Mar 31, 2021

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 7 of our series "Unit on the Brink." This is a multi-part story that is told in order. 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. This is Part 7 of "Unit on the Brink."

Welcome back to "Unit on the Brink," voices from the COVID frontline. We last spoke with frontline workers at the medical intensive care unit at the end of September 2020. At that point, there was a looming fear of a sharp increase in cases that could potentially overwhelm the state's medical system. The surge.

Back then, case numbers of coronavirus infections and hospitalizations were higher than they had been in the summer, averaging between 1,000 and 1,200 daily cases but at least the numbers seem to be holding steady. Yet just a few weeks after our previous episode ended, the situation started to take a turn.

Male: In Utah, COVID patients flooding ICUs. Doctors say they're now two-thirds full statewide, a few patients away from what they're calling unmanageable.

Female 1: This morning, Utah's doctors are sending an urgent warning. Hospitals are running out of ICU beds.

Female 2: We don't have the ability to continue to provide in unlimited amounts of care.

Female 1: The Utah Hospital Association telling the governor, they're less than two weeks away from having to ration care.

Female 2: If you have a heart attack or you get into trauma and all the beds are full, I mean, if you have a stroke, we can't care for you.

Mitch: On October 22, 2020, the Utah Department of Health reported a record number of hospitalizations for the state, 314, with more than a third of those cases needing critical care.

According to the Department of Health, the state's rising case count of COVID-19 patients was quickly becoming unsustainable. University Hospital was soon forced to reopen B-50, the COVID overflow unit, yet COVID hospitalizations continued to rise.

Throughout November and December, Utah broke one record after another. Two thousand, 3,000, 4,000 new cases a day with a record 5,662 infections on November 22. The surge that healthcare workers had been so anxiously awaiting for all of 2020 had finally arrived.

In December, Stephen Dark, a photographer, and myself were given the rare opportunity to visit the Medical Intensive Care Unit to experience firsthand what conditions in the unit were like during the winter surge. Over the next two episodes, we'll share what was going on in the hearts and minds of frontline workers during the time of ever-increasing pressure in the unit working to persevere against the wave of new patients.

A quick editor's note, you may notice a change in audio quality from our recordings and interviews from inside the unit due to safety protocols and the background noise that comes from a very busy unit as well as the sound of our photographer's equipment. With that all in mind, we now take you back to the University Hospital Medical Intensive Care Unit with Episode 7 here with the COVID.

Stephen: By 7 a.m., more than a dozen nurses and healthcare assistants in scrubs, masks, and protective eyewear were finding their way to the conference room at the medical ICU on the fourth floor of University Hospital for the morning safety briefing.

Amidst the din of caffeinated voices and laughter, they found seats at a long table or stood against the wall all the while looking down the list of current patients in the unit.

Nurse: Okay. Welcome, everyone.

Stephen: The charge nurse who had led the night shift started going through the patient roster stating their diagnosis and a thumbnail sketch with their medical status. Nurses picked their patients. If they worked the day before, they took their patient assignment back for continuity of care. As he went down the list, the charge nurse repeated the same diagnosis.

Nurse: Two, we have COVID on the vent volume control, 70% on [inaudible 00:05:04] is prone. In seven, we have here with COVID is prone and they're on the vent volume control 60%. Nine just came here from the floor with COVID. Three, we have he's here with the COVID. In six, we have he's here with the COVID. In 14, he's got COVID. Fifteen is here with COVID. Yes, 16 is Covid, 18 is here with the COVID.

Stephen: Out of 24 patients that night, 17 had COVID-19 and some were losing the battle.

Nurse: In 10 we have 78-year-old guy and we're just trying to address goals of care. And in 12 we have 70 years old DNR, but intubation is okay and she is walking that line in there. DNR, DNI. We're letting him eat and stuff and kind of moving in a palliative direction.

Stephen: Even as COVID-19's presence seem to weigh ever heavier in the room, the charge nurse still managed to crack a joke.

Nurse: Seventeen I left off his diagnosis. Can anyone guess?

Nurses: COVID

Nurse: Yeah, COVID.

Stephen: The unit was dealing with the aftershocks of Thanksgiving. Utah having achieved notoriety of sorts as ranking one of the highest states for holiday road trips despite nationwide advisories not to travel. And there were still the weeks after Christmas and new year to come with their anticipated further peaks in new infections.

Veteran MICU charge nurse Cat Coe was particularly concerned about how young nurses new to the unit were coping with the onslaught of COVID patients.

Nurse Coe: I can't imagine coming in . . . I think the ones that I worry about the most are the ones who are either new grads or they're fresh from the floor. Like they worked on the floor for a year, and now they're just starting to work on MICU and they're like in their early 20s.

And I just can't imagine coming in to all of this with very little experience and trying to make sense of it all and like being under the impression that this is normal, because like that's what they're training in. They're training in this environment. I don't know. I like if it were me, I would have been real worried about myself.

Stephen: One young nurse was finishing her night shift that December morning. Post-shift May 2020 nursing school graduate Reagan Lowe, who had chosen the MICU to cut her teeth on, was struggling with an even bigger decision, her choice of career.

Nurse Lowe: Sometimes I get overwhelmed. I think part of being a new grad is being kind of scared to show up to work and kind of scared that you'll miss something. Thursdays, where I dread coming. And sometimes I would worry is this going to be my life? Did I choose a career where I'm going to dread every day? Is it going to be a job that I don't want to come to anymore?

And it's hard, especially because I love the people I work with and I hate like feeling that way. So in those moments, I do kind of worry that I'm regretting it, and then I remind myself of all of the opportunities that I have to learn and to grow and to develop skills and interpersonal skills. And I feel really lucky to be here even when it's a terrible day. Even when it sucks to show up, I feel really lucky that I'm able to because I know a lot of people would kill for an ICU job straight out of school.

Stephen: As a certified nursing assistant in the last year of nursing college, Lowe had worked at the MICU in a support capacity for nurses. The MICU nurse would typically care for two patients a shift and often get to know them quite well since MICU patients tended to be there for weeks, if not months.

Lowe on the other hand, as a CNA, might cover up to 8 to 12 patient rooms a shift. So preparing a deceased patient she didn't have a deep connection with or their trip to the morgue was something she had become used to. Being a nurse, however, brought a starkly different perspective.

Nurse Lowe: But as a nurse, you have such a different responsibility and level of interaction with the patients where it is much more involved.

So as a nurse, helping people with death and through death and their families, I wish we could have more family around those situations, but as a nurse, you're there giving them the medications to make them comfortable as they've pass or you're holding their hand as they pass. And it's your patient and you know everything about them. You've built a relationship with them on a deeper level than you typically do as an aide. You kind of help with the process of passing more. You're a lot more involved in the process of passing instead of the process after passing.

I just think I'm lucky to have been a CNA before I was a nurse. Otherwise, I feel like I would have been shell-shocked starting as a nurse and seeing so much death, but it's still hard.

And my friends will kind of ask me like, "Oh, have you seen a dead body?" I'm like, "I've seen dozens. I've touched more than 50 dead bodies. I don't even know how many I have helped clean up." People kind of are shocked by that, and like I work in an ICU at a level one trauma hospital, I see death.

Stephen: As a child, Lowe's parents shared with her the joys and the challenges of nursing. Her father began his career as a nurse before later going to medical school, becoming an anesthesiologist.

Nurse Lowe: He was initially a nurse and worked as a nurse while he was in med school, and I think I was born while he was still a nurse. And I think a lot of it too was my mom telling me, "Oh, your dad's helping the people. Your dad's like, maybe dad's not home, but it's because he's taking care of people so that they can go home to their families."

Stephen: Like so many of her colleagues, Lowe came to nursing out of a desire to help others.

Nurse Lowe: And I like healthcare. I like taking care of people. I like being able to help people. And then my senior year of high school, I got my CNA while I was doing classes and loved that. I loved it so much. Just like watching what the nurses did. I want to do that. I want to help people. I want to make a difference in people's lives.

And so it was kind of just like all these steps that just kind of fell into place that allowed me to do it, and like all the steps felt right and I liked it so here I am.

Stephen: She had to learn extremely fast how to negotiate that line between compassion and self-care that all nurses learn. Although only those who started from the spring of 2020 onwards did so under the increasingly unrelenting weight at the pandemic.

Nurse Lowe: It's kind of like this tight rope where you're trying to balance like on this one little spot of the perfect amount of compassion and the perfect amount of personal protection.

You teeter one side and you care too much and you're over-involved and you teeter the other side and you seem cold. You worry that your patient thinks you don't care. You have to try to figure out how do I make them comfortable and let them know that I'm here without it coming home with me every night and it's hard. Sorry, sorry.

Stephen: No, you're fine. Take your . . .

Nurse Lowe: I'm sorry. Just a little tired.

Stephen: It's just the most exhausting time . . .

Nurse Lowe: It is.

Stephen: . . . in your life, I would imagine.

Nurse Lowe: Mm-hmm. And especially being a new grad and it's already an overwhelming job and you're learning so much and just watching people suffer is something that's really hard for me, but it also motivates me to be a better nurse to minimize that suffering.

Because we get patients that like remind me of like my family or remind me of a friend I know or who are young and or who are disabled and don't understand what's happening or don't know what COVID even is. And you're trying to tell them to lay on their stomach so that they breathe better and it doesn't make any sense to them, but you're not supposed to identify with that.

And they teach us in nursing school that you're not supposed to really focus on those patients. You're not supposed to focus on that resemblance because it hits too close to home and it can cause issues and can muddy the waters of patient and nurse relationship.

Stephen: That doesn't get in the way though of the many small acts of compassion that a nurse like Lowe brings to her vocation. In the mid-evening hours of December 9, Lowe had cared for a young man with a developmental disability.

Nurse Lowe: I feel like the ones that are difficult are often very rewarding. Not that he was difficult to care for, it's difficult for me to understand exactly what he's going through. Such an easy and kind and patient patient. And just putting myself in his shoes and being like, what are the things that are probably going to scare him the most? How can I prepare him for the things that are going to scare him? How can I mitigate the fear? How can I make him comfortable? I ended up finding . . . he wanted to watch this cartoon. And luckily our burn unit had it because they have pediatric patients, so I got the movie for him and played it for him. And he likes "My Little Pony."

Music: My little pony, my little pony.

Nurse Lowe: So I found the movie for him, and I figured out in a different room how to play it just because I didn't want to just get it in there and not be able to play it because I felt like that would be so mean. And so I figured out how to play this movie for him and then just, even just like the little things. He just wanted a bite of a graham cracker, so he had a bite of a graham cracker and watched this cartoon and went to bed. And that's all he needed was just a little bit of handholding and a little bit of patience and somebody to figure out what would make him comfortable.

Stephen: This small gesture of concern brought the patient joy.

Nurse Lowe: It made him happy. The laugh he gave me when I set it up, he got so excited and he let out this little squeal. It makes it all worth it.

Stephen: So he has COVID. Is that right?

Nurse Lowe: He does.

Stephen: And kind where is he in sort of the spectrum of sort of the evolution of the disease?

Nurse Lowe: So he's on the high-flow nasal cannula. So it's kind of other than our BiPAP and CPAP kind of the last line before we would need to intubate him. And our provider was saying really just don't want to because that would be traumatizing for him physically and emotionally because he wouldn't understand what we were doing.

So he was just kind of on that edge where we need him to lay on his stomach so it'll help his oxygen, but if he doesn't tolerate it and he gets worse, he might need to be intubated and have a breathing tube.

But for some of these patients that can be a death sentence or they're just on it for so long that they don't really get better or they have permanent deficits. And so it's this fine line of how long do we wait before we do these interventions? Are they going to help long term, or are they just going to be a death sentence?

Stephen: Charge nurse Robby Thurman joined the MICU in 2013. As with Lowe, the medical ICU was his first full-time nursing position. Spend some time at the MICU and it's quickly apparent, Thurman is one of the gang exchanging repertoire with other nurses, always upbeat and optimistic and clearly passionate about where he works.

Nurse Thurman: I get to be intellectually challenged all the time. I'm always learning things. I always have the ability to go and learn new things every day, you know, for a long time, still try to, you know, make a note of like something they learned new, like that day.

There's so much to know, and I really enjoy being able to spend more time with my patients even though like they can't talk all the time. I still like enjoy being able to spend time with them, just care for them. Taking care of them and turning them and giving them their baths and the camaraderie like the family that we have as a staff is great.

I don't know how we've been able to do it. We have such a high turnover with staff. We've always had people leaving for school and other things, but I feel like the list of phenomenal nurses that I've worked with just keeps getting longer because everyone's leaving but we still keep getting these great nurses that come here and become part of our family and I don't know.

Stephen: But even his buoyant, lively personality and his love for his profession was facing increasing challenges from the grinding weight of the pandemic.

Nurse Thurman: I don't know. It doesn't feel like these are some of the harder things that I've had to do. I get my, you know, in my weekend and I'm, you know, physically drained, I'm mentally exhausted, and I just don't have any more emotions to give sometimes, you know, where it's trying to provide for these patients physically.

When families are there, it's great because I don't become responsible for almost like caring for them emotionally, you know, because they have their family members and their loved ones that they are there with. But I feel like a lot of times we as nurses get tasked with caring for patients emotionally now too where we become the ones that they can talk to.

And it's like I've held more people's hand dying than I've ever wanted to. I don't like being the person in the room when patients die. If their family's there, I can do it, but I've done it more times than I have ever even thought I would have to, you know, because nobody deserves to die alone.

Stephen: Caring for patients who are approaching death, especially when they are younger than you expect, can undermine even battle hardy veterans like nurse Megan Diehl. By early December, she felt angry and frustrated at the isolation her unit was experiencing.

Nurse Diehl: And I feel like the general public is sick of COVID. I mean, we're all sick of COVID. Everyone is. People want to get together with their families for Thanksgiving and for Christmas and all of this, but when it comes down to it, it's not gone yet and it's more of a threat now I feel than it was before.

And I don't know if I just hit a point where it changed for me, but I feel more stressed about my family and about people that I care about now getting COVID than I did six months ago, which is weird. I don't know why.

Stephen: The spiking case numbers, the pressure on the number of available beds for coronavirus patients, the lack of attention among some members of the public to protecting themselves and each other from contagion, it all added up for nurses struggling to cope with the surge in COVID-19 patients. And then sometimes just like for nurse Lowe, a patient's death will strike too close to home.

Nurse Lowe: I had a patient a couple of weeks ago that was younger than my parents and had no other health problems and, you know, he was overweight and that was it. And he was younger than my parents. And I think I don't know what happened, I don't know how it happened, but I looked at him and it was like, I looked at how sick he was. I'm like, I saw for the first time I think I saw like this could be my dad and I think that's kind of what broke me.

And I don't know why it took so long, but it was awful. I just remember thinking like this person's five years younger than my parents, less of a health history than my parents, and is here and is just so sick just from COVID.

Stephen: The patient who had so underscored for her the vulnerability of her mother and father unexpectedly died after she had completed a shift. When she returned to the unit, she learned of his demise. She reached out to her parents.

Nurse Lowe: I texted them the next morning and be like, yeah, that guy that I told you about, he died. I don't know if that's what triggered me into this like less sense of security and this like constant anxiety with my family, but it was really hard. It was really rough. And I think a lot of us have, you know, if not that patient, there's another one where you have an experience and it just like changes. It changes you.

Stephen: Part of the wearing, grinding nature of the pandemic for MICU nurses Coe explains was that they never got to see patients recover. When nurses and providers talk about saves, that's to some degree what they mean, namely, patients who they've managed to turn away from the brink of becoming another SARS-CoV-2 casualty.

As soon as attendings felt a patient was well enough, they were quickly moved off the unit to go to B-50 or elsewhere in the hospital to make space for new cases.

Nurse Coe: The saves are happening, they just, unfortunately, have been happening less on MICU and had been moving to B-50. Now that has changed just very recently, just in the last like 10 days. B-50 is operating as more of a super sick ICU patient unit. They are taking patients that have to be proned still.

And when a patient's being proned, they are still very tenuous. The outlook is very much in question if they're still getting proned. That might start to level the playing field a little bit as far as like if we can keep some of our successes on MICU. Unfortunately, I don't think . . . I think that we will still have to push those less acute patients out somewhere because MICU is the epicenter of all of this and the sickest patients probably need to be there so that they're closest to our doctors.

Stephen: Which begged a question, where do you find joy when there seemingly is none to be had? For Coe, it was on B-50.

Nurse Coe: An example of like an aha moment seeing a patient get better, that made me feel like, "Wow, I am doing something that's really good." Unfortunately, I'm just not seeing that on MICU enough. I had a patient who had been on MICU very sick for at least a month. She had finally made her way up to B-50.

She was trached. She was being fed through a feeding tube through her nose, and patients get trached typically after they've been intubated for a long time to kind of preserve their trachea somewhat, and it also gives them a chance to like start moving their mouth again. And anyway, her trache had been downsized several times, so we're kind of moving in the direction of the trache being removed completely.

And she was at the point where the trache was small enough that she could put what we call a speaking valve on it and use that to start to make words again. And we're talking for like the first time in like five or six weeks and start using her mouth to chew ice chips again.

Stephen: That may not sound like much, but for a COVID-19 patient who's starting down the road to recovery, chewing ice chips is huge. A speech therapist came in while Coe was at the patient's bedside to teach her how to use the speaking valve.

The patient called a much-loved relative and Coe got to listen into the call. While the relative was overwhelmed, the patient was too exhausted to muster any real signs of emotion.

Nurse Coe: She wasn't very emotional. She was just trying to make words but hearing that family member on the other end of the line and her reaction to hearing the patient's voice for the first time in over a month and like that indication that she was getting better was huge. And I think I really needed that as a nurse. Her family obviously really needed that, but I also really needed that to like kind of remind me that some of these people are getting better.

Stephen: As the year headed towards the Christmas festivities, the growing pressure on the unit came not only from the medical needs of the COVID-19 patients but also from the MICU's role as a place of last medical resort. Robby Thurman saw firsthand of exhaustion from COVID-19 care, then coupled with other MICU functions only added the cumulative stress and exhaustion of his colleagues, including physicians.

Nurse Thurman: And our poor doctor who was on overnight, he was on service that week, and so Sunday day he was up all day doing his job. And then, you know, sometimes, you know, most times when they're on at nights, they can, you know, do their thing, take a nap, wake up to phone calls. This poor guy never got to lay down. They took like seven rapid responses from the floor. So like the nurse feels like they're unsafe on the floor, but they're not coding it. So they still have a heartbeat, so breathing on their own, but there's like, oh no.

So they call rapid response. We took seven of those, and I think they had a couple other admissions from other places. And then, so he was up all night and then up all day. Like we're just having more of those experiences where it's like I don't know how much more we can do.

We had beds, but it's like how much staff. I think that's the thing is, you know, a bed's great when we can throw them, we fill them all up but we're all getting tired. We're all working. I'm used to working overtime. I'll pick up extra so my wife can stay home with the kids so she doesn't have to work outside the home.

So I'm used to the, you know, one or two extra shifts a month and we're all tired. And, you know, we're all going to keep doing it because it's like we're there to care for patients. But I feel like it's like we're all getting a little more, we're all just getting more tired as it goes on.

Stephen: Try as he might, as the winter nights drew in and the yuletide season beckoned, optimism is proving evermore elusive, but still in those moments when it was just him and a patient when he could provide that intimate gesture of concern, of love for his fellow man, he found some glimmer of hope.

Nurse Thurman: I think while it's been harder to be cautiously optimistic, like it's just those little things of, you know, even if it's for a little bit like getting people off their breathing tube so they can have a conversation with their family. We've had a lot of patients where they've just had to be reintubated, but they're having, you know, FaceTime calls at night with family or just spending time in a patient's room, combing out their hair and braiding it. It's those little things that I get to do. I have the privilege of doing.

Mitch: Next time on Unit on the Brink we return to that shift change in the medical ICU in December. We witness what happens when a giant wave of cases finally begins to receive, leaving casualties in its wake. Meanwhile, news of widespread vaccine rollouts begin to show a glimmer of hope that one day the unit may return to normal, whatever normal looks like now.

Female 2: Like they say, we're getting a vaccine, but that's so far away. 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.

Mitch: Join us next time for Episode 8, "Trial by Fire." And if you'd like to see images from our visit to the MICU from the extremely talented photographer, Bryan Jones, take a look in the show notes for a link to the "Keep Breathing" multimedia story written 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. 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 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. Feel free to share at our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or email us at hello@thescoperadio.com.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music in this episode by Vortex, the David Roy Collective, Ian Post, ANBR, Rousseau Music, and Tristan Barton. Audio news clips from CNBC.

And of course our 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.

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