Sep 16, 2020

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 4 of our series "Unit on the Brink." This is a multi-part story 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. Don't worry, we'll be here when you get back. And for everyone else, this is Part 4 of "Unit on the Brink."

As the chill of March gave way to a warmer promise of April, some Utahns were trying to settle into the new normal that was beginning to form after Governor Herbert enacted the Stay Home, Stay Safe directive on March 27. In an effort to minimize the chance of exposure to the virus, the citizens of Utah were urged to stay home as much as possible.

For the large group of Utahns deemed non-essential, the stay-at-home directive was proving to be the worst of times. With public spaces being forced to shut down, restaurants becoming delivery only, and demand for most services dropping to near zero, employees across the state were seeing a drop in hours, being furloughed, or let go.

Between March 16 and April 17, 125,000 Utahns filed for unemployment benefits for the very first time. With the loss of jobs and the closing of school cafeterias, it was forecasted that if things didn't change, as many as half a million Utahns would be considered food insecure by the end of July.

Is it any wonder that social media feeds rang with the cries of revolution and defiance from a vocal segment of Utah's population concerned about the soaring unemployment rate, struggling local businesses, and arguments over their constitutional rights?

Although local orders had specified no large gatherings, on April 18, an estimated thousand people collected in front of the City County Building to call for an end to restrictions and to order the state to reopen for business.

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

Man: Small business is the lifeblood of this country.

Womnan: Let our people work. Let our people work.

Womnan: 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.

Mitch: For the medical workers in our story, these protests were unsettling. In just the first few weeks of April, the number of COVID-positive cases seemed to finally be leveling off. The measures enforced by the stay home directive, while impossibly difficult for so many people, it appeared to be working. The curve had been flattened.

But seeing these large groups of protests on television with very few masks in sight, there was a growing fear in the MICU of more outbreaks and a potential surge of new cases, cases of extraordinarily sick patients filling the MICU. What would happen if the public were to stop caring? Could the terrifying images of overwhelmed hospitals in Italy and New York happen here in the beehive state?

Presented by Clinical and written and reported by Stephen Dark, this is Episode 4, "The Last Resort."

Stephen: Critical care and pulmonary specialist Lynn Keenan, MD, had some sympathy when it came to businesses in Utah being forced towards closure by the abrupt arrival of COVID-19 and the state's response in locking Utah down. But when it came to not wearing masks, the physician drew a line in the sand.

Dr. Keenan: I can see the business's point because my father was a small businessman. He went bankrupt. But I don't think that they understand the impact or how serious this disease is, and they don't see it here in Utah because we have been doing social distancing and we've been . . . I mean, both coasts of the country were hit hardest first and they were taken by surprise, and I think that's one of the reasons why the impact was so great. But I think we need to learn from those experiences and realize that, yes, we need to continue social distancing and the business closures because the mortality is astounding.

Stephen: As nurse Megan Diehl watched the TV news that night, she found herself slipping from dismay, through disbelief, to tears of anger.

Megan: It's so frustrating because there are people that are fine. You know, 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 taking care of them, and trying to get their family . . . like, FaceTiming with family members and trying to keep their spirits up because they can't be there with them. 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?"

Stephen: It was difficult to watch those scenes of unmasked protesters and ignore the possibility that a few of them might soon come under their care. But one thing Diehl says is how she feels about the protesters, another about those who need her skills as a nurse.

Megan: Watching those protests and then thinking about the things that could happen and the people that we could get to take care of, it tears you in two ways as well. It's the same as, like, wanting to protect yourself but wanting to help the patient. I want people to stay home because that's just the right thing to do, but when they end up with us, it's like you were one of those people that thought that this didn't need to be . . . we didn't need to social distance and you didn't need to stay home. And now you're here and we're caring for you and fighting for your life just as much as you are.

Stephen: Nurses found themselves the target of criticism from national media figures questioning why these frontline workers would post about their pain and struggles publicly. A few asked, "Wasn't a history defining disaster like a pandemic the very reason they wanted to go into nursing in the first place?"

Rebecca: And then you read quotes like, "Well, isn't this nurses' . . . isn't this like the Super Bowl for nursing?" That was the one that really got the smoke coming out of my ears. "Isn't this the Super Bowl for nursing?" Like, "Isn't this what you've waited your whole career for? Isn't this your finest hour? Isn't this what you've . . ." No, not what I signed up for.

Stephen: What she did sign up for, however, was something MICU nurses aren't trained in. Brim was the first nurse from the cardiovascular ICU to go to the MICU and help give one last shot via a small box called an ECMO machine to an extremely sick male COVID-19-positive patient.

ECMO stands for extracorporeal membranous oxygenation. It's brought in for COVID-19 patients at the MICU when there's no other choice. What the ECMO does, in essence, is draw a patient's blood out of their body, oxygenate it, and pump it back in. It can be a shocking sight to the uninitiated, Diehl recalls.

Megan: I've only seen it when I've floated down to the cardiovascular ICU, and I'd never seen it put in before. And it's shocking. There's a lot that goes into that, and then just to be able to see the blood coming out . . . because it comes out of one tube, goes to the machine, and so it's like . . . It's weird because the blood is different colors when it carries more oxygen, so it's darker red when it first comes out and then to see it go through the machine and come back as a bright red, I was like, "You know, I've never thought of it, but that makes sense."

Stephen: Nurse Brim, from whom we will hear more later in the series, describes in sometimes visceral detail how ECMO helps COVID-19 patients, bypassing lungs that aren't working while ensuring oxygenated blood circulates around the body.

The ECMO machine is a last resort for lungs that have all but stopped working. It can bring you back from the point of death and give your lungs a chance to rest. Given its rigorous physical demands on patients, it's only for those deemed able to survive it.

Rebecca: So the VV ECMO, which is what we use for COVID, is basically a replacement lung. So they have a good working heart, so their heart can move the blood just fine, their heart works fine, but their lungs don't work. So before the blood goes into the lungs, we pull it out of the body, we do the work of the lungs, and pump it back into the body. The blood still goes through the pulmonary vasculature, through the heart, but then it's already oxygenated and ventilated before it goes through there. So you can have non-working lungs, put the blood through the tubes, basically through the piping to get out to the other side. It's brutal, but it works.

Because you can't rest the lungs. The heart and the lungs are two organs you can't rest. They've got to work all the time. They can't stop. You can't live if those two organs don't work. So they can get to a certain point . . . we can do ventilator. We can prone them. We can put them upside down on their bellies. You can do all these things for lungs, but when it gets to a certain point and they are not working, you've got to do something else.

Stephen: The obvious objective here is for a patient to heal to the point they can go home. But with how hard it is to fight the virus and how demanding it is on the body and the mind, staff members like Diehl still worry about their patients' future.

Megan: Even if you go through all that and you don't have any traumatic experiences, I think living through that and if they're able to live and coming back from that, the PTSD from that would be astronomical, especially because most of these patients or a lot of them have never been hospitalized before, had never been on a breathing tube before. So all of this is new and it's so severe that we're having to take all these crazy measures just to get them enough oxygen.

And then if you make it, which hopefully, then you end up with delirium from being in the hospital for so long and really stress and trauma and everything that comes on top of us just being like, "Oh, you're alive, but here's all the residual."

And people's lungs can be damaged forever from being on high ventilator settings for too long. So it's just . . . I mean, we feel like we've accomplished something when we get to send someone out of the ICU.

Stephen: There's a fear of going through the process again after you've survived it that can leave patients anxious even about sleeping. Some patients, Diehl says, have to battle anxiety that if they were to close their eyes, they might wake up connected to a ventilator again.

Megan: I think mentally, other than just the physical trauma of all of it, there's a big mental component that we'll see down the road.

Stephen: When you add up everything a staff member at the MICU takes home with them at the end of a long, exhausting shift, it must only heighten the sense of concern they have about accidentally taking home the virus from work or how easy it is for loved ones to bring it in themselves without even knowing it.

Healthcare assistant Cornelio Morales has not only his healthy family members to worry about, but also his 21-year-old daughter, Cathy, who has barely any immune system or defenses after a lifetime of living with a genetic disease. Cathy raises the stakes so much higher.

Cornelio: Yeah, that's the thing. So now with Cathy, it was for the last month I think we keep Cathy in the room. We don't let anybody see Cathy, just me and mom. Even my kids, they come say hi and then . . . but we don't allow them to touch her because we don't know.

And then we have a sanitizer in the room. Before we get close to Cathy, we're sanitizing hands, washing hands, and we wear a mask. Every time we get close to Cathy, we wear a mask. I have a mask for one day and my wife has her own mask outside the room. We go and see Cathy, wear a mask, and then we try to protect her more than anybody else.

Stephen: It's a virus that can impact anyone, Diehl stresses.

Megan: Sometimes it seems so unpredictable. At first it was, "Oh, they traveled," or, "Oh, are they older? It's this population." But we have patients of all ages and it impacts everyone differently. We've had a guy that's been on ECMO for weeks, which is like the last line of therapy that we can do, and he's in his 40s and has no medical history. And the guy that I took care of that got intubated was 75 and otherwise pretty healthy, and he is probably at home now again. So people think that they're safe because they're not in this at-risk population, but really it can affect anyone.

Stephen: On top of that, things can just go south so quickly for patients who seem so strong.

Megan: And some people look completely fine, like the patient that I had that we intubated. He looked fine. He was sitting up in his chair with his feet up on his bedside table, didn't look like he was struggling, but his oxygen numbers were just lower and lower and having some trouble breathing but otherwise doing okay.

It's interesting from a medical perspective, but it's terrifying to see how some people's bodies just aren't handling it, and they otherwise probably would have been fine.

Stephen: Where this can end up is a recognition that sometimes death is a mercy, even a release.

Womnan: I think sometimes it's we like know that people need to die. We'll have patients that we do everything to keep them alive, and we get to a point where we're like, "Coming back from this, you would have no quality of life." And so those patients, we recognize that they probably need to pass and we feel better once they've peacefully passed and we're able to help them through that.

Stephen: Processing a death at the unit can mean talking through the narrative of medical care with colleagues.

Megan: The traumatic ones that we don't expect them to die and they're young, those are the ones that are hard to deal with. And I think it's looking at it and what could we have done differently, or is there anything that could have changed this outcome and just walking through it together. We'll talk about it sometimes or talk about this patient and, "This is what happened when I took care of them."

And so we talk to each other, but I think a lot of us talk to our significant others or our families as well, and you just kind of take time to process it and then go back to work and do it all over again.

Stephen: If conversations can be healing, laughter, as it has often been said, is perhaps the best medicine for the wounded heart and soul. Diehl says, to staff, it's a necessary outlet for their stress, trauma, and pain.

Megan: I've seen posts with different things that I follow on social media, nursing groups, that some people are like, "Oh, it's so disrespectful." But you kind of have to have these outlets of, like, these terrible things happen at work, and we have to be able to laugh about some of it.

So they were doing a MICU Olympics because the Olympics were canceled this year. So they were like, "Well, what could we have up here that would be the MICU Olympics?" And so it's like, "Who can put on their PPE the fastest?" and funny little things like that we laugh about.

Stephen: And along with laughter, there's another source of pure escape -- music. And the MICU has its own particular resource when it comes to that -- the MICU COVID playlist. According to the description on Spotify, it's a bunch of people on a COVID unit getting by with a little help from the music. The featured songs have a curiously apt focus, behaviors and feelings that, seen through the COVID infection lens, achieve a new, sometimes bleak resonance. As one nurse says, the ICU, COVID-19 or not, can be a dark place. If you don't find ways to laugh, you can just end up crying.

Some of the choices on the playlist are predictable, like R.E.M's toe-tapper "It's the End of the World as We Know It." Then there are songs such as "I Need A Doctor" by Dr. Dre, Coldplay's "Fix You," or Ariana Grande's "Get Well Soon" that whimsically salute the MICU's mission. "All By Myself" by Eric Carmen, or "Kiss Me Thru The Phone" by Soulja Boy and Sammie that just seemed to perfectly riff off the bizarre cultural Zeitgeist, as defined by living through COVID-19. Some are just plain hopeful, notably Gloria Gaynor's anthem to resilience "I Will Survive."

There's room for everybody's quirky favorite it seems on the MICU's pandemic shuffle. Alisha Barker picks a Queen classic that captures her mood more often than not.

Alisha: I like "Under Pressure" by Queen because that's how I feel. So that dun-dun-dun-dun-dun-dun-dun.

Music: Pressure pushing down on me, pressing down on you, no man ask for.

Stephen: Conversation, laughter, dancing to that special tune, it all helps to ease the mental and emotional burden, the day-to-day patrolling the COVID frontline weighs down upon you.

Then there's the hospital's resiliency resources, particularly in terms of assistance with stress management, therapy, and counseling. Barker is grateful the hospital's mental health support system is more robust than it was a decade before with the H1N1 pandemic.

Alisha: Whereas H1N1 was still a pandemic, but I feel it wasn't . . . you know, not as many people were affected by that. The economy didn't close down for H1N1 as it has for COVID. And so it's a massive undertaking by the entire University of Utah Health institution. And so there is more support there.

Stephen: At times, though, only three words will do, especially when delivered by someone from the top of the hospital's administration, like Chief Executive Officer Gordon Crabtree. On May the 6th, Crabtree penned a poem called "I'm Not Even Joking" in response to heart-shaped cards filled with lines of gratitude from his frontline workers.

Gordon: My heart goes to you, the many who serve here, in whatever capacity you help. As you bring life and real joy to others with sincere words that are, for sure, deeply felt. We love you for what you are doing, your support in this COVID new world. And the cards and the hearts are the icing on top, some gems, and even some pearls.

Stephen: Crabtree's expressions of love for his staff do not go unnoticed, Barker says.

Alisha: I mean, to have the CEO of the hospital on every live broadcast that they do on Mondays and Thursdays, to close that out with -- here I go again -- with the CEO of the company telling you, "We love you," and you feel that.

And then to have the Chief Medical Officer, Dr. Michael Good, say, "We are not going to run out of PPE. I will not let that happen," when you are a frontline worker and you're the one that's putting on that equipment to take care of these patients and you hear your Chief Medical Officer say that, it gives you more faith. Whereas we've been operating on such a sense of scarcity, it's very reassuring when you're the one that's going in to take care of those patients.

Stephen: Such reassurances during those first months of COVID-19 helped strengthen a bulwark of hospital mental health resources for providers against the kind of burnout that during H1N1 had led to departures, Barker says, as well as her own struggles with a respirator mask.

Alisha: That's a massive, I think, change for me, and what I think causes so many people to leave the nursing field or to have the burnout and why they leave is because we're not addressing these. Whereas now it is more addressed and there are more resources for it. And so, hopefully, people will be better able to deal and they won't have a panic attack when they put on their N95 mask for 10 years after.

Stephen: One of the most important support systems the MICU staff have is each other. Many want to work at the MICU, Morales says, because they've witnessed its collegial atmosphere firsthand.

Cornelio: As I said, that's the reason I've been there for 11 years. It's a family, really help you with everything. I swear you're never on your own. You always get somebody else to help you, and that's what it is. They treat you like family.

Stephen: As the virus bore down on Utah, and more and more patients occupied the negative air rooms in the back of the unit, that mutual support culture only blossomed, Cat Coe says.

Cat: Maybe just that the culture in the MICU is really amazing. We have a culture of teamwork that's, I think, pretty well known throughout the critical care cluster in the hospital. And it's just been cool to see people volunteer to take COVID-positive patients, and I think we all try to help a lot. If we're not the ones that are in the rooms, we do try to help the nurses that are. It's been cool to see how we've rallied as a unit in a time of crisis or preparing for a crisis. Yeah, my coworkers are pretty amazing, like some of the smartest people I've ever met.

Stephen: It's exhausting work, Diehl says, but it's also something more.

Megan: I think that's probably how I would describe my job most days is exhausting, but exhilarating. And the days that are more exhausting are often more exhilarating because they're exhausting because you're having to really work to keep this person alive and run all around and think critically all day about what you can do to make sure that everything is okay, while also your other patient needs juice or a blanket or something. So it's running around and a lot of delegating to other people to help you with things. So it's good, but I'm very tired after my shifts.

Stephen: The summer months at the MICU are traditionally quiet ones before the flu season hits in the fall. Nurses and providers float to other departments, other floors, and see how they can help. But 2020 would bring a very different summer for the MICU team, one that would ramp up the pressure on a unit increasingly desperate for a break yet unable to get out of the way even for a day from bearing the brunt of the COVID storm.

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

Womnan: To be a nurse in intensive care means that I am the guardian of the critically ill. I am the keeper of hope, even when I know deep down that there is none. I am the keeper of hope when the family and the patient has lost all hope, but I know deep down that there is still hope.

To be a nurse is to bear witness to people's journey through illness. To be a nurse is to bear witness to their suffering when no one else can see it. To be a nurse is to bear witness to someone's transition from this life to the next, and sometimes I'm the only witness.

Mitch: Join us next week for Episode 5, "Keepers of Hope."

Before we go to credits, we wanted to take a moment to acknowledge a clarification brought to our attention regarding our last episode. Here at Clinical, we strive to ensure that our stories are told as accurately as possible. This includes a review process from not only our subjects but professionals in the field for each episode we release.

In regards to last week's episode, while pharmaceutical paralysis is sometimes used for aiding in ventilator compliance in some of the very worst patient cases, medical professionals do not remove sedation from a patient during paralysis because of the emotional toll such a harrowing experience would have on the patient.

Listener Samantha called into our Scope Listener Line to bring this point to our attention and articulated in precise and eloquent terms the important consideration she takes with her patients in this scenario.

Samantha: I'm a nurse in the medical ICU and I work alongside all the people you've been interviewing. I've been enjoying listening to the podcast and I'm proud to work alongside my coworkers who are speaking out and really representing us well.

I recognize the significance of removing all voluntary movement from a person. In my own practice, before initiating the paralytic medication, I always pause and consider the weight of what I'm about to do, in taking away their ability to do anything for themselves, to move their head or shift their arm or even blink.

I consider it a privilege to care for people in this state and to do for them what they can't. And it's important to me that people have a right understanding of what that looks like.

Like I said, I've been really enjoying the podcast, and thank you for giving a voice to our experience. I look forward to hearing more.

Mitch: We have since made the requested clarification in Episode 3, "Isolation Protocol." Stephen and I appreciate our listeners being so involved in this story. We know it means a lot to the frontline workers out there, and we want to make sure we get it right.

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/clinicalpodcast, and click on Voices from the Frontline. 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 Frontline.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music in this episode by Banana Split, the Dave Roy Collective, Ian Post, The Light Hearts, Rosa, Ryan Pruitt, and Yehezkel Raz. Audio news clips from KUTV. Special thanks to Charlie Ehlert and Jessica Cagle for their work on the companion site. And, of course, a heartfelt thanks to 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.

For Patients