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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.

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

I'm Mitch Sears, producer for The Scope Radio. For the past six months, we've been developing a series that really focuses on looking behind the scenes at everything that makes a hospital, well, a hospital, an institution that is not only able to treat diseases and traumas but really heal and care for the patients that enter through those sliding glass doors every single day, stories that look beyond the life-saving efforts of doctors and nurses to the hidden heroes that work behind-the-scenes to keep the heart of this medical institution beating in time with the needs of its community.

Now, the series itself isn't finished yet. We've been put on hold with the international pandemic of COVID-19. But our very first episode, "Keeper of the Keys," is focused on the efforts of the workers who have been killing germs, viruses, and pathogens for decades before we all found ourselves acutely aware of viruses and their spread in the year 2020.

Co-producer Stephen Dark has been reporting on the world of environmental services and talking to these frontline workers about their experience.

Stephen, what made you think about doing a story about the cleaners?

Stephen: Funnily enough, I have a personal connection. As a young man in England, I needed to earn some money to pay for a plane ticket to the States. I worked in the local hospital for a year cleaning floors. What stood out for me is how you get to know not only the structure and physical layout, but also the emotional rhythm of the hospital intimately. Yet at the same time, you feel invisible. It's as if you're part of the furniture or the wallpaper.

As I've walked the halls of University Hospital and seen people doing work I once did, I've often wondered, "What do they see and how do they feel about what they do?"

Mitch: And I'm sure they have a perspective that no one else has.

Stephen: They surely do, and that's what I wanted to learn about. Some come from conflict-torn countries with stories of trauma and suffering. They have built new lives here doing this work. Unfortunately, it's work that's often taken for granted and not as appreciated as it should be. And now, with COVID-19, we have a new urgency to concerns about cleanliness, sterilization, and keeping up our pathogen defenses at all times.

Mitch: Yeah. I mean, it really does feel like a whole new world in just the past few months. And especially for those workers that are in the hospital every single day potentially exposing themselves to an infection, I can only imagine what it's like to be on the frontlines doing this kind of work.

Stephen: One of the things that struck me as these first weeks ramped up was how vulnerable you must feel in a room where a COVID patient has perhaps died and not having the same background of medical knowledge that the nurses and the doctors around you have. And yet being called upon to essentially sterilize that room and prepare it for the next patient, there's a vulnerability and responsibility that has to weigh on your shoulders. And I wondered, "How do you keep coming in day after day not knowing quite what lies in wait?"

Mitch: And in light of the urgency we find ourselves in right now, we spoke with Jessica Rivera. She's a manager of Environmental Services at University of Utah health clinics. And she gave us a first-hand look and what it's like to be on the frontlines as an Environmental Services worker during the time of COVID-19. We at Clinical feel it's so important to draw attention to and recognize these frontline heroes and what they're doing to help keep us all safe.

Stephen: In the days before the virus, when I walked the corridors of the hospital and saw an EVS employee's cart parked by the restroom, one of those "Beware Slippery Surfaces" signs in front of the open door, I couldn't help but flash back 40 years to when I cleaned floors at a hospital in the county of Kent in Southeast England. I spent a year buffing floors, my 7:00 a.m. to 3:30 p.m. days dedicated to dragging a heavy floor polisher all the way to the left, all the way to the right, and back to the left again.

Hospital cleaning has evolved so much in the last four decades, including the name. Not cleaners, not housekeeping, not janitors. We're talking Healthcare Custodian currently, although Environmental Services Specialist is a new term that's being phased in according to some of the folks that we've talked to.

Currently during the COVID-19 crisis, only essential staff enter the hospital, doctors, nurses of course, while other staff such as pharmacists and food prep workers are on an as-needed basis. EVS staff, however, are needed round-the-clock. They are on the frontline with the providers. They are essential to battling the virus, and they provide so much that never makes it to the balance sheet that we'll tell you about in our series.

For now, I wanted to ask this one question: What's it been like for EVS employees to battle COVID-19? They are the first line of defense against the novel coronavirus in any medical facility. Don't they feel vulnerable? How do they keep coming back to work day after day after day to face this invisible killer for $15.75 an hour and benefits?

Jessica: My name is Jessica Rivera. My title is . . . I'm the Environmental Services Director for Community Clinics. I've been working for the university for about going on 12 years. And I make sure that my employees are well cared for and so is the facility, that it's a safe and clean environment for all of its occupants.

Stephen: Rivera's office is in South Jordan. It's next to the Health Center. Behind her is a floor-to-ceiling window that fills the room with light. It's spotlessly clean but not in the least bit sterile. There's a warmth to it that comes from Rivera herself. She has this big smile under a pixie cut auburn hair with just the tiniest of endearing gaps in her front teeth that somehow make her even more human.

She's the first to acknowledge that compared to my days of floor cleaning and waving a dust cloth at patient's bedside lockers, the healthcare custodian's role has dramatically evolved.

Jessica: We are environmental services technicians. Our employees clean to make the environment a safe and clean place, right? There are a lot of hospital-associated infections, so we want to make sure that when our patients come to our facilities, they come here to get healthy and not leave with something.

Stephen: Rivera's 80-odd employees are part of a 235-strong department that's responsible for cleaning all the used medical facilities from Ogden to Provo. She puts her faith in systems, in tried-and-tested formulas, in chemicals and routines. Every day, she and her staff draw a line between life and death with chemicals, sprays, and wipes.

But it's more than that. There's such a personal element to saving lives. As the media went 24/7 over COVID-19, she tried to explain to her team the task before them. It boiled down to two simple words: slaying pathogens.

Jessica: I know there's all this information coming out. So many webcasts and live feeds for all of these things. And I wanted to talk to the team and somehow reassure them and empower them that during these times of uncertainty, where all this new information is changing every single day, we could really protect ourselves and focus on the fundamentals of our cleaning techniques and our foundations. This is something that you do every day and you do it really well. You slay pathogens all day.

And while COVID-19 is scary, it's still a pathogen, and you still follow the same techniques for cleaning top to bottom, and cleanest to dirtiest, and in a methodical manner, whether that's clockwise or counterclockwise. You still follow those same principles, and you'll make sure that the environment is clean and safe for yourself, and our patients, and anyone who comes in the building really.

Stephen: It's a complex process, cleaning rooms and services, ensuring that no pathogen is left alive.

Jessica: We use a one-step cleaner disinfectant. It is EPA and hospital approved by Infection Prevention Control to say, "This is the chemical that you utilize to clean all environmental surfaces."

And then there are multidrug-resistant organisms that particular chemical won't kill. And so the clinical staff will place signs on the door that alert my employees that they need to wear specific personal protective equipment and, in some cases, use a different chemical, making sure that the chemical is on the surface for the kill time or dwell time to make sure that when that time is over, there are no longer any pathogens on the surface.

So each wipe has a different dwell time or kill time to kill those particular pathogens. So for the bleach wipes, it's four minutes. For the gray-top wipes, it's three minutes. And for the purple wipes, it's two minutes. So knowing that that surface has to remain wet for that long to kill those pathogens.

So with COVID, it's following those same processes that we were doing before to slay this pathogen, right? We are just now increasing the frequency of the different areas. So clean the lobby areas more frequently, clean the doorknobs more frequently, our cell phones. Those things that we use throughout the day get cleaned and disinfected more often throughout the day.

Stephen: But it must be at the back of your mind just how big a risk are you facing. Each room you go into, each surface you have to clean in the era of COVID-19.

Jessica: I guess, in some ways, it feels riskier because it's a new virus and there's a lot that we're still learning about it. And if you were to be exposed, we start assessing that risk, and how could we potentially be exposed at work, and what would happen if I was exposed, or if I was tested positive. Those are the thoughts and things that they go through my own mind, through the minds of our employees and our families.

And the pressure of feeling that those who are closest in your circle, your family, your friends, I think has a lot of impact whether or not you feel safe at work, because if they're watching the news, and watching YouTube, and they're telling you, "It's not safe out there. Don't go outside. Don't go to work," that can definitely shake your core.

Stephen: If there's an irony here for Rivera and her staff, it's that in many ways the clinics, the health centers, and the hospital feel safer than anywhere else. That's because of the protocols and the strict measures that are in place, the temperature checking, the universal masking, are there as barriers to the virus. They have the PPE they need, at least for now, and so, she says, they do feel protected.

Jessica: We're protecting ourselves from anyone who's walking in the building that's asymptomatic, and I think that feels super safe. So it's like a mix of a feeling so good, and confident, and safe, and this is the best place to be, but also managing those fears and that uncertainty that kind of creeps up.

Stephen: But when those risks, when those fears, and that sense of vulnerability start to work away at you, Rivera has to be a good listener, especially when her staff come to her for solace and support. Even when she knows she's needed elsewhere, she can't afford to lose any of her staff, especially now.

Jessica: There's a sense of anguish and sometimes even desperation in that they're coming to you and you can tell that they have thought about this for a long time, and it's just really eating at them. I always feel eager inside just to reach out and hug them or fix it. My first inclination every time is to say, "We're going to figure this out. It'll be okay. How can I help? What can I do?"

But I always have to remember that it's not that time yet. I have to be quiet and listen, because I think first and foremost they just want me to understand where they're coming from. And so I try to listen. And sometimes, that ends up being kind of a long affair for me.

I think it's good to have that conversation with them and kind of present that you can go to work and you can be safe. You can be vulnerable and scared, and also you can be brave and confident at the exact same time.

Stephen: Sometimes, though, even the best listener can't change the way someone sees the threat of the virus to themselves and their family. None of her staff have tested positive for the virus, but two quit weeks after the pandemic began in Utah, even though that meant they are unable to claim unemployment in the face of the COVID lockdown and fears of an economic collapse. And further, five of her team have taken time off leaving her to worry if they'll ever return.

Jessica: I had one employee who was sad to leave us. She sent me an email one night and expressed how proud she is of our team and just how proud she was to be out there fighting this good battle. But it's all for naught if the enemy sneaks in at her door because she feels like . . . She's older. She's in that higher risk category, and so was her husband. And she was really terrified of potentially bringing something home and then not having him around anymore. So for her, she said she would miss us and she was sad to go, but that's what she felt like she needed to do for her. And I totally respect that.

Stephen: The second employee has worked for her for five years, and you can hear in her voice how much his departure has impacted her. She says it was for personal reasons, and though she gave him 24 hours to reconsider, he did not change his mind. Rivera has taken over his post at the clinic.

Jessica: I'll be here every day. I'm not going anywhere, so you'll see me every single day. I'll be in the office. I'll come help you with whatever you need.

Stephen: She hopes her example and her presence will make her staff feel safer and more confident at work. But even Rivera, who comes across as so self-assured in her profession, still has doubts.

Jessica: And I know that's just such a hard task right now, even for myself in a sense sometimes. With all of the uncertainty, how do you feel a sense of confidence and the things that you're doing every day?

Stephen: She can't help but take these departures personally. And there are those moments when she starts to question even her own choices.

Jessica: It's difficult not to take it personally. And I think that's an important part that I'm willing to do, is to say, "Could I have done something differently? Could I have done something better? Can I change things? Can I change my tactic or my communication going forward?" and then just being able to know what I can do. And the things that I can't change, I'm just being able to be okay with that and then moving on, just accepting that and moving on.

Stephen: Everyone who works at the hospital during the COVID-19 crisis knows that daily routines and emotional connections have all been fundamentally altered.

Jessica: It's hard not to hug my dad. I don't hug my dad right now, but I did. Even if I saw him for five minutes, I'd still hug him twice or maybe more, a greeting and a goodbye. So we make sure that we do our little elbow touch every day and that he's safe and that he's protected because he's also in that high-risk group. All my sisters, my siblings, my brother, we go grocery shopping for him, whenever he needs anything. The tables have flipped. Now, we're telling him to stay home instead of him telling us to stay home, like when we were teenagers, and to be safe. And he listens to us.

Stephen: If Rivera is a shoulder to cry on, a sympathetic ear for her employees, there's always going to be those moments when she needs someone to turn to.

Jessica: At the end of Tuesday, which was a day filled with problems and things needing to be done, and just a long, long day, driving home at 8:30 at night, talking to my sister on the phone, I definitely cried. And she said, "Are you okay? What's going on, Jess?" I said, "Nothing really. I'm just shedding my tired tears. I'm exhausted."

Definitely ready for a break, ready for the weekend, but there's nothing more to do other than just release the tears and move on to the next thing. And for me, that's a good release. Definitely, I'm not ashamed to cry or afraid to cry. I think it feels good just to get it out.

Stephen: And then sometimes, there are those happy tears too.

Jessica: So to keep it light and to keep it fun, I still like to joke around with my team. I still smile. That's one compliment I get a lot, especially right now, is that, "Your team is amazing. Your employees are great. What is the magic? I see them walking around and they're still smiling. They're still upbeat. They're still happy." And I think that that makes everything a little bit better, a little bit lighter. For me, it's hard to just focus on what's not working. Call me an optimist, hopeful, whatever, but that's how I live my life.

Stephen: There's a history within EVS of managers expressing their gratitude in small heartfelt ways to their staff. Jessica is always thinking about little ways that she can say thank you. She has given each of her employees a mask made by one of her sisters to wear when they go grocery shopping.

But how can we say thank you to such remarkable people? Through the generous support of the hospital's interpreting team, Mitch and I offer our sincerest gratitude in some of the languages spoken by EVS staff. We say thank you for their work, for their dedication, and their unwavering commitment to keeping us save.

[Thank You Message from Interpreting Services]

Mitch: Thank you to all of the EVS workers and everything they do. When we talk about heroes during this pandemic, let's always remember the frontline workers that are slaying pathogens on our behalf 24/7.

Clinical is part of The Scope Presents network and brought to you by University of Utah Health. The show is produced by me, Mitch Sears, and Stephen Dark. Music by Ian Post and Muted Artist.

A thank you to Alisha Barker and Jessica Rivera for being willing to overcome the difficulties of recording while physical distancing to speak with us.

A very special thank you to Melissa Tingey and Yesi Timoteo with University of Utah Health's Interpreter Services. This episode wouldn't have been the same without their help recording over 20 different languages. A full list of the names of interpreters can be found on our website.

And as always, a thank you to The Scope team, Scot and Chloe. I couldn't do without you.

Aarim - Mandarin
Biljana - Bosnian, Croatian, Serbian
Confido - French
Endea - Wolof
Enyo - Fante
Helen - Navajo
Hemi - Indonesia
Karina - German
Lily - Cantonese
Malak - Arabic
Melissa - English
Mennie - Nepali
Rosa - Spanish
Sayid - Hindustani
Yessi - French
Yusuf - Somali, Swahili