Disease, Inequity and Resilience in South L.A.

SERIES ELEMENTS:

• For two COVID-19 patients, life and death rests on ‘el tubo’

• His lonely war in Room 533: How a COVID patient fought to keep his life from crumbling

• In South L.A., a legacy of limbs lost to diabetes tells a larger story

• In South L.A., the battle to stay ahead of the mental health turnstile never ends

• Bigotry confines their trans daughter at home. Her parents worry what she’ll do when they’re gone

​

For two COVID-19 patients,

life and death rests on ‘el tubo'

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | February 19, 2021
 

Gilbert Torres sat in his hospital bed, sheets wrapped around his legs, clutching his phone with trembling hands.

Three weeks before, he was working his shift at a truck wash on South Alameda Street, counting the minutes before he’d be home playing with his 5-year-old boy.

Now such moments were just a beautiful dream.

In the hallway, nurses peered through the glass doors, wiping their eyes as they watched him confront the possibility that he might have minutes left to live. He was only 30 years old. He looked desperately alone.

Nurses in white Tyvek suits and respirators stepped into the room to set up the ventilator.

Torres said goodbye to his girlfriend of nine years on video chat, laboring to get the words out. Even on high-flow oxygen through his nostrils, he struggled to breathe. He hadn’t slept in days.

He watched a team of nurses and doctors suit up in the hall.

“It’s happening,” Torres told her. “They’re going to intubate me.”

“Everything is going to be OK,” she assured him.

“I’m scared. I don’t want to die.”

Tears streamed down his cheeks. His body shook.

An emergency room doctor leaned in and told him it was time.

Torres turned off the phone.

The team came in. Wearing a bulky hood over his respirator and mask, the doctor stood behind him with the laryngoscope, ready to insert the breathing tube. A nurse released sedative and paralytic medications into Torres’ bloodstream.

He closed his eyes, clasping her hand.

:

They call it el tubo, and it haunts places like South Los Angeles, the Latino-majority neighborhoods hit harder by COVID-19 than almost anywhere in the U.S.

Intubation has become more than a medical procedure. It represents the terrible crossroad of this disease: the moment patients must decide whether to have a tube inserted into their trachea so a machine can take over their breathing.

While the procedure itself is relatively simple, it can spin out of control within seconds. The airway team generally puts the patients to sleep and stops their breathing. If their blood pressure isn’t stabilized as the rush of adrenaline abruptly falls off, or a doctor cannot secure the tube at the right spot quickly enough, oxygen levels drop precariously, leading to organ failure and death. But for people with severe COVID-19, the procedure can be the last bid for survival.

Arriving at this juncture presents one of the most agonizing choices a patient or family may ever have to make. Most people have no plan for what to do.

The only other option is to struggle on, with doctors managing the pain and anxiety with medication, as they lose oxygen and blood pressure and likely fall into cardiac arrest.

Most patients at this late stage will die whatever road they choose. While chances of survival might be higher on the ventilator, doctors say, those who recover could be left with major disabilities, including brain damage, severe respiratory problems and kidney failure. Younger people with no major underlying medical conditions fare better.

With so many people going to hospitals for COVID-19, many South Los Angeles residents have stories about going on the tube: the uncle who died just minutes after hanging up with his family. The friend’s father who came out alive but would need dialysis the rest of his life. The aunt who died after three weeks in a coma. The middle-age cousin who is recovering.

At the heart of the suffering is Martin Luther King Jr. Community Hospital, a privately managed, high-tech facility that replaced the troubled county medical center that had closed in 2007. The Willowbrook hospital has been packed with patients facing the terrible choice.

Mariano Zuñiga Anaya, 57, knew all about el tubo. His older brother died in May on a ventilator in Mexico.

Now Zuñiga was sick in the small apartment in Florence-Firestone that he shared with his daughter Ana and her 5-year-old girl and 2-year-old boy.

Zuñiga was a traditional show-no-weakness father who had turned into a playful, doting grandfather. He let his granddaughter paint his toenails and grandson draw “tattoos” all over his body with markers. He helped her learn how to read and write, and loved to listen to the stories she imagined up. They loved their abuelito.

Ana Zuñiga Diaz, 30, relished this new side of her father, and she was terrified now. Her mother and older sister still lived in Michoacán, and all the weight of his illness fell on her.

On Jan. 22, her dad was too weak to get up, could not eat and had a frantic, ragged cough. He had major health problems already, weighing over 275 pounds, with diabetes, hypertension and high cholesterol. He recently had lost part of a toe due to complications of diabetes.

Ana called her sister, Leslie, to explain his bad condition.

“She’s exaggerating!” her dad called out.

The family in Mexico feared if he went to a hospital he would be forced on a ventilator. Their uncle was dead within four days of getting intubated. They could not bear losing him the same way.

Back home in the mountain town of Zacapu, Mariano was a booming, fun-loving presence — the worker who left as a teenager, diligently sending money back for nearly 40 years. Twice a year he would return, hosting big fiestas with mariachi bands. He had a deep laugh and loved to joke and tell stories. Ana suspects he got COVID-19 on his flight back to Los Angeles after the New Year.

The family wanted him to stay out of the hospital, fearing it would be his death.

As Ana spoke to her sister, Mariano started coughing so violently it sounded like he was drowning. She hung up and called 911. The paramedics came and told him he had to go to the hospital. His blood-oxygen level was dangerously low. She felt helpless as they loaded him onto a gurney and took him away.

 

Torres, the young father, lay on his belly, unconscious on the fifth-floor ICU three days after his intubation. His ventilator pumped with its eerie hiss-tap-tap metronome. Nurses talked gently to him as they repositioned him or checked his settings.

Dr. Joseph Meltzer, a UCLA critical care specialist working at the community hospital during the surge, had told Torres that he had to be intubated. But he made a promise: “We can get you through this.”

Now, Torres was stable, but his oxygen saturation fell every time he was turned to lie on his back, which he needed to do for eight hours a day to avoid blood pooling. Meltzer turned up the pressure on the ventilator to bring his oxygen up. But too much pressure, over too much time, could damage the tiny sacs in the lungs where oxygen was absorbed into the blood and carbon dioxide released, reducing his odds of surviving.

The same morning, Zuñiga was wheeled to the south wing of the telemetry unit on the first floor, room 710 — four doors from the room where Torres was intubated. Since the surge, the unit was filled to capacity, and became the transition zone where COVID-19 patients recovered enough to go home, or went to the ICU on a ventilator.

Zuñiga was in bad shape. Doctors put him on high-flow oxygen through his nose. They set the machine to 60 liters per minute. Only the ventilator could deliver more.

He lay on his side and his shortness of breath gradually abated, but his blood-oxygen level remained perilously low. He was at risk of organ failure. Talking or moving made it worse.

His granddaughter Hayley sent him little audio texts. “You’re going to be alright grandpa,” she said. “Echele ganas.” Give it your best.

Ana called him every morning.

“How are you feeling, Papa?”

“Estoy bien,” he would say in a robust voice. I’m good.

But the doctors told her he was at a critical point. His oxygen delivery was at the maximum setting, and his blood saturation was not improving. They brought up the possibility of putting him on the ventilator, but he had refused it. When a reporter asked him why one day, he declared: “For fear, nothing else.”

The next day, Torres appeared to be rounding the bend. His blood pressure and oxygen levels were stable enough to gradually lower the pressure on the ventilator, to let his own breathing slowly take over.

On Jan. 24, Dr. Jason Prasso, a pulmonary and critical care specialist, decided Torres was ready to get off the ventilator. His team eased off the sedation.

But as Torres came to a low level of consciousness — still deeply blurred by the fentanyl — he grew agitated. They gave him an anti-anxiety medication as the respiratory therapist began to pull out nine inches of tube from his trachea.

When it came out, Torres panicked, struggling for air.

“Please intubate me,” he said. “I beg you!”

He grabbed Prasso’s hand.

“Just relax, breathe,” the doctor said. “I can’t put it back in you. You’ve made it through so much.”

“Imagine you’re on a beach in Hawaii,” someone said.

“Please!” said Torres. “Knock me out, put me under.”

When the anti-anxiety meds kicked in, Torres floated around in a fog. Why was he in Hawaii? He didn’t have his glasses, so he couldn’t see anything but muddled colors, blue sky in the day, circles of light in the dark night. The sounds were so jarring and constant, so alien: the beeping of the monitors, the hiss of his roommate’s ventilator, muffled voices through the door.

Every so often the loudspeaker blared “Code Blue.” “Oh my God somebody is dying,” he thought. He started to cry.

In a couple of days, his mind started to sort itself out. But he had no memory of his days before the intubation or how he got to the hospital. In his haze, he tried to figure out why he was taken to one in Hawaii.

Zuñiga continued to struggle after four days on maximum oxygen.

Dr. Krupa Gandhi noticed that “DNI” — do not intubate — was written in his notes. Seeing that he was only 57, she wanted to make sure that he understood what this meant.

She stepped into the room with a live translator on an iPad stand to speak with him in Spanish. Gandhi explained that if his vitals started to drop, the only way to save him might be the ventilator.

“I don’t want to be intubated. I want to die in peace,” he said. “I don’t even understand why you’re asking me this.”

He seemed to think he was doing well.

“You’re on a high oxygen requirement, and if you need more, you’re going to do worse,” she explained. “We have to know what your wishes are, so we have this conversation early.”

Zuñiga was adamant about not being intubated.

Even though he neared a point of no return, Zuñiga looked relatively relaxed. He wasn’t gasping for air, breathing rapidly, shaking or sweating. Every time a Times reporter visited him to see how he was doing, he always announced, in his strong voice: “Bien.”

“I think he just felt so comfortable that he’s like, no, I don’t need a tube,” Gandhi recalled shortly after her conversation. “I don’t know if his decision will change if he starts becoming more uncomfortable.”

Upstairs, Torres was moved back to telemetry, transitioning through the unit in the right direction this time. He could sit in a chair and look out the window. He had gone down the oxygen requirement chain to a simple cannula delivering a low flow of oxygen through his nose.

He was deeply shaken. He talked to his girlfriend, Lisseth, on the phone but couldn’t bring himself to talk to his 5-year-old son, Austin. Just thinking about it brought him close to sobbing. He missed him so much, and he didn’t want his boy to see him cry.

He was racked with anxiety over the trauma of the last week.

“It was the most scariest experience you could possibly have. You know why?” he recalled in a shaky voice. “Because you’re alone. Because you’re alone. That’s it. You’re alone.”

On Feb. 1, three days after Zuñiga rejected any option to be intubated, Dr. Ameer Moussa noticed that his oxygen and blood pressure were dropping. This would be the point to intubate before his organs failed.

“How are you feeling?” Moussa asked.

“Bien,” Zuñiga said.

“Any pain?”

“None.”

Moussa told him his condition was getting worse, that he could go into cardiac arrest at any moment, and asked him again if he wanted to be put on the ventilator.

“No,” Zuñiga said.

“Are you sure?” the doctor asked.

Zuñiga wavered. “Ask my daughter.”

The call from Moussa spun Ana into despair. She did not want this decision on her shoulders. Over the next hours, she called her sister in Mexico, then a cousin who was a doctor, then her dad.

Every time her father talked to her, his oxygen plummeted.

“These calls are making him worse,” said the nurse watching the monitors.

Ana finally called Moussa with the consensus that if he went into cardiac arrest they should try to resuscitate him and put him on the ventilator then — but not before. The doctor sighed. That didn’t make sense.

He went back to Zuñiga with the iPad translator, trying to understand his thinking.

He asked him why he wanted to be intubated only if his heart and lungs stopped.

“Vivo,” he said. Alive.

“If you want to live, then the best thing is to intubate now and not when it’s too late,” Moussa said.

Zuñiga was silent. “Does it hurt? he asked.

“No, I put you to sleep.”

Zuñiga stared up at the ceiling, thinking it over.

“Esta bien.”

Within 20 minutes of Zuñiga’s decision, Dr. Stefan Richter arrived from the ICU to carry out a procedure he had done hundreds of times — but which could still go disastrously wrong.

COVID-19 patients have usually been under a flood of adrenaline for days. The moment the sedative hits the brain, that drops off and their blood pressure tends to crash.

A minute later, the paralytic hits, and the patients’ breathing stops. With COVID-19 patients who were already severely oxygen deprived, it leaves the doctors seconds to thread the tube through the larynx into the trachea. And that small gap, next to the opening of the esophagus, can be hard to find.

Richter said a fraction of patients die within minutes or a couple of hours after intubation.

A dozen nurses and specialists waited outside room 710, ready for any possible emergency. Two nurses and a respiratory therapist assisted the doctor in the room.

At the center of this swirl of activity, Zuñiga lay still, silent and scared, tears glistening in his eyes.

The ICU nurse released the short-acting sedative etomidate into his IV, followed by the paralytic rocuronium. Zuñiga fell asleep almost instantly, avoiding one of the very rare but terrifying moments a human can experience: having the paralytic hit while they are still awake.

Richter took the sickle-shaped video laryngoscope and ran it down the right side of Zuñiga’s tongue, pushing it to the side to clear a path to the larynx. A camera and light at the tip of the sickle guided the way, displaying the image on a small screen on top of the scope. Richter guided it through folds of excess tissue, looking for the opening.

Zuñiga’s oxygen monitor rang an alarm as his blood saturation dropped below 80%. The respiratory therapist silenced it.

“Pressure is dropping; why don’t we start Levo?” Richter asked the ICU nurse.

Levophed supplemented his falling adrenaline, constricting his blood vessels to build the pressure back.

Richter spotted the opening, a small hole between the vocal cords, and ran the tube down a groove in the scope to guide it through. He stopped at 26 centimeters below Zuñiga’s front teeth. He pulled out the stiff wire that kept the tube from crimping and asked the respiratory therapist to inflate “the cuff” — a balloon around the tube that seals it to the trachea, keeping the pressure in the lungs.

A probe attached to the ventilator showed carbon dioxide coming out of the tube, a good sign it was in the right spot. Richter still wanted to be absolutely sure the tube hadn’t gone down the esophagus, which could be fatal if not fixed instantly. He took a stethoscope to Zuñiga’s stomach to listen for any airflow there. There was none. He listened to the lungs with his stethoscope and could hear air flow.

They all stared gravely at the iPhone-sized monitor on Zuñiga’s chest. His oxygen had crashed to 6%, a level that would rapidly kill him.

His blood pressure was down too, at 70/30, creating a potential shock to the kidneys and other organs.

The therapist let a burst of air from the ventilator to open any air sacs in the lungs that had collapsed during the procedure.

Slowly, Zuñiga’s numbers began to recover as the ventilator and vasoconstrictors did their work.

He was wheeled to the ICU with oxygen numbers in the low 90s and blood pressure of 100/70. But the initial crash in both loomed as a bad omen.

::

On the bright, crisp morning of Feb. 6, Torres was ready to go home. He beamed in happy disbelief. He put on an Avengers T-shirt and packed up his items.

A doctor came in and listened to his lungs and advised him to be alert for any new symptoms. He was still weak and needed oxygen. He’d have to come back to the post-release clinic in a week for doctors to check his progress.

Torres was wheeled out the modern glass entrance of Martin Luther King Jr. Community Hospital, smiling like a little boy.

He wept as his girlfriend walked up to him. She gave him a long hug.

The senses overwhelmed his emotions: her smell and touch, the sunlight and the cool breeze. “I missed you so much,” he said.

They loaded the wheelchair in the back of her sister’s car. He got in the backseat with his oxygen tank.

He knew he’d never be the same. Since he left the ICU, he promised God he would be a better man, someone his son would be proud of. He had made this vow over and over, and he had no doubt he would keep it.

“Can we just drive awhile?” he asked.

He opened the window and took as deep a breath as he could. He wanted to stay outside forever.

As they rolled along Central Avenue, he reached out the window and let his cupped fingers sail through the air, angling up and down, right and left, such a simple joy flying his hand in the wind.

::

At that very moment, Ana Zuñiga was on the fifth floor. Prasso had called her earlier that morning.

Two days after the intubation, Mariano Zuñiga’s kidneys shut down and he had to be put on continuous dialysis. Healthy kidneys use carbon dioxide to regulate blood acidity. His failing ones put a larger burden on the lungs to expel the gas.

Zuñiga’s acid level was rising while oxygen and blood pressure were dropping.

This was the end. Earlier that morning, Prasso stopped the dialysis and returned all his blood to his body to stabilize the pressure, just to give Ana enough time to come see him.

“There’s nothing else I can do for him,” Prasso said.

A nurse gave her a long hug.

Prasso explained that without dialysis her father was going to die within a day.

“Now if he could step out of his body right now, understand everything that was going on, how do you think he would want to pass?” he asked. “Would he want to pass attached to all these machines, or pass more naturally?”

“He wouldn’t want to die on all these machines,” she said without pause.

He had the nurses give her father medication to tamp down any pain, nausea and shortness of breath. At 11:05 a.m, they removed the tube. Zuñiga had no visible response. His mouth stayed open.

Ana put on a medical gown, face shield and N-95 mask and entered his room.

“Papa,” she said. She came to his side and gently closed his mouth. “I love you.”

She took deep breaths through her nose to keep from sobbing. She patted his arm and took care to tuck him better into his sheet.

“Wherever you are, I want you to be happy,” she said.

She clasped her father’s hand, hugged him and cried.

She didn’t know what she was going to tell her daughter. Hayley was so close to him, always sneaking in her abuelo’s room to check on him. His absence in their small apartment would be an inescapable hole.

Ana Zuñiga held him quietly and prayed.

“Please go in tranquility and peace. We are all going to be fine. We will always remember you.”

She patted her father’s arm.

“Adios Papa.”

---

For two COVID-19 patients, life and death rests on ‘el tubo'

For two COVID-19 patients,

life and death rests on ‘el tubo'

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | February 19, 2021
 

Gilbert Torres sat in his hospital bed, sheets wrapped around his legs, clutching his phone with trembling hands.

Three weeks before, he was working his shift at a truck wash on South Alameda Street, counting the minutes before he’d be home playing with his 5-year-old boy.

Now such moments were just a beautiful dream.

In the hallway, nurses peered through the glass doors, wiping their eyes as they watched him confront the possibility that he might have minutes left to live. He was only 30 years old. He looked desperately alone.

Nurses in white Tyvek suits and respirators stepped into the room to set up the ventilator.

Torres said goodbye to his girlfriend of nine years on video chat, laboring to get the words out. Even on high-flow oxygen through his nostrils, he struggled to breathe. He hadn’t slept in days.

He watched a team of nurses and doctors suit up in the hall.

“It’s happening,” Torres told her. “They’re going to intubate me.”

“Everything is going to be OK,” she assured him.

“I’m scared. I don’t want to die.”

Tears streamed down his cheeks. His body shook.

An emergency room doctor leaned in and told him it was time.

Torres turned off the phone.

The team came in. Wearing a bulky hood over his respirator and mask, the doctor stood behind him with the laryngoscope, ready to insert the breathing tube. A nurse released sedative and paralytic medications into Torres’ bloodstream.

He closed his eyes, clasping her hand.

They call it el tubo, and it haunts places like South Los Angeles, the Latino-majority neighborhoods hit harder by COVID-19 than almost anywhere in the U.S.

Intubation has become more than a medical procedure. It represents the terrible crossroad of this disease: the moment patients must decide whether to have a tube inserted into their trachea so a machine can take over their breathing.

While the procedure itself is relatively simple, it can spin out of control within seconds. The airway team generally puts the patients to sleep and stops their breathing. If their blood pressure isn’t stabilized as the rush of adrenaline abruptly falls off, or a doctor cannot secure the tube at the right spot quickly enough, oxygen levels drop precariously, leading to organ failure and death. But for people with severe COVID-19, the procedure can be the last bid for survival.

Arriving at this juncture presents one of the most agonizing choices a patient or family may ever have to make. Most people have no plan for what to do.

The only other option is to struggle on, with doctors managing the pain and anxiety with medication, as they lose oxygen and blood pressure and likely fall into cardiac arrest.

Most patients at this late stage will die whatever road they choose. While chances of survival might be higher on the ventilator, doctors say, those who recover could be left with major disabilities, including brain damage, severe respiratory problems and kidney failure. Younger people with no major underlying medical conditions fare better.

With so many people going to hospitals for COVID-19, many South Los Angeles residents have stories about going on the tube: the uncle who died just minutes after hanging up with his family. The friend’s father who came out alive but would need dialysis the rest of his life. The aunt who died after three weeks in a coma. The middle-age cousin who is recovering.

At the heart of the suffering is Martin Luther King Jr. Community Hospital, a privately managed, high-tech facility that replaced the troubled county medical center that had closed in 2007. The Willowbrook hospital has been packed with patients facing the terrible choice.

Mariano Zuñiga Anaya, 57, knew all about el tubo. His older brother died in May on a ventilator in Mexico.

Now Zuñiga was sick in the small apartment in Florence-Firestone that he shared with his daughter Ana and her 5-year-old girl and 2-year-old boy.

Zuñiga was a traditional show-no-weakness father who had turned into a playful, doting grandfather. He let his granddaughter paint his toenails and grandson draw “tattoos” all over his body with markers. He helped her learn how to read and write, and loved to listen to the stories she imagined up. They loved their abuelito.

Ana Zuñiga Diaz, 30, relished this new side of her father, and she was terrified now. Her mother and older sister still lived in Michoacán, and all the weight of his illness fell on her.

On Jan. 22, her dad was too weak to get up, could not eat and had a frantic, ragged cough. He had major health problems already, weighing over 275 pounds, with diabetes, hypertension and high cholesterol. He recently had lost part of a toe due to complications of diabetes.

Ana called her sister, Leslie, to explain his bad condition.

“She’s exaggerating!” her dad called out.

The family in Mexico feared if he went to a hospital he would be forced on a ventilator. Their uncle was dead within four days of getting intubated. They could not bear losing him the same way.

Back home in the mountain town of Zacapu, Mariano was a booming, fun-loving presence — the worker who left as a teenager, diligently sending money back for nearly 40 years. Twice a year he would return, hosting big fiestas with mariachi bands. He had a deep laugh and loved to joke and tell stories. Ana suspects he got COVID-19 on his flight back to Los Angeles after the New Year.

The family wanted him to stay out of the hospital, fearing it would be his death.

As Ana spoke to her sister, Mariano started coughing so violently it sounded like he was drowning. She hung up and called 911. The paramedics came and told him he had to go to the hospital. His blood-oxygen level was dangerously low. She felt helpless as they loaded him onto a gurney and took him away.

::

Torres, the young father, lay on his belly, unconscious on the fifth-floor ICU three days after his intubation. His ventilator pumped with its eerie hiss-tap-tap metronome. Nurses talked gently to him as they repositioned him or checked his settings.

Dr. Joseph Meltzer, a UCLA critical care specialist working at the community hospital during the surge, had told Torres that he had to be intubated. But he made a promise: “We can get you through this.”

Now, Torres was stable, but his oxygen saturation fell every time he was turned to lie on his back, which he needed to do for eight hours a day to avoid blood pooling. Meltzer turned up the pressure on the ventilator to bring his oxygen up. But too much pressure, over too much time, could damage the tiny sacs in the lungs where oxygen was absorbed into the blood and carbon dioxide released, reducing his odds of surviving.

The same morning, Zuñiga was wheeled to the south wing of the telemetry unit on the first floor, room 710 — four doors from the room where Torres was intubated. Since the surge, the unit was filled to capacity, and became the transition zone where COVID-19 patients recovered enough to go home, or went to the ICU on a ventilator.

Zuñiga was in bad shape. Doctors put him on high-flow oxygen through his nose. They set the machine to 60 liters per minute. Only the ventilator could deliver more.

He lay on his side and his shortness of breath gradually abated, but his blood-oxygen level remained perilously low. He was at risk of organ failure. Talking or moving made it worse.

His granddaughter Hayley sent him little audio texts. “You’re going to be alright grandpa,” she said. “Echele ganas.” Give it your best.

Ana called him every morning.

“How are you feeling, Papa?”

“Estoy bien,” he would say in a robust voice. I’m good.

But the doctors told her he was at a critical point. His oxygen delivery was at the maximum setting, and his blood saturation was not improving. They brought up the possibility of putting him on the ventilator, but he had refused it. When a reporter asked him why one day, he declared: “For fear, nothing else.”

The next day, Torres appeared to be rounding the bend. His blood pressure and oxygen levels were stable enough to gradually lower the pressure on the ventilator, to let his own breathing slowly take over.

On Jan. 24, Dr. Jason Prasso, a pulmonary and critical care specialist, decided Torres was ready to get off the ventilator. His team eased off the sedation.

But as Torres came to a low level of consciousness — still deeply blurred by the fentanyl — he grew agitated. They gave him an anti-anxiety medication as the respiratory therapist began to pull out nine inches of tube from his trachea.

When it came out, Torres panicked, struggling for air.

“Please intubate me,” he said. “I beg you!”

He grabbed Prasso’s hand.

“Just relax, breathe,” the doctor said. “I can’t put it back in you. You’ve made it through so much.”

“Imagine you’re on a beach in Hawaii,” someone said.

“Please!” said Torres. “Knock me out, put me under.”

When the anti-anxiety meds kicked in, Torres floated around in a fog. Why was he in Hawaii? He didn’t have his glasses, so he couldn’t see anything but muddled colors, blue sky in the day, circles of light in the dark night. The sounds were so jarring and constant, so alien: the beeping of the monitors, the hiss of his roommate’s ventilator, muffled voices through the door.

Every so often the loudspeaker blared “Code Blue.” “Oh my God somebody is dying,” he thought. He started to cry.

In a couple of days, his mind started to sort itself out. But he had no memory of his days before the intubation or how he got to the hospital. In his haze, he tried to figure out why he was taken to one in Hawaii.

::

Zuñiga continued to struggle after four days on maximum oxygen.

Dr. Krupa Gandhi noticed that “DNI” — do not intubate — was written in his notes. Seeing that he was only 57, she wanted to make sure that he understood what this meant.

She stepped into the room with a live translator on an iPad stand to speak with him in Spanish. Gandhi explained that if his vitals started to drop, the only way to save him might be the ventilator.

“I don’t want to be intubated. I want to die in peace,” he said. “I don’t even understand why you’re asking me this.”

He seemed to think he was doing well.

“You’re on a high oxygen requirement, and if you need more, you’re going to do worse,” she explained. “We have to know what your wishes are, so we have this conversation early.”

Zuñiga was adamant about not being intubated.

Even though he neared a point of no return, Zuñiga looked relatively relaxed. He wasn’t gasping for air, breathing rapidly, shaking or sweating. Every time a Times reporter visited him to see how he was doing, he always announced, in his strong voice: “Bien.”

“I think he just felt so comfortable that he’s like, no, I don’t need a tube,” Gandhi recalled shortly after her conversation. “I don’t know if his decision will change if he starts becoming more uncomfortable.”

Upstairs, Torres was moved back to telemetry, transitioning through the unit in the right direction this time. He could sit in a chair and look out the window. He had gone down the oxygen requirement chain to a simple cannula delivering a low flow of oxygen through his nose.

He was deeply shaken. He talked to his girlfriend, Lisseth, on the phone but couldn’t bring himself to talk to his 5-year-old son, Austin. Just thinking about it brought him close to sobbing. He missed him so much, and he didn’t want his boy to see him cry.

He was racked with anxiety over the trauma of the last week.

“It was the most scariest experience you could possibly have. You know why?” he recalled in a shaky voice. “Because you’re alone. Because you’re alone. That’s it. You’re alone.”

On Feb. 1, three days after Zuñiga rejected any option to be intubated, Dr. Ameer Moussa noticed that his oxygen and blood pressure were dropping. This would be the point to intubate before his organs failed.

“How are you feeling?” Moussa asked.

“Bien,” Zuñiga said.

“Any pain?”

“None.”

Moussa told him his condition was getting worse, that he could go into cardiac arrest at any moment, and asked him again if he wanted to be put on the ventilator.

“No,” Zuñiga said.

“Are you sure?” the doctor asked.

Zuñiga wavered. “Ask my daughter.”

The call from Moussa spun Ana into despair. She did not want this decision on her shoulders. Over the next hours, she called her sister in Mexico, then a cousin who was a doctor, then her dad.

Every time her father talked to her, his oxygen plummeted.

“These calls are making him worse,” said the nurse watching the monitors.

Ana finally called Moussa with the consensus that if he went into cardiac arrest they should try to resuscitate him and put him on the ventilator then — but not before. The doctor sighed. That didn’t make sense.

He went back to Zuñiga with the iPad translator, trying to understand his thinking.

He asked him why he wanted to be intubated only if his heart and lungs stopped.

“Vivo,” he said. Alive.

“If you want to live, then the best thing is to intubate now and not when it’s too late,” Moussa said.

Zuñiga was silent. “Does it hurt? he asked.

“No, I put you to sleep.”

Zuñiga stared up at the ceiling, thinking it over.

“Esta bien.”

::

Within 20 minutes of Zuñiga’s decision, Dr. Stefan Richter arrived from the ICU to carry out a procedure he had done hundreds of times — but which could still go disastrously wrong.

COVID-19 patients have usually been under a flood of adrenaline for days. The moment the sedative hits the brain, that drops off and their blood pressure tends to crash.

A minute later, the paralytic hits, and the patients’ breathing stops. With COVID-19 patients who were already severely oxygen deprived, it leaves the doctors seconds to thread the tube through the larynx into the trachea. And that small gap, next to the opening of the esophagus, can be hard to find.

Richter said a fraction of patients die within minutes or a couple of hours after intubation.

A dozen nurses and specialists waited outside room 710, ready for any possible emergency. Two nurses and a respiratory therapist assisted the doctor in the room.

At the center of this swirl of activity, Zuñiga lay still, silent and scared, tears glistening in his eyes.

The ICU nurse released the short-acting sedative etomidate into his IV, followed by the paralytic rocuronium. Zuñiga fell asleep almost instantly, avoiding one of the very rare but terrifying moments a human can experience: having the paralytic hit while they are still awake.

Richter took the sickle-shaped video laryngoscope and ran it down the right side of Zuñiga’s tongue, pushing it to the side to clear a path to the larynx. A camera and light at the tip of the sickle guided the way, displaying the image on a small screen on top of the scope. Richter guided it through folds of excess tissue, looking for the opening.

Zuñiga’s oxygen monitor rang an alarm as his blood saturation dropped below 80%. The respiratory therapist silenced it.

“Pressure is dropping; why don’t we start Levo?” Richter asked the ICU nurse.

Levophed supplemented his falling adrenaline, constricting his blood vessels to build the pressure back.

Richter spotted the opening, a small hole between the vocal cords, and ran the tube down a groove in the scope to guide it through. He stopped at 26 centimeters below Zuñiga’s front teeth. He pulled out the stiff wire that kept the tube from crimping and asked the respiratory therapist to inflate “the cuff” — a balloon around the tube that seals it to the trachea, keeping the pressure in the lungs.

A probe attached to the ventilator showed carbon dioxide coming out of the tube, a good sign it was in the right spot. Richter still wanted to be absolutely sure the tube hadn’t gone down the esophagus, which could be fatal if not fixed instantly. He took a stethoscope to Zuñiga’s stomach to listen for any airflow there. There was none. He listened to the lungs with his stethoscope and could hear air flow.

They all stared gravely at the iPhone-sized monitor on Zuñiga’s chest. His oxygen had crashed to 6%, a level that would rapidly kill him.

His blood pressure was down too, at 70/30, creating a potential shock to the kidneys and other organs.

The therapist let a burst of air from the ventilator to open any air sacs in the lungs that had collapsed during the procedure.

Slowly, Zuñiga’s numbers began to recover as the ventilator and vasoconstrictors did their work.

He was wheeled to the ICU with oxygen numbers in the low 90s and blood pressure of 100/70. But the initial crash in both loomed as a bad omen.

::

On the bright, crisp morning of Feb. 6, Torres was ready to go home. He beamed in happy disbelief. He put on an Avengers T-shirt and packed up his items.

A doctor came in and listened to his lungs and advised him to be alert for any new symptoms. He was still weak and needed oxygen. He’d have to come back to the post-release clinic in a week for doctors to check his progress.

Torres was wheeled out the modern glass entrance of Martin Luther King Jr. Community Hospital, smiling like a little boy.

He wept as his girlfriend walked up to him. She gave him a long hug.

The senses overwhelmed his emotions: her smell and touch, the sunlight and the cool breeze. “I missed you so much,” he said.

They loaded the wheelchair in the back of her sister’s car. He got in the backseat with his oxygen tank.

He knew he’d never be the same. Since he left the ICU, he promised God he would be a better man, someone his son would be proud of. He had made this vow over and over, and he had no doubt he would keep it.

“Can we just drive awhile?” he asked.

He opened the window and took as deep a breath as he could. He wanted to stay outside forever.

As they rolled along Central Avenue, he reached out the window and let his cupped fingers sail through the air, angling up and down, right and left, such a simple joy flying his hand in the wind.

::

At that very moment, Ana Zuñiga was on the fifth floor. Prasso had called her earlier that morning.

Two days after the intubation, Mariano Zuñiga’s kidneys shut down and he had to be put on continuous dialysis. Healthy kidneys use carbon dioxide to regulate blood acidity. His failing ones put a larger burden on the lungs to expel the gas.

Zuñiga’s acid level was rising while oxygen and blood pressure were dropping.

This was the end. Earlier that morning, Prasso stopped the dialysis and returned all his blood to his body to stabilize the pressure, just to give Ana enough time to come see him.

“There’s nothing else I can do for him,” Prasso said.

A nurse gave her a long hug.

Prasso explained that without dialysis her father was going to die within a day.

“Now if he could step out of his body right now, understand everything that was going on, how do you think he would want to pass?” he asked. “Would he want to pass attached to all these machines, or pass more naturally?”

“He wouldn’t want to die on all these machines,” she said without pause.

He had the nurses give her father medication to tamp down any pain, nausea and shortness of breath. At 11:05 a.m, they removed the tube. Zuñiga had no visible response. His mouth stayed open.

Ana put on a medical gown, face shield and N-95 mask and entered his room.

“Papa,” she said. She came to his side and gently closed his mouth. “I love you.”

She took deep breaths through her nose to keep from sobbing. She patted his arm and took care to tuck him better into his sheet.

“Wherever you are, I want you to be happy,” she said.

She clasped her father’s hand, hugged him and cried.

She didn’t know what she was going to tell her daughter. Hayley was so close to him, always sneaking in her abuelo’s room to check on him. His absence in their small apartment would be an inescapable hole.

Ana Zuñiga held him quietly and prayed.

“Please go in tranquility and peace. We are all going to be fine. We will always remember you.”

She patted her father’s arm.

“Adios Papa.”

---

His lonely war in Room 533: How a COVID patient fought to keep his life from crumbling

His lonely war in Room 533: How a COVID patient fought to keep his life from crumbling

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | June 3, 2021
 

As a boy in Compton, Richard Perry raised pigeons that were bred to tumble in the air. Now, as he lay in a hospital bed fighting to breathe, drifting in and out of consciousness, he saw his birds somersaulting across the sky.

For the four weeks that COVID-19 tried to kill him, Richard had nothing to do but wander through his mind. Thoughts of death and leaving his wife and daughter to struggle sent him into a panic. So he traveled back.

He was playing football in the street with his brothers Ray and Ronald, waiting for their mom to call them to dinner. He was letting his birds out of his backyard loft, a burst of squeaky wings. He was building bikes from scrap parts with his best friend, Dwayne, trading rims for handlebars, a rusty chain for grips, riding to the old Pike in Long Beach.

From his hospital bed in the weeks after he arrived Jan. 5, he thought about working on his first car with his dad. The hours together wrenching on a broken-down 1965 Chevy Impala — the spare words and scraped knuckles — set him on the path to become the man he would be.

At 58, Richard had a solid union job transporting and assembling satellite parts at Boeing Co. He was the one to whom his siblings came for help, the one his dad picked to take care of their mother if he died first. He had a wife of 34 years, Audrey; a grown daughter, Aushlie; and a house in Compton that he spent his weekends tirelessly remodeling and expanding into a family palace, with a rumpus room, sprawling patio and three barbecue pits to cook chicken and ribs for his brothers, sisters, nieces and nephews.

Richard claimed his berth in the middle class the way most Black people do — by sheer drive and against the odds, with little or no generational wealth to lean on in a crisis.

His father, Lapolum Perry, had left Jim Crow-era Arkansas for something bigger than a clearing in the woods with a rough-hewed cabin and an outhouse. When he landed in Los Angeles with a wife and young children in 1958, he worked as a truck driver for Shell Oil and in a year had saved enough to buy a little house in a tract of west Compton that was built for Black families aspiring to the middle class. Richard’s parents took a big step up in that purchase, and he took a big step up from that.

Now COVID-19 was showing how rickety this ladder was. By mid-January, Richard was watching the virus rip through nearly every aspect of his life, as it was doing to home after home, block after block in Latino and Black neighborhoods from Wilmington to Watts, Pomona to San Fernando.

If he died, his family might fall into poverty. His mother would be crushed. Then he worried that his own negative thinking was going to be the final blow. He needed to keep his mind aloft. And so off he went, sorting through his memories for meaning.

“I’m afraid I’m going to lose everything I worked all my life for,” he told a reporter visiting him in the hospital one day. “The moment I got sick, everything just started falling apart.”

He hadn’t returned to work since the Christmas holiday, and the paychecks had stopped coming in — while the bills did not.

Audrey lost her job cleaning airplanes at Los Angeles International Airport. He told her to turn in his leased Jaguar so they could pay the mortgage. Their Lincoln Continental would be next. They had been in the process of refinancing their house when he got sick. When the lender learned he had stopped working, it canceled their application.

Richard didn’t have the energy to make the phone calls and navigate the web to get his disability paperwork in order. He had no laptop. His brain was foggy. He couldn’t even sit up in bed without his blood oxygen dropping dangerously low. Normally clean-shaven and well-groomed, he had a thick gray beard and a painful ingrown toenail.

He was simply trying not to die.

It seemed that every call from home brought a new burden to bear.

One day it was the plumbing.

“I’m trying to see who I can call,” Audrey told him. “It’s still backed up right now, the toilet, the kitchen, everywhere.”

Richard closed his eyes and exhaled. His face was sunken. He lay flat on the bed, on his side to get more airflow.

He lifted his oxygen mask off to be heard.

“So we need to get a plumber out,” he said.

The words came out weak and shallow. His blood oxygen numbers dropped on the monitor by his bed. He replaced the mask and inhaled deeply.

“I don’t see how we can afford it to do that,” she said. “You’re in the hospital.”

He again pulled the mask below his chin.

“Well, you got to get it done.”

Normally, Richard would snake out the clog himself. It pained him to hire any type of handyman. At home, he did everything — appliance repairs, tile work, mowing the lawn.

He thought about asking his oldest brother, Lapolum Jr., to help, but he had also contracted COVID-19 and was just out of the hospital on supplemental oxygen.

“So is my unemployment complete?” he asked.

“No,” Audrey said. “The check’s smaller than the last time. I’m trying to find out what’s going on. Because it’s real small. I’m going to call her first, then I’ll call the plumber.”

“I wish I could make all these calls,” he said. “I know I’m relying on you to do everything.”

After these conversations were over, he often fell into despair. Two nights early in his hospital stay, he had felt he came so close to dying that it haunted him every day after.

::

Richard started feeling sick on New Year’s Day. By Jan. 5, he was lying on a gurney in the back of an ambulance, shaking uncontrollably and gasping for air.

His brother Ray peered in from the back of the ambulance, head hung down, looking scared and forlorn. Ray was Richard’s older brother by a year but was the sweet, jovial kid who never quite grew up. He never married or moved out of his parents’ home, and he was as gentle a soul as Richard knew. The expression on his face made Richard tear up.

“I gotta go,” Richard said. “Bye.”

Richard arrived at the emergency room of Martin Luther King Jr. Community Hospital with blood oxygen saturation of 56% — a level low enough that it would normally kill a person within hours, if not minutes.

Doctors put him on high-flow nasal oxygen. If his saturation did not rise to a safe level, they would have to induce a coma, intubate him and put him on a ventilator. The intensive care unit was full, so they couldn’t fit him in. They put him in Room 533 on the fifth floor and had him lie prone.

He was stunned when doctors talked to him about next of kin and his wishes for being put on a ventilator if his organs began to fail.

Nurses and doctors checked on him, gave him his medications, brought him his food. But mostly he lay belly down, face to the bed railing, alone.

His mind meandered as the hours passed, his sense of time fell away. He wondered why his dad bought that broken Impala when he was 17. Richard was an usher at the Vermont Drive-In Theatre in Gardena and gave his dad enough cash to buy a working car, as he had done with Richard’s two older brothers.

His father was a bit of an enigma to his city-reared children. Part Cherokee, he grew up on a tenant farm in the bottomlands south of Pine Bluff along the Arkansas River. As a boy, his parents had sent him out with .22-caliber rifle or cane pole to catch a squirrel or possum or catfish for dinner. Out of sheer poverty, he learned how to fix anything with his own hands. And all his life, he refused to go to a restaurant, for the waste of money it represented.

As a child, Richard couldn’t grasp how hard his dad was fighting to keep his family afloat in Compton. At one point, Lapolum was driving his own big rig all over the West, hauling recycled paper. He lamented being away from his family five days a week, but he had to pay the bills. When trucking wasn’t earning enough, he took a job as a foreman at a metal polishing business and spent his nights and weekends fixing up old cars and motorcycles for resale.

The Impala arrived on a tow truck one day in 1980.

“I gave you $800 for a car that don’t run,” Richard told his dad.

“Yeah, you got to put another transmission in, you got to rebuild the motor, put shocks on it.”

“I got to rebuild the whole car!”

“That’ll make you stronger.”

That fall, Richard and his dad took the cylinder heads off, lifted the engine block, removed the pistons, put on new rings, replaced the rods and bearings, adjusted the valves. They rebuilt the carburetor and installed new brakes and shocks. After four months, they were nearly finished. Richard sanded down the body and primed it. He couldn’t wait to show it off to his friends, and to girls at Compton High School. His first drive was to his drive-in job, the V-8 engine rumbling nice and throaty, Kool & the Gang pumping, as he cruised down Vermont like a king.

Just before he pulled into work, an old man ran a stop sign at full speed and T-boned the Impala’s fender on the driver’s side.

The car was totaled.

Richard stood on the corner, not sure whether to weep or rage.

Now, so many years later, in his hospital bed, he confronted this same feeling of grand injustice on a cosmic level.

His coughing was getting worse, and he was starting to panic for air again.

Richard’s oxygen levels dropped to 69% in the early morning of Jan. 7. He coughed so hard he vomited. Nurses rushed in and added a re-breather mask that increased the oxygen he inhaled through his mouth. They patted him on his back. “You’re going to get through this.”

A doctor from intensive care considered putting him on a ventilator but held off.

Richard prayed day and night.

Look, God, I been doing everything I can all my life to do the right thing. I followed the rules. I didn’t do drugs. I didn’t drink. I always respected everybody. And you want to take me? Give me another chance. I want another chance in life.

The next day, Audrey told him that his brothers Ray and Ronald were both taken to the hospital with COVID-19. She and their daughter Aushlie had also caught it, but their symptoms were not bad.

As he lay there after the call, he remembered playing slot cars with Aushlie when she was a little girl. They loved that. He regretted that he never introduced her to roller pigeons. She texted him a photo of them together to cheer him up. His eyes welled up looking at her smile.

On Jan. 14, Audrey called with terrible news. His older brother Ray had died.

Richard fell into a sinkhole of grief. He kept seeing Ray’s saddened face peering into the back of the ambulance. He was angry that Audrey told him. He couldn’t fight this disease and grieve at the same time.

“Don’t call and tell me anything else,” he told her. “The more you tell me, the more I stress out.”

As best he could, he tried to put Ray in a compartment to mourn later when he was healthy.

His lifelong friend Dwayne called to try to lift his spirits, remembering their bike treks to Long Beach and Redondo. So did a co-worker at Boeing, Raymundo Mena.

A shy man, Mena, 57, always appreciated how Richard went out of his way to make sure he was included, whether on business trips or just going out to lunch. When Mena was in the hospital for a heart problem, Richard was one of two people to call and sent a get-well card that he had everyone at work sign.

Now, Mena texted Richard photos of their travels together, delivering satellites to countries including Kazakhstan, Peru and French Guiana.

In Kazakhstan, the locals had treated Richard like a celebrity because he was the first Black man they had ever seen. They lined up to pose for pictures with him and ask for autographs. Texting, Mena reminded him of the haircut he got there, from a woman who had never seen a Black man’s hair, much less cut it. She mowed a bare landing strip up the backside of his head before he could stop it. He and his crew laughed over that the rest of the trip.

These reveries forced him to focus on getting better.

He started doing exhaustive breathing exercises on an incentive spirometer to expand his lungs. He managed to put his socks on by himself and sit up on the edge of his bed. He made progress one day, only to fall back the next.

Doctors were still deeply concerned that he might not make it. He had been struggling on the high flow of nasal oxygen now for 20 days, and that put potentially deadly strain on his organs. They’d seen people in his state, improving, only to suddenly fall into kidney failure or cardiac arrest.

On Jan. 27, he learned that his brother Ronald had been put in a coma and hooked up to a ventilator. Ronald was the tightly wound, argumentative counterpoint to laid-back Ray. A common family description of him is “roostery,” and Richard had had his clashes with him. But Ronald had a tender spot for children and was always there for anyone in need. He and Richard had the same deep bond they did as children, playing football on West Tichenor Street with Ray, under the Japanese elm their dad had planted.

He tried not to sink into a sense that the worst was inevitable.

When a Times reporter and photographer visited the next day, he showed off a photo of him and Aushlie buying her car.

“Reminds me what I got, and hopefully I still have this stuff when I get back. I don’t know what I’m going to have. I fight so hard. I do whatever they tell me to do. Because I want to see my wife and my daughter again.

“She loves to hang out with her dad.”

On Feb. 3, he woke up without fatigue. His mind was clear, and he wanted to exercise. The next day, he did arm lifts, stood in the walker for 10 seconds and sat on the edge of the bed for 10 minutes.

Feb. 5, a month after his arrival, he successfully walked from his bed to the window and back.

From that point on he walked farther and farther — until he was finally released Feb. 12.

As he was wheeled down the hallway with an oxygen tank, his nurses and doctors and therapists, who had seen so much death over the last two months, lined up to applaud him and wish him well.

At the entrance of the hospital, Audrey threw her hands up when he was wheeled out.

“Hi, honey, is that really you?” she asked.

“Yes, it’s me, I made it.”

She bent down to hug him. He rested his head on her shoulder.

::

Richard couldn’t go to Ray’s funeral because he couldn’t walk up and down the hill, even with the oxygen canister he towed behind him.

His friend Dwayne brought him breakfast while his wife and daughter attended the memorial. They laughed and cried and talked about old times. It felt like Ray might walk in the door any second. Richard still felt that about his dad, who died three years before.

He missed the old man. Richard had done everything he could to get him the best medical treatment, and then secured him a nice resting spot under trees at Rose Hills Memorial Park. His dad loved trees from his days in Arkansas.

Ronald died March 1, after more than a month on the ventilator.

Now Richard worried about his mom. Ruby Lee, 90, was devastated about losing two sons, both of whom were living with her in the old family home on Tichenor before they were taken to the hospital. With them gone, she started showing signs of dementia, calling Richard regularly in the middle of the night to say somebody was trying to get in, screaming that she didn’t want to die alone in a nursing home.

Richard couldn’t return to work unless he recovered fully. He still felt that he was on the precipice of financial collapse. The disability checks he’d received were a small fraction of his salary.

He had come so far from where his dad had started — hunting game for dinner as a youth. Now his footing still seemed so shaky.

Once a week he visited Martin Luther King’s COVID-19 ICU post-discharge unit for doctors to check his progress. Dr. Erin Dizon, an infectious-disease specialist, marveled at his recovery and, perhaps most important, helped him get all the forms filled out to receive his full disability payments.

By March, Richard no longer needed the supplemental oxygen, and the disability checks were coming in. His mother was in the hospital after several strokes. He would take care of her like his dad told him to do.

He figured he could make it now. That existential dread had receded. He thought of the Impala from time to time. The driver who totaled it was an old man with trembling hands who said he was racing home to get to his medicine. He promised his insurance would pay — and it did.

Richard bought a cool, clean 1973 Monte Carlo — maroon, with cream leather seats. He wooed Audrey in that car and made a life he was determined to keep.

---

Bigotry confines their trans daughter at home. Her parents worry what she’ll do when they’re gone

Bigotry confines their trans daughter at home. Her parents worry what she’ll do when they’re gone

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | July 13, 2021
 

He starts his shift before dawn working three industrial fryers at a frozen food factory. Jose Morales lifts a basket of burritos out of one vat of oil, hangs it to dry and dunks another in, all day juggling hot metal that has left mottled scars on his inner arms.

After work, he guides his 30-year-old stepdaughter Sandy Vazquez in a wheelchair through an out-patient clinic in Willowbrook. Jose is well short of 5 feet, his slight stature common in the part of Mexico where he grew up, where indigenous Nahua blood runs deep.

While he can barely see over Sandy’s head as he pushes, he has always been the big man in her life, the one who took her to Toys R Us to get her first princess Barbie dolls, the one who chased her tormentors away — and who never once questioned her when she said she was a girl.

For Jose and his wife, Reyna, their transgender daughter brought out an iron sense of purpose: they had to protect her until she found her own safe place.

They are a tight knot of a family mounting a bare-bones battle for the American Dream from an apartment next to the Century Freeway in South Los Angeles. In recent years, Sandy had starting to feel comfortable going out to parties with cousins and friends.

Her parents hoped she might be able to find a job and, some day, a partner who loved her.

The last year battered those hopes. The family caught COVID-19 in December and Reyna almost died of it before recovering. And in May, Sandy faced the prospect of losing her foot and lower leg from an infection.

Mortality has haunted them ever since with the dreaded question: What will she do when they’re gone?

::

Jose and Reyna met 26 years ago as they sewed shirts and dresses at a garment factory in downtown L.A. He had come to California a decade before, escaping an austere existence in the small city of Izúcar de Matamoros in the southern state of Puebla. His father had left the family when he was a baby, and his mother, unable to feed Jose and his brother, eventually indentured them to a local store owner. Morales was unloading boxes and arranging shelves at age 7 and never got more than four years of school. He joined the Army at 17 and came out two years later just as poor as he started.

Reyna left Acapulco for the same lack of opportunity. She needed to find work and send money back to her family so they could eat and have electricity.

As they chatted over their sewing machines, he showed genuine interest in her stories about the two young children she was raising alone, Sandy and her older brother, Arturo.

They went to quinceañeras, birthday parties, picnics in the park, lunches at McDonald’s — always with her kids. The pair moved into an apartment in the Broadway-Manchester neighborhood of South L.A. Sandy quickly grew to love Jose as her real dad. He affectionately pet-named her Gorda, his chubby girl.

Sandy was clear how she saw herself from at least age 3. When Reyna bought a skirt and blouse for her niece, Sandy wanted it. At first, Reyna indulged her as long as she stayed inside the house. At around age 6, Sandy started painting her nails and putting on lipstick. One day, she went out in the front yard in her makeup to dance. Reyna yanked her in before the neighbors could see, and spanked her. It was a moment of panic that still causes Reyna to tear up with regret.

Soon she came to realize she needed to let her child express herself. Reyna looked on with a mix of angst and joy as Sandy took her boombox out to the front yard and danced like Shakira or Thalia with a mop over her head. The neighbor boys laughed. Sandy didn’t seem to mind.

In Mexico, they knew that people like Sandy, as they became teenagers and older, were routinely beaten up, even killed. And Jose or Reyna were devout Catholics, going every Sunday to a church that wholly rejects the concept of transgender identity.

But they saw a simple, elemental truth: Sandy was their girl.

In grade school, Sandy still dressed like a boy and used her male birth name. She made friends and mostly avoided harassment, until she went with her mom to get her ears pierced. Soon after on the playground, a boy purposefully threw a utility ball at the side of her head when she wasn’t looking. Sandy came home with a bloody ear and a missing earring.

After that, letting her to go to school every day was agony for Reyna and Jose. They wanted to protect her, but they didn’t have the time to be there at lunch or after school. They worked in the garment factory all day, came home for dinner and a nap, and then cleaned offices for seven or eight hours at night.

By 2001, they had saved enough to buy a 1979 Chevy stake-bed truck and start a little mobile corner store from the back. Fresh food was hard to get in South L.A., so they stocked fruit and vegetables, as well as juices, sodas and candies. They called the business La Jefa Products after la jefa, the boss — Reyna — and soon made enough to buy a second truck.

They drove to downtown in the morning to stock up on supplies and sold around their neighborhood all day.

In four years, Reyna and Jose found a spacious home in South L.A., divided into two apartments, on a dead-end street shaded by eucalyptus trees on the Century Freeway embankment. The price was hefty, $510,000. But they qualified for subprime mortgage and second loan, putting only $12,000 down.

Jose felt he was escaping the crushing poverty that seemed to be his fate. And in a new neighborhood, and new school, Sandy felt she could finally be who she wanted to be.

On her first day of middle school, she wore jeans with a blouse, makeup and earrings — and introduced herself as Sandy.

The hatred did not take long to show its teeth. First it was just boys snickering and pointing. Then when teachers weren’t around, a group began to shove Sandy and hit her. Soon they were frisking her every day as if they were security guards, stealing any money she had, taking her phone, punching her.

“I told most of my teachers I was transgender,” Sandy says. “I wanted them to refer to me as she. But one of the teachers, she wasn’t having it. She’s like, ‘You’re a boy.’”

This provoked other students. “Is she a he or is he a she?” one asked.

“Pull his pants down and you can see who he is,” the teacher replied.

Her parents didn’t speak English and couldn’t confront the teacher. But they had to try to stop the attacks.

Jose went to the school to confront the culprits. As Sandy came out after the bell, a boy stopped her and started taking her things.

“Hey, que traes?” Jose called out. What’s up? The boy bolted but Jose ran after him caught him, brought him to the principal and told him what happened.

The memory of this time brings Reyna to sobs.

“We felt so powerless,” Reyna recalls. “To see how they were treating her and not being able to do anything. And all because she just wanted what she wanted to be.”

Sandy was reading more and more online about gender identity, and educating her parents. But she was isolated from any sense of community that could give her a sense of solidarity. “I didn’t know anybody who felt the same way as myself,” she says.

By the time Sandy landed in high school, the boys were bigger and the threats of violence more ominous. Her parents pulled her out.

A therapist who regularly visited Sandy got her enrolled tuition-free at a private academic program in North Hollywood that specialized in teenagers who had troubles adapting in school. There were only two classes of 10 students each, and no one bothered her. Reyna drove her daughter the hour-plus trip each way every day, adding to increasingly long days at work.

Their business was coming under strain. People tend to notice good fortune in places where it is scarce, and neighbors started running their own trucks. Worse, a clique of the 18th Street Gang was starting a sideline racket extorting the street vendors.

First it was just young teenagers asking for a free soda here, a chocolate bar there. But word spread and higher-ups in the clica confronted Jose demanding a weekly payment of $100 for each truck. They knew the extortionists since they were toddlers.

Jose and Reyna worked harder to make up for diminishing returns. When she dropped Sandy at home after school, she made her do the laundry, clean the kitchen and have the family dinner ready, while mom went back to work.

The gang threat took a toll on Reyna, who was terrified Jose would be shot. She had heart disease, high blood pressure and diabetes, and the stress made her health worse. As an undocumented immigrant, her Medi-Cal only covered emergency care.

But the big blow came from the banks. Two years after they signed their loan documents, their lenders raised their adjustable interest rates. Their mortgage payment jumped from $3,025 to $5,200.

The lead lender foreclosed as they continued to live in the back apartment and pay rent to a new owner. Jose swallowed the devastating blow and did the only thing he could do. Keep working.

In the streets, the gangs just got more menacing.

“La renta!” shouted a pistol-packing gangbanger in a wheelchair who was called El Wheelo.

“No tengo,” Jose said. He didn’t have it.

Ultimately, it was not the gangs but the competition from other vendors that spelled the death for La Jefa Products. Jose and Reyna, who was increasingly ill, sold the trucks as he started working at different factories through a temp agency.

After her junior year of high school, Sandy didn’t return to public school. She rarely left the apartment, depressed for months on end. She was scared to go out alone and was shy in ways she never had been. She didn’t want to work or go to college. She couldn’t envision her future and developed a fantasy that she didn’t have long to live.

When she did go out with her cousins and their friends, Reyna would not sleep until Sandy got home, thinking about news stories she’d seen about transgender women being killed in the street.

One summer day in 2018, her cousins persuaded Sandy to go to Hurricane Harbor, the water park in Santa Clarita. Walking barefoot on the hot pavement, she got a large blister on her foot. At 28, Sandy had diabetes like her mother, and in her depression, did not bother taking insulin or monitoring her sugar or weight, enabling the disease to damage the nerves and blood vessels in her feet.

The blister got infected and she went to the emergency room at Martin Luther King Community Hospital. A podiatrist, Dr. Myron Hall, cleaned out the wound and bandaged it, and told her to visit him at the out-patient clinic periodically to check on it.

She got better, but her mom’s health continued to decline and in December, with her underlying conditions, she was hospitalized for severe COVID-19. All Reyna could think about was leaving Sandy behind and putting the full burden of supporting her on Jose. If she recovered, she wanted to ensure father and daughter were seen as family in the eyes of God.

::

The wedding was an act of their enduring hope. Reyna bought a custom-made pearl dress with gold lace from a storefront in Huntington Park. Jose wore a black suit and gold tie to match the dress. Sandy did Reyna’s makeup, and sewed COVID masks made from the dress material. On April 24, the couple married at St. Michael’s Church, the chapel they went to every Sunday.

Sandy was brightening up bit by bit, going out with her cousins and friends more often. Jose hoped she might get a job, maybe working in a nail salon, and find her life’s path. Then a pedicurist accidentally reopened the wound on her foot. Dr. Hall cleaned it out again, but weeks later, Sandy walked on it too early, and got it wet in the shower.

On May 14, her foot throbbed in pain as she ran a fever and vomited. The wound-care nurse told her to go to the hospital immediately. Dr. Hall found necrotizing fasciitis — flesh eating bacteria — running through her foot up the inside of her leg. She was close to going into shock and dying. Hall did surgery that night to remove a piece on the side of the foot and told her she might need several more procedures before he would know if he could save her leg.

Reyna’s mother had lost her foot to diabetic amputation in Acapulco. She pictured Sandy unable to get around the house, bed-bound and more depressed, no job, no partner, no family of her own, no end to her parents’ protecting her.

The next day, Reyna, 60, suffered a stroke that paralyzed half her body.

After three more surgeries, Dr. Hall saved Sandy’s foot, her toenails still painted white for the wedding.

When she got home, her dad asked, with his usual practicality, “Are you hungry Gorda? What can I make you?”

These days Reyna and Sandy lie in bed all day under a poster-size photo of the wedding with Jose standing on his tiptoes. Arturo and his 12-year-old daughter, Destiny, come and go from work and school. Mom watches her favorite Turkish telenovelas dubbed in Spanish, Sandy keeps her foot elevated while using TikTok. Jose, 55, arrives home from his shift over the fryers in Cudahy and helps Reyna get to the bathroom, and then sits her in a chair; her insurance does not cover the rehabilitative therapy that her doctors told her could help her walk again one day.

Jose takes Sandy to see Dr. Hall at the wound care clinic. He shops for groceries and cooks their dinners and they all sit at the table by the back window, talking, teasing, worrying, laughing.

Jose asks if the food is good.

Sandy shrugs. “Eh, mas o menos,"she says — more or less, a running joke since her dad took over the cooking.

Jose and Reyna see God’s plan in Sandy keeping her foot. And for this, they remain steadfast: she will find her place.

 

 

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In South L.A., a legacy of limbs lost to diabetes tells a larger story

In South L.A., a legacy of limbs lost to diabetes tells a larger story

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | November 17, 2021
 

Her small toe was turning purple, and the pain was excruciating. Glory Paschal knew how fast this could spiral. She just had to look around her neighborhood in Watts to see how many residents were missing feet and legs.

She fought for a referral to a podiatrist, but by the time she saw one, it was too late.

On Feb. 10, 2011, doctors at Harbor-UCLA Medical Center had no option but to amputate her left leg below the knee.

This summer, the now 53-year-old Black grandmother was back in the hospital, this time with two infections particularly lethal for a diabetic: severe COVID-19 had her gasping for breath and gangrene was eating away at her remaining foot.

The coronavirus piggybacked on a catastrophe of poorly treated chronic illnesses rampant in South L.A.: heart disease, high blood pressure, lung cancer, kidney disease, asthma, arthritis, depression. And diabetes.

All of this made South L.A. a hotspot of COVID-19 deaths during the winter surge. But while that deadly wave receded, the high tide of underlying conditions remained, with Black and Latino residents facing nearly unrivaled numbers of diabetic amputations.

The loss of limbs embodies the enduring grief of generations in South L.A. — of entrenched poverty, the dearth of both supermarkets with fresh food and parks to promote exercise, and a deeply deficient primary healthcare system that relies on low payouts from the state’s Medi-Cal program and a scant number of qualified doctors.

“The tragedy is our community lacks almost every type of healthcare that you can think of and that most of us take for granted,” said Dr. Elaine Batchlor, the chief executive of Martin Luther King Jr. Community Hospital.

She said despite the efforts of her privately funded, high-tech hospital, the people of South L.A. are largely getting preventive care that is “separate and unequal.”

Nobody, Batchlor said, should have to live in a community “where you couldn’t go to the pharmacy and get the medicines that your doctor prescribed.”

“We wouldn’t live in a community where you couldn’t get urgent care. We wouldn’t live in a community where you couldn’t get an appointment to see your doctor for weeks or months,” she said. “But that’s what we’ve got in this community.”

When Paschal visited her primary care doctor in Lynwood for her toe pain, he told her she just had a case of athlete’s foot and sent her home with cream.

When she returned multiple times asking for a referral, the doctor told her she was “nothing but a problem.”

“You’d be better off if they cut your foot off,” she recalled him saying.

She eventually got an appointment with a foot specialist for $50. “You need to go to the emergency room right now,” he said.

Dr. Myron Hall has heard the story of this same cascade of failure too often to count. As a Black podiatrist at MLK hospital, he has devoted the last five years to salvaging limbs and lives.

Among his patients: Tony Zamora, 45, of Compton, was falling down the same hole as his dad, who lost both legs and died two years later. Bill Crawford, 66, has been lying in bed in Watts for two years after his two below-the-knee amputations, fighting kidney stones while waiting to get the physical therapy he needed to learn to use prosthetic limbs and walk again. Paschal was trying to preserve her remaining foot and survive COVID-19.

At MLK hospital, amputations are the most common surgical procedures. Researchers at UCLA found that diabetic residents here and other poor parts of the city were more than 10 times as likely as those in more affluent areas to have a toe, foot or leg amputated.

The high blood sugar associated with diabetes does its damage to organs and limbs by clogging arteries. In the feet, this means minor wounds don’t have the blood flow to fight off microbes, and small infections can turn lethal.

Removing the infected parts is too often the last resort — a decaying toe or two, then the metatarsals, then a foot or a leg. The decline in mobility can lead to social isolation, depression and the further deterioration of health. Studies show that between 52% and 80% of diabetic patients who get a below-the-knee amputation die within five years.

At the root of the health crisis in places like South L.A. is inadequate health insurance. Many residents have none or are enrolled in Medi-Cal, the state’s Medicaid program, which pays doctors about half of what Medicare pays for the same service. Many doctors won’t accept it.

A survey conducted by MLK hospital last year found that its service area of more than 1.3 million people had only a third of the full-time physicians required to adequately treat that population — a shortage of 1,300 doctors.

“There is no question that the healthcare disparities that we see across America and certainly in places like South Los Angeles are the long-standing results of systemic racism,” said Darnell Hunt, dean of social sciences at UCLA and co-editor of “Black Los Angeles: American Dreams and Racial Realities.”

The inequities are the heritage of a city’s drive, for 80-some years, to geographically segregate people of color with its own brand of Jim Crow, particularly as tens of thousands of Black people began arriving from the South during World War II.

Restrictive housing covenants and racist real estate agents kept Black families from moving out of South L.A. Redlining of the area prevented them from getting loans for homes and businesses. Black residents faced discriminatory hiring, second-rate schools and militaristic policing that became notorious for its abuses.

The policies effectively platted South Los Angeles as a zone of enduring inequity for subsequent waves of immigrants, whether from Louisiana, Mexico or El Salvador.

::

When Bill Crawford’s family came to Los Angeles from New Orleans in 1957, they moved to Watts. His dad was a Baptist preacher and became one of the few Black sheriff’s deputies at the time. His mom taught at Carver Middle School.

The neighborhood was a peaceful, friendly place of interconnected Southern families and plenty of local businesses. Across the street from his home on Compton Avenue was a jewelry store, a clothing shop where his mom bought his church clothes and a big supermarket where his dad helped cut the meat.

Crawford was a football star at Jordan High School, until he shattered his hip. That thwarted his prospects for a full-ride scholarship to USC, but he paid his way through Cal State Fullerton and later became an English teacher and coached football and basketball at Fremont High School.

On the side, he and his friends started a nighttime pickup game of basketball in the gym at Charles H. Drew Middle School that evolved into the famous Drew League, a pro-am summer league drawing such luminaries as Kobe Bryant, LeBron James and Kevin Durant. Crawford was the league’s announcer for 22 years and coached for 27.

His old friends call him “Still Bill” because he’s solid, never changing.

“The game doesn’t start until Bill comes in,” said Dino Smiley, chief executive of the league. “He’s our No. 1 legend.”

Crawford moved to Upland to get away from “all the drama, the gang stuff, the police brutality” in the 1980s but was commuting to his job in Watts and attended every Drew event.

At age 35, he was diagnosed with diabetes. The disease had already damaged his retina and he lost his sight for a month. He was also developing deep vein thrombosis in his legs and arthritis where he broke his hip.

He and his wife and two young daughters moved back to Watts so he could be near the Kaiser Permanente medical offices in Bellflower. Doctors there got his blood sugar under control and saved him after a pulmonary embolism in 2008. When he retired at 55 and shifted to Medi-Cal insurance, he started getting treatment at a local clinic.

To treat his deep vein thrombosis, the clinic sent him to a specialist in downtown Long Beach, who told him he needed a stent to open up an artery in his leg. But he never got the approval for the procedure that might have saved his feet. As his circulation diminished, he quit playing basketball and found it harder to walk.

One morning his wife noticed his foot was bleeding. Because the diabetes had caused a loss of sensation in his legs, Crawford hadn’t realized there was a wound. A tack had been stuck in the bottom of his slipper for who knows how long.

For two years, he cycled through doctor’s offices and hospitals.

At the Drew League championship in 2017, with Bryant and actor Jamie Foxx in attendance, Smiley made an announcement about a gift for a special guest.

“Knowing him the way I do, he probably don’t want no wheelchair,” Smiley said. “But we got it for him anyway.”

Crawford beamed, feeling all the love he put into the league returned to him.

Crawford first saw Hall on Dec. 21, 2017, with a massive ulcer where the pin-prick had been. The two hit it off. They were both sports junkies and high school football standouts.

Hall took some scissors and a scalpel to remove infected and dead tissue — debriding the wound — and had him return repeatedly over several months.

But it was late in the game. A home nurse nicked his other foot, and that wound got infected. Crawford was put on a catheter with antibiotics for six weeks and Hall kept debriding. But the infection was creeping into his bones and could kill him.

“We’d rather have no feet than no dad,” his youngest daughter said.

Doctors cut off Crawford’s right leg below the knee in November 2018 and removed the left one three months later.

Because of delays in treatment, Crawford hasn’t been able to get approval for the physical therapy he needs to walk on his prosthetic legs, which have been sitting in his garage for two years.

Crawford lies in bed surrounded by photos of his five daughters and the college and graduate degrees of his most academic child: from UC Berkeley, USC, UCLA.

His girls are his biggest motivation to continue the fight.

“Get me going, that’s all I want,” he says.

Hall never expected to be dealing with matters of life and death when he decided to go into podiatry. He thought he’d be mostly doing sports medicine.

After an early career as a naval officer, Hall worked at the Kaiser Permanente facility in Fontana before opening a private practice in Beverly Hills, with staff privileges at Cedars-Sinai Medical Center, where he does complex foot and ankle reconstruction surgeries. But he promised his mother, Gloria, that he wouldn’t just treat the rich. He knew poverty firsthand. He and his mom lived for a spell in the back of a restaurant and bar Gloria owned in Tennessee when she couldn’t pay the mortgage on her house. He can still smell the specialty — fried whiting fish.

When Hall was a running back in high school and she was chaperone for the cheerleaders, Gloria would run down the sideline with him.

“Don’t look back!” she yelled. “Why are you looking back? They can’t catch you.”

She died six years ago from respiratory failure, but her sideline voice rings in his ear every day. He started doing house calls in South L.A. and Compton, then opened a second practice out of Martin Luther King Jr. hospital in 2016. He often does rounds at MLK hospital at 4 a.m., drives to Beverly Hills when the morning traffic dies down and returns to MLK hospital to do a surgery at night.

::

Tony Zamora first visited Hall at an MLK clinic in Compton in 2019 with a blister on the side of his foot. Hall debrided and treated it with antibiotics. But Zamora’s coverage plan didn’t provide daily nurses to take care of the wound and the infection worsened. His big toe was turning black. On Zamora’s next visit to the clinic, Hall could smell the decay as soon as he opened the door of the examination room.

He amputated the toe and cleaned out all the other infected tissue he could see. Rather than cut off the entire foot to ensure the infection would not spread, Hall checked and debrided the wound. He tried keeping the infection down with antibiotics.

Zamora knew how quickly these losses accrued. He still grieved his father, Rafael, who died two years after losing his second foot at 61.

His dad’s death sent Zamora into a tailspin that ultimately led to a divorce and several years of drinking, meth use and homelessness. “He was the most important person in my life,” he said.

During that time, Zamora’s own diabetes went untreated and led to peripheral artery disease and a loss of sensation in his feet. But by the time he reached Hall, he had marginally pulled his life together and was working as a forklift driver and living in a tent in the back of his mother’s house.

After Hall removed his big toe, Zamora needed to be vigilant: Wear diabetic shoes, check his feet every day, keep his sugar and blood pressure down.

But he was distracted, devastated about his toe, missing his wife and two children, who were living near San Bernardino.

To get him out of his funk, his mother took him on a trip in April to her hometown in Mexico. He started drinking with his cousins and walked all over the village in regular shoes. He came home with an open wound covering most of the ball of his foot.

When he was told by his insurance that he would have to have the surgery at a different hospital than MLK, Hall intervened and got him approved to have it done as an outpatient procedure. Zamora came in at 6 a.m., had the bad tissue cut out and went home at noon.

One night, Zamora fell going to the bathroom and bashed the wound. More surgeries followed, and he lost a second toe. When he came to the emergency room on June 2 in severe pain, his condition was so dire that Hall ordered that he not be transferred to a different hospital

That night in the operating room, the doctor prayed and washed up for surgery.

“He’s got air bubbles under his skin and that’s one of the obligatory emergencies we have,” Hall told The Times. “If you have gas, you have gas gangrene and possibly necrotizing fasciitis, which is the flesh-eating bacteria that is life-threatening.”

Hall removed his remaining toes, and all the metatarsals — the front half of the foot.

If he didn’t lose more, Zamora could wear a shoe filler and walk on that leg.

But he struggled with his diet. This month, Zamora’s blood sugar was dangerously high and his leg was swelling up with a new infection. He was back at MLK hospital on a catheter line of antibiotics to save his life.

::

After Glory Paschal’s leg was amputated in 2011, she switched primary care doctors but battled to get adequate treatment through him and his network. She relied on the emergency room instead. The ER at MLK hospital was designed to treat 40,000 people per year; it sees 100,000. About 40% of its patients are seeking primary care.

Paschal went there in September 2020, feeling sick and exhausted. A vascular surgeon, David Tobey, told her that her kidneys were failing and hooked her up with peritoneal dialysis. In February, Tobey did an angioplasty to restore blood flow in her right leg, and had Hall look at her feet.

Paschal, who came to California as a 4-year-old from Magnolia, Ark., showed a grit that reminded Hall of his mother’s determination. But when she dropped the cantankerous front she needed to fight for her medical care, she was warm and sharply funny.

Her mother raised her and her two brothers in the Nickerson Gardens public housing complex in Watts. In the summer, they went to the beach. On warm nights, her mom and aunt would sit on the porch talking, and the kids would fall asleep on the lawn.

But her mother died of heart disease when she was 9. Paschal and her brothers were sent to live with different aunts and uncles. She went to high school in the Central Valley and came back to Watts during her senior year in 1986 without getting her diploma. The area’s economic backbone had been gutted by the closing of the auto factories, tire plants and steel mills that had provided solid blue-collar work since World War II.

Paschal found a job doing laundry at the Los Padrinos Juvenile Hall in Downey.

When she had her son Nelson, she qualified for federal aid. She raised the boy and his younger sister Keynna to be respectful to adults, say “yes ma’am, no sir.” They were diligent in school and kept out of gangs. She loved nothing more than escaping into old TV westerns like “Bonanza,” “The Big Valley” and “The Rifleman,” where the difference between good and bad was clear as day.

She mostly didn’t have a car and often ate at Hawkins House of Burgers across from her apartment because it was cheap and easily accessible, and the nearest supermarket carried old meat and stale produce. At age 32, she was diagnosed with diabetes and hypertension, and her long journey through the Medi-Cal system began.

On May 21, she had large blisters on her foot, and Hall had to remove her two small toes. She didn’t have enough skin left to close the wound, so he left it open for the tissue to regenerate.

Every Wednesday after that, Nelson, now 27, drove his mom to the wound care clinic and wheeled her up to the second floor, towing his sister’s two little girls behind. He worked two 24-hour shifts every week as an emergency medical technician and took care of his nieces the other days.

“He’s the uncle, but he’s Uncle Daddy,” Paschal says.

The wound improved but on July 10 Paschal came to the ER for urogenital bleeding and tested positive for COVID-19. Her symptoms were mild at first, but her condition worsened fast. Within a week, she was on high-flow nasal oxygen at the maximum setting.

She said no to being put on a ventilator, sure she would die on it.

She struggled to breathe for weeks, and fell into a delirium, reliving a terrifying memory when she was thrown into a pool as a little girl, unable to swim.

Her wound deteriorated as anti-inflammatory medications for COVID-19 compromised her immune response and her tissue was getting less oxygen. By August, she was recovering from the virus, but the foot infection was in the bone, where it could enter the bloodstream. Hall had to remove the rest of her toes to save her foot and her life.

After 54 days in the hospital, she bore the loss stoically, knowing Hall did all he could do.

In her apartment, her little granddaughters lift her spirits.

“Granny, it’s exercise time,” they call out, coming home from kindergarten.

They help her as she lifts her arms and legs.

She’s confident she’ll be able to walk again.

But she’ll forever resent her initial doctors’ lack of attention.

“I may as well have gone to Dr. Seuss.”

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In South L.A., the battle to stay ahead of the mental health turnstile never ends

In South L.A., the battle to stay ahead of the mental health turnstile never ends

By Joe Mozingo | Photography by Francine Orr | Los Angeles Times | December 27, 2021
 

The sense of emptiness gutted him. Sketching in his notebook in the dim light of his room didn’t bring Sergio Nuño the usual solace. He could barely summon the will to pour a bowl of cereal.

Nuño, 23, was on summer break from community college and laid low by depression and anxiety. He rarely left his parents’ apartment in Compton.

Late one night in August 2019, intrusive thoughts were telling him to bang his head on the wall. Trying to stop the suicidal impulses, he clenched his jaw and paced circles in the living room until his mother and father woke up.

The only therapists and psychiatrists his parents, immigrants from Jalisco, Mexico, ever saw were on TV. Back home, going to one branded you as crazy.

In South Los Angeles and surrounding areas like Compton, mental disorders mostly go untreated until they have caused irreparable damage.

Many of them are inextricably tied to other calamities that befall people who live in L.A.’s poorest neighborhoods at disproportionate rates. Even before COVID-19 hit, Latino and Black people here were dealing with more poverty, addiction, unemployment, chronic disease, homelessness, disability and childhood trauma, all of which worsen mental conditions, which then further feed those underlying problems.

Behavioral health practitioners fear the pandemic has accelerated this spiral in a way they will be coping with for years and decades to come.

Under the Affordable Care Act, Medi-Cal began covering care for mild to moderate mental health conditions in 2013, but access to care has remained low in low-income areas of color. The city of Compton has just five licensed psychologists. Santa Monica, slightly smaller in population, has 361. The system is skewed heavily toward those in wealthier communities who can pay out of pocket.

“What I see in South L.A. is unfathomable,” said Dr. P.K. Fonsworth, a bilingual addiction psychiatrist who works at Martin Luther King Jr. Community Hospital in Willowbrook. “There’s two different Americas in mental health.”

Four days a week, the psychiatrist works in the emergency room at MLK and sees the relentless ravages of long-untreated mental illness.

With his parents’ help, Nuño found his way to MLK’s outpatient clinic on Rosecrans Avenue. He was lucky his father had a family insurance plan through his job at the Cheesecake Factory in Cerritos. Fonsworth prescribed him medication and scheduled him for biweekly follow-ups.

Within weeks, the improvement in Nuño’s mental health was palpable. He had a job at Home Depot, began selling his artwork, and was accepted to the Otis College of Art and Design for next fall. He wants to become a toy designer.

“When we invest in people and care for people, they can get better and have more meaningful and connected lives,” said Fonsworth.

But he likens to much of what he does to treating “end-stage organ damage” because the preventative care did not occur.

Mental health in South L.A. has been so neglected it is still largely uncharted terrain.

“The number of people in need is massive,” said Dr. Jonathan Sherin, director of the Los Angeles County Department of Mental Health. “The exact number is difficult if not impossible to track because the system is so fragmented.”

L.A. County operates centers to treat people with more serious mental illness, but they are vastly inadequate. There is no clean hand-off from hospital emergency rooms for acute patients, or to the managed care plans for those who are improving — leaving bureaucratic fissures on both sides.

“It’s a deep hole and you just fall into it,” said Sonya Young Aadam, chief executive of the advocacy group California Black Women’s Health Project. “We call it a system, but it isn’t a system.”

The Department of Mental Health is working to bring a “full continuum of services” to South Los Angeles, Sherin said, in part with the opening next year of the $335-million Mark Ridley-Thomas Behavioral Health Center, with 32 beds for acute patients.

But one of the biggest obstacles to care in South L.A. is the overall lack of outreach to Black and Latino communities to remove the stigma from mental health care.

Courtney, 35, first summoned the courage to seek treatment with the county 11 years ago. When she got off the bus on East 120th Street and saw the sign for the Augustus F. Hawkins Mental Health Building, she flushed and walked in the other direction, terrified someone she knew might see her.

When she saw no one paying attention, she switched course and slipped inside.

Courtney, who is Black and asked to use only her first name, was raised at first by her father’s mom in Perris in Riverside County. Her grandmother was nurturing, and they slept in the same bed, talking as they fell asleep. When her “Nana” sensed Courtney was awake in the morning, she’d tickle-scare her: “Raaa!”

But Courtney’s life was upended at age 8 when her mother came to take her to L.A. “I can’t live with Nana anymore?” she cried.

She does not remember if she was sad before that day, but she has felt lonely ever since.

She was bullied and isolated in school and at home by her seven siblings. Dark thoughts crept into her mind. She questioned her own existence. “I felt like wasted space,” she said.

Even if she turned to her closest aunt, her dad’s sister, she was rebuffed. “You should just shake it off.” She didn’t even bother telling her mother.

“When you talk to someone who doesn’t understand it,” she says, “it’s like talking to a wall.”

As she grew older, she saw movies with white people seeing therapists, and ads for antidepressants asking: Do “you feel sad or lonely?” Slowly she developed a nascent awareness of the concept of mental health care.

And so she found herself at Augustus Hawkins that day, speaking to the therapist, releasing a lifetime of bottled-up emotion. She felt like she could breathe for the first time.

While her anxiety and depression did not vanish with therapy and medication, they became more manageable. She began to socialize more.

But the stigma was pervasive and painful. Her friends and several boyfriends made comments about her medication.

“The meds are fake,” one said. “It’s a way for the industry to control you.”

“Depression’s not a real thing, everyone feels bad sometimes.”

“That’s for white people.”

And when she started feeling better, she wondered if she truly needed the drugs. She fell into a cycle of dropping out of treatment, then deteriorating, then going back to Hawkins.

When she wasn’t working as a security guard, she stayed in her apartment in the Nickerson Gardens Public Housing Project in Watts, cartoons playing on the TV on mute. Eventually she stopped going to Hawkins altogether.

In 2019, Courtney landed in the emergency department of MLK Community Hospital in severe pain from endometriosis. As part of a new initiative to integrate behavioral and medical care, a mental health counselor screened her and referred her to Fonsworth.

Since the privately managed hospital opened in 2015 as a linchpin of healthcare in South L.A., practitioners there have been struck by the degree of mental illness and addiction in patients who came to the hospital for complications of diabetes, cancer, heart disease, emphysema.

The hospital set up a team of social workers and counselors to get those patients into long-term treatment within its own health network and outside it. Just in the first two months of 2021, Fonsworth and a mental health counselor identified 113 people in the emergency department or other wings of the hospital in need of some kind of residential or outpatient therapy. Only 29 declined the referral.

On Dec. 2, while assessing patients in the hospital for psychiatric problems, Fonsworth examined a 42-year old homeless white man, David Varvarosky, a day after he came to the emergency room in a state of psychosis with sores all over his hands. He had tested positive for methamphetamine and marijuana.

Varvarosky rested in a heated tent by the entrance of the overcrowded ER. He came out and sat in a chair, swiveling his head around, twitching slightly. Fonsworth delicately questioned him about his life.

“David, help me understand, do you have any trouble with drugs or alcohol?”

“I do drugs and alcohol, but I don’t have trouble with them.”

“Have you ever been to rehab?”

“No.”

“David, is rehab anything you’re interested in?”

“No, I don’t have a drug problem.” He mumbled about God creating drugs for a reason. “Jesus drank wine.”

“David, have any psych meds been helpful for you?”

“Yes, Buspar and Wellbutrin,” Varvarosky said. He had been in treatment at some point.

Fonsworth tried to get more at his troubles.

“David, anyone in your family die from suicide?”

“Yeah.”

“Who was that?

“My dad.”

“What was going on with your dad, what happened?”

Varvarosky closed his eyes and turned away, clearly not wanting to talk about it. “I don’t know, he just shot himself.”

He was done. He just wanted to get his sores treated and get back on the street, and the next day he walked out of the emergency room with the only relief Fonsworth could give him — a month’s supply of medications.

Far more rewarding to Fonsworth are the patients who are open to the benefits of long-term treatment.

Adrith Felix, 25, sank into paralyzing depression as a child when her father left the family to live with another woman in Chicago. She would sit in the one bathroom of her tiny apartment and silently cry. Her mother, Blanca, an immigrant from Nayarit, Mexico, couldn’t understand her moods. On the surface, Blanca had had a much more difficult childhood than her daughter.

“Oh, you should be thankful that you have me here,” Blanca would say. “I didn’t have my parents because I came over here and I had to do things on my own.”

Felix learned to keep her emotions silent, until she was 13, and took about a dozen Naproxen pills and was taken to the emergency room, then to a psychiatric hospital in Costa Mesa.

Her father flew from Chicago and lectured her. “You’re smarter than this,” he said.

Nurses removed her shoelaces and the wire in her bra to prevent another suicide attempt. Felix felt ashamed, and scared to be alone in a hospital filled with patients she saw as crazy.

But group counseling taught her she was not alone, and she left three weeks later with insight into her condition and a referral to therapy at Augustus Hawkins.

With the help of social workers, her mother gradually understood her daughter’s need for treatment.

After high school, Felix enrolled at Cal State Northridge and majored in psychology, hoping to return and help her community in South L.A. She had gone to white therapists whom she simply couldn’t connect with because they didn’t understand her background. She knew there needed to be not just more Latino and Black practitioners, but doctors and counselors with training in the cultures of the communities they worked in.

She was busy at Northridge as a student advisor for Latinas on campus and a listener at a crisis intervention line, buoyed by the social network of her fellow students.

But when Felix graduated and came home, she lost that network and her thread of purpose. She got a job helping autistic students navigate the classroom, and otherwise stayed in her apartment, watching Netflix. She had gained 40 pounds, and didn’t feel like she was worthy of grad school.

She called her mom’s insurance plan and was referred to a therapist, Linda Espinoza, at the MLK clinic on Wilmington Avenue. She hit it off with Espinoza, who urged her to reconnect with old friends, get exercise and keep a self-esteem journal. Fonsworth helped explain how a better diet could improve her mental state.

She rebuilt her confidence and now runs three miles a day, and this winter break is sending her applications for master’s programs in social work.

Nuño has turned 25, and will be off his dad’s insurance on Jan. 1. He is worried that, even if he gets Medi-Cal, he won’t be able to see Fonsworth or will have a gap in his medication.

Courtney’s managed care through Medi-Cal stopped approving visits to Fonsworth, and she dropped out of treatment, not up to the struggle of finding another provider who understands her. Her anxiety is growing worse and she now fears taking medication. She’s gone to the dentist six times and each time left in a panic before she got in the chair.

But she is managing, as she always has. She wonders what her life would have been like if her mom took her to treatment in her formative years. Would she have gone to college? Would she have a profession?

“I just can’t imagine what I could have done with that help.”