Struggling to breathe, Yesenia Guevara had tried to get medical attention at a hospital miles from the dusty camp beneath the 118 freeway.
But Guevara and Richard Wisar, who had been with her at the Pacoima camp for years, said they cut short their visit hours later because they felt ignored.
When something goes wrong, Guevara later declares, “I’m my own doctor.”
A week after her aborted hospital stay, a medical team showed up outside the tent shared by Guevara and Wisar and informed them that a mobile clinic was stationed a short walk away near the Ritchie Valens Recreation Center. A nurse showed people a photo on her smartphone and pointed them to a sky-blue truck the size of a tractor-trailer.
“We want to be able to provide medical care where you are,” said Dr. Parham Khalili to Guevara as she and Wisar arrived at the truck.
In Los Angeles County, homeless people were already suffering from rising mortality rates before the arrival of COVID-19. Deaths among homeless people rose sharply in the year after the pandemic began, and not just because of COVID-19. Public health officials noted that drug overdoses were the biggest reason for the fatal increase and that other leading causes of death for homeless people — including heart disease — also claimed more lives than before.
The pandemic had pushed the Los Angeles County Department of Health directly into street medicine, but the need stretched beyond the coronavirus as its medical teams, who offered COVID-19 vaccines, also tended to other street diseases. In some cases, patients required medical procedures that local road teams could not readily provide.
So this fall, the Department of Health launched its own system of rolling clinics, expanding the range of medical care its clinicians can provide immediately to homeless people.
The big blue trucks, each equipped with two private examination rooms, provide a range of services that are difficult or impossible to perform on a sidewalk or in a tent.
The Rolling Clinics can provide primary and emergency care, including ultrasound and electrocardiogram; psychiatric care and substance use treatment, including medication to alleviate addiction; and gynecological care such as pap smears, among other services. The mobile clinics can also connect patients with social workers and financial auditors to enroll them in programs.
Since September, the county has regularly stationed the clinics in locations near homeless camps where there is a shortage of medical supplies.
The rolling clinic allows healthcare providers to perform medical procedures “that we wouldn’t otherwise be able to perform on-site” or that are safer in a clinic, said Dr. Absalon Galat, Medical Director of the Mobile Clinic and Street Medicine Program at the LA County Department of Health Services. “We’re trying to plug the holes in the system.”
Outside the blue truck, Guevara gave her medical history to a nurse. “So shortness of breath and chest pains – how long have you had this?” Nurse Richelle Legaspi asked.
“Nine months,” replied Guevara, 47.
Legaspi asked her about nausea and pain; alcohol and marijuana and meth; mammography and vaccinations. Guevara once told the nurse she hated needles; Legaspi assured her they could dodge them today. When the nurse asked if she had recently fallen, Guevara nodded.
“I had to pick you up and carry you,” added Wisar, 40, who was sitting next to her.
“He’s my angel,” Guevara replied, smiling, placing her foot on his knee.
Khalili, the physician dedicated to this area of LA County as part of the mobile clinic program, proudly stated that the rolling unit has the ability to match or exceed the services available at stationary clinics, and not just ” Second Class Care”. And unlike a stationary clinic, the blue truck can move when homeless camps move.
Health officials said the mobile clinics are designed to ensure immediate access to medical care that homeless patients might otherwise find difficult to reach. District teams found that 83% of the camps they visited had unmet primary care needs; nearly half needed urgent care; and almost a third of the camps had unmet needs for women’s health care.
Other services that the homeless use, such as Advice for the Homeless. That can mean homeless people “making a decision about whether to get a meal or to queue for a walk-in appointment.”
Some unaccommodated patients were reluctant to leave their pets or belongings to make a long journey to a medical center. League also cited the practical barriers many homeless patients face in reaching a clinic and a deep-rooted distrust of healthcare, “very often as a result of themselves or those close to them receiving poor care at some point along the way.”
Faced with these realities, mobile units have become a growing element of LA County’s care for homeless patients. The Saban Community Clinic opened a rolling clinic this summer. The Venice Family Clinic did just that last year, adding a van to its street medicine program. UCLA Health has also created medically equipped vans to visit camps, shelters and other places where homeless people are congregated, with the aim of getting a range of basic, emergency and specialty care to the streets.
League called the LA County Department of Health Services’ efforts “very unique” nationwide. Medical vehicles of the size LA County uses — as big as a semi-truck — are often used for one-off events rather than consistent care, League said. Because of the cost and practical challenges of setting it up, few exist nationally, she said.
What LA County is doing is rare in its “size, staffing and consistency,” League said.
So far, LA County has four units in its new fleet, each parked in the same spot for about seven hours on each visit. The COVID-19 street teams had already helped map camps, giving the county a clearer picture of where they were needed.
The county spent more than $2.2 million to purchase the vehicles with federal funds intended to help healthcare providers supporting COVID-19 patients. Day-to-day operating expenses are borne by the county through its general budget, although it also seeks reimbursements from health plans.
Khalili described each mobile clinic as an “anchor” from which medical teams would fan out in smaller vans to find patients; Galat called this work “wandering rounds.”
Many types of medical care can and will continue to be provided on the street, but patients can also be brought back to the mobile clinics for additional help. The LA County Department of Health Services intends to move the mobile clinics to the same locations every two weeks for consistency, while allowing smaller teams to visit more frequently to follow up on patients.
When Khalili sat down with Guevara, he briefly spoke to her about a drug that could help her with drinking, but reassured her that she didn’t have to decide just yet as the team hopes to see her again. “Maybe next we can do a little test together,” Khalili said. “Is that ok for you?”
Guevara agreed. “We’re going to just go top-down,” the doctor said. With gloved fingers he touched the sides of her neck and felt her lymph nodes. He asked if it was okay to stick a stethoscope in the back of her shirt to listen to her lungs. At one point, towards the end of the examination, he stopped at her leg and asked if it was from a burn. No, she said, a broken bottle.
“I know you don’t like needles,” Khalili once told Guevara, but the woman stopped him and told him she was willing to have blood drawn to see what was making her sick.
In the truck, she sat quietly and watched her blood fill one vial and then another. Guevara said she can’t remember the last time she had blood drawn, but “I just want to make sure everything’s okay.” At one point, she reached out and gently brushed a loose strand of hair away from the nurse’s face who she cared for.
“I’m proud of you, Yesenia,” licensed professional nurse Munisa Saidova told Guevara after bandaging her arm.
Khalili explained that on-site blood collection can be difficult, as clinicians need to ensure blood samples are kept at the right temperature and transported to a lab in a timely manner. The blood samples could help the doctor check Guevara’s kidney and liver function; see if she was anemic; and detect other metabolic conditions.
While Guevara was having her blood drawn, the doctor was in the other exam room with Wisar, asking him to raise and rotate his arms to try to figure out the cause of his back pain. Khalili decided to prescribe a soothing gel for Wisar and checked the pharmacy’s address to make sure he could reach it. Many medications can be dispensed straight from the truck, including a range of antibiotics and other drugs to control high blood pressure, help people struggling with use of alcohol or other substances, and relieve nausea and pain.
Khalili told the couple the truck would be back in a few weeks but he would return earlier in a smaller vehicle to check on them. Guevara and Wisar left camp in the scorching sun with a bag full of bottles of water and Gatorade, and boxes of Narcan to prevent opioid overdoses at the camp.
“All right, doctor, take care of yourself!” Wisar called, and they strolled arm in arm back to their tent under the 118 freeway.
https://www.latimes.com/california/story/2022-10-13/la-county-mobile-medical-clinic L.A. County launches mobile clinics as big as semis