the car window reduces the spray in my direction. The virus itself could not devise a more ingenious method of spreading itself to its enemy, healthcare providers who seek to eliminate it.
A plastic face shield protects me in the parking lot. One of my providers had her son build one from a hardware store, the other found his own, and we have a few from a 3D printing effort. On days when there is freezing rain the shield blocks some of the wind, but it could use wipers and a defogger.
“Just wait in the parking lot and call us,” we text to patients who need to see us, “don’t come in the building.” We swab the patient in the car, then wait a couple days for the result. At night, when the parking lot is empty, we stay up reviewing results. Last night I texted a dozen positives in a row. It becomes mechanical. Copy Paste “This is PJ, doctor at Mango House, your test shows you have Corona Virus.” Then I paste a blurb about staying home.
This week we had some patients whose result read negative, and we gave “return to work” papers, but then the lab told us they screwed up, and the result was really positive. Turns out only four of them, and it seems none had gone back to work yet, but maybe they did feel a longer leash in the day or two between. Uh-oh.
Actually our parking lot isn’t always empty at night. Sometimes people camp there. It comes with the neighborhood. We usually don’t mind if they are gone in the morning, or are low profile. This week we had one that was there all day blasting music and getting drunk, while we were trying to see patients a few feet away. We asked Aurora police to remove them.
We try to keep most patients from even arriving at the parking lot. We are now handling things by phone. We always knew we could, but we weren’t allowed because insurance companies required face-to-face visits. That means up until last month, doctors offices had to spread contagion in order to stay afloat. These “face-to-face” rules were written by the government programs (Medicare, Medicaid), and the private insurance companies followed. But now, suddenly, all doctors are readily paid for “televisits.” I don’t want to do parking lot medicine forever, but I sure don’t need to see you in my office to help you. Stay home and call!
“Should I get the test?” I have been asked this in the parking lot. I try to tell them that the result may not matter, that they should stay home anyway. Some want a test to see if they already had it and are better. We need a different test called an antibody test and those were just invented. We should have them this week and soon be sticking fingers in the parking lot. I experimented with one on myself yesterday and am awaiting result.
Getting the tests has been an exercise in decentralized medicine, working through reps that seem like used car salespeople with websites that look like scams, and labs that compete and give the rep a cut. Our system doesn’t allow for a reassuring government presence, even if one existed, especially not in small private practice.
“We brought you some food,” I was told in the parking lot. A few times. People are stuck at home feeling helpless and want to do something. This has resulted in free food for us, free shoes for us, free energy bars for us, and free 3D printed masks for us. The utility of each of these things varies, but it is the same theme I saw when refugees were the topic: people wanting to increase their service in times of need. I applaud it, but encourage using times like this to consider how we can all orient our lives to more service even when there is no emergency. The American lifestyle is otherwise quite a selfish, money-grabbing one that leads to great inequalities we can see in our own neighborhoods. Often we use the security or prospects of our own kids as rationalization, at the expense of other’s kids. Sure, send some free food to your local doctor, but also look around your house, and consider how you can come out of this with more ongoing service.
What do our refugee medical and dental clinics at Mango House really need? N95 masks (not really other masks), disposable gowns, alcohol wipes, and latex gloves. If you are going to bring food, we prefer random packaged snacks, especially those from Trader Joes. Or if you want to help subsidize rent for some refugee churches who can’t pay, go to our clinic website and click donate on the bottom left. If you want to help Mango House in general, please see our current volunteer or donation needs at http://1532galena.com.
