Unit on the Brink: E3 - Isolation Protocol

Mitch: From University of Utah Health and The Scope Presents, this is Clinical.

I'm Mitch Sears, producer for the Scope Radio, and you're listening to Episode 3 of "Unit on the Brink," a multi-part series that offers a snapshot at one state, one hospital, one medical ICU, and the frontline worker who's tasked with treating the most severe COVID-19 patients.

This is a story told in order. If you haven't listened to Episode 1 or 2 yet, we highly recommend you start there in your podcast app. Don't worry, we'll be here when you get back. For everyone else, this is Part 3 of "Unit on the Brink."

For the citizens of Salt Lake City, nerves were already shredded by the first weeks of March 2020. They had spent weeks picking through barren shelves at the grocery stores trying to get their hands on basic necessities like toilet paper, household cleaners, and flour. Long lines of Utahns ran outside of state-run liquor stores or rushed to buy bottles of Everclear in hopes to use it as a disinfectant because of a bottle of hand sanitizer, if you could find it, could cost you an arm and a leg off some stranger from Craigslist. Soon, bottles of grain alcohol were actually being rationed across the notoriously dry state.

Woman: A Utah man diagnosed with coronavirus is back in the beehive state. He spent three agonizing weeks quarantined on a cruise ship in Japan, and he'll be sleeping in a Murray Hospital room tonight.

Mitch: The first Utahn to have been exposed to COVID-19 had just come home after his three-week quarantine in Yokohama, Japan, trapped on the Diamond Princess cruise liner along with 3,600 potentially infected guests and staff. The man received a positive diagnosis just one week later back in Utah on March 6th. That same day, a state of emergency was declared.

Man: This breaking news is about the Coronavirus in Utah.

Woman: Governor Gary Herbert is declaring a state of emergency to deal with the Novel Coronavirus.

Mitch: Just a few days later, by March 10th, a woman in Weber County had become the second confirmed case in the state. The next day, Utah Jazz player, Rudy Gobert, became the first NBA player to test positive for the virus. By the 14th, a man in Summit County became the first known case in Utah of community spread of COVID-19.

Just a few days after that, businesses and other public spaces began to close down as a precautionary measure. Universities and colleges went online. Ski resort lifts were turned off. Abravanel Hall, home of the Utah Symphony, fell silent. Theaters, senior centers, libraries, golf courses, they were all closing down to try to stop the spread.

By the time Wasatch County got its first positive case of community spread on March 16th, restaurants had been forced to close their dining rooms. The Salt Lake City airport was filled with anxious families hoping to glimpse their loved ones as LDS missionaries from all over the world we're being called home.

To say that Utah had completely changed in just two weeks would not be an understatement. For citizens in the state, especially those in metropolitan areas like Salt Lake and Summit County, many of us became glued to our phones, refreshing newsfeeds over and over throughout the day waiting for the next bit of bad news.

Then came the morning of March 18th, 2020.

Woman: Oh my gosh. Earthquake.

Man: Parts of the far northern . . .

Woman: Oh my god.

Mitch: At 7:09 Wednesday morning, a 5.7 magnitude earthquake hit Salt Lake. With an epicenter just 104 miles from the city center, the 2020 Salt Lake City earthquake was the largest seismic event to occur within the valley since the city was founded in 1847.

To further pile on, an hour after the first quake, false report spread like wildfire across social media warning citizens that a much larger earthquake, "the big one," would occur sometime that same day.

While these warnings ended up being nothing more than a baseless rumor, it didn't help that the ground kept shaking with aftershocks. Not for hours, not for days, but for weeks. A total of 591 aftershocks were tracked by the University of Utah by the end of the month.

For the medical professionals in our story, they were facing all of this as well, but the cases of COVID-19-positive patients were still rising and they still had a job to do, one that was proving more and more difficult by the day as the severity of the illness in some patients was only getting worse.

Presented by Clinical and written and reported by Stephen Dark, this is Episode 3, "Isolation Protocol."

Stephen: By late March, efforts to halt the spread of community infection in Utah have been stepped up significantly. The state had asked residents to voluntarily stay home, and University Hospital had closed its doors to visitors, only allowing in patients and essential staff. Veteran charge nurse Alisha Barker was struck by how the once typically bustling corridor, the main lobby, and ground floor had all but been drained of life.

Alisha: The hospital, it's very eerie, right? It's amazing how many visitors . . . I realized, "God, we have a lot of visitors at the hospital." Just that it's so full. I mean, patients are coming in and out for procedures and appointments and it is a ghost town and it feels so eerie and weird. And then you get to our unit and most of the time it's a circus. It's just crazy busy, and then you walk out and you go to Starbucks to get a coffee and it's dead, and you're like, "This is just 'The Twilight Zone.'"

Stephen: In contrast to the echoing silence of the ground floor, the back rooms in the MICU rang with more than half a dozen COVID-positive patients constantly coughing in rooms sealed off from the rest of the unit. Barker struggled with watching how painful it was for her patients to continuously cough.

Alisha: They cough a lot. It's agonizing to watch these patients cough, especially when they're on the ventilator and then the breathing tube. They're gagging. They're coughing. It's miserable. And so we try and keep them as comfortable as possible with sedation medicine.

Stephen: Patients diagnosed COVID-19 positive were isolated in negative pressure rooms and treated by nurses and physicians in gowns, gloves, N95 masks, and sealed air recycling systems called PAPRs, which stands for powered air purified respirators.

If their condition deteriorated to the point they had acute respiratory distress syndrome, or ARDS, the next step was putting a breathing tube down their throat.

ARDS is a life-threatening condition where lungs are starved of oxygen called hypoxia. The breathing tubes permit ventilators to hammer oxygen down into drowning lungs. The MICU's Pulmonary Critical Care attending, Lynn Keenan, MD, found that compared to her H1N1 patients a decade before, getting oxygen into COVID patients' lungs was a tougher fight.

Dr. Keenan: It's interesting that their lungs aren't quite as stiff as someone with, let's say, H1N1 influenza, but they are still profoundly hypoxic. So the ventilator settings can be a bit more challenging.

Stephen: Especially for the patients, Barker says.

Alisha: The therapy on the ventilator, the therapies that are proven to work, some of the times it's called recruitment where your lungs are built of lots of little alveolar sacs, right? And so we expand . . . we try and recruit them to get oxygen exchange happening, and so we put a lot of pressure in there, and it would feel ungodly I'm sure.

Stephen: The virus's destructiveness shocked the typically stoic Keenan.

Dr. Keenan: I mean, viruses cause more havoc with the airway than bacteria. Bacteria form pus. The viruses cause intense inflammation. So the bronchial tubes, when you look at it with a scope, it looks like raw meat. It's just so irritated and so inflamed and that's why people get a secondary bacterial infection, because your mucosal barrier has been violated, so bacteria can get in. That's why so many people died that year of the Spanish flu. It wasn't so much from the Spanish flu. It was from the staph pneumonia.

Stephen: The visceral impact on patients' lungs and their sudden isolation from human touch was only the beginning of a terrifying journey.

Dr. Keenan: I think the patient must be very frightened because they have a tube in their mouth. They can't speak. Or if they don't have a tube yet in their mouth and they're in ICU, they're on high flow oxygen and it's very difficult for them to speak.

And also, they can see our eyes, helmet on, and the hood, and the occlusive mask, and the occlusive gown. It must be very frightening and isolating. And it's hard for them to hear us, particularly if they're elderly and they're hearing-impaired, and it's hard for us to hear them through the whooshing of the personal protective gear.

Stephen: Keenan tried to comfort patients the best she could.

Dr. Keenan: I always tell patients, particularly before I put a breathing tube down or any time, that we're here to take good care of them. And I always tell them what the plan is for the day so that they know, and I tell them how they're doing, if they're doing the same, and I tell them in my world stability is a great thing.

Stephen: For a few, the sickest of the COVID-positive patients, there can be one more step they face. If their lungs are so stiff or their body is actively resisting the ventilator and stopping it doing its work, then they have to be temporarily paralyzed. To mentally survive that paralysis, they have to be sedated, MICU nurse, Cat Coe, explains.

Cat: When you're on a ventilator with ARDS, typically, what we'll do is, yeah, put people into a coma by sedating them as well as . . . often, we'll paralyze them, pharmaceutically paralyze them. And whenever you pharmaceutically paralyze a patient, you also heavily sedate them because, as you can imagine, being paralyzed and being fully aware of it would be terrifying for anyone. So we sedate and paralyze them so that they have a chance to let the ventilator do all the work, so they don't fight the ventilator.

Stephen: The chemically-induced coma is interrupted every 12 hours, MICU staff bringing you around briefly to check you haven't had an adverse event, meaning a stroke or other issue, and to assess that the sedation is working or not.

Try to imagine this worst-case scenario, slowly waking up to realize something is wedged down your throat, your hands are tied to the bed. And because the sedation initially wipes your memory, this is the first you know about it.

Dr. Keenan: It can definitely be terrifying because they can be amnestic to the events before then and not remember why they're there, so we always reorient patients. That's why I always reintroduce myself every day and talk to them and let them, as I said, know what I'm doing and know where they are and how long they've been there.

I had one patient in Seattle I took care of. She was on the ventilator a month, and I would just talk to her every day. And then when I saw her in the office a couple of months later, she said, "You never finished that story about your brother's visit." So she heard everything I was saying.

Stephen: COVID-19's irritation of the walls of the lungs is such that as the body's immune system tries to fight it, the lungs swell and become increasingly inflamed then filling with fluid. It made it extremely difficult to get oxygen into even people who've been healthy their whole lives, such as one young man, Cat Coe recalls, who fought so hard to breathe.

Cat: So no matter how hard we tried to oxygenate him, he still had low oxygen saturation in his blood.

Stephen: That called for extreme measures.

Cat: We usually only keep people paralyzed for a couple of days, and a lot of times when they're paralyzed, we'll turn them over onto their stomach, which is called proning, so that we can try to recruit that other side of their lungs and give them another chance to oxygenate better.

So, yeah, these are kind of the extreme measures that you do for people in ARDS who just aren't getting better when they're in your typical sedated states supine on a ventilator.

Stephen: MICU staff worried about their daily exposure to COVID. In Coe's case, both she and her partner, Jeremy, are frontline healthcare workers.

Cat: I came home and I was like, "All right, Jeremy, we need to have a routine. We need to shower at work or as soon as we walk in the house. We need to be taking off our scrubs at work, putting them in plastic bags, not touching them before they go in the wash. We need to not have anybody over here. We need to not be going over to other people." It was just like . . . it hit me that, "We need to be super careful."

And I think also hearing that there were asymptomatic carriers made me really worried about us giving it to someone else, like if we were exposed. He works in the emergency department. I'm in the MICU. So we're the top two departments where you're going to get exposed. So I started to get pretty freaked out about us passing it to someone else.

I mean, I still feel like if we were to get it, then chances are we'd be fine. But yeah, obviously seeing the worst case in the ICU makes you play out all the worst-case scenarios in your own mind about your own situation.

Stephen: Alisha Barker worried about the errors she saw others make around her at the unit, particularly residents rotating through. She told colleagues at the MICU they needed a code word to tell each other to stop touching their faces rather than incessantly repeating the same warning.

Alisha: I was like, "We need a code word to make this fun." Because I hate saying, "Hey, you're touching your face. Hey, knock it off." It makes me feel like I'm being a massive nag.

Stephen: On a conference call, they polled for a creative code word.

Alisha: Twenty-three nineteen was what someone came up with and we all laughed because it's from the movie "Monsters, Inc.," where one of the monsters . . . Have you ever seen it?

Stephen: Yeah.

Alisha: When the monsters come back from scaring little kids, they check them and one of them had a sock on him, and they were like, "We've got a 2319," and this massive force comes and this tent goes over him and he's screaming and the hair is flying, and he's shaven, and he's completely decontaminated and he has no clothes on. So now when we see someone touching their face, we're like, "2319, go sanitize your hands."

Stephen: Nor did the outside world necessarily offer respite, Dr. Keenan found.

Dr. Keenan: Well, to me, I feel less vulnerable about taking care of patient I know has COVID-19 because I have all the personal protective gear. I'm more afraid of catching something from someone I don't know who has it, who I don't have that protective gear on around, just a mask. So I feel very well protected at work. As long as I'm careful and follow all the protocols, I don't really feel vulnerable to it. I feel more vulnerable at the grocery.

Stephen: While the personal protective equipment, or PPE, provided a sense of security against the virus, it also imposed painful limitations on the public service role that defines nursing, the very reason Coe abandoned her love of mountain climbing to pursue her calling.

The MICU permits one visitor for a dying patient who remains on the ventilator to not potentially release COVID-19 into the air. The patient is placed on comfort care with medication to ease their passing, but for a nurse seeking to comfort a grief-stricken relative, PPE erected a barrier they could not easily overcome.

Cat: One of the hardest things for me in the last few weeks was having a patient that transitioned to comfort care, and family was allowed to come and say goodbye to this COVID-positive patient, and I couldn't touch them. Like, I couldn't touch the family members. I couldn't give them a hug in the room because I have this astronaut helmet on.

And it just felt so inhuman to be in a room with a grieving family member and have this astronaut helmet blowing air in my ear so I can hardly understand what they're saying while they're telling me very sweet stories about their family member who's passing away in front of us, and just feeling a little bit like a robot because that's what you have to do in a COVID-positive room.

Stephen: She finds herself trapped in a plastic gowned bubble, all her feelings and yearnings to connect emotionally with traumatized human beings drowned out by the endless hissing of mechanical measures necessary to protect herself and the very people she so wants to reach out to.

Cat: Normally, I would hug a spouse who's crying, or a son, or daughter who's crying, or at least reach out and touch their shoulder. It's just so bizarre to not be able to do that.

Stephen: Caring for distressed relatives and friends of patients is a fundamental part of a healthcare worker's role. After all, severe illness is emotionally crushing, not only for patients, but the people waiting at home for news, good news, any news about their loved one. In all these cases, nurses offer what comfort they can.

In 2009 during the H1N1 pandemic, Dr. Keenan, then a physician at University of Washington Medical Center Northwest, treated 26-year-old Jowed Hadeed, member of a band called Eclectic Approach. Hadeed had been given a 10% chance to survive the virus and was on the ventilator in a medically-induced coma, just like so many thousands of patients across the world in 2020.

His fellow band members recorded a song, "The Waiting Room," inspired by their many hours of waiting for news about his condition, just down the hallway from his hospital room.

Once he left the ICU and recovered completely from the virus, he went on to finish Eclectic Approach's debut album, perform with his band on Jimmy Kimmel, and invite Keenan to his wedding.

Song: I close my eyes I see your face,

So heavy on my heart that you're in this place,

So scared but I know that you'll make it through.

We join our hands in prayer and faith,

Asking the Lord for his healing grace.

So scared but we know that he'll make you new,

We'll be waiting for you in the waiting room.

Sending our love through the door so you'll make it through,

We'll be waiting for you in the waiting room.

Sending our love through the door so you'll make it make through.

Stephen: MICU healthcare assistant, Cornelio Morales, understands all too well the need articulated in the song "The Waiting Room" to support a loved one, a close friend battling for their life in an ICU.

Corn, as his colleagues call him, has been at the MICU for 12 years. In deference to his depth of knowledge and experience caring for extremely sick patients, physicians have been known to call him Dr. Morales. What also stands out about him, Alisha Barker says, is something subtle, something you have to watch for carefully.

Alisha: Yes.

Stephen: Morales?

Alisha: Yeah. Cornelio is good. He's been there a long time. He's a character. He's funny, and he's very smart, and I just love his humor. And he's very behind-the-scenes charismatic. He does. I watch him doing a lot of really thoughtful and caring things for patients, but very below the radar, and it's fun to see. Like, it brightens my day to watch him. Every time I work with him, he's doing something little that's very meaningful.

Stephen: Morales grew up in Oaxaca de Ju·rez in southwest Mexico, a colonial capital city famous for its churches.

Cornelio: Well, I came from a family of seven back in the day. So, when I was little, my parents barely made enough for us.

Stephen: His parents sent him at age 12 to a school run by priests. After three years, he moved in with relatives, his father paying them a few dollars a month for food. He then went to live with his brother. When Morales finished junior high school, his brother suggested he consider nursing.

Cornelio: I wasn't sure what I wanted to do, but then when I stayed at my brother's house in Oaxaca, they told me about this nursing school. They can offer you job, easy to find, and it was true. Nursing is one of the . . . I mean, there's always a place to work, and then you can work in a hospital or you can work privately. You can work in the clinic. I mean, there's a lot of options.

Stephen: After several years of working in hospitals and clinics in Mexico, Morales decided to join his brother in Los Angeles. He took a CNA course and worked as a nursing assistant in L.A. for seven years before moving to Utah and starting at the MICU.

He shares the same root passion Barker, Coe, Diehl, and Keenan all give voice to -- the desire to help people. And at the heart of that passion is someone he loves, his daughter, Cathy. It's through her he sees not only his patients, but also the needs of their families. Cathy was Morales and his wife's second child. She was born with a genetic disease, he says, a chromosome that didn't develop correctly.

Cornelio: She has some limitations. She doesn't walk. She doesn't eat. She doesn't talk. She's at home. So my wife takes care of my daughter. When I'm off, I take care of my daughter, and my wife takes a break. She needs care 24/7.

Stephen: He was told she wouldn't live long.

Cornelio: This is the funny thing. When she was born in L.A. in 1999, the genetic doctor said, "Hey, your daughter has this disease. And usually, kids with this chromosome problem, they have a heart problem, they have a seizure disorder, they don't walk, they don't eat, they don't talk."

Stephen: The physician told him life expectancy in such cases as Cathy's was only a year. Back then, Morales's wife didn't understand English very well, and she asked him what the doctor said.

Cornelio: I said, "She will be fine. Don't worry." I never told her the doctor said life expectancy was one year only. And looking now, my daughter is 21, still with us.

Stephen: A few years ago, he told his wife about that conversation, and she laughed at how he had kept the bad news from her. Doctors, Morales says, don't always know a patient's fate. And that's not all he's learned in the years of being Cathy's proud father. She's taught him how to see others, how to consider their feelings and their needs.

Cornelio: We have a lot of patients at the MICU with Down syndrome, and I see it differently because I see the family, like putting myself like their family. Sorry. Yeah, it's hard because my daughter has been sick many times. First year of her life, we were in the hospital most of the time, and my son somehow got affected because one time he told me, "You guys don't love me. You love Cathy more," because we spent more time with Cathy because she was at the hospital. Now he understands, but when he was little, he thought we spent more time with Cathy because we loved her more, but no, because she was sick. She was more time in the hospital.

Stephen: When he sees a relative with a patient with a disability in the MICU, his heart goes out to them and he offers what help he can.

Cornelio: For the family, you sometimes have a chance to say, "Hey, do you want a drink? Can I get you a soda? Can I get a sandwich?" I treat them differently in that respect. Not better care. We always provide better care, but that little thing that people don't see because they don't have this problem, they don't have this background. I mean, they haven't been in this place like me, and my wife, my kids.

Stephen: Perhaps part of what Barker sees reflected in Morales is how she too brings to work what she's learned from caring for those close to her. Barker married her high school sweetheart after he was medically discharged from the military. His parachute had failed to open properly, and 20 years on, his back injuries still impose physical limitations and chronic pain. Looking after him has made her a better nurse.

Alisha: I think it helps me to pay closer attention to smaller things, where pillows are placed or positioning when he sleeps. His position is so important, and just to see how . . . And it also gives me perspective in patients who are in pain or who are experiencing a lot of pain and just their coping ability to cope with a lot of other things is very diminished.

I experienced that firsthand with my husband, and so that also gives me perspective and the ability to not take things personally or to be able to care for someone for a long period of time. Twelve hours is a very long period of time when your patient is miserable and in pain and hard to deal with.

Stephen: As nurses and physicians address the medical demands of the virus on their patients' cough-wrecked bodies, on their concerns for their colleagues and their loved ones, if not themselves, hanging over all this was an even bigger fear -- the surge.

By mid-April, expectations created by computer models and the experiences of healthcare systems outside Utah meant that hospital administration feared there will be a tidal wave of positive patients overwhelming exhausted staff and straining to the point of no return already depleted sources of PPE. This expectation was called the surge and overshadowed everything.

And yet, as those first weeks then months went by, the surge did not come. Directives from state and municipal leaders to stay at home and practice social distancing appeared to be working. Utah's numbers were some of the lowest in the country. In early spring, Cat Coe was grateful her fears of the surge had yet to be realized, even as she and MICU staff still prepped for the worst.

Cat: I don't have a daily fear the way I did a few weeks ago, but I also think that is because we haven't had a huge surge and that that could change any time in the next few months. So I don't feel scared daily, but I also feel we need to be ready, like be mentally prepared for a surge, because that's definitely not out of the question.

If you look at the trends from the 1918 flu, there was a surge in the spring and then it kind of dropped off in the summer, and then it surged again in the fall. Yeah, I think probably until there's a vaccine there's going to be an unsettled feeling about what could happen if there's a surge.

Stephen: But even though the last aftershock from the March 18th earthquake was nothing more than a fading memory, a new earthquake of social rather than seismological proportions was about to strike.

Mitch: Next time on "Unit on the Brink."

Man: Hundreds called for an immediate opening of Utah businesses downtown.

Man: Small business is the lifeblood of this country.

Woman: Let our people work. Let our people work.

Woman: Hundreds in agreement that it's time for coronavirus restrictions to be lifted.

Man: I wanted to be part of this movement to open up our country.

Woman: Like, you have no idea, and you can't know because you're not in it.

Woman: It's so frustrating because there are people that are fine. People come in and they're on a little bit of oxygen for a little while, they go to the floor, they go home. And the other side of that is seeing these people that are so sick and likely won't live, and then seeing people completely disregard all of that and be like, "Well, I want to go get my nails done. I want to go get a haircut." I'm like, "Do you realize that this person is here dying?"

Mitch: Join us next week for Episode 4, "The Last Resort."

Clinical is part of The Scope Presents network and brought to you by University of Utah Health. If you liked what you heard, please be sure to subscribe and share with your friends. And if you haven't yet, why not give us a rating on Stitcher or Apple Podcasts? Those ratings really help new podcasts like ours, and it really makes our day to read them.

And to all the nurses, doctors, admins, interpreters, operators, technicians, and all the other hospital employees out there, we know you're listening, and we want to hear from you. Do you have a frontline story or a message for us or for the people in our story? Feel free to share at our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or email us directly at hello@thescoperadio.com.

And finally, be sure to visit our podcast companion site at thescoperadio.com/clinical, and click on "Voices from the Front Line." There, you can find bios and portraits of the professionals in our story, see what it looks like in the MICU, as well as bonus content we hope enhances your podcast experience. Again, that's thescoperadio.com/clinical, and click on "Voices from the Front Line."

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music by Ian Post, ANBR, Spearfisher, and collective artists. The song featured in this episode, "The Waiting Room," is by Eclectic Approach. You can hear more from them on iTunes or Spotify, or visit their website at eclecticapproach.com. Audio news clips from KUTV and Fox 13.

Special thanks to Charlie Ehlert and Jessica Cagle for their work on the companion site. And, of course, a heartfelt thanks to the men and women who have shared their stories with all of us and fight to this very day to keep each and every one of us safe.