COVID-19 Homelessness Medicine Seattle

Some Notes Related to COVID-19.

Some notes:[1. Personal notes that reflect my own opinions, not those of my employer!]

To my knowledge, as of this writing, no individual staying in our shelter or housing programs has tested positive for COVID-19. (Note: Only a fraction of them have been tested.) This continues to boggle my mind. There may come a time very soon when I will look back on this post and think, “Well, that was quaint.”

I received a phone call from a medical epidemiologist this afternoon. Among other things, he said that his job is “to get swabs into people’s noses”. I won’t lie: I had to stifle a laugh.

The medical epidemiologist also shared that there is apparently a shortage of “viral media”, though he didn’t want to “get into the sordid details” about that. My secret source commented that the cause of the shortage of viral media is a shortage of bovine serum albumin. Holy cow.

I haven’t talked so much about nasal anatomy and swabs in my life, even as a medical student learning anatomy. The FDA has apparently approved self-swabs for COVID-19 testing, which include sampling from the anterior nares (nose picking) and mid-turbinates, both of which are easier to access than the nasopharyngeal region (the experience of which has been described as “brain tickling” or a “brain biopsy”). Supplies are limited, though, and we don’t know how to access them.

Homeless shelters and other congregate settings are the lowest priority to receive personal protective equipment (PPE). The only way these settings rise in priority is if there is a confirmed case. Thus, volunteers have made cloth face masks for PPE. It’s wonderful and terrible at the same time.

With Washington State’s “stay home, stay healthy” order, most of the people now on the streets are pushing overflowing carts, wearing soiled blankets, carrying stuffed trash bags, and carrying broken backpacks because they have no homes in which to stay. It is hard to witness this.

I appreciated Ed Yong’s article about How the Pandemic Will End. You may, too.

Consult-Liaison COVID-19 Education Medicine

Vulnerability and Resilience.

We had our medical staff meeting on Friday, which was the first time we had all convened since the COVID-19 epidemic was announced in Seattle-King County.

I shared with the team the following framework, which is from a paper about demoralization.[1. It is common for other medical specialties to request a psychiatric consult for a patient who seems depressed. Consultation psychiatrists often learn that it is demoralization, not depression, that results in consult requests. (Though demoralization and depression share features, most psychiatrists agree that they are distinct conditions. These distinctions are discussed further in the paper.)]

The authors note that:

Demoralization refers to the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

and later comment that “[a]cknowledging suffering and restoring dignity are potent in strengthening a patient’s resilience to stress.”

This is the valuable table from the paper:

During this extraordinary time of the COVID-19 pandemic, this framework may help you, whether you work in medicine or not. Sometimes the act of putting words to our emotions can alleviate our discomfort and help us feel more empowered.

We may all feel overwhelmed with the emotions and experiences on the left side of the table. Many, if not all, of us during the past few weeks have felt confused, helpless, and resentful. We have felt lonely and isolated, though we may recognize that we’re lonely and isolated all together. Sometimes fear gets the best of us and we wonder if anything we do matters. Vulnerability is often an uncomfortable position.

Remember that there are things we can all do to nudge us over to the right side of the table. Thanking others helps us reconnects us with people. Looking for the helpers can inspire us and give us hope. Taking a breath (or two or three) and slowing down helps us pursue clarity so we can find the signal in the midst of all the noise. The choices we make in each moment can help us recognize and cultivate our own courage and resilience. How we choose to react to what’s happening around us can shape our purpose. Do we react in anger or kindness? Do we have faith that we will do the best that we can in face of uncertainty, or do we assume the worst in others and ourselves?

To those of you who work in emergency departments and hospitals, regardless of your role, we thank you for your courage and efforts. We in outpatient settings are doing our best to keep people healthy and out of EDs. We all look forward to the time when this will be just a memory.

COVID-19 Nonfiction Observations Seattle

Spacious in Seattle.

Downtown Seattle isn’t completely empty, but there is suddenly more space. Buses zoom by, though they carry few passengers. Rush hour traffic is a faint memory as cars speed along the avenues. Instead of weaving my way through crowds of people, I now have meters of sidewalk all to myself.

I went on a cookie break this afternoon. The sole employee in the cookie shop saw me pause at the front door while I read the sign: “Express window is open”. From inside, she beckoned me to walk three meters to the right, and when I arrived at the window, she slid it open.


“Hi. Do you have day-olds?”

“Yes, right here.” She waved a gloved hand over the small basket sitting just inside the window. Cookies, stacked three high, were wrapped tightly in saran wrap. I selected a standard chocolate chip stack and a double chocolate stack.

While we waited for the credit card reader, we talked about these extraordinary times.

“Thanks for providing cookies to those of us who are working.”

“Thank you for buying them!”

“Yes, I’m glad that this shop is open. At least we have jobs.”

She nodded vigorously, then added, “Yeah, we are lucky.”

About an hour earlier, I asked one of the younger nurses at the agency how she was doing. She said that she was doing okay, then shared that she was grateful that she still had a job. She grimaced while she shared this anecdote: “Have you heard of This Fancy Restaurant? They laid off all of their staff on the same day. They can’t even collect unemployment.”

After tucking the two stacks of cookies into my coat, I saw this:


The restaurant serves a type of Asian cuisine. The man behind the counter was helping a customer, so I didn’t go in to thank him. Had I done so, I think I would’ve started crying.

Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.

Education Seattle Systems

Recommendations to other physicians from Washington re: COVID-19.

This post isn’t polished, but (a) it seems important to get this information out and (b) it also helps me feel like I have some control over something:

I work as the medical director for a non-profit agency that serves people who are currently or formerly homeless.[1. This post is NOT on behalf of my employer! I am writing as a private citizen who has opinions.] I am trained as a psychiatrist and have previously worked in local government. I live in the county in Washington State where people have died from COVID-19.

Here are my recommendations for other physician leaders in other regions, particularly those who work in outpatient, non-profit settings. I hope this information can help you if once COVID-19 arrives in your area.

Start talking with other physician leaders that intersect with your work now. Talk about how you all will coordinate together. How can your teams all work together to ensure that only people who need ED-level services are sent there? What sort of screening will you all do? If people who don’t have homes need to self-isolate, where can they go? Establish a communication system now because when COVID-19 arrives, you don’t want to fumble through that. If you haven’t met these other people yet, meet them now.

Start talking with physicians who work in your local government. My observations thus far are that physicians in government haven’t been active in planning for systemwide medical issues, and not because they’re not interested, but rather because they are overwhelmed and there’s not enough of them. Start asking questions like: if people who are homeless need quarantine, where should they go? has the city or county started talking with the hospitals to determine a system of where people with COVID-like symptoms should go? who will get tested? is there a centralized phone number clinics can call to alert county authorities of outbreaks? what sort of communication is the city or county having with the state?.

Keep up the advocacy with state and local partners with questions related to system processes. The state and local partners likely won’t have answers, particularly if you serve underserved patients. Since COVID-19 is affecting everyone, governments are thinking about the majority of people, many of whom are the “worried well”, can self-isolate, can go see their own doctors, etc. People without the same resources can’t do the same prevention and early intervention activities, so it is vital to keep following up with government partners so they don’t forget about these underserved populations. (This also includes populations that may not seek health care services, like immigrant and refugee populations.) If you can keep up the questions to your physician partners in government, they will feel empowered to keep asking their partners (e.g., state and federal agencies) for information.

Start teaching stuff to your non-medical partners. Sometimes physicians and nurses forget what we know; we think everyone knows what we know. Agencies that serve homeless populations often don’t have medical staff, so their leadership and line staff may have questions like, “Will an air purifier eliminate COVID-19?” or “Will hydrogen peroxide kill COVID-19?” People may not know HOW to wash their hands. Advocate with your agency leadership to get hygiene supplies now (because most of the suppliers locally are sold out) and make it easy for your staff to practice good hygiene. And don’t make assumptions that people know how to do hygiene stuff.

A small minority of people will do things you won’t like. There are people calling health care agencies pretending that they are the WHO or CDC and are asking for financial information so they can steal money. Supplies, like face masks, may suddenly go missing. Prepare for these sort of disappointing behaviors.

You can’t overcommunicate. In the face of uncertainty, frustration arises. Don’t lie, either; tell people what you know and don’t know. That way, they will be more likely to trust you when you do have recommendations.

Support your staff. You can’t rely on your staff to take care of other people if your staff don’t think you are taking care of them. We heard a comment today during a phone call that an estimated 40% of staff will be out of the office due to illness. Some may also call out because of fear. We can appeal to the better natures of our teams, but they won’t rise to the challenge if they think we don’t care about them. And if they don’t think we don’t care about them, then they won’t have the emotional and cognitive capacity to care for patients. (This applies to local government, too: They must take care of the agencies that provide services on their behalf, or otherwise the agencies will feel unsupported and may not extend themselves.)

People are expressing and demonstrating anxiety, which is fine—there are reasons to worry. But there are things we can do as leaders to acknowledge and mitigate that anxiety. Start now.