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So we've been dealing with COVID for a while now, and we are seeing kids who have what we call long-hauler symptoms. So what are these and is there anything that can be done?

In general, kids do pretty okay with COVID. Some have mild symptoms, some get pretty sick but recover after a week or two, and some kids have no symptoms at all. But more and more what I'm seeing are kids whose parents are saying, "I didn't know it would be this bad," or, "Why are they still having symptoms?"

Unfortunately, no one can predict who will develop long-haul COVID symptoms. There is a study out of England that shows that up to 15% of kids up to age 16 will still have symptoms five weeks after they initially test positive for COVID.

Long-haul symptoms can happen in kids who have minimal or no symptoms or in kids that have severe symptoms. That's the tricky thing with COVID. It doesn't follow any rules and it seems to do whatever it pleases on its own time frame.

So what are the symptoms of long-haul COVID? The most common are fatigue, brain fog or difficulty concentrating, breathing issues, chest, joint, or muscle pain, chronic cough, and headache. We also see changes in the sense of taste or smell, mood changes, or lightheadedness when standing up.

I know. It seems like anything can be a symptom of long-haul COVID. And not all of those symptoms can be attributed to having had COVID in the past.

How is long-haul COVID diagnosed? Well, that's tricky too. There are no specific tests that can be done. Your pediatrician can rule out other conditions and will usually refer your child to a specialist if their symptoms persist. But there are no good tests.

We have no idea how long it will last, we don't know what causes it, and we don't know what the treatment will be other than supportive care and treating your child's symptoms as best as possible. But there is no cure.

As we continue to move forward with COVID, hopefully we will have more answers as to how to help long-hauler symptoms. Until then, treating your child's symptoms and getting them set up with specialists to help with their specific medical needs is the best we can do.

There have been concerns by some parents that they don't want their kids wearing masks because they believe their child will be inhaling their own carbon dioxide with prolonged mask wearing and that will cause oxygen deprivation. Some say that children will inhale up to six times the safe limit of carbon dioxide.

Let me help clear the air on this one. It's not true. Here's the science behind the truth. Carbon dioxide poisoning or hypercapnia from re-breathing the air we normally breathe out doesn't happen because carbon dioxide molecules are extremely small, even smaller than the respiratory droplets, which is what we are protecting against when we wear the masks. They cannot be trapped by cloth or medical masks or any sort of breathable fabric. Those tiny molecules just pass right through the material.

Surgeons, nurses, respiratory therapists, all of us in the medical profession, in fact, wear our masks for hours and hours during the day. Studies done by having surgeons wear oxygen monitors during their entire time in the operating rooms show that masks have no effect on the amount of oxygen they have in their bodies.

If your child is wearing their mask properly, covering their mouth and their nose and fitting snugly over their face with the ear loops or ties, then your child will be protected from the respiratory droplets we don't want going through the breathable fabric, but still letting them breathe in oxygen and exhale carbon dioxide through their masks.

The bottom line is masks work. Last year during what is usually a very busy winter season, I hardly saw any sick kids. Now we are seeing RSV and rhinovirus and all sorts of other winter viruses because people have loosened up on mask wearing and viruses are taking advantage of that. Hospitals are full with kids who are having respiratory virus complications. I've had parents of children with asthma tell me that since their kids wore masks, the last school year, they didn't get sick and didn't have any asthma flare-ups. We can do this.

The kids I've spoken to have no problem wearing their masks. They like to coordinate their masks with their outfits and get cool ones with princesses and superheroes on them. I tell them they actually are little heroes. They tell me they have no problem wearing masks all day at school either. My own kids even say that they're so used to their masks, they don't even think about them anymore. And they're in junior high and high school. So mask up. And if you have any other concerns about COVID and COVID precautions, be sure to talk to your child's pediatrician.

A lot of parents of younger children are now asking themselves a big question. I'm vaccinated against COVID, but my kids are too young for the vaccine. Can I let them play with their friends again? Do they have to wear a mask?

Kids have usually seemed to fare better with COVID than adults. But we know this isn't always the case. There are those kids who get COVID and then are affected by MIS-C, the multi-inflammatory system complication that will land a child in the intensive care unit. That is seriously scary. And that's why so many of us pediatricians worry about kids around COVID.

Another big concern has been that younger children would bring the virus home to vulnerable adult family members, and those would be the ones who would become significantly ill. So now that many places are not requiring masks anymore and places are opening up, it puts many parents in a situation where they're not sure what to do with younger kids. These kids have missed a whole year or more of socialization with friends and are really wanting to get back to playing.

The current recommendations are that if a person is not vaccinated, they should continue to wear a mask. That said, if your child is playing outside with friends that you trust and who have also been following precautions, it may be okay to let the kids play outside without masks on. There is evidence that kids who play outdoors have a low risk of being infected. There are also a lot of summer camps now, where masks are still being required. But they offer a lot of fun activities for kids who are too young to be vaccinated.

Adolescents ages 12 and up can be vaccinated now. My kids are both fully vaccinated now, and it was their choice, especially knowing that next year there will be no masks in junior high or high school in our area. They asked a lot of good questions about the vaccine and understood the science behind the vaccine. They both said it was such a relief to know that they are now protected. Vaccine trials are now underway for kids older than six months old at the time I'm recording this. The current projections are that kids ages 5 to 11 may be able to be vaccinated as early as September. And kids ages six months to four years may be able to be vaccinated by next spring.

The more people around your child who are vaccinated, the safer they will be. The bottom line is this is a choice your family needs to make. Are others in your family at high risk? Do you know who your kids are playing with? Are they outside? Is anyone sick? Or has anyone been exposed to COVID within days of the playdate? There is hope in sight for the youngest population, and science is working as fast as possible to get everything back to normal as quickly as we can.

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 9 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 the frontline workers in our story, as the number of COVID patients continued to grow throughout the winter, there were moments where the end of the pandemic seems so very far away. If our visit to the unit on December 10th was any indication, the presence of SARS-CoV-2 had settled into the unit, establishing a new normal that tested the resilience of everyone in the unit.

The extensive safety protocols that had seemed so novel months prior had become second nature. That daily repetition of safety briefings with the rote recitation of COVID diagnosis after COVID diagnosis, the whoosh of PAPR is becoming the background noise of every patient interaction. The threat of infection becoming a gnawing thought in the back of the mind, but much quieter than it had been back in March. Day in, day out. COVID.

Hope it seemed was becoming hard to come by, but on the morning of December 15th, in a large exam room at the university hospital, things began to change. At 11:32 a.m., Utah's very first dose of Pfizer's COVID-19 vaccine was given to MICU charge nurse Christy Mulder. For those in the room, they describe an electric moment of excitement that seemed to jump from person to person as the needle pierced her arm, and a small round of applause broke out among the few people gathered there.

From the footage and photos of the event, you can see smiles break out on the face of everyone there, even if those smiles were covered by masks. Finally, a glimmer of hope, of protection, of an end to all of this. On this episode, we tell the story of one Christy Mulder, the woman who was the recipient of the very first dose of vaccine in the state of Utah. Her story is a reminder of the need for resources and a support system that every nurse, provider, and family member so needed to draw on in the face of the onslaught of cases.

And how faith, no matter what forms it takes, whether religious or simply the comfort to be found in Utah's landscapes, can provide a source of guidance even in the darkest of times. Hosted by Clinical, and written and reported by Stephen Dark, this is Episode 9 of "Unit On The Brink," "Keeping The Faith."

Stephen: When Christy Mulder graduated from nursing college, she knew she wanted to work in an ICU, having fallen in love with the fast-paced frontline work while a critical care intern at the Huntsman Cancer Institute. She applied to work at the Medical ICU in University Hospital, only need to be asked a question in her initial interview that would come back to haunt her.

Christy: And I remember in my interview, MICU, I remember being asked the question, "How do you cope with pain and suffering? Because you are going to see a lot of death and it's not going to be an easy place to work. So how are you going to cope with that?" And I was 21 when I graduated nursing school, I had no idea. I mean, I didn't even know anything about life, let alone death and pain and suffering.

Stephen: The MICU hired Mulder, and after a break to clear her head hiking with her father and then doing some global health work in Nepal, she started at the fourth floor Medical ICU. Like all newbies, Mulder found her first year on the unit a daunting daily visit, the fire hose that left her beyond exhausted.

Christy: You're running around just trying to keep people alive. And then I think after the first year, it kind of settles in and you're able to process a little bit more.

Stephen: A sense of where she was working became ever clearer that second year.

Christy: Just because, once everything settles in, you can actually open your eyes and process the death and suffering that surrounds you.

Stephen: And with the advent of the COVID 19 pandemic, that pointed, direct question from her interview would gain ever greater urgency and poignancy. It would force her, as it has done all who work there, to draw on resources, on personal strengths she might otherwise never have planned. And in Mulder case, it led her to draw on her spirituality.

To understand Mulder's journey, both as an ICU charge nurse and a person of faith, you have to go back to the roots of where she grew up. Mulder's parents came over from Vietnam. They were refugees, but not in the common sense of urgency you might associate with the boat people. They came years after. First her father, later her mother.

Christy: I mean, in one sense, yes, they came as refugees. My uncle came as a refugee right after the Vietnam War in the '70s, but my parents didn't come until '90s.

Stephen: Not that it wasn't for the want of trying.

Christy: My mom would tell me these amazing stories of when she was a young girl and trying to escape and get out of there. She would sneak out with her friends in the middle of the night and buy her way onto a boat to like leave. And she was unsuccessful. But no, I guess they didn't officially come as refugees, but in a sense, yes, because Vietnam was a terrible place to live when they were there.

Stephen: She grew up in Salt Lake Valley.

Christy: So I was raised in Vietnamese home, Vietnamese culture, which means, my parents were not really . . . they were kind of nominal Buddhists. So my dad grew up Catholic. My mom grew up Buddhist. And I guess a nominal Buddhist would look like a lot of ancestor worship, but just around a certain time of year.

Stephen: According to Mulder, her experience with Vietnamese culture isn't necessarily one that prioritizes warmth and human touch.

Christy: You don't touch each other. You don't . . . My mom tells me she loves me once a year on my birthday. Do I doubt that she loves me? Absolutely not, but that's just like we just don't. Vietnamese people don't share their emotions in any capacity. And it's very much like you just deal with it, you move on.

Stephen: Growing up in Utah, she struggled with the demands of the local culture and her place in it.

Christy: And I'm so ashamed and embarrassed to say this, but I think growing up here, I always wanted to be white. Like all my friends are white. Everybody I know is white. Why am I not white? I don't get it. Why is my family different? Why do I speak a different language? I mean, I didn't learn English until I went to school.

Stephen: At preschool, she confronted the unyieldingly pervasive nature of English beyond the walls of her home.

Christy: I have these like very short vivid memories of speaking Vietnamese to my teachers and had no idea what I was saying obviously. And I remember being so discouraged by that and just feeling like, wow, I feel really out of place here.

Stephen: As she grew older, so she started to carve out a sense of herself in the English language.

Christy: But then, you know, you adapt as most young kids do. I learned English very quickly. I learned cultural social skills very quickly, and then it became less of a problem. And now, I mean, I love that I grew up in a home that is very culturally Vietnamese. And then in a place in a city where it's also very culturally Utah, I don't know, American culture and Vietnamese culture mixed together and I love that. I love that I get to have both of that.

Stephen: As much as she came to know, through her social circles, a sense of Utah's unique religious culture, she nevertheless found far more questions than answers.

Christy: But of course, like growing up in Utah, I was very much exposed to the LDS culture. And so a lot of my friends were Mormon, and I grew up going to all the youth activities with them and hanging out with them. And I really wanted to be Mormon, because I wanted to fit in with that. But I think as I entered into young adult college, I started to question a lot of things and felt like I'm not quite sure I understand this. I just had lots of questions. I was pretty open to all sorts of worldviews and interested in different worldviews.

Stephen: In college, she met a friend who was Christian.

Christy: The biggest thing that stood out to me about her was she had a deep friendship with God that seemed very genuine and very personable. And that was very foreign to me because I was like, whoa. I think in my head, God was always like somebody who was far off, like watching you and telling you to do these things. And then you do these things and then you like earn your way. But this friend, she just, she was very clear that, you know, this is my relationship with God. I don't have to earn my way before him. He loves me just as I am.

Stephen: That friendship was also composed of many conversations about the possibilities of faith.

Christy: I think ultimately I really came to believe that I have nothing to offer God and yet He still loves me and cares for me and desires to know me. And I think that's been freeing, you know, not to have like this expectation to be a certain way or live a certain way or whatever. And He doesn't see us as these people who need to be perfect. It's like if you are broken and if you are needy, like even more so does He want to draw closer to you.

Stephen: It was that understanding, that coming to terms with the messy complexities of life that, in some sense, helped her confront the challenges of caring for COVID-19 ravaged patients. And for her then colleague charge nurse Cat Coe, Mulder's strength in the face of the virus' onslaught, helped her face those same difficulties.

Cat: She definitely turns to her faith consistently to help sort of make sense of and cope with everything that we see. And she . . . I would not consider myself religious, but I do find that talking to her about these things, whether she brings religion into it or not is very helpful.

Stephen: Something in the strength that helps anchor Mulder through the pandemic also helps deepen the bond between the two friends.

Christy: One thing that Cat and I have really grown in our friendship together is to be able to look at the situation we're in and realize like this is hard stuff that we're seeing. We're seeing people die, we're seeing people suffer, and we don't have to put this perfect bubble wrap over it and say that everything is fine because it's not. And that's okay to just take that as it is.

Stephen: Friendship is what nursing is all about, says the MICU's nursing manager, Naydean Reed.

Naydean: That's one of the things that I've noticed, like especially with critical care, but in all nursing, I think. You go through these extremely traumatic events and, you know, the traumas happening to other people, but you you're there witnessing it. You're living through it. You're trying to save their lives. And I think when you go through something like that with somebody, there's an intimacy that forms between you and your coworkers that I can't . . . I mean, I can't even explain it other than to say it's an intimacy and a bond.

Stephen: Nursing creates bonds of strength, of love the last decades, even a lifetime says, Reed.

Naydean: And I have people that I worked with, I don't know, close to 30 years ago that they call me up randomly and say, "Hey, I need this." And you would drop everything and go do it for them, because there's just like this bond that you can't even, I don't know. I can't even explain it, but it is. It's an intimacy that you have with your coworkers when you're trying to save someone's life.

And like these nurses that have been through this for this last year, I definitely see that with them. And I would see it when they would come to my office and just like almost in tears because they're so worried about their coworkers and, you know, "Hey, I talked to this person last night. I don't know if they're going to be okay. Will you please check on them?" And you would see that before, but they just care so deeply for each other now. It's they've been through so much trauma together.

Stephen: Each person reacts to patients suffering in their own way.

Christy: I think a lot of nurses it's easier for them to just not feel that pain. Like we all cope differently. We all respond so differently to these situations. And for some, it's just numbing themselves. They go to work, they do their thing, they leave, they cut it off. And however you cope, that that's how you're going to cope. And I think, over time, I've seen nurses, healthcare workers who are just jaded. And I think if you're jaded, you shouldn't be in the ICU. And that might be a way of coping, but I don't think it's a healthy one.

Stephen: By her second year at the MICU, Mulder's uneasy relationship with the pain and suffering around her was one she managed to push largely to one side.

Christy: I think for a long time I didn't know how to process it. And it was easier to not. It was easier to just not think about it, to just go home from work and just move on with your life.

Stephen: But towards the end of her second year, a really bad flu season hit.

Man: Coughing, sneezing, body aches, and fever are impacting a lot of people in Utah right now.

Man 2: In this country, the flu has reached epidemic proportions. The CDC reported today that the virus is now widespread across the entire continental United States. Twenty children have died. Just over 100 died last flu season.

Man 3: The Utah Department of Health is now saying influenza is on the rise. More than 400 Utahans had been hospitalized because of the flu. Most of them older than 65.

Stephen: A confrontation with death proved unavoidable.

Christy: It felt like every shift I worked there was somebody who died. And that's when it really hit me hard, and I remember like just feeling so low and not really like being able to like process through it very well.

Stephen: At her Salt Lake City church, one Sunday in February 2018, during this deeply troubling time, it seemed as if her pastor was in some way speaking directly to her from a passage from the Book of John.

Christy: It was a sermon on death and suffering essentially, which was everything I was going through in the MICU. And the sermon helped me process through a lot.

Stephen: Mulder found in just two words an answer to her struggles.

Christy: I just remember it so distinctly, a sermon about how Lazarus dies and Jesus feels that weight and that suffering and that pain. And I think, and then he cries. It's like Jesus wept. I think that's the shortest verse in the Bible or something. I don't know. But Jesus wept, and I think that to me, it was like, oh, wow, okay. Yeah. This was not like . . . this is meant to be painful. This is meant to be heavy. We are supposed to cry. We're supposed to be broken over death because it's a painful thing.

Stephen: Two years later, in the early spring of 2020, as COVID-19 hit hard and held onto the lives of MICU staff with ever-growing tenacity, that lesson came back to her.

Christy: And so I think that has played in my head through COVID a lot because I had a feeling, when COVID hit, that I would feel that same kind of heaviness that I felt two years ago. It's different, but I think a similar idea of needing to hold on to this hope.

Stephen: Many of Mulder's colleagues reached out to therapy or embraced nature for support, says Reed.

Naydean: They got really tired. And I think some of them looked to each other a lot, I think. They organized different exercise groups outside of work. They would go on hikes. One of our nurses, Jared, was fantastic with trying to get people together. He'd have them out in his backyard and they'd have cookouts. And he did a really good job. I think they looked to each other.

Stephen: Reed relied on audiobooks to escape into her own little world. But as summer came with it rising rates of infections, she too struggled.

Naydean: But you, my son, Ruben, who you met in the beginning when I'd come home and I'd like to take my shoes off, my husband would bring me a glass of wine. I'd go out on the back porch. I wash down all my stuff, and I would just sit out there and I would just like cry.

And when my son came home from Costa Rica, I overheard Ruben talking to him and he's like, you know, "Mom's different, right?" He's like, "Well, what do you mean?" He's like, "Well, she just comes home from work, and she sits on the patio. And she drinks a glass of wine, and she cries for a little while, and then she comes in and has dinner."

Stephen: And then the virus hit home to her in a way she never would have expected.

Naydean: I had a really close friend take his life in February. And he was at an ER physician, and COVID was just too much for him and he just couldn't do it anymore. And then when that happened, that kind of put me over the edge.

Stephen: One thing was COVID-19's devastating impact on her unit's patients. Another learning that the horrors of the pandemic had cost the life of someone she loved.

Naydean: Yeah, it was just so personal and so close and somebody that I loved and admired so much. And I mean, I think it just brings home that, you know, even though so many people are dying of COVID, there are also have been so many suicides over this last year.

And, you know, I know of the two that affected me personally, but I just think there's a lot. So much mental health, and, you know, it's just, I don't know, just all the isolation and everything. It's been hard to watch.

Stephen: In an article on the website, Kevin MD, a palliative care doctor described the deeply erosive feeling of powerlessness that came from watching his patients die from the virus. The provider wrote, "We are morally injured and unable to reconcile what we have experienced with who we are as healers." Through the suicide of her friend and all that her nurses and she have gone through, Reed understands these words all too well.

Naydean: It's just hard to watch that time and time and time again. And I think that that helplessness of not being able to stop this disease, not being able to do anything for these patients, and just watching so many of them just die in front of you. And I liked how he articulated in the article that like these are good people.

Stephen: That phrase, "moral injury," sounded the depths of the despair that the virus has driven so many to.

Naydean: It makes you question, why you're . . . why am I doing this? Why do I keep coming day after day when I . . . am I even making a difference?

Stephen: Mulder saw her colleagues struggling with those same questions.

Christy: Truthfully, it's just, that has been, I think, more than the death and the pain and the loneliness. The hardest thing for me about all of this is seeing people that I love, like Cat, just go through a really hard time. And it's sweet because we get to go through this hard time together, but that's been a bigger weight for me.

And so I think to see friends feel very depressed and very at their wit's end, that's been the hardest and the best part about all of this, because it's provided for a deep opportunity to grow our friendship and care for each other and love each other well during a hard season.

Stephen: She is more than aware that faith isn't for everyone and that others have different ways in the face of the pandemic of coping, of fortifying themselves, or blocking out what they've been through.

Christy: Some people are going home and numbing themselves with alcohol or TV or video games or whatever they're numbing themselves with. Other people are numbing themselves with, you know, staying busy, whatever that looks like for them outdoors. I think, you know, obviously, the outdoors are amazing. They're beautiful, especially here in Utah.

Stephen: It was in the outdoors that Reed found a measure of comfort after losing her friend.

Naydean: I think there are a lot that rely on nature and getting outdoors. A lot of the staff on their days off, they're down in the desert, they're out in the mountains, and that is their spirituality. That is their escape. I was finally able to get out to the desert about two or three weeks ago. I just went overnight by myself, sat in the dirt, and went for hikes and it's just like so healing.

I mean, I think if I had anything, that would be the closest thing to my religion. And I know, Eli, one of our nurses, he goes every single day off he's down there in the desert. Sam, same thing. He's out doing things. Kirk and Jared and a lot of the nurses climb.

So I think, you know, Christy has her spirituality and I think that for a lot of these nurses, that is their spirituality. However you say it. That's where they go to find their refuge and where they refill their buckets and make it so that they can come back and do it again.

Stephen: Reed drove the two and a half hours to the wedge overlook in Emery County, Utah. She pitched her tent along the ridge of what's called the Little Grand Canyon, a timeless red rock canyon formed by millions of years of erosion by the San Rafael River.

Naydean: Yeah. I just went and went for a hike and built a campfire and listened to my book and drank some whiskey and went to bed and got up the next morning and went for a nice long hike. It was really, really nice. It was very peaceful just to get out there by myself and think.

Stephen: By the end of 2020, as the attrition rate in staff departures at the unit continued to climb, even Mulder started to think about leaving.

Christy: I'm part-time. So instead of working three days a week, I work two days a week. And I think that makes a huge difference. I'm just not there as much.

Yeah. I think when I have friends that a lot of my dear friends have left. Cat resigned recently and she put in her two weeks. So when people you love and respect and care for are starting to be done, naturally you're going to question the same thing.

Stephen: On the days when she felt too exhausted to keep going, her Wisconsin-born husband supported her through prayer.

Christy: He prays for me every morning before I go to work. Sometimes I don't even have the energy or desire to pray. Just like, I'm just like, okay, here we go.

I'm so wrapped up in this like mountain I have to climb up the workday. It's good to have somebody like my husband, who is just like, hey, before you walk out the door, like God help Christy to be a good nurse today. That's all he says. And that's like enough to just remind me that, you know, I desire to be a nurse that's honoring before God with integrity and do what I do with intentionality instead of just this thing that I do.

Stephen: Mid-December, 2020, Reed asked Mulder if she was interested in being the first person in the MICU to receive a dose of the Pfizer vaccine.

Heidi: Light at the end of what has been a very dark tunnel. That's how Utah frontline workers are describing the rollout of the Pfizer vaccine today. Ginna Roe kicks off our team coverage this evening. Ginna.

Ginna: Yeah, Heidi in the last half hour, I actually heard from U of U Health, and they tell me they have vaccinated 80 healthcare workers so far today, and they are still vaccinating right now. Now, that some of these healthcare workers held back tears today. They said they're emotional. They're proud to be getting this vaccine out and to be getting this message out to Utah public.

Christy: It feels like a weight lifted off.

Ginna: Christy Mulder, the first Utahans receive the Pfizer vaccine says she's overwhelmed by what this means.

Christy: As healthcare workers, on one hand, it's, it's an honor to be able to care for our community during this time.

Ginna: For the frontline workers who have been at the heart of this battle today is the beginning to an end.

Stephen: After nine months of the pandemic, the dramatic arrival of the vaccine proved a game-changer for the MICU staff.

Christy: I think the vaccine coming has been a huge morale booster for our unit, a huge ray of hope, and a next step for all of us. Just a pretty clear vision of, okay, this going to end at some point. We're making huge progress towards that, so I think it's been really encouraging for everyone on the unit to have the vaccine.

Stephen: It brought her a measure of fleeting fame. Interviews with media, local and national, and also a curious Utahan honor being drawn by The Salt Lake Tribune's legendary cartoonist, Pat Bagley.

Christy: Honestly, I didn't even know who Pat Bagley was. And then Hatton was like he is very famous. I was like, oh, cool. Like, that's awesome. That's really exciting, but I didn't know who he was before.

Stephen: She didn't feel anything with the first shot, something she attributes to the excitement.

Christy: Lots of cameras. I just like, I think there were more cameras on my second dose. Lots of people like constant photos, several news stations, videos, like it was a pretty big deal. Lots of cameras at the first one too.

As far as getting the vaccine itself, no pain. Like I didn't even feel the needle. I think it was all the adrenaline. I didn't feel the needle at all. Now that we're 25 hours out, like I have a headache. I feel very tired and just achy.

Stephen: That Mulder was first in line didn't come as a surprise to her friend, Cat Coe.

Cat: Christy is universally well-liked on the unit. She is a charge nurse. She's been there for, I don't know, maybe four and a half years, and she has been a huge reason why I have stayed in that job. She's wonderful.

Stephen: Despite the glimmer of hope the vaccine represented, Mulder didn't want to simply rush away from what's happened.

Christy: I think it's still going to be a long road and a lot of recovery from, you know, even if we are on the downhill. I do think that is still important to keep processing. Not like be in a hurry, to blow past everything, you know, but actually take time to process.

That's what I've been really like talking to Cat a lot about was like, hey, you're not at MICU anymore. Like I need like take time to process because you're coming down from heavy, heavy stuff. So don't just blow past it and move on to your next job. Like actually take time to think and reflect on the last year of life and really just your time on MICU as a whole.

Stephen: On May 6th, Mulder completed her last day at the MICU. The following day, she graduated as a family nurse practitioner before heading to Alaska with her husband to go backpacking, along with taking time to simply rest and reflect.

Cat Coe was never far from her thoughts. In part, because she was a reminder of how important processing the past year they spent together really was.

Christy: And I've appreciated my friendship with Cat and a few others in that way of just like being able to confront it and face it. And it's not easy, but I think that's better than, you know, looking forward to something else constantly that you're never really processing what you're going through right now. Or hiding it so deep down and covering it up with so many whatever various coping mechanisms, jokes, laugh, being jadedness. It's just like, I don't think that's as helpful long-term for the PTSD that we may be feeling.

Stephen: Mulder and Cat Coe are bound together by more than simply nursing during a pandemic.

Christy: I mean, Cat has said that to me several times, like, man, I feel like I have this wartime camaraderie with you. And I guess I didn't think about it that way until she said it, but I was like, yeah, that's true.

Stephen: Even though many have left, it's the experience of providing care during the coronavirus pandemic that binds these men and women to each other in a way that few say veterans of wartime conflict can truly understand.

Christy: We have gone through things. I mean, as nurses, we experience things together that normal people don't experience together with their coworkers and colleagues. So there's this pretty . . . just COVID aside, I think there's a pretty profound relationship that nurses can have through their job together. And I love being a nurse and I'm so thankful that I get to be a nurse during COVID, even if it has been really hard. I think it's an honor.

Mitch: 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'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.

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, message for us or someone in our story? Feel free to share it 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 Annie Zhao, "Beneath The Mountain," The Church of Jesus Christ of Latter-day Saints, Ian Post, ANBR, and Yehezkel Raz. News clips provided by FOX13 and KUTV.

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.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people to learn about skincare. I'm Michelle Tarbox. I'm a dermatologist in beautiful sunny Lubbock, Texas. And I'm being joined by . . .

Dr. Johnson: I'm Luke Johnson, dermatologist at the University of Utah in Salt Lake City, Utah.

Dr. Tarbox: So we're making this podcast to help educate people about how to take the very best care of their skin, and we plan to release an episode every two weeks. On this podcast, we will mention specific skincare products that we have found in our medical opinion to be very helpful and beneficial to our patients. We are not sponsored in any way or supported by any of the manufacturers of these products.

Dr. Johnson: Nope, but we are medical doctors.

Dr. Tarbox: I like it. Dermatologists are medical doctors who specialize in the care of the skin and of the hair and the nails. We're going to talk about skincare in the COVID era. So, Luke, what do you think is the most important aspect of skincare in this very unusual time we're all living through?

Dr. Johnson: Well, everybody is washing their hands a lot more because of the Coronavirus, which I think is a good idea. But a lot of people have noticed that their poor hands just get so dry and chapped afterwards. We say they have irritant contact dermatitis. Dermatitis, inflammation of the skin, because of contact with an irritant, in this case water. And it's helpful to know what to do if your poor hands get all dry and chapped.

Dr. Tarbox: And that definitely can happen in this day and age when we're all having to clean our hands very frequently. I think now more than ever it's really important to have a good skin care regimen that helps protect the integrity or the intactness of your skin, because our skin is important. It helps to protect us from the world, from bacteria, and viruses, and chemicals, and so we need to take the very best care of it. So what's your favorite moisturizer, Luke?

Dr. Johnson: Well, I love just plain old petroleum jelly. The brand name is Vaseline, but you can buy just the generic brand petroleum jelly. It's great for so many reasons. I have written a small love letter to Vaseline. It doesn't rhyme or anything. But first of all, it's super cheap, especially if you buy the generic version. You can get a big tub of it for about $3. It does a great job moisturizing the skin. So, in dermatology, we talk about transepidermal water loss, the water loss through the skin, and petroleum jelly prevents 99% of it. Also, nobody gets allergic to petroleum jelly. Love it.

Dr. Tarbox: It's easy to find, most people have access to it, and it works very well. Now, I know some people aren't always comfortable using petroleum jelly for various reasons. So, if you're one of those people, and we just can't convince you with our passionate love of Vaseline, we can . . .

Dr. Johnson: It's great.

Dr. Tarbox: It is fantastic. But we can recommend some other things as well. For some patients who don't want to use Vaseline or petroleum jelly, the nut butters may be beneficial. So shea butter can be helpful. Some of my patients have liked a product called Waxelene, which is actually derived from beeswax and is sort of a crunchy granola replacement for Vaseline or petroleum jelly. But the important thing is just to use it regularly.

Dr. Johnson: Waxelene?

Dr. Tarbox: Waxelene. I know. That's what it's called. You can find that usually in health food stores or Whole Foods markets.

Dr. Johnson: What I tell my patients often is that I know Vaseline is not for everybody. It's kind of messy and greasy. So, if you don't like it, use something you like. So just find the thickest, greasiest thing that you kind of like putting on your skin. In general, things that you have to scoop out of a jar are going to be more effective than things that squirt out of a bottle.

Dr. Tarbox: I kind of love that analogy, and that's definitely true. So you want your lotion that you're going to use to moisturize your hands in this unusual time to be more like icing and less like chocolate syrup. So when we are talking about moisturizers, if you're wanting to use something that's more of a cream, there are several over-the-counter products that I think Luke and I can agree on are very helpful to the skin and are very minimally irritating, so they don't have any excess fragrances or harsh preservatives.

Dr. Johnson: Well, if people don't buy into Vaseline, I usually don't have anything specific in mind. But the point of all this is not just to make your hands feel better, though it will. But there is a little bit of concern amongst some dermatologists that if you've developed little cracks in your skin, that could actually be a portal of entry for the Coronavirus. So the Coronavirus likes to attach to certain proteins in order to get into cells and those proteins might be present in those cracks in your hand. We call those fissures. So helping them to heal up is important, and these moisturizers will help that happen.

Dr. Tarbox: Absolutely. Now, a lot of people are using hand soap to wash their hands. Your choice of soap is also very important. Some soaps are going to really strip the natural oils from the skin, and others may be irritating because of fragrance or chemical content. So using a soap that's designed to be gentle is a good choice. What's your favorite?

Dr. Johnson: Well, as far as I can tell, the party line among dermatologists across the world is white Dove bar soap. Everyone seems to really like it.

Dr. Tarbox: I like that one. I also like . . . Vanicream makes a bar soap as well that's very hypoallergenic. Another good product is CeraVe Hydrating Cleanser. This is a cleanser that won't foam. It doesn't have the ingredient that makes soaps foam, which is usually something called sodium lauryl sulfate, which can be a little bit more dehydrating to the skin. But you don't actually need the foam to cleanse. It's just something we associate with cleanliness. So that's a great product as well and it's very gentle.

Dr. Johnson: Though I'll admit at my home I use just random generic liquid soap because my hands don't seem all that sensitive, but I do put moisturizer on them afterward.

Dr. Tarbox: It's a good idea. There's also, of course, hand sanitizer that people are using. And remember that it has to have a certain percentage of alcohol in it for it to be effective against the Coronavirus. Now, alcohol is naturally dehydrating. That's one of the ways that it actually works against enveloped viruses like the coronavirus. But that same property where it can be dehydrating can make it a little bit hard on your skin.

Dr. Johnson: And of course, in general in terms of the Coronavirus, as you'll hear everywhere, if you can avoid touching your face, that's great. In dermatology, we learned that people just touch their faces all the time for no good reason. In fact, I think I touched mine over the past two minutes like five times. So just bear in mind that there could be dirt or other nasty things on your hands that you don't want to put on your face.

Dr. Tarbox: Yeah, I think that it's something that we all have to kind of monitor our subconscious activities with and really try to pay attention to that behavior and stop it before it potentially transmits a virus we really don't want to deal with.

Dr. Johnson: Well, we mentioned moisturizers in general earlier, but this is a special spot where my favorite Vaseline really outperforms. So something nice and greasy will help it heal. Wounds heal best when they're kept moist and greasy. So I've talked to a number of patients who have said, "Won't my wound heal better if I leave it to dry?" And it's interesting because the medical community used to feel that that was the case. But something like 20 years ago, we realized it's not. If it's moist, then the new skin cells can crawl across the surface more easily. So, if you remember hearing, "You should leave your wounds dry for them to heal," that's outdated knowledge. Now, keep them greasy with Vaseline.

Dr. Tarbox: I like to think of it like trying to regrow a dead patch in a yard. So, if you think about where you've got your grass and you want it to grow back over a place where the grass has been lost for some reason or another, is it going to grow better if you have a nice moist soil that's easy for the grass to grow back through? Or is it going to grow best if you have hard, dry dirt?

Dr. Johnson: I do not have a green thumb, but I'm guessing the moist one.

Dr. Tarbox: Exactly. So I think that that's a very important thing now.

Dr. Johnson: Just don't wear a mask.

Dr. Tarbox: Ah, ba-dum.

Dr. Johnson: No, a joke. I mean, I guess if you can avoid wearing a mask because you are staying at home or whatever, that's fine. But masks are pretty important to prevent the spread of the Coronavirus, so they're a necessary evil. Avoiding other stuff that's on your face under the mask, specifically makeup. So I admit I don't wear a lot of makeup.

Dr. Tarbox: What?

Dr. Johnson: But it seems to me that if you are going to be wearing a mask anyway, then why put makeup on the part of your face that's going to be covered? It can exacerbate the problem. It also kind of messes up the masks and makes them harder to reuse if we end up needing to do that.

Dr. Tarbox: I agree. I've actually taken this whole time as a little permission to be a little less involved with my beauty routine. So while I'm paying very good attention to my skin health, and I'm trying to kind of baby that skin and be gentle with it, I'm really not using makeup hardly at all, because what's the point? It's underneath the mask and no one is going to see it. So I don't understand why I would do that anyway.

Dr. Johnson: How do you wash your mask, Michelle? Do you just throw it in the washing machine with everything else?

Dr. Tarbox: The masks that I've had, I've had some that have actually been made by people in my community, who are just wonderful, lovely volunteers. So, in my free time, I actually enjoy participating in community theater. And when this whole outbreak began, the seamstresses and costumers that are a part of the theater made this beautiful effort and sewed all of these fantastic masks out of 100% cotton and then took them to the hospitals and gave them to the doctors and nurses there. And I thought that was a wonderful thing that they did. I found that just washing them like you would wash normal clothes is a very appropriate way to take care of them.

Dr. Johnson: I like that one, and I like the Costco version of it. I don't remember what it's called. Kirkland brand Free and Clear, or something like that.

Dr. Tarbox: I found that the Tide cleansers are a little bit more harsh to the skin, and even their Tide Free and Clear still causes problems for me and some of my patients. So I tend to avoid that one.

Dr. Johnson: Sometimes it's not time to do laundry and I still want to wash my mask. So we've just washed them by hand just with a little bit of laundry detergent on our fingers, or wash them in the kitchen sink and then put them in the dish dryer to dry. That seems to work okay.

Dr. Tarbox: I think that's a great way to do that. And then you also want to make sure that if you are having to wear a mask every day, your skin can get really irritated. There are some adaptations that you can make. Some of the masks tie behind the headset instead of behind the ears. So potentially altering the style of mask you wear day to day might help protect that skin behind your ears. There are also little straps or buttons on headbands to clip behind the head that will hold the ear loops of the mask.

Dr. Johnson: And for anybody out there who's an aspiring dermatology nerd, there are medical, fancy terms for all this stuff. So the medical term for maskne is Acne Mechanica, and it can also occur with anything else that's sort of rubbing or lying on the skin. I know it's seen in military recruits who have to wear backpacks all the time, for example. And then the medical term for your poor sore earlobes after you've been wearing a mask all day is acanthoma fissuratum. There you go. We make up words to sound smarter than we are.

Dr. Tarbox: Science! So, before this outbreak, the most common place that I would see what we call maskne, what we technically call Acne Mechanica, was in my football players who were wearing chin straps and masks because they were playing football. And it being Texas, you see a lot of that.

Dr. Johnson: And the other thing I think is that's helpful to know is if you do get some of the acne stuff onto your mask, one of my favorite over-the-counter products is benzoyl peroxide. It's in a lot of acne treatment products. So look for that particular ingredient. It comes in a lot of different ways. It comes as little spot treatment pads or gels or cleansers. I kind of like it as a cleanser, because I figure you're washing your face anyway, might as well put some medicine in there, but it works fine as a spot treatment if you just have one or two spots.

Dr. Tarbox: It will bleach your towels.

Dr. Johnson: And potentially your clothing.

Dr. Tarbox: And if you have lighter colored hair, it can get your hair.

Dr. Johnson: And I want to agree with everybody that the Coronavirus sucks. I'm sick of it.

Dr. Tarbox: One hundred percent. It is not our favorite thing. If you are treating the acne, you want to be a little bit more gentle than you normally would be. So I wouldn't go for the mega acne control hot lava cream. Use the sensitive skin products right now. Take it a little bit easy on your skin.

Dr. Johnson: Yes, I'm very proud to be part of the University of Utah Department of Dermatology. It's a great place to live, Salt Lake City. It's great place to work. And if you are a super dermatology nerd and are interested in sort of some of the research behind it, Michelle and I have another podcast. It's called "Dermasphere" and it's really intended for dermatologists. Maybe you're a dermatologist. What do I know? But maybe you're just dermatologically curious. If so, you can check out "Dermasphere" on your podcast platform as well.

Dr. Tarbox: Well, we'll be releasing a new episode in two weeks and we hope to see you there. Thank you for learning with us about the skin today here at "Skincast."

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.

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 of 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 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.

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.

Interviewer: The challenge to provide expanded asymptomatic COVID-19 testing for 62,000 Utah university students, faculty, and staff. The solution is a story about innovation and collaboration, and a group known mainly just to researchers called HSC Cores. Dr. Michael Good, CEO of University of Utah Health, the dean of the University of Utah School of Medicine, and the Senior Vice President of Health Sciences, visited HSC Cores to learn how they made it happen.

Dr. Good, what was the main challenge when it came to making asymptomatic testing more widely available, and how did HSC Cores help solve that problem?

Dr. Good: We started that program last year, with those that lived in our dorm residence but were having trouble getting the capability, enough tests at an affordable cost and was really pleased when, through Dr. Andy Weyrich, our vice president for research, Dr. John Phillips, and other members of our research community pointed out that we do PCR testing in our Core laboratories, that we could probably scale this up. But, also, you know, this innovation starts with this capability in our lab, but it is surrounded by our clinical operations team, who set up a methodology that specimens could be obtained in a very efficient manner. And then our IT teams had to come together, the notifications are automated, people get an email notice back with results typically in somewhere between 4 to 10 hours, almost always same day. And there's a . . . so there's a really neat, and I think, uniquely Utah story there, with related to IT, with related to clinical operations, with related to Core Lab PCR capabilities, are all coming together to offer this great service to our team members throughout the university.

Interviewer: Just a great example of cross-campus collaboration to make more testing happen. But there is also some innovation going on, I understand, at HSC Cores in order to do the number of tests that were needed. Tell me a little bit about that. You saw what this system looks like, and I guess it was pretty incredible.

Dr. Good: First of all, kind of at the heart of this, if you will, is a very clever, it's about a oh, an inch tall, and maybe 3/8 of an inch wide, a very small collection tube that has a orange cap on it. In the little bag with the collection tube is a funnel and a toothpick. When you first see that, you say, "Well, what's that for?" and then later on you say, "That is so amazing."

So, first of all, you take the cap off of the . . . the orange cap of off the collection device, you drop the funnel in, and as the team will tell you, they'd actually like you to drool, rather than spit. We do know that saliva carries the coronavirus. Work by our faculty showed that actually saliva is a reliable source for doing these tests.

So anyway, put the funnel into the little collection tube, and then drool until the one inch or so tube is filled up. Now, this is where the toothpick comes in handy because on occasion you'll get an airlock. Your drool, your saliva will be in the funnel, but it won't make in its way down into the collection device. So you take the toothpick and just kind of help break that airlock and get the saliva into the tube. And that is, kind of, if you will, the clinical operations piece of this on the front. You know, the risk of the shoutout is I'm going to miss a whole bunch of people. But this is Dr. Richard Orlandi and Cameron Wright, a key member of his team, Michael Bronson, Nikki Gilmore. We've got a group of about 8 or 10 people that work on the frontend of this, if you will, the collection.

Interviewer: So then you got to see what happens after you drool in the tube and how it gets processed on the backend. Tell me about that.

Dr. Good: And that's where the Core Lab team really comes to work. Again, a lot of innovation has gone into this. So I believe the number's 96 tubes are loaded into a cartridge, into a rack. Now, they're going to add the reagents that are necessary for the test. But think about it, you got 96, 1-inch tubes, sitting in this rack. So the team went to work, and to help with throughput, actually acquired a decapper, D-E-C-A-P-P-E-R, decapper. So the cartridge goes into the decapping machine where a whole bunch of mechanical hands come down, if you will, and literally unscrew the caps off of these 96 specimens, and then from there, the decapped specimens go in, under a hood, and that's where our Core Lab team goes to work.

Derek was on point, running the bench the day I was there, as he explained about . . . I think they mixed it 10 times, if you will. A micropipetter first put in the reagent and then pulled it in and out of the micropipette 10 times to make sure it was mixed. Back in the decapper, now the recapper, R-E-C-A-P-P-E-R, those caps come back down on the cartridge, the cartridge goes into a heat deactivator, the heat both deactivates, if you will, the virulent properties of the coronavirus. It also deactivates enzymes in our saliva. If we don't deactivate those enzymes, they could potentially degrade the coronavirus that they're trying to detect.

From there, that cartridge with the reagents for the PCR reaction go into the analyzer, and then the machine goes to look for the specific genes that have been identified as being most reliable to detect the coronavirus. If one of those tubes start to show a positive reaction, if they start to detect coronavirus, the instrument knows which sample, and which individual that ties back to. And the tray I was watching be analyzed, I think three or four specimens were starting to show coronavirus as the machine cycled, and they kind of floated up to the top, if you will, so that the team there could take a look. And they get a really nice visual display that they can look at the pattern coming off the machine and visually confirm that, "Yeah, that looks like . . . that is the pattern we see when coronavirus is in the specimen."

Interviewer: Just amazing. Amazing innovation. The toothpick thing, I can wrap my head around all the stuff you explained, I don't even know how people come up with that. Just an amazing group at Cores, to be able to not only do that type of testing, but then when called up to scale it up, it sounds like they just responded in such a great way.

Dr. Good: I am so impressed and I just want to reiterate how helpful this is to our campus. I've received numerous thank you's and compliments from all across the campus. Any member of the University of Utah team, with or without symptoms, can now get a test. And, you know, the piece of this, has been taking the Core Laboratory capability, particularly the PCR capability, and then the team that just really came together. I mentioned Dr. Weyrich and Dr. Phillips. Derek Warner was the one mixing the reagents under the hood. Really a shoutout for Derek, I think he's put a lot of the pieces of this puzzle together. James Cox, another member of the Core Lab team who helped my tour, who led me around, introduced me to members of the team. Michael Powers, Brenda Smith, Elliot Francis. This isn't just one or two people coming together. This is three separate teams, the Core Labs, the clinical ops team, and the IT team. Within each of those teams, there's probably six or eight people that played a leading role in making all this happen. So this is uniquely Utah, and it's so important and such an important service, now available here on campus.

Well-child visits are still happening during COVID. What can you expect during your child's visit?

When COVID first hit hard, the American Academy of Pediatrics had a big concern that came true for a lot of pediatric providers -- well-child visits would come to a screeching halt. We also became concerned that there would be outbreaks of diseases again due to kids, especially babies, not coming into the office to get their vaccines.

Well, the good news is, in most cases, your doctor's office is probably one of the safest places to be outside of your house. Every office is different, but most of us are trying to divide the waiting room into sick and healthy sides. At check-in, every person is asked screening questions to see what area they need to wait in and also to make sure if someone is sick, that our staff takes appropriate precautions.

Only one parent is allowed in a visit per child. Parents are informed of this when they schedule the appointments, and I know we welcome the parent who couldn't be in the clinic to be involved in the visits through FaceTime. I've actually done two visits today where the parent who couldn't be in the visit was involved via FaceTime, and we were able to have a great conversation. Everyone is wearing eye protection and surgical masks also, and if there are concerns about COVID, we have complete PPE gowns and respirators that we wear.

We disinfect chairs, table, and toys in between each patient, and I have several rooms, so we are able to let the room sit for about 15 minutes to let the disinfectant dry by rotating which rooms we have patients in. We have separate exits for the patients who do not need to go back to the front of the clinic, and there is abundant hand sanitizer. We also have strict precautions for when we think somebody has COVID in terms of letting the room settle with the droplets, cleaning everything including the floors, and using special filters to cycle the air through.

What about virtual well-child visits? Some providers are doing them that way if there are no vaccinations needed. Others are doing only in-person. It's best to check with your pediatrician's office to see what they're doing.

So the next question is, how do you know if your child is due for a well-visit? Well, at our office, we do what is called outreach, meaning that our computer people can generate a list of all the kids that are coming due for well-visits or shots. We call and send letters reaching out to those families to have them schedule appointments. Not all offices have this ability though. If you're not sure if your child is due, please call your pediatrician's office, and they can let you know if an appointment is due and help you schedule at the same time. Your child's health is very important to your pediatrician. Please be sure to keep up with all of their necessary visits during this crazy time.

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

Here at Clinical, we strive to bring you the stories of the people that make a hospital a hospital. Not just the talented doctors and nurses, which we definitely have, but also the compelling lives and efforts of the often unsung workers that make up the complex ecosystem of healthcare.

Over the next few episodes, we'll be taking a look at a group of professionals that have been on the frontline against dangerous unseen pathogens well before the COVID-19 pandemic. Armed with an arsenal of cleaners and a regiment of protocols and a wealth of knowledge about microscopic enemies, it's the technicians and custodians of Environmental Services that ensure the safety of the facilities for every single person that enters those doors.

At a time when the world seems to rush ever faster by, we wanted to get to know the people who we see in the hospital keeping it spotless and germ-free without ever knowing their names or the often arduous journeys that brought them here.

Presented by Clinical and written and reported by Stephen Dark, this is "Keeper of the Keys."

Stephen: It's 5:00 p.m. in the north stairwell in University Hospital, and Jacobo Lucero is hard at work. As doctors and nurses go up and down the stairs past signs inquiring, "Did you get your steps in today?" Lucero digs into corners of the steps with his broom.

In his gray tunic and black pants uniform of Environmental Services, the 60-year-old keeps mostly to himself as he cleans the 6 stairwells and 10 visitor lifts assigned to him.

The Guatemalan native is a shy, quiet man with a soft, melodious voice that draws you in as he describes work he's done for more than a decade. He's taking English classes, but prefers to speak in Spanish.

Interpreter: I've been cleaning the staircase for 13 years.

Stephen: How many?

Interpreter: Thirteen years cleaning only the staircase. It's funny, isn't it? Time just passed by. I like cleaning because I didn't have to force myself to study English.

Stephen: Doors slam and American voices echo down the stairwell. Lucero wields his broom and mop exchanging only the odd word in English with those who take the time to say hello.

Interpreter: They all go passing by. Do I say hello to anyone in particular? No. After so many years, that doesn't happen. There are a few that I say hello to with two or three little words, but nothing else.

Stephen: Outside of his friends in EVS, no one knows his name, where he came from, how he got here. But like so many of the 235 people who work as Environmental Services Technicians at University of Utah Health, the journey that brought him to the beehive state was far from easy.

Lucero was born to farm laborers in Asuncion Mita, a sleepy little rural town in Guatemala, on the border with El Salvador. His parents moved him and his six siblings to the capital when he was 4.

Man: Good evening. A UN debate was dramatically interrupted Friday afternoon with the emergency announcement that 5,000 Indians in a Guatemalan village were about to be murdered by government troops.

Man: [foreign language 00:04:23 to 00:04:36].

Stephen: In the early 1980s, Guatemala was in the end stages of a 36-year civil war that saw over 200,000 killed and 45,000 disappeared, the vast majority indigenous Mayan civilians. The United Nations attributed 90% of the atrocities committed during the war to the military dictatorship, which was determined to stamp out dissent among the rural poor. Lucero was 23 when two of his older siblings vanished.

Interpreter: I don't know what to say because they were kidnapping everybody. There were so many disappeared. My brother was at the university, and my sister had graduated from beauty school and was already cutting hair.

Stephen: And what happened to them?

Interpreter: We never saw them again.

Stephen: Lucero had a little store. And together with his sister, they adopted the siblings' orphaned children. He and his sister, he says, did the best they could for their niece and nephew. His sister immigrated to the United States and settled in California and told Lucero to come and join her. He traveled from Guatemala through Mexico to cross the border into the United States. It's a trip that over 30 years on he still can't bring himself to talk about.

Interpreter: Extremely difficult. For me, it was very difficult.

Stephen: In what way? If you want to talk about it. You don't have to talk about it.

Interpreter: I don't want to talk about it.

Stephen: Roughly one-third of EVS staff are refugees who came to United States seeking asylum, shelter, food, and the opportunity for a new life. Some came here from childhoods of trauma. Others fled violence, genocide, civil war. Some came from Eastern Europe, others from Asia and African nations. Many also have come from South America, most crossing the border with Mexico without papers at some point in their past. They can only work at the hospital or neighborhood clinics if they have since secured work permits, green cards, or citizenship.

In total, Environmental Services boasts employees from 30 different nations, making it the most diverse department in the healthcare system. What they all have in common is finding a stepping-stone, an opportunity at EVS to build a better life for themselves and their loved ones.

Alisha Barker is the charge nurse in the medical ICU. The MICU takes the sickest of the sick, and during the pandemic became the COVID-19 unit. EVS plays a fundamental role at the MICU, Barker explains.

Alisha: They are on the frontline. They're handling a lot of . . . they're emptying the trash, whereas I can't tell you . . . I throw all kinds of gross stuff in those garbages or the linens. It's incredible. I mean, I have just a great sense of respect for the EVS personnel. I mean, they make our jobs possible.

I'm so grateful when if we have a very sick patient, and we're doing all kinds of things in the room, and we're filling up the trash cans, and opening packages, and frantically working and your garbage can gets full and then you start to have to throw things on the floor, most of the time they're very aware of which rooms are busy and they will come and get the trash for you. Just that simple task is huge to making our job easier.

Stephen: While to some staff and visitors EVS technicians are invisible, for others, there are opportunities to forge relationships, discover commonalities, even if language isn't one of them. Barker found common ground with one EVS employee from Ethiopia, Simret Hagos.

Alisha: She's from Africa, and we talk about kids. We show each other . . . she shows me pictures. I show her pictures of ours. So we have that connection.

Stephen: Hagos' nickname is Mimi, one that her dad gave her. The 35-year-old was born in Addis Ababa, Ethiopia. When she was 19, family and friends brought her over to the United States. She came to the U.S. to help her family back home and to get to grips with the English language.

Mimi: Just to learn the language, and to get a job, and to work, and to help my family.

Stephen: Her father passed away. She supports her mother, she says, and her siblings in Ethiopia. That role has necessitated getting a second job as a cashier at a big-box store.

Mimi: My mom, she no work no more. I'm the one helping her. But my sister . . . I have a younger sister and younger brother. They live in my country. They go to the university, and I'm the one who helps them.

Stephen: She started working for EVS in 2008 in the hospital emergency department. She did nighttime shifts, which proved challenging.

Mimi: So when I came in the night, I have to clean every OR detail, like the ceiling, the walls, the trash, the table, everything, sweep them up.

Stephen: A lot of blood.

Mimi: A lot of blood I have to clean. I just don't touch the instrument, but I have to clean everything. I think I have three ORs every night I come in.

There is a lot of blood, especially I remember room 16 or 14. It's a big room because that room is for heart surgery. It takes a long time. So when they finish, they have a lot of blood we have to clean. So it takes you a long time than in other ORs.

Stephen: She reserves a deep passion for the staff at the Medical ICU from which she was reassigned over a year ago.

Mimi: Oh, I really miss . . . I can't even . . . I don't know. Working in MICU is really good. That's like my second home. I really love MICU. I don't know how to say thanks to them, the doctors, the nurses, the manager, the nurse manager, and the physical therapy, the pharmacy, the CNA, the hack. Everybody loved me crazy and I love them crazy.

Stephen: The Roman god Janus was the keeper of the keys, a two-faced deity who marks beginnings, endings, and doorways. The word janitor finds its roots in Janus, someone who guards entrances and, metaphorically, keeps the keys to the kingdom. A custodian performs a similar duty guarding, cleaning, and protecting access points, record, stores, and individuals.

At University Hospital, with the advent of the COVID-19 pandemic, Mimi and her fellow keepers of the keys found themselves thrust onto the frontline with critical care nursing staff and providers, medical specialists who have vast tracks of knowledge to draw upon when it comes to understanding the virus they face. But for EVS stuff, some rely on more abstract notions to keep them safe.

Mimi: It's not new training. But when COVID came in, I have to be careful. The training is the same.

Stephen: Were you concerned or worried about it?

Mimi: I worried too much because I say, "I'm the one cleaning COVID room in ED." I'm really scared when I clean the room. But I leave it to God.

Stephen: Over time, she's got used to it a little.

Mimi: Yeah. When I clean those rooms, I'm stressed. Stressful, because I'm thinking, "Oh, while I'm cleaning, I know I'll be careful, but you don't know sometimes what's going to happen." So maybe I'm going to have these COVID, but right now no. But when they start, I was so scared, but right now it's okay.

Stephen: They are essential workers without whom the very fundamentals of hospital care simply could not continue. They weren't always seen this way, however.

Man: Despite the temporary imposition of martial law, the Shah's new government appears determined to press ahead with liberal reform.

Man: University students demonstrating in Tehran shouting, "Death to the Shah," pledged allegiance to the Islamic movement of the ayatollahs.

Man: The number of killed in Tehran since the beginning of the month is probably well over 100. But people in this crowd were saying and believing 7,000 have been killed. Emotions over the . . .

Stephen: 1979, the Shah of Iran had fled abroad, leaving his supporters to their fate as a brutal coup swept away the former regime. For University of Utah foreign student [Abbas 00:15:22] Bakhsheshy, overnight he had been severed from his past and his country. Over 11,000 kilometers away in Salt Lake City, Utah, he felt alone in the world. Shy, timid, and extremely introverted, he nevertheless had to find work if he was to eat. That first job was washing pots and pans at a kitchen in University Hospital.

Abbas: If you think that dishwashing is as noble as it is, it's not something that anyone wishes to pursue as a career. Dishwashing is actually a promotion to pot washing.

So I remember that the very first day that I was washing pots and pans and my skin was red and my fingernails were so soft, I really decided that this is not the life for me. I had a difficult time. I was shy, bashful, timid. So I was really incredibly devastated. I didn't know how to go about living in this country and I missed my parents.

Stephen: His colleagues in the kitchen saw how hard he was struggling, one in particular.

Abbas: More than anything else, I remember the very gentleman who taught me how to wash pots and pans. His name was Kurt, that had so much patience, and so much love and care. He was telling me how important it is to fill out this massive metal sink, put certain amount of chemicals in there, make sure that the temperature is the right temperature, and make sure to let all these pots and pans be soaked before you actually get in there and try to clean them. I still remember to this day that he told me, "If you do the job right the first time, you do not have to redo it."

Stephen: They taught him a lesson that stayed with him all his life.

Abbas: It's the pride and satisfaction that you take in achieving those series of goals that happened to be your responsibility.

Stephen: Not only did he learn valuable life lessons in the kitchen, Bakhsheshy also found a support system among his colleagues.

Abbas: Those were truly genuinely my heroes because they're the ones that supported me. They stood by me. They tried to coach and mentor me so that I did not end up doing something drastic, such as ending my life.

Stephen: For the next four years, he worked his way up the ladder with the help of his new friends.

Abbas: So because of the kindness, empathy, compassion, and love of these individuals, I was promoted from pot washer to the dishwasher, to working on tray line when you put food together and send to patient. Then I became team leader. I became assistant supervisor, supervisor, manager, assistant director, associate director.

Stephen: Until finally, in 1983, he took over the newly named Environmental Services. The department had struggled with high staff turnover for years.

Abbas: The perception came from the fact that these are the lowest paid individuals, the perception that these are not important people. They're a dime a dozen. They're expendable. They come and go.

Stephen: Bakhsheshy knew he needed to change the culture at EVS and how employees felt about their work. To do that, he used the lessons he'd learned in the kitchen.

Abbas: At that time, it was like a revolving door. People would come and people would go. It's not a glorious job. People don't want to stick with it unless you develop some sort of pride in what they do. You give them meaning associated with that contribution. You give them the feeling that you are as important as a physician, as a hospital administrator. Once they find meaning associated with their contribution, they become inspired. They become motivated.

Stephen: Since the majority of his employees did not graduate high school, he sought to educate them in air quality, hygiene, safety, cleaning supplies. In essence: why when it came to removing germs and bacteria, that job mattered so much. And then to further support his own staff, he set up a coaching and mentoring team to provide additional training on the job. He hammered home, "If you get the job right the first time, then you don't get called back."

Abbas: So, if you do the job right in the first place, you do not have to receive a call from a nurse manager or from a supervisor to say, "This room was not vacuumed properly," or, "These equipment are not cleaned properly, so come and redo it."

Stephen: Which brings us to 10 coins. Every morning, Bakhsheshy would put 10 quarters in his left trouser pocket. Those coins were there to remind him, as he walked around the hospital, to look for 10 employees living up to the hopes he had had for all his staff.

Abbas: And the moment I will see one of the employees doing something nice for another employee, or a patient looking confused trying to find a particular location and this custodian put the vacuum aside and says, "Sir/Ma'am, can I help you? Which department are you looking for?" and then he or she would take that visitor or that patient to the right floor, to the right room, after that I would go and tell him, "Thank you very much for going out of your way to help patients and visitors."

Stephen: And he would move a coin to his other pocket, one coin for each act of generosity, kindness, thoughtfulness, and caring. And each night, he put the coins on the table and he'd sit down in his office and write 10 thank you letters to the loved ones of the employees that he had seen do a good deed that day.

Abbas: But then I also wanted their wife, husband, children, and others to know that his wife or her husband is such a wonderful contributor to the overall wellbeing of . . . and I will say, "Thank you for supporting him. Thank you," because I felt that the moment they go home, they could be hero in the eyes of their wife, husband, children, others. As a matter of fact, employees would tell me that this is much more significant than anything else that we have done for them.

Stephen: By 1990, employee turnover had shrunk.

Abbas: Our turnover dropped dramatically. I believe, in less than four years, our turnover from somewhere between 60% to 70% dropped to about 10% to 15%. And that 10% to 15% were mostly associated with being promoted to different position within the same institution, outside of the department. So it was really significant.

Stephen: And they were no longer invisible. The evidence for that is on a wall adorned with citations and awards in Bakhsheshy's office in the David Eccles School of Business. The dapper professor, folded handkerchief peeking out of his jacket lapel pocket, singles out one photograph as one of his most meaningful achievements: 200 people from 30 different races smile up at the camera that April 1990 afternoon, the white borders of the image covered in signatures of his former employees. That was the day Environmental Services was named best department in University of Utah Health Sciences Center for "its loyal and dedicated service."

Among those upturned faces on Bakhsheshy's wall is Connie Becerril. Then a supervisor, 30 years on, Becerril is about to retire after almost half a century in Environmental Services. It's a department that different disciplines of which still fascinates her, as it did when she began.

Connie: You weren't just in radiology, you weren't just in maternity, and you weren't just in an intensive care unit. You became an integral part and a requirement to know everyone's purpose within the hospital. So that's what intrigued me and I stayed with it.

Stephen: Ask her why she stayed so long in one profession, one department, and she says that it's because of the people she's worked with. They matter to her as they matter to the hospital, which is why she gets upset when she hears people using the word housekeeping to describe her employees.

Connie: So we have continued to evolve. Matter of fact, no one in my organization is permitted to use the word housekeeping. They know that very well in front of me. If they do, they owe me a dollar. If anybody uses the word housekeeping, they are to pay a dollar. It goes into a fund for the custodians.

Stephen: There's so much more than that, she says.

Connie: A housekeeper may be someone that you hire to come to your home to help you do the dishes, and clean the dirty bathroom, and vacuum a carpet. They do much more than that in Environmental Services. They go hand in hand with our medical team. The medical team may be eliminating bacteria/organisms that live internally, and our Environmental Services staff eliminate those bacteria and infections that are in the environment. They manage the environment. If we don't do well, then our physicians and our nursing staff aren't able to do their best either.

Stephen: She sees her department much as Bakhsheshy did: as a stepping-stone for those who want to advance, as well as a place to build new lives. Some, she knows, were highly educated, white-collar workers in their home countries, but the United States government doesn't always recognize their educational credentials. Others found the work a stepping-stone into medicine.

Connie: I've actually had people who have come in and are now nurses. I have one gentleman that went on to be a doctor.

Stephen: Becerril has worked hard to modernize her department. Four years ago, she secured funding for eight ultraviolet cleaning robots to help support her staff, a squadron of machines she calls her R2-D2s.

Connie: The robot can actually . . . the UV light, it breaks down any residual. It is probably the final piece when you're cleaning and turning over a discharge room.

Stephen: Imagine a tall cylindrical robot that spins out purple beams hazardous to life. It's locked away inside a patient room, zapping proteins and bugs after an EVS employee has finished cleaning it post-discharge of the patient.

Connie: So the robots were our last piece of defense to ensure that we were not exposing the environment to harsh chemicals, something that could cause other people to be sick. And it has been championed by all of our medical pathologists throughout the country and outside of our country, and so . . .

Stephen: For all the hardware she's managed to secure to bring EVS into the 21st century, it's her people that she's proudest of, like Lynette Nelson. Nelson grew up in Gary, Indiana, and came to Utah when she was 21 to find work. Seventeen years ago, Becerril hired Nelson to join her staff of frontline workers. One patient was so moved by Nelson's attentive, caring manner, a family donated money to the university in her name.

Lynette: The donation was I took care of a patient, a mom patient in the family. I guess they really liked me. And then Connie said, "Lynette, you got a donation from that family." So, yeah, I felt pretty proud, but I'm not a bragger or nothing. I don't know. It wasn't talked . . .

Stephen: Becerril identifies something crucial in that story when it comes to understanding the impact EVS has on the hospital.

Connie: She made such an impression on them, was such a kind soul. She's just a sweet girl. She was very genuine. She would do whatever it took to make them happy. And she took time out of her day to talk to the patient.

I think that's what many people don't understand, is that the patient in, I would say, a very, very high percentage has more of a connection with the person that's cleaning their room than they do with the care provider. They see that person every day. That person speaks to them every day. They sometimes tell them things that they would not tell their nurse.

Stephen: If Nelson epitomizes the idea of how employees in EVS fulfill Bakhsheshy's philosophy of always trying to do more, then Jacobo Lucero is, in many ways, the nightly living embodiment of that gift.

More often than not, when employees of University Hospital use the stairwell in the late afternoon or evening, they'll hear a voice that belongs more in a church or a cathedral than in such a utilitarian space as a stairwell.

Jacobo: [singing]

Stephen: For many nurses and other carers in the hospital, Lucero provides a moment of respite, even solace, during difficult times. He offers them spiritual care in his own anonymous church as he sweeps and mops the floor. Charge nurse Alisha Barker finds Lucero's voice almost bewitching.

Alisha: It's just an escape and it's calming. And he just has a beautiful voice. I've tried to make eye contact with him and to be friendly with him. You walk by and he's very closed off. And he'll stop singing and you walk by and you're like, "No, keep going. Hi. I can't tell you how much I love your singing and how much it helps me."

Stephen: Lucero has never had a singing class. He laughs at the idea. In Guatemala, he sang popular songs by Latin American artists for his own amusement. In Utah, he found a church on North Temple that he liked, and it was there he sang for the congregation with a guitarist from Honduras. He sings, he says, to relax. He finds peace in his singing. That's because he's singing to someone else.

Interpreter: To sing, for me, is to communicate with God. For me, one has to worship God all the time. Even if I'm sad and I'm with someone, I still have to praise God because that is my responsibility as a good Christian. Thus, "What's it worth?" the Lord says. That you have to praise him all the time, in time of illness, in time of poverty, in time of prosperity. And singing is a way to praise him.

Stephen: Praising God through his singing, he says, brings him a sense of freedom.

Interpreter: And when one sings where the spirit of God is, there is freedom. If someone can't sing, it's because he isn't free. The enemy doesn't want him to sing. The devil has him tied up so he can't sing.

Stephen: So you're expressing . . .

Interpreter: The freedom that God gives me.

Stephen: In the months since the pandemic has taken an ever-tighter grip of the University Hospital and its critical care staff, his songs of compassion and love have created their own oasis in this otherwise nondescript stairwell.

If Lucero sings to his God, he's also singing for God's people. In this echoing chamber of steps connecting one lifesaving floor to another, he treats wounded hearts, offering no more than the precious, priceless gift of his melodic balm.

Jacobo: [singing]

Mitch: Next time on Clinical, we revisit the self-described maverick, Jessica Rivera, and share her journey to becoming a director of the many teams at the University of Utah Health clinics and explore not only Environmental Services' response to the COVID-19 pandemic, but also how the managers are balancing not only being caretakers for the hospital, but how they care for the workers that they're responsible for. Join us next time for A Bushel and a Peck.

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?

And to all of our doctors, nurses, admins, interpreters, operators, technicians, and all the other hospital employees out there, we know you're listening. Do you have a story that you would like to share with us? A message to the workers that you've heard about today? Feel free to reach out to our listener line by calling 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. A very special thanks to Francisco Soto and Interpreter Services for providing translation and voice acting for this episode.

Music by Bottega Baltazar, Vortex, Giants & Pilgrims, Ian Post, Muted Artist, Nadav Coehn, and Ziv Moran. Audio news clips from PBS NewsHour, C-SPAN, and the American Archive of Public Broadcasting.

And of course, a heartfelt thanks to the men and women who have shared their stories with all of us and work to this very day to keep each and every one of us safe.

We are several months into this pandemic, and schools are back in session. For some, they're online only. For others, they're in person. And for some, they are a mix of both.

Several schools are closed because of outbreaks. So how do we keep this up, and how do we keep our kids and teachers safe? First, I think there are a lot of kids doing a terrific job wearing their masks. I have been really impressed with how kids as young as 18 months have kept their masks on. We need to praise them when they're following the rules and let them know we appreciate how they're helping to keep themselves, their friends, and their teachers healthy.

Speaking of teachers, I've spoken to several since before school started. They're doing such a hard job of trying to keep our kids educated and everyone safe. In many cases, they're doing double duty by preparing in-person lessons and online lessons. I'm not sure if this is something that could still happen, but I think it would be great if teachers would be able to wear masks that are clear over their mouths so the kids can see them talking. My son has a mask like that that is for his American Sign Language class. Also, another option is to make sure they have face shields, especially the elementary school teachers. As we all know, kids that age don't necessarily cover their noses or mouths when they sneeze.

With a few exceptions, kids love their teachers. I think that became even more apparent when distance learning started. I know my kids really miss certain teachers. They are working long, long hours. If your child is a distance learner, please make sure they are logging in and doing their work. I know my kids are doing in-person, four days a week, and they are struggling with keeping up with all of the assignments given to them. It seems like some teachers are overloading them, but I think they're just trying to get as much in as possible in case the kids get sick. If kids are doing distance only, there's a tendency to get a little further behind because you don't have that in-person accountability. I've heard that phrase from a lot of parents whose kids are doing distance learning.

The only thing we know for sure is that this situation isn't going away anytime soon. We all need to adjust and figure out what works best for our kids and their teachers to keep them both safe, keep kids on the path of getting their education, and keep the teachers from burning out.

Interviewer: This Thanksgiving and Christmas, it's going to be very different than Thanksgivings and Christmases in the past. It used to be you would get together with family and friends, and now health officials are saying that perhaps you should reconsider that because of the spread of COVID-19, that you should maintain that family bubble.

However, even within families there are a lot of different opinions on how dangerous the virus is and what kind of safety precautions could be taken. So having those conversations with family members about whether or not to come to Thanksgiving or get the whole family together could be very, very challenging.

Dr. Benjamin Chan is a psychiatrist at University of Utah Health and in communication, communicating your thoughts and feelings is referred to as assertive communication, and it can be a very challenging thing to do. And I wanted to find out how somebody could be an assertive communicator, not aggressive, but an assertive communicator in talking about plans for Thanksgiving and Christmas. So is that what you call it? Is that what you call it, is assertive communication in your field?

Dr. Chan: Yes, Scot. And again, we're all in the middle of a pandemic. This is historic, unprecedented, and incredibly challenging. And in years past, Thanksgiving dinner would be a time that we get together, see and talk to long-lost cousins, aunts, uncles, grandmas, grandpas, maybe some neighbors, family friends. That is not safe this year.

And there's a lot of disagreement in the community about how to get together for Thanksgiving. A lot of people have different thoughts and feelings about COVID, and what social distancing is, and what masks are. And this time more than any other is the time for you to be assertive because you have to protect your own health. You have to protect your family and your loved ones. And COVID is silently transmitted. This is not the podcast that goes into it, but you can listen to many others. But there's a lot of different research and data out there that shows how pernicious and silent COVID can spread.

So assertiveness means behaving and communicating in a manner that equally values your rights and opinions on par with other people's rights and opinions. And the opposite of assertiveness is passiveness. And passiveness is when you put someone else's rights and opinions above your own. So now is the time to be assertive.

Interviewer: Have those assertive conversations beforehand. What does that look like? Because I mean, some people, myself included, we don't like conflict, right? So it's really difficult for us to know . . . I'm going to be talking to somebody in my family who thinks that COVID maybe isn't a big deal, that we should still get together, and it's going to be tough for me to express, "No, I disagree." How do you do that in an assertive way?

Dr. Chan: You do that in an assertive way by first recognizing that the other person has a different opinion and feeling than yourself. And then you segue into statements that start with, "I feel." So, "I feel scared for my own health because when I hear that you're going to host a Thanksgiving get-together and not everyone there is going to be wearing a mask or socially distancing, I feel scared that I might get COVID." And you frame things where you recognize the other person's belief or values, and then you maintain your own beliefs and values.

And people want to be heard, they want to be listened to. So my experience has been if you immediately start talking about what you believe and do not give the other person the recognition for what they believe, that's where conflict really starts escalating because the two parties don't feel like they're being listened to or heard. But if you can restate perhaps in their own words or maybe a summation of what you understand what their belief is and then give your belief, that gives an opportunity for that person to feel that you actually listened to them, an acknowledgement, and then you can present your belief.

Interviewer: I tell you what, I can see the spiraling for me pretty quickly, because I think people that do believe that COVID is a serious threat to the health, when they hear somebody that does not necessarily have that same belief, we just want to go, "Well, I understand you don't think this is a big of a threat impact as I do." Would that be the restating? Is that fair enough? Is that all I need to say? I mean, it's so hard not to do that judgmentally.

Dr. Chan: I agree, Scot. And it's credibly difficult. It might take practice. And I think when you, like, your example you just gave is a very quick response and people's responses tend to be much longer. So if you say, you know, "When I hear you, it sounds like you do not feel that the COVID pandemic is as serious as some of the public health officials have said or as serious as some of the hospital officials have said. I do believe those individuals, and this is why I believe them." I agree, it could start spiraling, but to me the key is to reframe it through core values. Just go back to values.

So people want to feel safe. They want to feel heard. They want to feel that they're being listened to. So if the core value is health, you can talk about like, "What is your value about the health," and they'll talk about the memories and the mental health of getting together for Thanksgiving. And you can use that as a springboard of, "Okay, this is my conceptualization of health. I'm worried about COVID. I'm worried about the fevers and the respiratory problems and everything else associated with COVID." If you have a discussion about values, the vast majority of people have core similar values, and then you can just explore those basic values together.

It's hard, Scot. It's incredibly difficult because people are drawing upon information from a wide variety of sources. Some of these sources might not have the same beliefs that you believe or might have different versions of facts. But you need to be assertive during this moment because if not, you will open yourself up to potentially being exposed to COVID and then a lot of hurt feelings will stem from that.

Interviewer: You know, being assertive doesn't necessarily mean the other person is going to react in a positive way. And if they don't, I guess you just have to go away with, you know, "I tried my best, but I have to make this decision for myself, or for grandma, or for grandpa, or for whoever." How do you deal with that? So again, I don't like conflict. I don't like it when somebody, you know, doesn't like me anymore. How do you deal with that? Is there a closing phrase you would use? Like, "I'm sorry we couldn't come together on this, but I still love you and care about you very much."

Dr. Chan: Yeah. Again, Scot, you did a great job. I think it's like you want to normalize this as best as you can during a pandemic. So this is an important holiday coming up. It's very important to a lot of people, but it's simply one day out of the year. And we have talked about previously, we're in a marathon. This is not a sprint. There's a lot of things happening in the country as we're trying to address this. So in my attempt to normalize, it's like, if everyone got together for Thanksgiving there's going to be disagreements. We've always had disagreements over the Thanksgiving table. Sometimes it's about the Dallas Cowboys and the Detroit Lions football teams. Sometimes it's about someone's political beliefs. Sometimes it's about someone not doing well at school or their job. It's normal to have conflict during Thanksgiving time.

This is a time when it might be normal to have a disagreement if we should really get together, or if we get together, it needs to be socially distant and safe with masks, or maybe we don't get together this year, or maybe we do a Zoom Thanksgiving and a virtual Thanksgiving. And that's okay because the most important thing is safety and health. And we want to stay together as a family in the coming months, and there's a light at the end of the tunnel. We all feel that. We all believe that. We want that to happen. That's still very much many months away.

So I try to end all these difficult conversations kind of like you gave with positivity. Let's say something nice. Let's say something that we can all agree on. I always like in these tough discussions kind of like a U shape. You start off high, you kind of go low, you go really deep, you kind of talk about feelings, emotions, values, and then you rise back up. You never want to end these discussions at the bottom of the pit. You want to rise to the top and say some nice things to each other, and agree to, you know, let's talk about something that's not as emotionally taxing, like the Dallas Cowboys or the Detroit Lions. Let's talk about something that we can agree on because these are difficult conversations. It's really hard to be assertive, but now more than ever it's really required.

Halloween is a magical time for kids and adults. So how can you continue to enjoy Halloween during COVID? I've got some ideas for you on today's Scope.

Okay. So I admit it, I love Halloween. I was so looking forward to this year because Halloween is on a Saturday and there's a full moon, the perfect setup for the Halloween party we host every year at our house, and then COVID had to happen and mess everything up. Well, not everything. There are still a lot of fun things that you and your kids can do.

For example, we still plan on doing our outdoor decorations. We plan on welcoming trick-or-treaters but in a safe way. Our street is setting up tables that will go from our driveway to our neighbor's driveway across the street, not blocking the road, of course. And we will all be in costume, chairs for family set at least six feet apart, or people are bringing blankets to sit socially distanced on. The houses will all be decorated. We'll be wearing fun Halloween masks, COVID masks, and we'll be passing out individually wrapped treats, but we'll be using hotdog tongs to pick up the treats from the bowls and dropping them directly into the bags of the trick-or-treaters.

We also will have plenty of hand sanitizer available. We also have food and non-food treats. See, we are a teal pumpkin house, meaning we understand about kids with food allergies. I have many food allergies myself. And so we give away things like little tubs of Play-Doh. If kids want to walk past our place and just see all the scary decorations, that's great. If they want treats, we've got them. It's all what parents are comfortable with based on the risk factors that their family has.

So what are some other ideas that can make Halloween during COVID more fun? You can try an outdoor costume parade in the neighborhood or at a park with friends, keeping in mind that the kids still need to have their face masks on and stay six feet apart. And the masks that come with costumes, that's not what I'm talking about. We're talking the regular face masks that you wear every day.

You can also do virtual costume parties if you're good at setting up Zoom meetings. You can have all the kids dress up in their costumes and chat with each other. You can host an outdoor Halloween movie night with age-appropriate movies, or just have a Halloween movie marathon at home as a family. And don't forget decorating and carving pumpkins.

If you're planning on trick-or-treating, remember, again, the masks that come with the costumes are not a good substitute for the double layer COVID masks. Also, have the kids wait at the street if there are already kids at the door. Only go trick-or-treating with your immediate family members. And parents, if you're going with your kids, be sure to wear your masks also. Most importantly, remember this is a time for kids and parents to be creative about ways to celebrate Halloween in a safe way. Happy Halloween.

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

I'm Mitch Sears, producer with The Scope Radio, and you're listening to Episode 6 of our series "Unit on the Brink." This is a multi-part story told in order, and if you haven't listened to the previous episodes yet, we highly recommend you go back and start with Episode 1 in your podcast app. For everyone else, this is Part 6 of our story, "Unit on the Brink."

For many, summer is a season of rest and renewal, a time for vacation and travel, to get outdoors and enjoy the warm weather. And inside the University Hospital Medical Intensive Care Unit, the summer months are typically their offseason, with low numbers of critical patients. MICU staff would lend a hand to other units that see an increase in patients during the summer, like the neuro and burn units.

Summer was always a few months to take a breath and collect themselves before flu season begins in the fall. The MICU is the unit tasked with taking care of the most severe cases of influenza during their "on" season. Typically, the unit will see an increase in influenza hospitalizations starting in October, with cases usually reaching their peak in February. By April or May, the unit can finally relax as the rate of flu infections tapers off, and they can clear their beds of patients with life threatening respiratory complications.

But the summer of 2020 proved to be completely different. The coronavirus pandemic persisted through June, July, and August. And in Utah, the numbers of COVID-19-positive patients climbed even higher than what we had seen earlier in the spring, and the hospitalization numbers were following suit.

While many of the patients arriving to the unit eventually do get well, heal, and leave, only returning for the occasional clinical visit, the unit is dealing with many more severely sick patients than they are used to treating this time of year. This summer, rather than a few months' reprieve, the unit found itself dealing with many more severely sick patients than they were used to treating during the season.

This year, it was the MICU that was in need of reinforcements from other units in the hospital during the summer. And on top of that, flu season was fast approaching. What would this winter look like in the unit if a wave of influenza patients were to come, if COVID cases were still filling their beds?

Throughout our series, you've heard the raw tales of the healthcare workers holding the frontline against the novel coronavirus. But the stories that you've heard so far, they were from interviews conducted in April and May of 2020, the early months of COVID-19. After six months of treating the victims of the global pandemic, how were they holding up?

Three nurses from the unit agreed to discuss what happened over the summer. Veteran charge nurse Alisha Barker, nurse Megan Diehl, and nurse Juan Paulino Rodriguez, who joined the unit on Halloween 2019. The three sat down in a University of Utah Health conference room on a Wednesday morning in early September, Rodriguez fresh off the night shift. Over three hours, they revealed to us what it's like being at one of the medical epicenters of COVID-19 in Utah, during a peak in the virus crisis, discussing their fears, anguish and frustration, along with their love for the profession.

The conversation has been edited for length and clarity. Presented by Clinical and written by Stephen Dark, this is our sixth and final episode of the season, "Waiting to Exhale."

Stephen: On July the 26th, newly appointed charge nurse Cat Coe wrote an email about how much had changed at the University Hospital Medical Intensive Care Unit since early spring. Back then, the first suspected COVID-positive patients, some struggling with acute respiratory distress syndrome, or ARDS, had started trickling in to await diagnosis. But by the summer months of June and July, the MICU was being hit harder by COVID-19 than at any prior point in the pandemic.

Cat: The beginning of this pandemic was very different from what it has become in the MICU in the last six weeks. Nurses, HCAs, and some doctors are getting very tired and burned out. We have seen so much death this summer both from COVID and other things. And the MICU is full every day, which never happens in July. Many patients are getting proned, and I've never seen so many people with such bad ARDS all at once.

Stephen: Nurse Megan Diehl agrees with her 1,000%.

Megan: We can put our PPE on in like 10 seconds now. It's impressive the change of just easy . . . like, putting on your PAPR and tying everything. So the mentality has changed a lot, and we are exhausted, burnt out. There's a lot of people that, you know, "I can't. I just can't come in today." And so they'll call off work, or they'll talk to our management and be like, "I just can't deal with it today." And that totally makes sense. We're feeling a lot of the burnout from it, because we've been doing this the whole time. And people are just like, "Well, I'm tired of COVID."

Stephen: It's not just COVID-19 they're tired of.

Alisha: And it's been a lot. It's just a lot of death lately.

Cat: Mm-hmm. It's hard.

Juan: Yeah.

Stephen: Summers before COVID were quiet enough for MICU staff to unwind, to float to other units, Barker says. But with the spike in cases in June and July, they never seemed to turn a corner, to have a chance to recharge.

Alisha: It's just a constant feeling of being tired, but knowing that you have to keep going. And it's almost like it's . . . again, it's kind of like this destabilizing feeling in the pit of your stomach, where you know you're okay because you know what it looks like. We've been working in this environment for several months now, and we're accustomed to it. However, there's not really an end in sight that we know of. And so it's just not a comfortable feeling. But we're all getting accustomed to being out of our comfort zone. But that's exhausting.

Stephen: Before the pandemic, death was a more sporadic visitor to the unit. But with the virus, its presence was painfully more evident. Nurse Juan Paulino Rodriguez recalls a day when the unit experienced three or four deaths in just one shift, including one just as exhausted nurses and doctors were handing over their patients to the next shift.

Juan: There were these lulls where, yeah, you would lose a patient, but then you would have so many recover, and then you'd have another patient that you would lose, and then you would recover because you would get to see other patients go home. But with COVID, it's constant.

Stephen: Diehl recalled one shift change where a young nurse blamed herself for a patient's death, even though she had fought as hard as she could in that patient's corner.

Megan: She had been fighting for this patient all day, and she's such a good nurse. And she just broke down when the patient started coding. And I was trying to talk to her, and there were a bunch of us trying to comfort her, because she felt like she had failed. Like, she had been working with this patient all day and trying to get, "Can we try this? Can we do this?"

Stephen: Whether new or veteran, the number of deaths of COVID and non-COVID patients exacted a brutal price on already exhausted staff.

Megan: You see it wear on everyone. I mean, someone that's been here for 7 years or, I don't know, 15-something, some crazy amount of years that Alisha has been here, but even for this just brand-new nurse, the constant death just really gets to you.

And even with our non-COVID patients, we've had a really solid amount of people that are not COVID patients but are dying in very traumatic ways, or they come in and they're so sick and it's not something that we usually experience during the summer.

Stephen: And when multiple patients die during one shift, it's overwhelming, Barker says. Yet somehow, the mind finds a way through, at least at the moment.

Alisha: Just speaking from many years of experience, when shifts like that happen, you feel disconnected. And I think it's almost like a coping mechanism so that you can survive and that you can continue to function and complete your shift. You have to turn yourself off so that you don't break down and cry.

And I have had those shifts where I have broken down and cried, and I've had to go in the locker room and try and get myself together in the bathroom stall. And it's even worse when someone comes and checks on you to see if you're okay. The moment someone shows you compassion or gives you that look or touches your arm, you just like break down again, so you're like, "Don't talk to me. Don't. Don't."

And then you've got to go home from your shift and you've got to be that person who you are at home when you're completely wrecked. I've had shifts where I've called my husband and I've said, "It's been a terrible day. I can't come home right after work because I can't help you put our daughters to bed. I can't do that. And so I need you to put them to bed and then I will come home."

Stephen: She drives to a park by her home.

Alisha: I will just pull into the parking lot, and I'll just sit there. And for me, personally, again, where I have to turn it off so that I can still function at work. I sit there, and I try and turn myself back on again so that I can feel it. I try to cry, and sometimes I can, and sometimes I can't. So I literally just sit there and I try and conjure up the feelings. I think through the shift, and I'm trying not to berate myself of where I thought I failed.

Because when your patient does code, you think back and you're like, "What could I have done differently? How could I have prevented it? What did I miss?" And so you're trying to not beat yourself up about it so that you can return to work again, and do the same thing the next day or whenever you have to go back to work.

Stephen: And when those setbacks happen, exhausted nurses have to confront their own emotional limits. Diehl talks about an extremely healthy male patient, who when she had to start turning up his oxygen, knew immediately what that meant and broke down.

Megan: And then I got a patient who had COVID, looks pretty healthy. I mean, I had to get a different blood pressure cuff because his muscles were so big in his arms. He was a healthy guy. And taking him as a patient after that death, and then starting to have to turn his oxygen up, he started crying, and I went into the hallway and just cried, because I couldn't . . . I was already . . . you're like already broken down, and then the littlest thing can just push you and just knock you over into a place where you're not in a good headspace.

So it's just . . . it's like you feel one thing, and then even if something slightly bad happens, or your patient cries, and you have to be strong for them, and you can't . . . I don't know. It was a really hard day.

Stephen: When patients experience those first moments when the virus' hardest truths start to hit home, Barker tries to fortify them by shifting their attention. "Focus on what matters to you," she tells patients battling to comprehend what they may face with the virus. She recalls one scared woman who missed her husband and was waiting to be determined COVID negative or positive.

Alisha: I could tell she was very scared, and her husband couldn't be with her and her family couldn't be there. And I just remember looking her in the eye and just being like, "I am going to take excellent care of you. You are in the right place. And I need you to stay in a mental-positive space. I need you to try and just think about your loved ones and your family. And you're going to be okay. It's going to be okay."

And I hate saying it's going to be okay when you don't know if it's going to be okay or not. In the end, I believe it's going to be okay for all of us, whether which way it goes. But I just make sure that they know and that they believe we are going to take excellent care of you. But I just tell them the patients who are able to stay in a more positive mental space are the ones that I see that do better.

If you can hang on to the reason why you want to get better . . . and sometimes I'll make them. I'm like, "Tell me why you want to get better. Tell me what you're grateful for in this moment right now. Tell me who you're going to get better for." So if I can get them to make that switch versus out of panic mode and into this moment where, like, "Yes, I'm going to make it through this," then I feel like it just changes a little bit. It changes the atmosphere for, who knows, maybe only five minutes, but in that moment, I have them with me and I'm like, "We're going to take care of you."

Stephen: If some patients break down as they realize the severity of what they may face, others refuse to accept it at all. Barker brings out the reinforcements in such cases, namely her voice.

Can you give me an example of that voice? I know it's hard.

Alisha: Stephen, your oxygen is 82% right now. I need to put this mask on you. If I don't, your oxygen saturation could drop more, and you might stop breathing. So I can put this on you now, or we can see if you stop breathing later. You decide.

That's my sort of mom voice.

Stephen: And has anybody actually not done what you've told them?

Alisha: It usually is like, "Uh, okay." I don't remember a point where someone didn't do what I wanted them to do when I was talking to them in that way.

Stephen: A change in tone of voice is not the only tool a nurse can brandish from their professional toolbox. For some MICU staff members, there's a sense of almost vocational renewal in the simple act of holding an iPad so relatives unable to visit the unit can communicate with their loved one, even if the latter can't speak.

Megan: Then you're like, "Can they see them? Am I tilting the right way?" I have so many other things that I can be doing, but you're bringing the family comfort by going out of your way and adding a step to your day so that they can FaceTime with their loved one and say prayers or talk or even just look at everything that's happening so that they can grasp, with the treatment that we're doing, how sick this person is, and that they can just actually visualize their loved one that you're taking care of.

Alisha: Yeah, it's a chance for them to see their loved one and everything that they're going through and everything that we're doing. Yeah, I do love when the patients are able to converse with the family on FaceTime. I love FaceTiming with patients and families. I will stay in the room and hang out and FaceTime with the patient, with their family, just because their eyes light up and the families are just so happy just to be seeing them and talking to them.

And I do, I find myself even when I have other things that I have to go be doing, I'll be doing stuff in the room just so I can be a part of that energy. I find that little things like that and little things that we do that the patients would like or find comforting, I really focus in on those things, and I try to be mindful and present when those things are happening, because those are little things that get me through a shift or a difficult time, or when I'm feeling stressed or pressured. It's those little things that help to relieve me and to remind me why I love being a nurse.

Stephen: The pressures of a climbing COVID-19-positive patient census have demanded a new approach to how many sick patients nurses need to care for each shift. Typically, a MICU nurse would have two patients to care for, one very sick, the other stable. But as more COVID patients filled up negative air pressure rooms shifting the majority of patients from non-COVID to COVID, Diehl found herself caring for two extremely ill patients at the same time.

Megan: Usually, those patients would be . . . if you were having a really sick patient, you would pair them with someone who is pretty stable, pretty okay. But when we had as many COVID patients as we did, it was, "You've got a patient that's paralyzed and proned and tubed, and things really could go wrong at any minute. And your other patient is kind of on the borderline of maybe being intubated, and that might not go very well either."

So you had this sense of stress and just peaking, and then also kind of a sense of dread because your workload had completely changed, and then you were responsible for two really sick patients. And the rest of the unit was pretty much the same way.

And so, even if you needed someone to help you, there were so many times, and I know all of us have felt this, where you're in your room and you just kind of stick your head out because you don't want to take off all your PPE and go out of the room, and there's no one outside at the nurse's station or anywhere around that could help you. And you're like, "All right. Well, I guess I'll figure it out."

So we had lots of COVID, and then we didn't have enough nurses, and then everything changed. And it was just COVID peaked and our stress level peaked too.

Stephen: There was a keen awareness of some colleagues who weren't faring as well as they would like.

Alisha: The sad side of this is that while we're laughing and trying to do things together outside of work, and people are going hiking together, and all these other really good things that are happening, we also know that there are staff members that are really struggling. Our manager will say, "I've got a couple people on my radar that I'm trying to keep tabs on, that I know they're in a dark place."

Stephen: As the MICU staggered towards the end of July, staff concerns inevitably began to include the impending influenza season. As Diehl talks through the implications of what flu and COVID might look like in the fall, despite the brightly lit room, it starts to feel claustrophobic.

Megan: And really, sometimes it feels like in the MICU lately these waves are coming and are literally just crashing into us over and over and over. And the winter is our busy season. Each ICU, I think, has a season that is busy for them. And so it'll be really interesting to figure out how to have all these COVID patients, and then also have the flu, and then the regular stuff that we usually get in the winter.

Juan: And I just see the whole rollout process too. "Is it the flu? Is it the COVID? Is it both?"

Alisha: I know. It's just precautions for everyone.

Juan: Everybody, yeah.

Stephen: What would both look like?

Juan: I have no idea.

Megan: A patient that has both?

Stephen: Yeah.

Megan: I'm terrified to think about that.

Juan: Yeah, because just seeing what COVID is doing and then . . .

Alisha: And then having . . .

Juan: The flu on top of it . . . We've already seen what the flu can do just on its own in healthy individuals too, so . . .

Stephen: If public support had helped keep spirits up in the unit through the first and easy months of the pandemic, once the MICU's walls echoed with rooms full of struggling COVID patients, that same support seemed in some quarters increasingly muted. Indeed, the days of the lockdown when they had experienced so many public displays of gratitude, Rodriguez says, had by then faded away to something that felt at times almost unpleasant.

Juan: At the start of this, like I . . . because working nights, you just get off, you go to the store, you're still in full uniform. At the beginning, it was like, "Oh, thank you for everything you do. Thank you for everything you do," to now when people see . . . I don't like going to the store anymore in my scrubs, because now when they see you, people will give you that stare, they'll step back, or they will go to turn down the aisle when they see you, and then they're like, "Nope," and then go the other way. And it's like, "Whatever. I don't want to talk to anybody right now anyway."

Alisha: I'd be like, "Thank you for socially distancing."

Juan: Yeah, exactly.

Megan: But we're so much safer at work than we are anywhere else.

Alisha: Oh, yeah.

Megan: I feel so much more comfortable in a COVID room than I do out in the public.

Alisha: At the grocery store. Yeah.

Stephen: Some wounds of rejection, particularly those experienced by colleagues, by those standing on the frontline with you, hurt the most, remain the most incomprehensible.

Megan: There's one person in particular who had found another hobby, another source of joy other than just being at work, and COVID happened and everything shut down, and this person couldn't go do that anymore. And then once things started to reopen, he was able to go back to that place. And once they found out that he worked in the COVID ICU, they asked him not to return.

And I think it's people . . . people look at us and they take a step back when we say we work in the COVID ICU. And we feel safe. Other people don't always feel safe around us, and I think people need to recognize that that hurts. And the implications that it can have, and how it makes us worry about someone that we may not have been super close with before, but we're looking out for each other. I'm so doing so poorly with this.

Alisha: No, you're doing great.

Megan: It's so hard. People don't get that, and they put us in this box, this COVID box, and this possible infection and all this. We're still people who we need an outlet. And for the people that don't have that, we are worried about them. And it's hard. I don't know. There's a couple people in our unit that are having those experiences, like, "Hey, my friends are getting together, but they don't want me to come." And that sucks.

Stephen: So you are you are being discriminated against by some.

Megan: I would say yeah, in a sense.

Alisha: Yeah, I worry about that with my . . . I have two school-aged children, and the parents, they . . . I mean, for the most part, it's been good, but I worry about that, that they're being left out of things because they live with me and because of what I do.

Stephen: Barker has struggled to find a nanny for her children. No one she talked to was comfortable coming into her home given where she worked. At the same time, she was also nervous at the thought of hiring a stranger who might bring COVID into their family.

Barker told her mother about her problem. Five days later, her mother called back. "I'm calling to apply for your open nanny position," she said. A relieved Barker was so moved she couldn't speak and cried for several minutes. Rodriguez had similar problems.

Juan: Yeah, even on the medical side, I have a niece who has a brain tumor and we've been dealing with it for the last three years, and she was very young. And when COVID started, the clinic that she goes to, they asked her, "Do you have known exposures?" to my sister. And she was like, "No, but my brother, he's a nurse. He works in the COVID ICU, and he hasn't been around often, and we do everything that we need to." And they basically like, "Okay, well, you need to do your appointments virtually now." And it's like how can you do this virtually? The exposure risk is minimal. Like, it's . . .

Megan: Frustrating. It's frustrating.

Juan: Yeah. When she told me, I'm like, "So what? I can't go around her? Is that what the hospital is saying? Is that what they're telling you to do?" It's frustrating, yeah.

Megan: It's because people are telling us that we're heroes. And at the beginning, it was, "Oh, you guys are such heroes. This is so great. Thank you for all that you're doing," but like, "Don't be around me, and I don't want you around people that I know," or, "You can't come here because you're such a hero."

It's a weird thing. We were supported, but it's support from afar. Or we were supported, and now we're kind of being put in this other bubble. So it's a weird feeling. It sucks.

Juan: Yeah, it does.

Megan: But it's sucks together. I mean, we all have that where we've had these experiences, or we know someone that has, and it's really affected us too. And so we share in that together, and we'll still get together outside of work because we're not afraid to be around each other.

Stephen: MICU staff try to support each other, whether it's organizing a staff exercise meet in Sugar House Park or taking time to check in on personal projects. There's a table designated for sharing, where staff like Barker can simply visit, chat, and ask questions.

Alisha: You see some people sitting at the share table, you go and you sit, and you're like, "Okay, what are we talking about? What's going on?" You'll get little clues as to how your coworkers or how people are doing just by what we share at the share table, what we talk about. And so often there we just try and say . . . like, we talk about personal things.

Stephen: Barker will ask Diehl how work is proceeding on her new home.

Alisha: Like, "Hey, how's your house renovation going?" or . . . yeah.

Megan: It hurts me inside.

Alisha: Yeah.

Megan: But that's exactly it. We lean on each other, and we know when someone's had a hard shift, because usually we're right there with them, or we've been stuck in our rooms all night and we're like, "Man, I haven't seen you this whole time and I know you've had just as crappy as a night as I have." So we're I think really good at talking about how things are going and really good at making each other laugh. We really support each other, I think.

Stephen: By the end of a summer unlike any other in living memory, Utah had experienced not only the ebbs and flows of a global pandemic, but also hurricane-force winds battering the streets of its capital. With no end in sight to the crisis, staff wearily steeled themselves for the days to come.

At the end of September, the Beehive State hit its highest ever daily infection numbers for the pandemic, over 1,400 cases. In the MICU, after a brief lull in the run up to Labor Day, numbers yet again began to climb.

As nurses, healthcare assistants, and providers rallied once more to treat the rising number of cases, they drew on each other for morale and support along with their own resources, histories, and quirky personalities. Tired and burned out as many were, they needed all they could find, as the virus laid siege on their patients day after day after day.

Charge nurse Alisha Barker's disciplined, unflinching approach was seeded on the softball fields of Central Utah when she was an ace pitcher coached by her devoted father.

Recently appointed charge nurse, Cat Coe has her years of mountaineering and guiding with all the fear and stress she learned to negotiate to steady her resolve before the onslaught of extremely sick patients.

If healthcare assistant Cornelio Morales' loving approach to caring for patients with disabilities and their loved ones was ingrained in him from the many years he and his wife have cared for their bedridden daughter Cathy, there was also his 11 years working at this unit to guide him.

Unit respiratory specialist Lynn Keenan, MD, had both her family's deep ancestral roots in medicine and 5:00 a.m. jogs, when the peace and promise of Salt Lake's morning streets awaited her.

And if nurse Megan Diehl had thought that a business major would have been too stressful for her, nursing through a pandemic brought to the fore her compassion and her natural qualities as a leader.

And for the very worst cases this unit would face, they can always rely on reinforcements from the CV ICU, professionals like nurse Rebecca Brim, who has walked the gray line of life and death for most of her long career and will do whatever she can to help bring her patients back from the brink.

None of them, however, have faced quite the emotional vortex that consumed nurse Juan Paulino Rodriguez when his grandfather, a man he called Appa, was diagnosed with the virus and cared for by his own unit. Rodriguez was quarantined for most of Appa's time at the unit, only to be there in his last hours to say goodbye and hold the iPad so that many of his relatives might also say their farewells. We'll tell that story in a future episode.

But however long this pandemic would run, whatever the fate of the unit's patients and their committed staff, they remained unbowed before the brunt of COVID's relentless pressures.

The MICU staff knew they had each other to rely on as they confronted the virus' wrath and worked towards the end of all this, whenever that end would come.

Mitch: And that brings us to today, the first week of October 2020. The pandemic continues. The frontline workers at University Hospital are still fighting every day to save the lives of some of the very sickest members of our community. In the past week, we've seen record high numbers of new positive cases in the state, and the overflow unit at the hospital has been reopened.

This has been a story of loss and the pressure that this pandemic has brought to bear on those tasked with treating the sick. But it has also been a story of bravery, dedication, and the saves that make the job worthwhile. A tale of the grace and strength of those who devote their lives to healing others. The story of one state, one hospital, one unit, and the ordinary people facing extraordinary circumstances, coming together and supporting one another through these unprecedented times.

While this may be the conclusion of our first season, this is not the end of our story. We'll be staying in touch with the medical professionals and provide updates as they happen.

And be sure to stay tuned. The Clinical team has been hard at work on a series of "Unit on the Brink" specials coming out over the next few months that aim to share other perspectives of this story, such as the way the virus has impacted Utah's Latinx community, the perspective of a COVID-19 patient themselves who came back from ECMO. And we'll hear from the resiliency center, the people that helped take care of the mental well-being of our frontline workers.

Stephen and I want to take a moment to thank the people who, without their help, this series wouldn't be possible.

First, the professionals who were willing to share their often difficult stories with all of us and helped give a voice to the experience of those in the unit working to hold the line against the virus -- Alisha Barker, Rebecca Brim, Catherine Coe, Megan Diehl, Dr. Lynn Keenan, Cornelio Morales, and Juan Paulino Rodriguez.

A thank you to MICU nurse manager Naydean Reed, for her assistance and guidance on this project.

Our gratitude to the support of the rest of our team -- Cathy, Scott, Chloe, Alex, Charlie, and Jessica.

And of course, thanks to you, our listeners. Without your support, none of this would be possible.

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 Podcast? 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/clinicalpodcast, and click on "Voices from the Frontline.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Be sure to check out the rest of The Scope's growing catalogue of shows at thescoperadio.com, including Bundle of Hers and Who Cares About Men's Health.

Music in this episode by ANBR, the David Roy Collective, Ian Post, 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.

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 five 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 one in your podcast app. Don't worry, we'll be here when you get back. And for everyone else, this is part five of "Unit on the Brink."

As the rest of the state seem to settle into the new normal, for the professionals in the medical intensive care unit, they were realizing that the battle against the novel coronavirus was becoming a war of attrition. The number of COVID-19 positive cases in the state were staying steady through the month of May. The hospital beds were still full of very sick patients with treatments lasting for weeks with some of the more severe cases.

Two months prior, an ambulance had pulled up to the University Hospital carrying a man experiencing severe pains in his chest and a shortness of breath. A 42-year-old veteran who had felt fine just a few days prior, just a little headache and a sore throat. But after being seen by doctors in Tooele, Utah, he crashed, falling into a state of fever, chills, and hypoxia. The man had to be put on a ventilator, and he was not getting any better. The virus had ravaged his lungs and he was unable to breathe.

If the medical professionals at university hospital weren't able to help his body get the oxygen that it so desperately needed, he would suffocate. It was time to call in reinforcements and try some extreme measures to save this man's life. It was time to call in the specialists in the cardiovascular intensive care unit. This episode follows the journey of one Rebecca Brim, the CVICU nurse over this man's care, and the intense emotional and psychological toll that caretakers face as they treat these COVID patients that are facing the gray line between life and death. Presented by Clinical and written and reported by Stephen Dark, this is episode five, "Keepers of Hope."

Stephen: For her 40th birthday, in April 2020, Rebecca Brim and her girlfriends booked a cruise ship to Catalina and Ensenada. Her dreams of lounging on a cruise ship deck, partying into the night and watching the sea glitter beneath the moonlight from her portside window began to crumble shortly after the new year. That was when the 15-year veteran charge nurse at university hospital's cardiovascular intensive care unit CVICU started watching with growing alarm events in Wuhan, China.

Female: The mystery virus started here in the city of Wuhan. Chinese authorities pinpointing its source to this food market. Dozens have been infected, but experts here believe the actual figure is closer to 1,700 cases.

Nurse Brim: It was like, oh damn, China's having a problem. You know, like, ooh, look at China. You know? And I remember talking to a coworker because it's a respiratory and like just the rumblings, you know, the news rumblings. And I remember talking to Kathleen at work like, "Hey, you heard about this mystery illness in China." And she's like, "Oh yeah, we're already talking about it." I was like, "Oh, for VV ECMO?" She's like, "Yep."

Stephen: The CVICU deals with everything between the diaphragm and the neck, Brim likes to say. And as its name implies, the biggest focus on the 20-bed unit tends to be the heart. All nurses who start work at the CVICU are trained on the ECMO, which stands for Extracorporeal Membrane Oxygenation.

It's essentially life support for the heart and lungs and can be a startling sight for the novice. In the ensuing months, Brim knew if the pandemic reached Utah, she and her colleagues will be called upon to help fight the respiratory virus. But as the winter months moves towards early spring, Brim's battles were closer to home with the growing anxiety she saw in her community.

Nurse Brim: And then come March was like, okay, well, what's going to happen? And by, you know, I kind of refused to give into any anxiety or craze or worry about it for quite a while. Like didn't stock up my pantries, wasn't doing that. I was like, "I'm not going nuts at Costco. I am not buying toilet paper. It's fine. We're fine. I don't need all this food."

Stephen: And then things got real. Her husband was told to work remotely from home. Her daughter's school sent her home for the remainder of the semester. Brim's anxiety started to climb as she worried about bringing the virus home to her husband and daughter. She knew the Medical Intensive Care Unit, the MICU was on the frontline caring for COVID-19 positive patients. She also knew that sooner or later she will be part of that same fight.

On March the 18th, a 5.7 earthquake hit Salt Lake City, escalating Brim's anxiety. "Is this the apocalypse?" her husband jokingly asked her. Brim wasn't amused. Then several days later, she got the assignment she had been expecting. She was sent to the MICU to oversee care for the first COVID-19 positive patient her unit would work on, Justin Christiansen, a 42-year-old Iraqi war veteran from Grantsville, Utah.

Justin was on DV ECMO, which was supporting his ailing lungs by pumping out his blood from a large vein in his neck, oxygenating it, and ventilating the CO2, then pumping it back into the same vein. That's what the VV means. Veno-venous, using the same vein. This gives lungs brutalized by both the virus and the medical treatment trying to defeat it a chance to rest. But Justin's oxygenator box needed to be replaced, which meant the life-saving tubes in his neck had to be clamped. With the VV ECMO clamped, oxygenated blood was no longer circulating to his lungs, which were drowning in thick secretions from the virus.

Nurse Brim: So we were up there in a foreign land of MICU corner pocket, negative pressure room, and I wasn't in there, so I was the charge nurse. So I stood at the doorway and like did a lot of looking in and answering questions for the nurse and passing in supplies. And because the second they put in that ECMO, it's us. And the MICU is great and they want to help, but they're like, "This is not what we do. This is what you do." And our team to our doctors take over taking care of them.

Stephen: She stood outside the room with the ICU attending, watching through the window as the nurse stopped the flow of oxygenated blood by literally clamping the tubes.

Nurse Brim: So when you clamp them, so the ventilator is still going and this guy has a beating heart, but you're stopping his lung support. So his oxygen levels start ticking down, and they got down to 20. You and I sitting here, we're probably 98. If you got lung disease, maybe, you know, like maybe you're a little lower, but we want higher than 92. So you and I are for sure higher than 92. This guy got down to 20, and this is not compatible with life. And I'm just sitting there like don't code, don't code don't, don't, don't, don't, don't because your heart can't necessarily beep.

Stephen: She needn't have worried she learned later. This patient was a survivor.

Nurse Brim: As I got to know this guy, realized he's tough as nails, and had I known him better I knew he wouldn't have coded then. So it was just scary.

Stephen: Brim went onto work every shift, treating Justin at the MICU. That his first name was the same as her husband's couldn't help but encourage her to identify with him, perhaps just a little more than she would other patients. She's been a nurse 15 years and knows all too well the dangers of connecting too closely with those she cares for particularly when it comes to a tough environment like the CVICU, where machines like the Mo as brim calls the ECMO, keep patients alive, in some cases long after much of their body has passed the point of revival. And when the decision has been made to turn off the Mo, it's Brim who has to flip the switch. This also involves clamping. And while such an act is a merciful one, it nevertheless haunts her.

Nurse Brim: There are things where, you know, a lot of times when we withdraw life support on an ECMO patient or a patient that has these, because like I said, with the machines in the unit that I work on, your body can stay alive indefinitely. I mean, it's unbelievable how long we can keep a body going on this life support. And when it's time to let them go, the person in there turning the machine off and clamping it is me. That's me. I'm the one ending their life by shutting because the second you shut that machine off, they're gone.

Even though it's the right thing to do and it's what they need and it's what everybody has agreed on, it doesn't make it easier. I just ended their life, and I got to go home from work with that. And then I got this amount of time to drive home from work and let it go. I end their life and then I got 20 minutes to pull it together and come home and be a wife and be a mom and talk to them. And I like, how do you do that? So I get help.

Stephen: Even with therapy and the support of her family, friends, and colleagues, sometimes it's just not enough. She simply has to let her pain out.

Nurse Brim: And my car was my emotional, my box of emotion. My car knows more about what I feel than any other thing in the world. If you had a camera in my car, you would because I've screamed in my car. I have like . . . my car is like my little private box of emotion, where it just explodes out. It's a Subaru. I have little Subaru Legacy. I got it in 2012.

If that car could talk, man, that car, because you know, part of that . . . well, I used to live in Draper. So I used to have 40 minutes to decompress, and I would sob the whole way home and the whole way to work every day. Like that's straight-up unsafe driving how hard I would cry in this car. Because by the time you walk in the door, you got to be like, "Hello. Hi, everyone." Or you get to work and you're like, "Here I am ready to go."

Stephen: Brim is a larger than life figure. One moment she's paragliding high in the Utah sky or standing on a paddleboard late at night on Mirror Lake, the Milky Way reflected in the dark waters around her. The next she's making clay coffee mugs in her home pottery studio. Talk to young CVICU nurses, and they express admiration for her. Brim made an immediate impact on Delaney Williams in 2017 shortly after she had started work at the CVICU.

Delaney: The first time I met Becky and I actually just thought of this, it was my last week of orientation and I had this patient who got flown in from I think it was Idaho, I can't remember, and he was having a heart attack. And so we were working him up, treating him, and then he all of a sudden stroked and then coded, and so we were throwing in bedside ECMO.

And I don't know if Becky, I don't think she was charging that day, but I remember Becky being next to me and my preceptor on the other side of me, and I was pushing meds during this code, which was one of the gnarlier codes I've seen in my career thus far. And I remember Becky just handing me flush after flush. And she's like, "You got this girl. You got this." And I actually think that was the first time I met Becky.

Stephen: Ask Brim to define what a nurse is and there's a lengthy silence. A day later, a two-page answer arrives in your inbox, peeling away the layers of what her vocation means to her. Most of all, she writes, she is an arbiter of hope.

Nurse Brim: 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.

Stephen: Brim was a teenager when she fell in love with nursing, thanks to the most heartfelt testimonial she could imagine from her father.

Nurse Brim: So my dad had two open-heart surgeries when I was young. One when I was in like third grade and then when I was in sixth grade. He had rheumatic fever when he was three or so. Damaged his heart. He had a murmur his whole life, and so he had to aortic valve replacements. And then in high school, when I was about 15, I remember distinctly had broken his leg riding a motorcycle and was sitting in the kitchen. Like the picture is so vivid. I wish I was a really good artist, I would draw it. He's sitting there and he's doing these like foot exercises. And I don't know how we got on it, but he said, "You know, the surgeons may have done my surgery, but the nurses saved my life." Like that quote is like I need to put it on the wall in my house. It just stuck.

Stephen: One of the interviews for this episode was conducted at Brim's rambler in Sandy, Utah. It is quiet one Sunday afternoon as she reminisces about nursing. After a while, you realize there's something missing, the tick-tock of a clock.

Nurse Brim: Yeah. My dad, you know, after his second heart surgery, he was pretty much like he wheeled and dealed in clocks, could fix clocks, was a clock collector. My mom's house is full of ticking clocks, which is funny because he had a mechanical valve so he clicked. So when there was no TV on, he ticked in addition to everything else, which I just love so much, but he literally ticked. He had a St. Jude valve, which is a metal cage and the ball goes up into the ball hits the cage and makes a clicking sound.

Stephen: Yet despite everything cardiovascular nurses and doctors did for her father, she shied away from the heart.

Nurse Brim: It's almost like I am called to be a nurse. I can't really explain it. There's not some I need to take care of my dad because I shied away from heart surgery patients forever. And I was like, "I don't like cardiac. I don't like heart surgeries. Trauma's my jam." Anything but heart surgery, you know, anything but heart surgery. It was kind of weird. I was like not into taking care of people like him. And now where I'm at, I take care of him all day long. So it just kind of fell into place and I love it.

Stephen: She moved to Salt Lake City in 1998 to be a ballet major at the University of Utah. After ballet fell through, she trained to be a nurse instead and in 2005 started working in the 20-bed university hospital surgical ICU. In 2014, the ICU was split into two units, one a surgical ICU and the other, the cardiovascular ICU, which absorbed all the cardiology patients previously treated by the medical ICU.

That left the MICU with critical illnesses that aren't surgical in origin and pulmonary disease, while the CVICU tackled heart failure, heart attacks, and lung and heart surgery. Justin Christiansen's medical needs as a COVID-19 patient not responding well to ventilator treatment brought the two units together. Brim's journey into the virus was threaded through not only overseeing the Mo in Justin's room but also connecting with her patient's wife.

Nurse Brim: Do you know, I got to know his wife more because I spent a lot of time taking care of him in his really critical phase when he was still heavily sedated, not awake, like kept him down because he would be very unstable when we would lighten his sedation, like heart rate, blood pressure, you know, oxygen levels. So he was very, very heavily sedated, and I spent a lot of time on the phone with his wife and a lot of time Skyping with his wife.

Stephen: The similarities between her husband and her patient wove their own spell.

Nurse Brim: It was a lot. I think because my husband's the same age, my husband has the same name, my husband's almost the same build as him. So it generated a lot of fear of COVID for me that I still have because I look at my husband and I go, "Damn, that could be you."

Stephen: And even as she helped care for Justin, the world outside continued to fall apart.

Nurse Brim: My sister and my brother-in-law are losing their job. My kids having panic attacks, like the world's falling apart. And then I'm here in it taking care of it. It's like all of it together, you know, one whole thing. And then here we are with the last-ditch effort, VV ECMO, which is what that is. Like, that's your last oomph like that we've got for people.

Stephen: After Justin had been weaned off the fentanyl and propofol used for sedation, she started to learn more about who he was.

Nurse Brim: He said this is easier than Iraq. And I was like, okay, I'm getting a picture of what kind of dude you are. And like, I was like, okay. So I would like to talk to him in a year and see if that's still like the case and see, yeah.

Stephen: In order to protect a patient's vocal cords while on a ventilator, surgeons will sometimes put an air vent in their throat called a tracheostomy and hook up the ventilator to the trach directly. Brim was one of the first nurses in the state, she says, to assist two surgeons performing the procedure on a COVID-19 positive patient.

Nurse Brim: We do trach people so we move their airway to down here. And so hopefully that helps because then they don't have the garden hose in there in their mouth.

Stephen: On April the 21st at 7:20 a.m., Brim and her colleague were at the nurses station. They could see the patient on a video camera while they were giving their report, and then everything went haywire.

Nurse Brim: I'm staring at the screen while they're talking, and all of a sudden the patient who had been flipping channels on the TV, very calm. I mean, he's trached, he's on the ventilator, he's got his ECMO, all, you know, all these IV pumps behind him, but he's chilling, watching TV, no sedation, starts flailing in the bed. He's coming unglued in the bed. Like something is wrong. Like one minute he's calm, and on the camera, he's coming apart in the bed flailing.

And so two nurses immediately grab PAPRs and I go to the doorway and it's negative pressure. So you can stand the doorway. So I opened the door, and I've just got an ear loop mask on. So I opened the door and I'm like, "Justin, calm down. We are coming in, like stop." And he starts, he like pulls at his trach, and he looks at me for a second and like grabs the rails and then he goes back to like . . . I don't know what's wrong. And he does one flop, and he reaches up to his neck.

Stephen: Unbeknownst to Brim, while rearranging his pillow, Justin accidentally knocked his trach and it blocked his airway. In his desperation at not being able to breathe, he unwittingly tried to yank out the tubes that were pumping his blood out and feeding it oxygenated back into his body. Pulling out the ECMO could have led to a massive hemorrhage. In all likelihood he would be dead in seconds.

Nurse Brim: He reaches up and he comes forward and he's got his ECMO in his hand, he's got both cannulas and he's coming forward. And that like his arm's extending and there was like there was no more standing at the door talking him down. He was pulling his ECMO out. It was coming out. It was going to happen. So I ran in there and just like grabbed his wrist and like eyes to eyes, you are going to kill yourself right now. Like, stop, stop. We're coming in. And so I held his hand because he's like, you know, got this tension on his hand. And I don't know, I stood there for a moment while they finished putting their PAPRs on.

Stephen: Afterwards, she tried to take stock of what had happened.

Nurse Brim: So I like changed my scrubs and got a new mask and washed, you know, my whole arms that were exposed and kind of sani-wiped my neck, but it was really frightening. I mean, I was real emotional about it, and I felt helpless at the doorway, you know, yelling at the guy just to stop. Because normally something like that happens and you just, you go in the room, you go in there, you just go to your patient when they're having a hard time. But instead I like froze at the door, you know, and there's this big push like you're first. You don't jump in front of the bus. You don't put yourself at risk. That's not what you do. But I couldn't stand at the doorway and watch him pull out his ECMO. That was like, and it was almost knee-jerk. To stand there and try and talk him down from the door was hard enough.

Stephen: She called work wellness and was initially told her risk was minimal. She could go home.

Nurse Brim: So that day I call and the guy I talked to was like, "Well, your risk is pretty much zero." I was like, "Okay." Went home. And I have my own protocol for entering the house. I go change my clothes before I leave work. I go straight to the laundry. I strip to naked and wash my scrubs and then I Clorox wipe everything that I've touched on the way to the shower. And so that's how I come home from work now, especially taking care of him for that, you know, all those shifts.

And then I don't come in and say hi to my family anymore. I come in through the garage and go straight to the laundry, and there's a tub of Clorox wipes there and then I backtrack up to the shower. I streak through my house naked to the shower, and then Clorox wipe like every doorknob, the garage door closer.

Stephen: So that's what she did. No need to change her routine, she thought.

Nurse Brim: I did that. I went home and I slept in the bed with my husband. I hugged my daughter, and I'm just so glad to be home from work. And I had this crazy thing, but they said my, you know what, I'm very clear with my husband, very open because I want him to be comfortable too. Because, you know, he worries like, "Well, should you be sleep . . ." Because we had many, many discussions, hours probably like, "Well, do I need to be sleeping in a separate room? Do I need to be social distancing from you guys?" We're all trying to figure it out. And then, so I went home that night and we haven't been . . . I was feeling comfortable with my PAPR and everything and entering my house in that way.

Stephen: The next day, the hospital called with distressing instructions. They wanted her to get tested for COVID-19 and quarantine for two weeks. The news felt like ice water on her family, and learning she would have to be tested, upset her. Like so many in the medical profession, Brim refused to even consider the possibility of being a patient herself.

Nurse Brim: She's like, "Well, we really want you to get tested. How do you feel about that?" And I said, "Well, to be real honest, I don't feel good about it at all. I am downright terrified. I don't want that test. I don't want to do it. But if you want me to do it, if I need to do it for my job, I will do it. I will do what I need to do for my job." I do a lot of things I don't want to do. I do a lot of things that aren't awesome. Here we go. Like if I need to, if that's what I need to do for my health, it's fine. Also fell on my 40th birthday weekend.

Stephen: Her 40th birthday, a time she had so looked forward to before the pandemic, when she would be on a cruise ship sipping margaritas with her gal pals. Instead, she was going to a parking lot in front of a health care center to get tested for COVID-19.

Nurse Brim: So my husband drives me to COVID testing, and I think it's the situation. I think if I was actually sick or I think I might have had a different mindset, but again, it's the whole thing of it. It's the whole, like, it was scary, it was emotional, and then now I'm off work and I'm supposed to be quarantining at home. I'm fine. No symptoms whatsoever. I'm taking my temperature. I got to answer these email things, and the girl comes up to me in a PAPR with the kit in her hand to my window and it's like, "You know what? I'm supposed to be in the one in the PAPR. I should not be in the seat." And so I kind of told her the situation and being a nurse like loving, like I got you girl, like that look like, like they made it like okay, these nurses.

Because I was like, you guys, like I told them what happened. And so, but this nurse in the PAPR with just and her like helper behind her, like just the look on their face was so comforting. And they like, one girl held my hand over here, and my husband held my hand over here. And they just, you know, I wish I could like hug them and tell them how much just their love meant. They're like, "We got you, like, you're one of us. Like we got you, girl. It's okay. You're okay. I promise we'll be gentle." And they were. I mean, I think they were as gentle as possible for a swab.

Stephen: When the result came back negative, she contacted work to ask if she could return.

Nurse Brim: They're like, nope, can't come back to work. And the first week I was off I tried to reframe it like a gift. Like, okay, I'm getting basically a 14-day paid staycation because they told me they would pay me out of their thing. And the first week I was fine, like, you know, hung out with my daughter. She's turned into a latchkey kid. You know, she's home alone a lot. And I can just hang out with my daughter and we did painting and we did homeschooling and I ran. I have a trail behind my house and went running.

And the second week at home, I don't know what happened to me. I just like, like emotionally, like took a dive. I don't know what my problem was. My anxiety was horrible, crying all the time.

Stephen: Her husband struggled to understand since she was negative why was she having such a hard time dealing with the day-to-day? But even her aging, sick dog's need to be put down was too much for her to bear.

Nurse Brim: And I've got this elderly dog at home. This is totally not nursing. This is just life right now. I've got this dog. He's 18 years old. He needs to go to heaven, and I can't do it. I can't do it. And I've messaged the vet a couple of times, and they won't come to the house.

Stephen: Her patient's and her dog's needs oddly merged.

Nurse Brim: He's given me the pleading look sometimes. I'm like, I know that look, dude, stop. I can't like . . . can you please pass on your own, because I can't clamp your ECMO right now, dude. It's like one of those like I can't clamp it. You're going to have to do it on your own.

Stephen: At the end of her leave, she returned to the hospital to find Justin had been discharged, but it was his wife with whom she felt she needed to say goodbye.

Nurse Brim: It's not uncommon for me to go see my patients up on the floor just to say, "Congratulations, look at you. You're getting better." So I messaged her and said, "Hey, I wasn't able to be there, but I just wanted to tell you, like, it was such a pleasure to take care of him. I'm so glad he got better. I think you guys are great. You know, wish you the best of luck. His recovery has been amazing."

Stephen: Despite how desperately sick Justin was, Brim never doubted he would one day make it home.

Nurse Brim: Oh no, not at all. I told her. I said, "There is no reason that he can't come home to you." And so I told her, I said, "There's not . . . I don't see any reason why. There is all the hope in the world."

Stephen: Brim has Buddhas all over her house, in her front garden, on shelves and the dining board in her living room. If she were religious, she says she'd be Buddhist. It's a faith meant for the nurses, it might be argued. After all, the goal of a Buddhist on earth is to ease the suffering of others she wrote in her email.

As a nurse, she not only eases suffering, she bears witness to life and its earthly ending. Sometimes she's the only witness to their death. But whatever her faith or her instincts about the gray line between life and death, she argues, it's all about looking, listening, being there in the moment.

Nurse Brim: Right? And you just kind of have to pay attention. You just have to pay attention. And there's been, I tell you there's been times when I think I'm so consumed with my personal life because, you know, personal life ups and downs, and it's not all . . . and sometimes you can't leave your personal life at home, and I think sometimes you get a little blocked as to what's going on or right in front of you in the room. But other times not, I don't know. There's been weird things that have happened over the years, that I'm not a religious person, but after working in the ICU for 15 years, I'm not nothing like, because what you see you believe and what you feel like you start looking at things differently.

Stephen: Months on from when she was tested, Brim still vividly remembers the compassion in the masked nurse's eyes as she swabbed her. The way the nurse had gripped her hand so lovingly stayed with her too, holding the very hand that had stopped her patient seconds before he pulled the life-saving tubes out of his neck.

It might seem that her career, her calling, her profession is often bittersweet, but she'll take the pain with the joy every time. There's so much beauty in or in the journey of a nurse in intensive care, she wrote in her email. Nurses have to see the pain and suffering to be able to savor the incredible saves that they are a part of. And for charge nurse, Rebecca Brim, the name Justin Christiansen will remain with her forever as one of those remarkable saves.

Mitch: Next time on "Unit on the Brink," for professionals in the medical intensive care unit, summertime is usually a time of rest and recollection with low patient numbers before the flu season starts in fall. But in 2020, the coronavirus pandemic persisted throughout the summer months with Utah numbers of COVID positive patients climbing even higher than we had seen in spring and hospitalization numbers were following suit.

You've listened to the real and raw tales of those healthcare workers holding the frontline, but the interviews you've heard so far, they were conducted in April and May of 2020, the very first months of COVID-19. How were the frontline workers holding up as we enter the seventh month of the global pandemic?

In the last week of August, the Clinical team sat down with frontline workers to check in and see how they were doing four months after we first spoke with them. Join us next week for the conclusion of our first Unit on the Brink series with episode six, "Waiting to Exhale."

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 podcast? 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 at hello@thescoperadio.com.

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

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music in this episode by ANBR, the Dave Roy Collective, Ian Post, Paper Planes and Ziv Moran. Audio news clips from Sky News.

Special thanks to Charlie Ehlert and Jessica Cagle for their work on the companion site. 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.

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.