The New York Times. April 04, 2020

THE NEW YORK TIMES, SATURDAY, APRIL 4, 2020 N A

LOS ANGELES — One is a top-
ranked research hospital in West
Los Angeles, with buildings
named after Steven Spielberg and
Barbra Streisand. Its hallways are
hung with works by Picasso, Miro
and Warhol, part of a 4,000-piece
collection of donated art. Holly-
wood celebrities and royalty vie to
recover in its first-come, first-
served luxury suites.
The other is a community hospi-
tal in South Los Angeles, sur-
rounded by fast-food chains, liq-
uor stores and discount shops. It,
too, is a state-of-the-art institu-
tion, albeit one with far more lim-
ited resources, serving one of Los
Angeles’s most vulnerable com-
munities, home to the working
poor and the uninsured as well as
homeless tent encampments,
where a significant portion of the
population has underlying
chronic health conditions.
But the coronavirus pandemic
is testing both Cedars-Sinai Medi-
cal Center and Martin Luther
King Jr. Community Hospital in
ways never seen before. At one
level, there is a growing fear that
the crisis could lay bare long-
standing inequities in the nation’s
health care system that could ulti-
mately make the virus more
deadly in Los Angeles’s poorest
communities. At M.L.K., doctors
worry especially that they will be
shortchanged by a system that al-
locates more supplies to larger
trauma centers like Cedars-Sinai.
At the same time, the distinc-
tions between the two hospitals
are fading fast, as confirmed coro-
navirus cases in Los Angeles top
3,000 and both institutions brace
for conditions they fear will over-
whelm them. Neither has the
equipment it says it needs to de-
fend itself or its patients. In both
places, doctors are already grap-
pling with ethical dilemmas,
putting off even needed surgeries
in order to clear beds, and, as they
digest the news in harder-hit
places like New York and Italy,
they are contemplating the even
tougher life-or-death choices they
fear are coming.
In many respects, they say, the
virus is the great leveler.
“It doesn’t matter who you are
or where you come from — this
isn’t a matter of wealth,” said one
Cedars-Sinai emergency room
doctor, who was not authorized by
the hospital to speak publicly.
“This isn’t brain surgery. It’s just
logistics and supplies.”
In normal times, 20 miles of in-
terminable gridlock separate Ce-
dars-Sinai and M.L.K. But these
days, a stay-at-home order has
made Los Angeles feel small. Its
infamous traffic has disappeared,
replaced by an eerie sense of
calm.
As health care workers here
track the horror unfolding in New
York City, where hospitals are
overwhelmed with patients and
deaths are increasing, they are
girding for a similar surge to hit
Los Angeles.
“I was asked by a reporter to-
day, ‘Is Los Angeles the next New
York?’ ” Mayor Eric Garcetti of
Los Angeles said last week. “And I
said, ‘Sure, in the same way that
New York is now the next Italy,
and Italy was the next Iran, and
Iran was the next China, and no
matter where you live, you are the
next.’ ”
Los Angeles County had 3,
confirmed cases as of Tuesday,
and 54 deaths, but testing is so
limited that officials say they do
not have a handle on how many
people are actually infected, even
as they believe social distancing
measures have probably slowed
the spread.

A Question of Resources

When a surge arrives, Los An-
geles County emergency manage-
ment officials say they plan to
spread patients out among all the
county’s acute care hospitals,
meaning that where you live may
not necessarily dictate where you
end up. No one requiring hospital-
ization for Covid-19 will be turned
away based on lack of insurance
or inability to pay, state and fed-
eral officials have said.
Cedars-Sinai, a top research
hospital, has in recent days devel-
oped its own in-house testing, and
can get same-day results. M.L.K.,
with fewer resources, hasn’t been
able to move as fast on in-house
testing, and still relies on commer-
cial labs.
As one of Los Angeles County’s
largest hospitals, Cedars-Sinai,
with its Level I trauma center and
886 beds, will most likely bear
much of the brunt, both in terms of
numbers and severity of cases.
Already, doctors there are see-
ing an uptick. The number of con-
firmed or suspected coronavirus
patients at Cedars-Sinai has
grown from about 50 on March 17
to about 115 as of Tuesday morn-
ing, according to a hospital official
who requested anonymity be-
cause the hospital’s policy is to not
release those numbers.

M.L.K., which has 131 beds, has

seen only a handful of cases so far.

But it faces its own set of chal-

lenges.

So far, most of Los Angeles’s

positive coronavirus tests have

come from wealthy communities

like Brentwood, Melrose and West

Hollywood, closer to Cedars-Sinai

than M.L.K. Public health officials

have speculated that is because

many residents there have both

the wherewithal to travel over-

seas — possibly contracting the

virus that way — as well as easier

access to testing.

But doctors at M.L.K. worry

that no one knows how deep the

virus has spread within their com-

munity’s vulnerable population.

That is because tests are scarce

and the county is reserving them

for the sickest patients and health

care workers. It is all the more

concerning because many in

South Los Angeles suffer from un-

derlying conditions like diabetes

and heart disease that could lead

to higher death rates when the vi-

rus hits hard.

“The bigger story is the people

who are vulnerable because they

haven’t gotten medical care all

along,” said Dr. Elaine Batchlor,

the chief executive of M.L.K.

“These are the same people who

are preparing food in fast-food

restaurants, taking care of people

in day care centers.”

Even when patients are hospi-

talized, the basic treatment for the

coronavirus is fairly straightfor-

ward. Some need fluids and oxy-

gen and a fever addressed, while

the more severe cases may need

to be sedated, ventilated and fed

through a tube.

Dr. Peter Chen, the head of pul-

monary and critical care medicine

at Cedars-Sinai, said his team has

been conducting drills to accom-

plish those tasks as efficiently as

possible and be able to handle

more patients. But, he added, for

“the majority of people, it’s not

rocket science.”

“They have a single organ fail-

ure — their lungs,” he said. “We

manage the lungs until the lungs

hopefully calm down. That’s it. It’s

pretty much supportive.”

The challenge comes in getting

the supplies needed to treat pa-

tients with the highly infectious

virus. Like hospitals across the

country, Cedars-Sinai and M.L.K.

are scouring for masks, gowns

and ventilators.

There, Cedars-Sinai has some

advantages over its counterpart:

It will get a greater portion of the

emergency government supplies

coming down the pike because of

an allocation formula that favors it

and the 12 other hospitals in the

county designated as trauma or

disaster relief centers. Cedars-Si-

nai has also been able to tap into

donations from private sources,

like Goldman Sachs, which re-

cently delivered a supply of

masks.

Still, Dr. Chen said the hospital

was “barely scraping by,” with

staff members forced to reuse

masks for an entire shift in order

to conserve them, as are their col-

leagues at M.L.K. As for ventila-

tors, the shortage is dire enough

that Cedars-Sinai is considering

whether other machines, such as

a BiPap, which assists breathing,

could be safely modified for coro-

navirus patients.

“My biggest fear is that we run

out of protection for our staff,” Dr.

Chen said. “We’re physicians —

we took the Hippocratic oath. We

will run into a room even if we are

out of masks, but what happens if I

get infected, now I can’t take care

of 20 other people whose lives I

could possibly save.”

At M.L.K., doctors and nurses

are spending their off-hours call-

ing up every plumber, electrician

and contractor they know, plead-

ing with them to donate masks.

The hospital has 16 ventilators

right now, and has put in an order

for four more. Doctors say they

could possibly operate up to 40, al-

though they worry about having

enough trained staff to operate

them.

Dr. Oscar Casillas, the medical

director of M.L.K.’s emergency

department, sees the county’s

system of distributing emergency

supplies as fundamentally unfair.

M.L.K., he said, had a dispropor-

tionate 112,000 emergency visits

last year, compared with 91,000 at

Cedars-Sinai, a reflection of how

many people in South Los Angeles

rely on the emergency room be-

cause they lack basic primary

care. One of the most common

surgeries at M.L.K. is amputation

because of complications from di-

abetes.

“Our story explains how differ-

ent it is in this community than

anywhere else in L.A.,” Dr. Casil-

las said. “There just isn’t enough

primary care in this area to sup-

port the population.”

Some doctors rotate between

several hospitals, including

M.L.K., where they arrive for

shifts and tell colleagues that big-

ger hospitals have a better supply

of protective equipment, and that

can breed resentment.

“There are some of these hospi-

tals right around us like U.C.L.A.

and Cedars, and those folks are

getting those supplies, and so the

physicians come here and say,

‘Why aren’t you guys wearing

this?’ ” said Jorge Gonzalez, the

nurse manager in the emergency

department at M.L.K. “And it’s

scaring our staff, because they are

seeing right in front of their faces

the differences and the dispari-

ties.”

Despite Cedars-Sinai’s reputa-

tion as the “hospital to the stars,”

that shorthand frame of rich ver-

sus poor belies a more complex

picture.

The community Cedars-Sinai

serves is significantly more pros-

perous, with a median household

income of about $70,000, than the

one served by M.L.K., where it is

$37,000. But Cedars-Sinai is also

the No. 1 recipient of Medicare pa-

tients in the state, and a top

provider to Medicaid patients. A

recent policy change also makes it

the most generous nonprofit in the

state in terms of free and dis-

counted charity care.

Laying the Groundwork

Like hospitals across the coun-

try, Cedars and M.L.K. are work-

ing to identify any usable space to

isolate non-coronavirus patients

from those they suspect are in-

fected. Both hospitals set up out-

door intake tents; and a 1,000-bed

military hospital ship that just

docked at the port of Los Angeles

should help free up hospitals by

treating non-coronavirus pa-

tients.

And to prepare for the coming

surge of those carrying the virus,

both are doing their best to clear

beds, sending patients home or

delaying surgeries they normally

would not.

Dr. Richard V. Riggs, Cedar-Si-

nai’s chief medical officer, said

that at first, only elective surg-

eries were postponed, but as the

urgency has mounted, the hospi-

tal has also begun postponing can-

cer surgeries that oncologists say

can wait until after May, when the

peak is expected to hit.

But at M.L.K. clearing beds is

complicated, because many of the

patients do not have doctors in the

community who can handle fol-

low-up care.

“At least in Beverly Hills, when

they send a patient home they

have a doctor they know is going

to take care of the person,” said Dr.

Batchlor. “In our community there

is just a huge deficit.”

And, they worry, they may be

sending people home to living ar-

rangements, such as homeless

shelters or group homes, where

social distancing is difficult, if not

impossible.

“We’re feeling the pressure to

clear the decks yet we feel that in a

good majority of our patients if we

clear the decks we actually could

be creating more of a surge later

on,” said Alaine Schauer, senior di-

rector of critical care at M.L.K.

But if their challenges are

slightly different, their fears are

much the same. One doctor doing

coronavirus triage at Cedars-Si-

nai went home last week and, af-

ter stepping into the foyer to strip

out of scrubs and bleaching the

area, reread the Hippocratic oath.

“There is a ramped-up anxiety

that I don’t think I’ve ever seen be-

fore,” Dr. Casillas said. “Everyone

is trying to do the best they can in

an unprecedented situation.”

LOS ANGELES

How 2 Very Different Hospitals

Are Taking On the Pandemic

‘It doesn’t matter who you are or where

you come from — this isn’t a matter of

wealth. This isn’t brain surgery. It’s just

logistics and supplies.’

An emergency room doctor at

Cedars-Sinai Medical Center, above

PHOTOGRAPHS BY JAKE MICHAELS FOR THE NEW YORK TIMES

A server at The Ivy, a restaurant around the corner from Cedars-

Sinai in West Los Angeles, waiting for takeout orders.

Martin Luther King, in South Los Angeles, is surrounded by

fast-food chains, liquor stores and discount shops.

‘Our story explains how different it is in

this community than anywhere else in

L.A. There just isn’t enough primary care

in this area to support the population.’

The medical director at Martin Luther

King Jr. Community Hospital, below

By JO BECKER

and TIM ARANGO

Tracking an OutbreakThe Front Lines