News from the COVID-19 Front Line:
An ER Outside of New York

Published on April 3, 2020

News from the COVID-19 Front Line: An ER Outside of New York

By Won Chung, Carrot Health Chief Medical Officer (@WGCMD)

“If you’re homeless, how do you shelter-in-place?”

Yelling and screaming, our usual “frequent flyer” Paul* is brought into the ED, smelling of alcohol and other odors that are not easily identifiable but unfortunately familiar to the emergency staff everywhere. That is not unusual for his presentation, but what is unusual is the Easter-yellow colored face mask he’s wearing. “Hey, Doc,” says the EMT who brought him in, apologetic in tone but also matter of fact, “We picked him up at the shelter ‘cause he was drunk, but he also says that he was exposed to corona by his girlfriend.”

For the next few hours, along with numerous elderly, middle-aged and young patients with clear COVID-19 symptoms, Paul is treated in our emergency department at the Connecticut hotspot of COVID-19. As the chief medical officer of Carrot Health and as an emergency medicine physician, I straddle the two of our society’s many fronts in the current fight against this deadly disease. While I take care of the sick and injured in the hospital, our team at Carrot Health has been working non-stop to put together the data and algorithms to predict who are those most vulnerable to COVID-19 and critical infections. Turns out, many of those at highest risk are just like Paul.

Here’s why that is crucial: One of the biggest issues with COVID-19 infection is a sizable subset of patients have medical needs beyond simple intravenous fluids and medications or oxygen delivered via nasal cannula, such as in a “regular” hospital bed. For many patients, the airway tubes to keep lungs open, ventilators to deliver oxygen, powerful medications to monitor and machines to bypass the heart and lungs are only available in the intensive or “critical” care units (ICUs). There are no other alternatives for these critically ill COVID-19 patients, and they need these services for an average of 14 days each. We absolutely need to address the supply-side as quickly as possible in addition to working on the demand side (total number of COVID-19 patients).

Aside from what we are doing already as a nation, is there a way to further increase the supply and decrease the demand? At Carrot Health, we are looking at our health data which is composed of over 260 million U.S. consumers to determine who those potentially critical patients are and where they live. With this list on the supply side, Carrot Health is helping our national and local governments, as well as various healthcare systems to smartly deploy the limited medical supplies and equipment to the most appropriate areas. In addition, on the demand side, by identifying the individuals at risk, we allow an early warning network to be developed to give those patients (and the support system) some time to prepare for a possible infection.

For someone like Paul, numerous clinical factors such as age, diabetes, and alcoholism put him at higher risk for critical illness if he were to have COVID-19, but his lack of stable housing multiplies that risk many times. Generally, in homeless shelters, the open layout with many other residents with chronic respiratory issues is already a challenge. In Paul’s case, the shelter did not even want to take him back due to the fear that he may spread his illness to others. After two additional hours of phone calls between social workers and the shelter, he was finally able to be placed in a separate area for a few nights until his viral testing returned.

Over half a million people in the U.S. are thought to be homeless and 10-15% of the general population are classified as “housing unstable.” Although the shelter-in-place works for many of us, lack of housing and other aspects of social determinants of health point to potentially disastrous outcomes for this vulnerable population.

*Paul is not the patient’s real name

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