Unit on the Brink: E8 - Saying Goodbye

Mitch: For 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 8 of our series "Unit On The Brink." This is a multi-part story that is told in order. And if you haven't listened to our previous episodes yet, we highly recommend you go back and start with Episode 1 in your podcast app.

"Unit On the Brink" is a story that intimately explores the firsthand experience of medical frontline workers during the coronavirus pandemic. The stories that are shared are raw and occasionally deal with personal trauma. Listener discretion is advised.

For nurses and providers working in intensive care, death is something that comes with the vocation. After all, medical workers in ICUs across the nation are tasked with treating the sickest and most severely injured patients, yet the severity of the COVID-19 virus and the safety protocols enacted to contain its spread was testing the emotional limits of even the most battle-hardened veterans in the medical intensive care unit, people like charge nurse Alisha Barker who had served through the H1N1 pandemic of 2009.

Throughout the winter surge, COVID death rates for Utah were increasing. Despite new and refine treatment procedures and protocols showing real promise in improving survivability, the sheer number of new SARS-CoV-2 cases were filling up Utah hospitals with extremely ill patients.

Where Utah had seen a statewide average of 1 to 5 daily deaths between March and August, those rates more than doubled throughout the cold winter months, with a high of 36 Utahns passing from the virus January 26, 2021.

We now return to the morning of December 10, 2020. Shift change in the medical intensive care unit, the frontlines during the winter surge of cases in Utah, to share what it was like for frontline workers that found themselves bidding farewell to more patients than many had ever had to before and how they found the courage and resilience to carry on and maintain hope through the dark winter months.

Presented by Clinical and written and reported by Stephen Dark. This is episode 8, "Saying Goodbye."

Stephen: By 7:40 a.m. that December 10th morning at the University Hospital Medical ICU, the charge nurse had finished going through the roster of patients. Nurses had chosen their patients for the day shift, and all that was left was to send them on their way.

Nurses and healthcare assistants fanned out to talk to the night shift about the patients they were taking over for more detailed insight into how the night had gone. The transfer of care complete, the unit went eerily quiet for a while as nurses busied themselves attending to their patients.

Then, at 10:00 a.m., proning began. That's when sedated patients on ventilators are turned over. Proning helps patients with their breathing because it aids delivery of oxygen to parts of their lungs that aren't otherwise reached when they're on their backs.

But staff knew that as more patients needed to be proned, some more of them were edging closer to not coming back from the brink that COVID-19 had pushed them to.

Being put on a ventilator, after all, was in no way a guarantee that they would survive the virus, but rather a reflection on how much damage the virus had inflicted on their lungs.

As more COVID-19 cases filled up the MICU's roster, staff had to organize into groups to do seemingly endless numbers of exhausting pronings. For larger patients in each of the equipment-crowded rooms, that means three nurses each side, along with the primary nurse or attending provider reading the protocols, and the respiratory therapists, if available, managing the patient's airway.

The physical energy and mental concentration that goes into each half-hour proning, especially when you have to repeat the process at the end of the shift, leaves staff drained.

One shift, charge nurse Alisha Barker recalls it was simply overwhelming in the number of patients who had to be proned.

Alisha: This was a couple of weeks back where it was a hellacious shift and we had a lot of patients to prone or unprone at the beginning of the shift, and then we had to flip the patients back over, like prone them again at the end of the shift. We were just exhausted, and it's 5:30 p.m., 6:00 p.m. We're all a bit delirious by this point, just going from room to room to the next room to prone these patients.

Stephen: As they moved from room to room to room end of shift, the mood was becoming increasingly brittle. Physical, mental, and emotional exhaustion had already exacted so greater toll on Barker's colleagues. She had to find a way to rally the troops to get them through these last pronings.

Alisha: So by the third patient, we're proning and we're all just like almost in tears. We don't want to be doing this anymore. I got the bright idea to start reading the instructions in a different accent, and it completely changed the mood of the room.

And everybody was talking back to me in their own version of the Russian accent that I was doing, and there was no other place in the world that I would have rather been in that moment than in that room with my coworkers, because we turned a very dismal, miserable situation into something that was really, really fun.

Stephen: Caring for a patient who can't communicate because they are sedated with a breathing tube down their throat leads some nurses, like charge nurse Cat Coe, to worry that they are losing sight of who they are caring for because of the very nature of the treatment they are called on to provide.

Cat: I think it's more the nature of the disease makes it pretty impossible for us on the MICU because a lot of them desat if they talk. So that means that basically their blood oxygen levels go dangerously low if they talk or eat or sit up or, God forbid, stand up. So I think it is hard to form relationships with them when some of them really can't talk without desating.

And this is not just with COVID, but I think in the ICU in general, it can be very hard because the patients are so sick that they can't communicate very well. It can be very hard to have any concept of what they are like as a human being outside of the hospital. And I think that that can actually be dangerous for a nurse to stop seeing a patient's humanness. You know what I mean?

Stephen: Nurses facilitating family members by using an iPad to allow them to talk to their sedated, intubated loved one can be one way of getting around relatives not being permitted to visit COVID patients due to safety policies.

But, Coe says, FaceTiming can also open the door to secondary trauma when it comes to being the only physically present witness to someone's death while assisting relatives in saying goodbye virtually.

Cat: Witnessing FaceTime conversations that would normally be a private conversation with families around the patient's bed, we're now facilitating these conversations and oftentimes having to stay in the room to deal with whatever technical difficulties. Or if it's a Zoom meeting, admitting another person to the meeting, or whatever. And we're witnessing these goodbye conversations or the families trying to get the patient to engage in a "Do you want to keep going?" sort of conversation and/or decision.

I think being in earshot of that often these days is just heavy. It's sad. It's so sad to see these families on FaceTime not able to touch their loved one and trying to figure out what is the best thing to do for them.

Stephen: Nurse Megan Diehl has also struggled with the realities of supporting relatives through the process of shifting a patient to comfort care when those relatives can only be present virtually. Helping loved ones say goodbye online, she says, as difficult as it is for them, is uniquely challenging for nurses who have to attend to facilitate these farewells.

For weeks, while a patient has been sedated and on a ventilator to battle the pulmonary ravages of the virus, they have been reduced to a silent slumbering form. Suddenly, in their last moments of life, as families say goodbye, the nurse learns who the patient was and how much they mattered to their loved one.

Megan: Being on a FaceTime call with a family, they will talk about the type of person that their loved one is, or they'll share stories. And it's different with each patient, but a lot of patients that I've done FaceTime calls with while they're saying goodbye . . . Death takes a little bit of time sometimes, and so we stay there the whole time to be able to give medications and do things and, with FaceTime, make sure the camera is pointed the right direction and things like that.

And they'll sit there and talk through stories about, "Oh, so-and-so, remember when we did this?" or talk about other family members that have also passed, like, "Oh, when you see grandma, you guys can do this together."

Stephen: If a patient up to that point has been a mix of numbers, heart rate, ventilator settings, and drug administration, all the medical information that has to be monitored to assess their health, suddenly all that falls away.

Megan: But it turns it from looking at those things into looking at the person, and it kind of takes all those numbers and things away. So you don't have to worry about any of that other stuff as well, which is part of it. When someone is passing away, you don't care what their heart rate is doing because you don't have to fix it. You don't care about ventilator settings because you're not going to add oxygen. You're not going to intervene and do treatments.

So instead of thinking about what treatments you can do, you don't have to think about that. You just think about whether or not they're comfortable and then you listen to the family. I think it's that, taking away everything else and making them more of a person, that makes it really hard.

You have to displace yourself from it almost because otherwise you can't handle it. Especially if you're in a PAPR, which we usually are. If you cry in a PAPR, you can't get to it. There's no sticking a tissue up underneath it and wiping your tears away. You're just crying, so it's so awkward. And then you don't want the family to see you crying because you're supposed to be strong for them too.

Stephen: Key to these online farewells are the stands on which the iPads rest.

Megan: We have some now that are on little stands and I usually try to get one of those. Or if it's something like that, I try to get one that I'm not holding because if you need to give medications or do anything, you want to have your hands free and not be like, "I'm going to lay you down for a second. Hold on."

So there's a little stand with the wheels on it and it has a bendy arm. And so you set it up and get them to where they can see the patient. And we'll call in a couple of different people, so it's three or four different little boxes on the screen, and then they're talking to their loved one and telling stories about them and telling stories about them.

Stephen: It's a delicate virtual process, trying to bring the family as close to the patient as possible.

Megan: So if the family can't be there, which usually they can't, we'll take the breathing tube out. Everything is turned off. We can put the monitor so where we can see the numbers, but it's not going to beep at us and make noises and everything because you don't want to distract from the moment.

And then I try to get to where they're just looking at their family member, like pretty close to their face. I don't usually do a full body. You want them to be close enough to see them.

Stephen: Relatives sometimes ask a Nurse us to physically connect with their loved one. Hold their hand, comb back a lock of hair from their temple, touch their cheek so they can say goodbye to them in a physical sense, leaving the nurse as the most intimate witness to their relative's departure.

Megan: It's things like that. The family will ask you to do things because they can't. And so you kind of have to step in and be there if that's what they want from you. Other people will just talk and you just tell them . . . you walk them through the steps of what's going to happen, how things are going to go. I always tell them, "If you think they look uncomfortable, let me know. We can give more medication."

Stephen: In such an intimate, painful space, a nurse finds herself a spectator to a farewell that feels almost unbearable.

Megan: It just breaks your heart to see these people. It's just us. It's a nurse there and then their family talking to them, which is better than nothing, but I can't imagine saying goodbye over a FaceTime call, being so far away or giving that to someone else to be there while my loved one died.

Stephen: In the face of so much trauma and so many patients' deaths, many nurses have found themselves for the first time seeking help. Whether that has meant connecting with the University of Utah's Resiliency Center or an independent therapist, Barker stresses how important being straight with yourself and others about your mental health needs has been during the pandemic.

Alisha: It's more so how are we dealing with the day-to-day? How are we getting through each day? And I will have some thoughts about that. How am I going to be when this is all over? I don't think there's anything wrong with needing to seek help from outside sources, whether that's therapy or medications or a combination of different resources. I think there's absolutely no shame.

And I think that one of the positives of this is that mental health will be more accepted and regarded and there will hopefully be less shame with people having mental health issues, being open about them, and dealing with them.

Some of the most meaningful conversations that I've had with my coworkers lately have been about being honest about how we're really feeling and how we're doing and how we're coping. And I feel like it benefits everybody when you are honest about how you're really doing and the things that you are doing to help cope with it.

Stephen: Simply through the process of reaching out for advice, for help, for sounding boards to answer her own doubts, Diehl found colleagues in the same troubled place as her.

Megan: I don't know. You have to step back and analyze yourself more than you did before. So I came to a point a couple weeks ago where I was like, "Maybe I need to start talking to someone. Maybe I need to start thinking about therapy or thinking about a way to figure out how to organize my emotions and how to deal with some of the stuff that I'm going through."

And I talked to another one of my coworkers about it because she was at that point. I had texted her about something and she had kind of let it out to me that she was not feeling okay emotionally. She told me that she had found someone to talk to that she really liked. And so I've started to try to reach out and find someone to talk to as well.

I reached out to a nurse we used to work with who was really open about going to therapy, and this was pre-COVID. I reached out to her and I was like, "How did you find someone that you felt comfortable talking to?" She gave me a bunch of information and she said, "There have probably been 10 other MICU staff that have reached out to me about this."

Stephen: Those last eight months taught many nurses that the defenses of gallows humor and camaraderie was simply no longer adequate to deal with the added stresses of the pandemic, particularly when it came to witnessing another way of saying farewell to a patient by a loved one that in some senses was even more grueling than FaceTiming, says Cat Coe.

Cat: I think the part that is still really heavy is seeing the families and just seeing them . . . if it's a COVID patient, they can't go in the room. I think it's one now that is allowed to stand outside the room while the patient is passing away, and seeing them have to do that is really heartbreaking.

I often put myself in their shoes and think how hard it would be to stay outside the room and how sad I would be to watch my mother, father, brother, whoever, pass away alone. It's heavy. I think a lot of us are going to therapy right now.

Stephen: One shift when the pandemic surge was pressing down on the MICU, Coe experienced an unfortunate personal record. She accompanied three patients down to the morgue, two of them having died from COVID-19 complications.

Cat: So there were I think two patient transporters, and they were super nice. I mean, they were just like, "Wow, we'll be back, and we'll be back." I don't know. I mean, it's part of the job. We go to the morgue a lot as MICU nurses. We have one of the highest death rates in the hospital, if not the highest, and we're all very familiar with the death packet.

We've had nurses float to us before, like nurses from other units, not familiar with the death packet or haven't had to fill it out in a year and a half or something, and we're all like, "Welcome to MICU."

Stephen: Charge nurse Alisha Barker finds a sense of comfort in the process of escorting a patient on their final journey.

Alisha: It's a very strange journey. I never have gotten used to it in my 13 years of doing this job. There are two transporters who bring a special cart up and we place the patient's body in what's called a post-mortem bag. And we place them on the cart and then we put a sheet over the cart.

So you wouldn't necessarily really know what it was if you were just a lay person walking through the hospital and you saw this cart with a sheet over it being pushed by two people. And then it's followed by the nurse because you've got to go and provide some paperwork and log the patient into the morgue.

Stephen: For Barker, each time she goes to turn away from having brought a patient to this way station before the journey that will lead to their final resting place, she can't quite let go.

Alisha: It's weird. You leave them there, and I always have this hesitation when you leave. Once you do your paperwork, you can leave and the transporters will take care of that patient's body from there. They just will put it in a holding area until the funeral home that the family has selected comes to pick the patient's body up.

And I always have this weird hesitation. It's almost like I'm dropping my kid off to school and I want to stay and look at them through the window or something, or the doorway. There's a weird hesitation there, and you just kind of have to take an inhale and an exhale and release and walk back to the unit.

Stephen: By the beginning of February 2021, like an eternally building tsunami that had finally crushed down onto land only to begin to recede leaving so much damage in its wake, the numbers of new daily infections began to drop along with the numbers of new hospitalizations.

The healthcare system, all its providers and nurses, both ICU and general floor, felt the first signs of pulling back from a brink that at moments had seemed close to, but never quite did, overwhelm it. Not that things would ever be quite the same, including at the MICU where familiar faces had departed or announced their decision to move on.

Charge nurse Cat Coe resigned, her last shift on January 2. She left for a change of pace working at U of U Health's ski injury clinic at the Snowbird Resort. There, she could continue working in critical care, but with the added bonus of backcountry skiing before work and hill laps during her lunch break.

Charge nurse Alisha Barker said she too was leaving in April to pursue her ambition of becoming a nurse anesthetist. If there's one thing that COVID-19 taught her, it's that now is the time to live your dreams.

For those that remain at the MICU, like newly appointed charge nurse Megan Diehl, they look forward to that growing glint of light on the horizon when the pandemic can finally be declared under control.

That December 10 morning, as the safety briefing heralded yet another change of shift, Diehl prepared to wrap up on B50. She considered the impending ramifications of vaccinations both soon and long term, and yet still she managed to joke.

Megan: Maybe. It seems so far away, because they say we're getting a vaccine, but that's only June or July maybe and that's so far away. So I don't know. Maybe eventually we'll be back to floating all over the hospital and complaining about floating instead of complaining about COVID. I don't know.

Stephen: And for some nurses, like 23-year-old Reagan Lowe, who began her career as a nurse in the MICU in May 2020, there are personal celebrations to look forward to. On May 1, 2021, she's getting married at the Highland Gardens in Utah County. Her fiancé is an electrical engineer and he's always careful, she says, to pay attention to how she's coping with work.

Reagan: Sometimes it's kind of hard to describe things the way he . . . like, when he describes his job and the math he has to understand, it goes straight over my head. And it's the same when I'm talking about certain procedures and situations and trying to explain. But also, it's nice to just . . . he's a break from the COVID. A breath of fresh air. It's kind of nice to have someone that just doesn't feel it and see it the same way.

Stephen: Whether it's in Lowe's commitment to her marital future as well as a nurse or Barker's decision to realize her long-held dreams, it's the resilience of the human spirit in the face of adversity that lingers most in the mind after months of talking to nurses at University Hospital's Medical ICU.

But there's a sense in something that charge nurse Barker argues that speaks to nurses, not only at the MICU, not only in University Hospital and so many other clinics and hospitals within The U's system, but indeed nurses across the globe. Even at the lowest points of the pandemic, she says, she and her colleagues were still able to find the strength to go on.

Alisha: Where you can find resilience in the pit of despair, in the bottom of feeling like you absolutely can't go on, and then all of a sudden you're laughing and having a great time, I'm like, "Wow, that's a miracle." That's a miracle of the human spirit, I think. And I hope that my coworkers can recognize that.

Yes, it's very hard and there are things that aren't fair about this and things that will make you angry if you let them, if you think about them and wish that things were being dealt with differently. There are always things we wish that could be different, but we also have the capacity to be extremely resilient in this.

And so, hopefully, people are experiencing their ability to do that and to realize that they're a lot stronger than they thought they were and that we're making it through.

Mitch: Next time on "Unit On The Brink," December 14, a mass vaccination effort in the state begins for frontline workers. Charge nurse Christy Mulder was the first person in Utah to receive the COVID-19 vaccine. We share her story and how the promise of vaccination was providing not only a boost of morale for the medical workers at University Hospital, but a glimmer of hope for a return to normalcy for everyone in the state, whatever form that new normal may take. Join us next time for "Unit On The Brink," Episode 9, "Keeping the Faith."

And if you'd like to see images from our visit to the MICU from the extremely talented photographer Brian Jones, take a look in the show notes for a link to the Keep Breathing multimedia story brought by Stephen Dark and designed by Stace Hasegawa.

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.

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Clinical is produced by me, Mitch Sears, and Stephen Dark. Music in this episode by ANBR, Vortex, the Dave Roy Collective, Ian Post, Laurel Violet, and Yehezkel Raz.

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.