Unit on the Brink: E1 - Duty of Care

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

There's a ritual in New York City. Throughout March and April when the city saw the very worst brunt of the COVID-19 pandemic, every night at 7:00 p.m., New Yorkers would open up their windows to clap and cheer for the healthcare workers that were risking their lives on the front lines.

Throughout the United States, there were similar outpourings of support for medical workers. Billboards were plastered with photos of nurses and doctors wearing N95 masks. Mass donations of food, masks, and care packages arrived at hospitals. In Utah, community members started wearing white ribbons and placing signs in their front yard. Parades of police cars and fire trucks drove by the hospital with lights and sirens blaring to show their support.

It's easy to support the abstract idea of a hero on the front lines, to wear a pin, and clap, and feel a sense of pride and gratitude, but the term frontline should not be taken lightly.

For the medical staff risking infection daily, this pandemic is very much a war zone. Clinical co-producer Stephen Dark was given the opportunity to speak with seven medical professionals about what it's like to work in the unit that is treating the very sickest of this pandemic's victims.

This is "Unit on the Brink: Voices from the COVID Frontline," a multi-part podcast series that offers a snapshot of one state, one hospital, one medical ICU during the very first months of the pandemic, a raw look at what a group of healers treating COVID-19-positive patients face every day in the battle against this deadly virus.

This is not only the story of the pandemic itself, but the story of the lives of the men and women on the frontlines fighting to hold the line against the novel coronavirus. These seven medical professionals have opened up to us to share an intimate look at the very real toll the virus takes not only on their patients but on the medical workers themselves.

Presented by Clinical and written and reported by Stephen Dark, this is Episode 1, "Duty of Care."

Stephen: Alisha Barker is a veteran charge nurse at the medical intensive care unit, or MICU as the staff call it, on the fourth floor of University of Utah Hospital. It's a 25-bed unit that provides round-the-clock critical care for severely ill adult and geriatric patients, and it's not for the fainthearted.

The ratio of nurse to patient is the lowest in the hospital at one-to-two. Patients are simply that sick. When nurses first start at the MICU, they see and do things at the bedside they'd only associated before with the operating room, like assisting a physician to do an upper gastrointestinal endoscopy where you put a camera into your patient to look at the esophagus, stomach, and small intestine.

There's undoubtedly the miracle saves that lead to grateful patients leaving in a wheelchair, but there's also heart-rending moments that lead to the withdrawal of care and the sheet-covered trip to the morgue, outcomes that MICU staff face far more often than anywhere else in the hospital.

Death has a different standing at the MICU, Barker acknowledges.

Nurse Barker: I think the medical ICU still has the highest death rate in the hospital. For a long time we did just because our patients are the sickest of the sick.

Stephen: Some patients cling to life, while in other cases it's the family that clings to the patient, desperate for them to recover, for the MICU to use every technological advance they have at their fingertips to keep their loved ones alive, no matter how much they suffer or how truly beyond repair their bodies are.

Nurse Barker: I've taken care of patients where they didn't want to let go, they were afraid to die, or their family was afraid to let them go, or patients weren't in the position or of their right mind to make those decisions.

Stephen: Sometimes a patient has had enough and is still able to decide their own fate. Barker talks about one young patient, a husband and father, who'd been on the unit for more than a month and was not getting better.

Nurse Barker: At this point, he'd been in our unit for a few months and he had a tracheostomy and he was connected to the vent that way, and he just decided he was done.

Stephen: At the patient's request, the unit withdrew care.

Nurse Barker: They took him off the ventilator and we were giving him medication to make him comfortable and he just passed away very peacefully with all of his loved ones at his bedside. So I think that was probably the first death that really affected me.

Stephen: Some patients like this young man appreciate all that is done for them and are unfailingly polite. They make nursing a pleasure, she says.

Nurse Barker: He was just a nice . . . there are certain patients where you're like, "Ah, this is going to be a good shift." He's a very nice patient to care for and grateful and says please and thank you and is enjoyable to take care of. So to lose a patient like that is very hard.

Stephen: This is the taxing reality that Barker and the MICU team deal with day and night, and this is well before any of us had even heard of COVID-19.

Barker originally joined the MICU in December 2007, after getting a much sought after slot on a six-month critical care internship. But in 2016, she quit her position as an assistant manager at the MICU, a decision driven in part by family needs, but also by her own concerns about the toll her work was having on her own mental health.

Nurse Barker: Oh, gosh. You find yourself attached sometimes to certain stories of patients that affect you, and it's different for everybody. And you notice that you're getting attached to this patient's story, and then you realize you can't make it part of your story because you're not going to be able to do your job effectively.

Stephen: After two years in preventive cardiology, her memories of the MICU drew her back.

Nurse Barker: I missed the MICU. I missed working alongside of likeminded nurses. I miss the intensity of it. I've definitely learned more how to better take care of myself and how to handle the stress and come back day after day to the fire hose that it is.

Stephen: It took her six months to settle back into the exacting, sometimes soul-wrenching rhythm of caring for patients facing severe medical issues and, in some cases, coding, medicalese for a patient going into cardiac arrest and death.

And then just as she had healed from the psychological strains of seeing too many young patients dying during the 2009 H1N1 pandemic, just as she had put back on the mantle of MICU charge nurse, and had found her feet again supervising the unit, COVID-19 came knocking at the MICU's door.

A friend with whom she studied nursing expressed sympathy to Barker for returning only to find the novel coronavirus just around the corner.

Nurse Barker: She was like, "Oh, I'm sorry. You're back at the bedside now and you've got to deal with this." And I'm like, "Actually, I feel maybe this is why I came back. I don't know. I feel like I'm glad to be back because of my experience."

Stephen: Talk to enough healthcare staff and you hear amidst the stories of patients saved and lost that same philosophy, that oddly mystical connection they feel with their patients and their calling.

They walk what one nurse calls the gray line of life and death every day, testing the limits of their strengths and their flaws. You find yourself asking, "What could possibly have drawn them to such a challenging career?" They all give the same answer as Alisha Barker. They just each get there in their own way.

Nurse Barker: I loved the idea of just taking care of people.

Stephen: She grew up in Price, central Utah. Most folks in Salt Lake know Price as a gas stop on the way to the red-rock tourist mecca, Moab. For Barker, as a child growing up, it was a rural paradise where, in the evening, she'd look forward to her father coming home so together they could watch the 1970s TV sitcom, "M*A*S*H." It was the recurring role of a nurse played by Loretta Swit who helped sow the seeds of Barker's future passion for nursing.

Nurse Barker: My dad, when I was very little, he worked the swing shift, and I would always try and stay awake or wake up when he would get home from work because that was a time where I got to just hang out with him. He always watched "M*A*S*H" when he got home from work to wind down, so I loved sitting on the couch with him watching "M*A*S*H." And I remember just loving watching the female characters of "M*A*S*H." They were lively and they were . . .

Stephen: Hot Lips Houlihan?

Nurse Barker: Yes. Hot Lips Houlihan. She was my favorite. And something about the women on that TV show, the nurses on that TV show, I just really liked. I liked them. They were assertive and powerful, and they didn't take any crap.

Stephen: The educational process that molds and informs a desire to care for others into a fully-fledged nurse is nursing college. Like Barker, MICU nurse Megan Diehl went through four years of college to get her nursing license. In summer 2014, she gave a speech to 80 fellow nurses and their guests at the pinning ceremony at Ohio University.

The ceremony where each nurse receives a pin dates back to Florence Nightingale, the founder of modern nursing, and celebrates not only their entry into the sisterhood and brotherhood of nursing, but also that they are ready to serve their community as healthcare professionals. She thanked the families, relatives, partners, and loved ones for supporting them.

Nurse Diehl: I'd like to take a moment to say thank you to the parents and grandparents, aunts, and uncles, brothers and sisters, girlfriends, boyfriends, best friends, and, of course, to our faculty. You're a huge part of the reason we made it to graduation. You stood by us and supported us when we were too tired to talk, crying too hard to understand, and too upset to be kind. We've been exhausted from long days and nights of clinical and studying, stressed beyond belief about tests and checkoffs, worried about our grades, and upset about everything.

Stephen: In sophomore year, they claimed their first scrubs and stethoscopes, marking the first time they truly felt like nurses, but they also made mistakes.

Nurse Diehl: We missed steps, dropped pills, got lost, and didn't know how to talk to our patients. We wrote care plans for hours and hours and fretted over checkoffs in the lab.

Stephen: Four years on from when they started, she said, now they complained about their scrubs and how uncomfortable they were, shoved their stethoscopes in their bookbags, and did injections quickly and efficiently instead of worrying if they're completing all the steps.

Nurse Diehl: From here on, we're not just mere students, but a nurse with responsibility and knowledge. People will seek our opinion for advice, refer to our knowledge for answers, and look to our actions for guidance, and most of all, trust our expertise with their lives.

Stephen: Diehl was three years into her career as a nurse when she joined the MICU in October 2018, the same month Barker returned to the unit. Diehl found those first months daunting.

Nurse Diehl: It was terrifying.

Stephen: The first day on the unit is called orientation, and it sees the novice MICU nurse pair up with a veteran healthcare provider. As Diehl walked around the unit with the staff member, she saw things that as a nurse she'd heard of, but not witnessed before, such as intubation, putting a breathing tube down a patient's throat.

Nurse Diehl: But I remember specifically watching a patient get intubated and thinking, "Oh, well, it's fine. They're going to go to the ICU now," and then realizing, "Oh, you're in the ICU," and being like, "Oh, crap."

The first probably month, it was a lot of the feeling really excited about, "I'm here now. This is awesome. I'm going to be such a badass. This is going to be so great," and feeling completely terrified because I didn't know how to take care of these patients yet.

Stephen: Orientation lasts three months. Then you're on your own. You're given a couple of weeks with patients who are stable before you get thrown into the deep end. Stability, however, can be deceptive. Diehl felt she was ready to take on a very sick patient, so she cared for a young mother who by the end of her first shift was doing well.

Nurse Diehl: The first shift that I was like, "All right. I'm ready. I'm going to take a patient that's really sick." I had come back from the previous day and my patient had been fine. Then that morning, when we were getting a report, they were like, "She had a heart attack at midnight, and then at 4:00 a.m. she started having signs of bleeding. So they're going to CT right now." And all of these crazy things are happening and I was like, "Well, I wanted to do this. I'll take this patient back."

Stephen: The nurse reported that the brain attack team from the neurology department had taken the patient away for CT and MRI scans, which revealed the patient had had a stroke. And then things got worse.

Nurse Diehl: So we're doing that, and I'm trying to get a report from the night nurse, like, "What happened? She was fine yesterday." And we got back up to the floor and she started coding. I had never had my patient code before, and I was by myself. I remember being there and trying to do what was right, but everyone jumps in. There were other people who were there helping me out, but trying to push meds and trying to do what was right for the patient.

Then a provider had called a family member because there was no way she would have survived with the brain injuries that we then knew that she had, and so then transitioning to keeping her comfortable while she passed. It was traumatic. It was a really hard experience.

Stephen: Diehl found herself shepherding a young mother to her death, a woman who just a day before had been fine.

Nurse Diehl: I remember doing that transition to where we're not going to code her anymore, we're just going to let her pass and trying to work with the provider and stay at her bedside and hold her hand while she died. So that's probably one of the most traumatic things that I've experienced.

We see people pass away all the time. It's nothing new. It was new for me then because I had only seen it a couple times, but it's one of the only ones that really hit me hard.

Stephen: Diehl underscores the constant tension that runs through nursing, the need for empathy and the need for distance.

Nurse Diehl: It's hard because you want to have emotions and be able to treat the patient and give them their dignity and respect, but a lot of it is distancing yourself from that, I think, so that you can provide care without becoming too emotional.

Stephen: When the first suspected COVID-19 patients trickled into the unit in March, Diehl, Barker, and their colleagues discovered that the very nature of nursing, of walking that line of emotional distance that allowed them to do what they do every day, suddenly became even more complex, even more difficult.

They were used to making calculated risks when it came to throwing themselves into the line of contagion to save a patient's life. Self-sacrifice is in the DNA of healthcare, says Barker.

Nurse Barker: Us as healthcare workers, we're just . . . it's a no-brainer to sacrifice ourselves to go and try and save somebody.

Stephen: But the contagiousness, scale, and potential casualties of COVID-19 demanded that they doubled down on self-protection. They had to put themselves first, supervisors told them, which meant putting on the time-consuming layers of mask, gown, and gloves, collectively called personal protective equipment, PPE for short, before going into the isolation chambers that are the rooms of COVID-19-positive patients.

Nurse Barker: If a patient has a cardiac arrest, you have to put on your N95 and your PPE before you can go and try to save this patient and start doing chest compressions and stuff. And those are precious seconds. We are trained to react instantaneously when that happens, and so to not be able to do that and to have to protect ourselves first, which is very important, but it weighs . . . you can just see that weigh so heavily on everybody. You have to first make sure that you have a mask on the patient and that you have all your PPE on before you go into that room.

It's okay to not be okay. There's no answer. There's nothing that's going to comfort you about that. The chances are less likely that that patient will survive because you are using valuable seconds to protect yourself first before you get to that patient.

Stephen: Nurses constantly face the possibility of exposure to infection. But what would happen if the first line of defense, this laborious yet utterly necessary personal protective equipment ran out? That question was on the mind of many among the MICU staff, Diehl says, as they saw how healthcare staff in besieged New York hospitals were reduced to wearing bin liners. This fear set in even as Utah, at least back then, had very few cases.

Nurse Diehl: It really just makes you think about, "If we run out of PPE, will you still go in those rooms?"

Stephen: It's the kind of question that wakes you up at 3:00 a.m. in a cold sweat.

Nurse Diehl: It's a question that we all think of. We're doing okay right now, and they're figuring out ways to recycle things and use things and sterilize them. But if it gets to the point where we run out, would you take care of these patients? And it's a question that really makes you think about your level of caring, but also protecting yourself.

Stephen: Who do you put first? Where does your duty of care lie? The patient coding in front of you? The many other patients that do and will need you? Your colleagues? Your family? Yourself?

Nurse Diehl: There's a very fine line between wanting to run into a room when a patient pulls out their breathing tube because you need to be there because they need help, but you also need to be protected because you don't want to run into where all of this is aerosolized and you'd be breathing it all in.

We saw a nurse do that, run into a room without her stuff because the patient was doing something that they shouldn't be doing or something bad happened. I don't remember what it was, but we were like, "You need to make sure that you're safe too or take some precaution." She was like, "But they needed me." So it's interesting.

It's hard with those situations too because . . . I was just at the code class. When we run on codes now, you don't even start compressions unless you have a mask on the patient. So it's like you don't want to delay care to this person, but to protect the other people in the room or to protect yourself, you have to follow other steps first. It's a battle. It's a battle between wanting to care and wanting to help and wanting to protect yourself and the people that you love and care about.

Stephen: Sometimes there isn't time to make those calculations. Instinct simply kicks in, Barker says.

Nurse Barker: Last week or the week before, we had a younger patient, a male in his 40s, otherwise healthy, difficult to sedate, 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. Well, this patient was having a coughing fit and he was coming out of his sedation and his restraint was loose and he was about to self-extubate.

Stephen: Self-extubate, when a patient pulls out the breathing tube that feeds oxygen from the ventilator to their lungs. If removed without medical supervision, it can prove fatal to the patient since without the much-needed oxygen, they can go into cardiac arrest. At the same time, if the patient succeeds, their coughing will render the virus in their lungs airborne.

What Barker saw as she came out of a patient's room was not only this COVID-19-positive patient about to self-extubate, but a nurse struggling to don her PPE before she went in. Barker still had her N95 mask in her hand and a pair of gloves on. If she didn't go into the room right then, she knew the patient would pull the tube from his throat.

Nurse Barker: I had just come out of a COVID patient's room and I still had my N95 mask and I had just set it down, and she's frantically trying to get her equipment on to protect herself. So I put my mask on really quickly and a pair of gloves. I threw everything on really quickly and I ran in and caught his hand just in time. And I wasn't wearing the protective gown.

I figured it was a gamble. I either catch him before he pulls the tube out and aspirate, COVID particles are everywhere, or I go in now without my gown on, but I have my mask on and catch him and then it's fine. It's a closed system and he's not pulled it out. So I took the gamble. It paid off.

Stephen: That's a damn close call.

Nurse Barker: It is. And that's the training. You try and you stop that. It's hard to program yourself to . . . you've got to put on all those PPE, but had we waited before we were completely gowned up, he would have had that breathing tube out and it would have been a major mess of an emergency trying to get the doctors back in to get him intubated. And that's more people who are exposed potentially. Either way, it's awful.

I remember I caught his hand, was getting it . . . The nurse had finally made it in and she was giving him another dose of his medicine, the sedation medicine, so that he would cough less and calm down. And still, mask on, but I don't have any other protections, so I'm trying to just tie his restraint so that his arm is . . . so he can't reach his tube and then getting out of there.

Stephen: As the adrenaline subsided, she faced new questions. "Was I exposed to COVID? Should I go home?"

Nurse Barker: Because I wasn't fully protected . . . I had the most important piece on. Then it was on my mind the rest of the time, like, "I should be okay. It's fine. It's okay. Is it okay? Should I go home now? Should I sleep in the same bed as my husband tonight? Should I . . ."

Stephen: Did you shower before you left?

Nurse Barker: Yes, I showered before I left. I scrubbed hard, washed my hair, got everything. Yeah.

Stephen: She drifts briefly into silence. You can almost feel the abyss that seems to open before her, all the unanswered questions, the doubts, the fears, and the horror that this pandemic has brought to bear upon her unit, let alone the many, many secrets the virus has yet to share with those who are trying to first contain and then extinguish its spread.

And what awaits at the bottom of the abyss, Barker knows all too well, is perhaps the greatest tragedy the virus inflicts upon many of those who end up in the MICU. They die alone.

Nurse Barker: The brutal realities . . . the hardest part I think is that, in a sense, you're alone. You're surrounded by us, the medical professionals who are helping to take care of the patients. However, your loved ones can't be there with you.

Stephen: That was because visitor policies there to protect people from the virus kept most out of the hospital.

Nurse Barker: But oftentimes it's so chaotic when they're dying. We're trying to prevent that from happening.

Stephen: And in the midst of all this frenzy and chaos . . .

Nurse Barker: These patients who are dying are . . . most of the time, they're still on a ventilator with a breathing tube in. But I think more so just being . . . the loneliness part of it. There have been quite a few patients that have died alone.

Stephen: But not always. Even as the ventilators continue their relentless efforts to push oxygen into starved lungs and harried nurses and physicians run from one bed to another, behind a closed door an exhausted nurse who has finished her shift finds that moment of grace that propels her to accompany a human being in their final moments.

Nurse Barker: Most recently, there was a patient . . . I don't think he had COVID, but there weren't any visitors and we had withdrawn care. And one of the night shift nurses stayed past her shift. Her shift ended at 7:00 a.m. She stayed until 10:30 because there was no one else that was able to stay with this patient, and just stayed in there and cried and held his hand. And it's very moving to see.

Stephen: In the gathering shadows of the evening on a municipal sports field in downtown Price, a teenage Barker and her father would work on her softball pitching skills every single day. Now, between February and June once school ended at 3:00 p.m., all that hard work bore fruit on the school field.

Nurse Barker: As a pitcher, I was known for my accuracy and the different pitches I threw and I could move the ball and put it just so.

Stephen: The catcher would signal Barker the pitch she thought she should throw, Barker making her own mind up on what it will be. In her mind's eye, she reviewed the field. The batter making short, sharp, stabbing practice swings. The runners on their bases ready to fly. Holding the ball in her right hand against her thigh, Barker found the grip on the seam she needed. Then hiding the ball in her mitt, she found the point of balance that commenced the start of a pitch and began winding up before pushing off with her hips and bringing her arm up and over to release the ball. Watching the ball drop, curve, rise, or strike out the batter, she felt the pure joy of a perfectly executed accomplishment. On that mound, she says her Type A controlling personality was born.

And at the MICU, as she prepared for the next admission, assessed the nurses she would assign, the medications needed, monitored the medical status of all the patients under her care, there will come those moments when she experienced that same unadulterated joy she did as a teenager pitching the perfect softball. It could be doing something that improved a patient's quality of life or just their day, or when she watched a nurse she's mentored and trained solve a patient's problem on her own.

Nurse Barker: It ticks that Type A box for me.

Stephen: Only now it was patients with COVID-19 who were placing their lives in her hands. And this virus came with questions that her preparation as a student, as a nurse, as a charge nurse still couldn't answer.

In March, when New York's hospitals all but drowned in virus cases, as Barker watched EMTs in PPE wheel in yet another suspected COVID-19 patient, she couldn't help but envision a nightmare scenario.

Nurse Barker: And you wonder, "Oh, my goodness. What if every single patient in this unit had COVID-19? This would be a nightmare." And then you think about colleagues who are in New York, who every patient in their unit has it, and it is a nightmare. So it's a bit of a preview, and so I'm very grateful that the efforts that have helped to some degree and, hopefully, they continue to help, but who knows.

Stephen: Barker appreciated the vocal support from the hospital's leadership and the much-improved emphasis on providing mental health support. But even so, an inescapable dread in the pit of her stomach took hold that this pandemic was only just beginning.

Mitch: Next week on "Unit on the Brink," Episode 2, "Echoes of the Past." Before COVID-19, there was another global pandemic back in 2009. The international outbreak of influenza H1N1 shares eerie similarities to what the world has been dealing with since spring of 2020. But back then, most of the public had no idea what was really going on in the world's intensive care units.

Voice #1: But first, the latest on the swine flu epidemic, which the CDC said today is spread widely and cannot be contained.

Nurse Barker: It was like someone just flipped a switch and all of a sudden we had three patients coding in one shift. To have at least three patients code and die during your shift became normal.

Voice #2: And then there was a lull in the summer and then resurgence in the fall again, and they were profoundly ill with acute respiratory distress syndrome. Our ICU was filled with people who are proned for weeks.

Nurse Barker: I just remember feeling . . . just being like, "What is going on?"

Mitch: Tune in next week for that story.

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.

You can also help others find us by leaving a review on Stitcher or Apple Podcasts. Those reviews really help out new podcasts, and we really appreciate them.

Do you have a story of fighting on the frontlines of COVID-19, a nursing story you'd like to share, or just a message of gratitude to the men and women from this story? We want to hear it. Feel free to call our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or feel free to email us at hello@thescoperadio.com.

And finally, if you want to see the inside of the MICU and the faces of these brave professionals in our story that are working to save lives, you can visit our podcast companion site at thescoperadio.com/clinicalpodcast. There, you can find bios and pictures of these frontline healthcare workers, bonus content, and teasers for future episodes. Again, that's thescoperadio.com/clinicalpodcast.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music by Ian Post, Yehezkel Raz, and collective artists. Audio clips from C-SPAN and KUTV. Special thanks to Charlie Ehlert and Jessica Cagle for their work on the portraits and 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.