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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 2 of "Unit On The Brink," a multi-part podcast series that offers a snapshot of one state, one hospital, one medical ICU, and the frontline workers tasked with treating the most severe COVID-19 patients.

This is a multi-part story told in order, and if you haven't listened to Episode 1 yet, we highly recommend that you start there in your podcast app. Don't worry, we'll be here when you get back. For everyone else, this is Part 2 of "Unit On The Brink."

Man: And at the table, familiar face to our viewers, is Dr. Anthony Fauci, who is Director of the National Institutes of Allergy and Infectious Diseases. Give us a sense of what the government here in this country and the WHO, let's say, are expecting this coming fall.

Dr. Fauci: Well, we know that the virus is here and it spreads easily. We first noticed it in the spring in April here in the United States and the Southwest, and Texas and California, and in Mexico, and then within a period of a few months, it went worldwide. So we know it's here, and we know it's in a pandemic level.

Mitch: That was Dr. Anthony Fauci, the Director of the National Institute of Allergies and Infectious Diseases. You may have seen him on the news in 2020, either at a White House press briefing or a congressional hearing. He's been a sort of de facto figure of scientific and medical thought during the U.S. coronavirus outbreak. Well, that clip you just heard, with the description of an easily spreading virus and how quickly it became a pandemic, that's not from 2020. It's from 2009.

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

Mitch: Influenza A, virus subtype H1N1, or casually called the swine flu, was a virus that spread across the globe beginning in spring of 2009. Well, technically, this was the second time the virus became a worldwide pandemic. H1N1 first entered the history books back in 1918, where it infected over 500 million people and killed between 17 million and 50 million worldwide in just two years. Sound familiar? History buffs probably know it by a different name, the Spanish flu.

The most recent outbreak of H1N1 began in April of 2009, spreading rapidly across Mexico and the United States. In just one month's time, there were 2,000 recorded cases in parts of the Southwestern United States and Mexico. By June, H1N1 had spread to 62 different countries with over 17,000 cases worldwide.

For most people that became infected, the effects of the virus were similar to a bad flu. For others, it could mean death. Unexpectedly, the virus seemed to impact younger people more than anticipated, and treatment for severe cases included the use long-term intubation on a ventilator.

As the calendar turned to July, some specialists at the time believed that the virus would sort of peter out over the summer with increased temperatures and new treatments, but they were wrong.

Man: What I'd like to do this afternoon is give you an update on some of the recent developments with H1N1 influenza. H1N1 influenza is here. It is spreading in parts of the U.S., particularly in the Southeast, and in fact, it never went away. We had H1N1 influenza throughout the summer in summer camps, and now with colleges and schools coming back into session, we're seeing more cases.

Mitch: When schools reopened in the fall, a second wave of H1N1 infections hit the U.S. CDC estimates that by November, 22 million Americans were infected with H1N1. And that was after a vaccine had started to be distributed.

By the time the United States had got the virus under control in April of 2010, the final numbers were staggering. 60.8 million Americans had been sick, 274,000 were hospitalized, and 12,469 Americans died.

If the similarities between the pandemic in 2009 and the current COVID-19 pandemic in 2020 make you uncomfortable, you're not alone.

Some experts like Dr. Fauci suggest that the U.S. may have yet to finish its first wave of the novel coronavirus, and the U.S. death toll has already reached 173,000 as of recording.

For many of the healthcare workers in our story, COVID-19 was not the first pandemic virus they went to war with in the medical intensive care unit. These nurses and doctors already had battle scars from the fight against H1N1 less than a decade ago, and frankly, some are still dealing with their trauma while they don their PAPRs and N95s once more to battle a new and deadlier foe.

Presented by Clinical and written and reported by Stephen Dark, this is Episode 2, "Echoes of the Past."

Stephen: Lynn Keenan, MD, wanted only to practice medicine.

Dr. Keenan: I always wanted to be a physician. Always. There was nothing else, all my life.

Stephen: Nothing else?

Dr. Keenan: Nothing else.

Stephen: Born and raised in Philadelphia, after graduating high school, she joined the U.S. Army since it would put her through medical school. For the last three years, she's been pulmonary critical care attending physician at the medical intensive care unit at University of Utah Hospital. And the roots of her passion for medicine, it's certainly in her family. Her grandfather was a physician, but the connection goes further back than that.

Dr. Keenan: My great-great-grandmother was the fifth woman physician in the country.

Stephen: Marie DeVoll, MD, went into medicine after her husband, the captain of a whaler, whose brutal treatment of his own crew led to a mutiny and his murder, left her with four children to support. Back then, however, a woman physician wasn't well regarded by many. Not that DeVoll let that stand in her way.

Dr. Keenan: She actually joined the public health service because no one would go to a woman physician in the late 1800s. She graduated Harvard Medical School in 1878, and she went out to Dakota Territory and worked for the Indian Health Service, and then came back to Augusta, Maine, and founded a hospital.

Stephen: Back in DeVoll's day, a physician would walk with a staff, a holdover from the days of the Bubonic Plague when such staffs identified medical practitioners to the public. The staff bears both an hourglass and wings, a reminder to all who saw it that time is fleeting. Keenan has the staff now, but that's not the only gift her ancestor handed down through the generations.

Dr. Keenan: She's a role model of independence and doing what you needed to do in the setting of adversity.

Stephen: Keenan left the military in 1997 and, after a spell in private practice, eventually ended up at University of Washington in Seattle to both teach and work in the ICU. And what drew her to the ICU? The saves.

Dr. Keenan: The rewards of the saves, seeing people come in gravely ill with multiple organ failure and working very hard and diligently with them and bringing them back to a meaningful quality of life and seeing them in the office later on back at their normal life.

I have one gentleman I took care of during the H1N1 in Seattle who was in the ICU for three weeks and intubated for three weeks. And just seeing him going to his wedding and seeing him go back to a normal life.

Stephen: H1N1. Worldwide, the CDC estimated that in the 12 months to April 2010, 12,469 Americans died from complications relating to the virus. Worldwide deaths totaled 575,400 in those same 12 months, the vast majority under 65. Keenan was in Seattle when H1N1 hit.

Dr. Keenan: So it came on the radar about May 2009, and then there was a lull in the summer and then resurgence in the fall again. And the striking part about it was the two populations that it really effected most, the young population in their 20s, and young and obese in particular, and then older patients over 65 immunocompromised. So just that bi-modal type of disease. They were profoundly ill with acute respiratory distress syndrome and had tons of secretions.

Stephen: ICU beds were filled with patients struggling to breathe, some sedated into temporary comas, and turned onto their stomachs, a practice known as proning, so the lungs could recuperate from the constant pounding they were receiving from the ventilators.

Dr. Keenan: I mean, our ICU was filled with people who were proned for weeks with refractory hypoxemia, because you breathe better and it's better for your lung health to recruit your lungs and less sheer forces on your lungs to be proned and supined.

Stephen: And were you losing many patients or were most recovering?

Dr. Keenan: Actually, we didn't lose any, which was amazing.

Stephen: At University Hospital in Salt Lake City, Alisha Barker was just two years into being a registered nurse when she encountered swine flu in the MICU. The arrival of the pandemic threw her and MICU stuff into a traumatic world where the young died so quickly, they didn't have time to send the body to the morgue before the next patient was coding.

Alisha: I remember it being . . . it was just like one shift we started to get really sick patients. And it was like someone just flipped a switch, and all of a sudden, we had three patients coding in one shift. To have at least three patients code and die during your shift became kind of normal, which it was just . . . It was very exhausting to have so many sick patients at one time.

I just remember feeling very tired, very taxed, I guess, just being like, "What is going on?" And it was a lot of men in their age ranges of, like, 20 to 50. Those were the patients I remember being extremely sick and who would die, were these younger men who would just come in like balls of fire, would just go out in a blaze of glory basically. It was really hard.

Stephen: Blaze of glory?

Alisha: A blaze of glory. Like, they were just very sick and we were . . . yeah, respiratory failure, in septic shock, and you're working frantically to try and save them.

Stephen: During H1N1, Barker started to feel that her face was almost permanently welded to an N95 mask, which protects the wearer from airborne droplets. She had to wear the mask so often during crisis moments with patients, it became synonymous with fighting to keep patients alive or losing the battle.

Alisha: I find it ironic. So we would wear the N95 masks really tight to your face, coding patients, doing CPR, and working frantically to try and save these patients' lives. And you're gowned up in this PPE with N95 masks on, and you're hot and it's exhausting.

If you've ever done CPR on a patient where you're pushing on their chest, you do it for two minutes at a time and then you check their pulse. Well, after about 20 seconds, it feels like you've been doing it for two minutes and you look up at the clock and you realize it's only been 20 seconds and you've still got to go for quite a bit longer. And so doing that . . . and it's a young person who normally wouldn't be in your unit, and it's just kind of . . . it's shocking.

Stephen: The mask became a painfully oppressive reminder of the anguish she went through each time she tried to keep a patient alive, only to lose them to the virus.

Alisha: I couldn't wear an N95 mask for a long time. It actually made me claustrophobic. I can't be on elevators, like crowded elevators. I don't care how many flights of stairs it is, I will take the stairs versus get on a crowded elevator.

Stephen: Along with claustrophobia, the mask also induced panic.

Alisha: Wearing the mask and coding so many patients with that N95, with wearing an N95 mask, it gave me a panic when I would put it on. It made me panic. Being physically hot, trying to save someone's life, working frantically, all while you've got this mask on your face and . . . yeah.

Stephen: By the time the second wave of the H1N1 hit in the fall, Barker had even more concerns.

Alisha: I was pregnant with my first child, and I remember being very wary and frightened, in a sense, to take care of these patients, just because of the risk that I was putting myself and my unborn child in. But no one that I know of got sick, no staff members, which is a testament to when you have the proper PPE and you put it on and take it off properly.

Stephen: The horrors of the 2009 pandemic remained largely behind closed hospital doors. COVID-19, however, began making inroads into the American consciousness in January 2020, as global media reported the virus' emergence in Wuhan, China, and its first fatality on January 11th.

Man: Meantime, the World Health Organization holds an emergency meeting today to determine whether to declare a public health emergency regarding the coronavirus. Chinese officials say the death toll's risen to 170, 7,900 cases worldwide, and the number of cases in China surpasses the total cases during the SARS epidemic of '03.

Stephen: By January 21st, the United States had had its first recorded case in Washington State, and two days later, China took the unprecedented step of quarantining Wuhan, a city of 11 million people.

By mid-February, the disease had a name, COVID-19, and had been confirmed as a global pandemic by the World Health Organization. Deaths were also being confirmed in France, Italy, Iran, and South Korea.

Man: And an update now on the coronavirus outbreak in Italy. The government's racing to contain the biggest outbreak of the virus in Europe, imposing restrictions on about 100,000 people and shutting down public gatherings.

Stephen: In Utah, some began to panic. People hoarded toilet paper, masks, food. Grocery stores couldn't keep their shelves stocked as panic buyers stripped them of everything.

Woman: Nearly 1,200 people poured into the South Jordan Costco this morning, up about 450% over a regular Thursday.

Woman: I definitely want to stock up, make sure I have everything I can, because I don't know what's to come.

Stephen: MICU nurse Cat Coe, and her partner, Jeremy, had decided to take a break from social media and the news cycle, and so were unaware of the pandemonium around them. She had heard a few stories about the virus' impact in Italy, but it was her neighbors who first alerted them that things weren't quite right in their hometown.

Cat: Honestly, my neighbors told us that they had gone to Costco and stocked up on food and toilet paper and stuff. And we were both like, "What?" I mean, they're good friends of ours and they're saying . . . and we are like-minded in a lot of ways, and we were just kind of like, "Oh my god, this is maybe a bigger deal than we thought."

Stephen: Then her friends began canceling trips abroad.

Cat: I think actually the wakeup call for me was listening to an episode of "The Daily" where they interviewed an Italian doctor and he talked about what was happening at their hospital. It just sounded like a war zone. He described it like a war zone. That put a picture in my head of what this thing could do if there weren't any efforts to control it, I guess. And I actually started to get pretty scared after that.

Stephen: Coe started at the MICU in October 2017. It was a dream she had aspired to for years. While she had studied magazine photojournalism and English at Georgia University, and gone on to become an instructor in rock climbing, backpacking, and mountaineering, as well as a mountain guide in Jackson Hole, in her heart, she yearned to be a public servant. It was that desire which drew her in her early 30s to nursing.

Despite professors at Montana State University College of Nursing advising her post-graduation to do a year on a hospital floor rather than plunge straight into the ICU, at 34, she felt she had no time to waste. Coe wanted to get to the ICU as soon as she could. She successfully applied for a nursing position at the University Hospital's MICU, only once there to quickly question her haste.

Cat: Oh my god. Let's just say I was like, "Why did I think I wanted to do this?" It was so hard. Like, I have never felt so dumb as an adult. The learning curve was just . . . it was so much steeper than I ever could have imagined.

Stephen: Her first day, an elderly patient coded, meaning she went into cardiac arrest.

Cat: Seeing someone arrest before . . . I'd never even seen people doing CPR, and I did CPR on my very first day. Yeah. Obviously, I'll never forget that. That's so significant. I think the first time you ever have to do CPR, you're breaking someone's ribs and potentially cracking their sternum, and to pound that hard on another person's chest, it feels so . . . it's what you have to do to resuscitate someone, but it also feels so barbaric.

So I think it just . . . it was shocking to me to feel myself doing that to another person. But then also, I was really proud that I knew how to do it and that I was in a position finally after so many years of school and training and thinking about working in the ICU . . . I don't know. It was a lot of mixed emotions. I went to the bathroom and cried.

Stephen: Drinking from the MICU fire hose for 18 months is super stressing, she says, to the point where it started to undermine her engagement with her work. And then in January 2019, a friend in Montana invited her to join a climbing expedition to Patagonia, Argentina. Coe went to see her manager at the MICU.

Cat: And I was like, "Here's the deal. I've been asked to go on an expedition that could be a once-in-a-lifetime kind of thing. I really want to do this. And basically, I'm going to do what I have to do in order to be able to go." And she was so awesome. She was like, "We'll make it happen. Tell me the dates, we'll make it happen, and you'll still have your job when you come back."

Stephen: Coe and her climbing partners scaled multiple routes in the Andes and in the Fitz Roy Massif in Southern Patagonia.

Cat: The weather is heinous. It's insane. I had never seen anything like it guiding in Wyoming or Montana. The wind can literally pick you up off your feet and flip you over. It's crazy. But it was cool. It was what I needed, was to just go out in the mountains and get completely worked and remember what I have here that's really good, you know?

Stephen: She came back to the MICU committed, recharged, and grateful that she had both her vocation and the job to pursue it. If Coe had been largely disconnected from news feeds and social media as COVID-19 started to make inroads in the U.S., the MICU's Lynn Keenan, MD, first heard about the virus taking American lives from former colleagues in Washington.

Dr. Keenan: It came into my radar in about January or February, and particularly when the cases popped up in Washington, and it just remind me of H1N1. I keep in touch with all my colleagues from Washington, and they said it was similar, but different. H1N1 had a lot of secretions. Patients with COVID tend to have a lot of really dry, unrelentless hacking cough.

Stephen: Registered nurse, Megan Diehl, who joined the MICU a year after Coe was also hearing about COVID-19 from friends at her former place of employment.

Megan: I was a nurse in Seattle before I was here, so I had heard a lot about what was happening there. And it was, "Oh, they've got a case of it in Seattle." And then, "Oh, now there's this many cases." And it was just . . . things kept popping up

Stephen: The diagnosis of COVID-19 cases on U.S. soil had special significance for MICU staff. The MICU is the hospital's code bio unit, which means that along with dealing with severely ill patients, they also take patients who have been given the code bio designation.

Code Bio B for blood-borne and body fluid illnesses, such as Ebola, which requires staff to wear head-to-toe suits, and Code Bio A, for airborne and droplet diseases, such as COVID-19 and measles. Code A requires wearable air purifiers or N95 masks and shields, along with contact precautions, namely gowns and gloves.

As the biohazard unit, the MICU is designed to enclose itself away from the rest of the hospital and the community, explains nurse Megan Diehl.

Megan: Our unit is set up so that we can put a wall down over four or five rooms and then kind of separate that, like section it off, so that all of those are negative pressure rooms.

Stephen: In total, there are nine negative pressure rooms, each with a vent to the outside, and specialized filters that trap anything infectious. After COVID-19 was categorized as Code A at the beginning of the coronavirus crisis, two nurses were put in charge preparing the unit's response to the virus. Patients were moved to other units. The code bio area was isolated and staff trained.

But as the patient load climbed, so they had to adapt their protocols, and staff required further training on how to not only deal with an evolving medical crisis, but also the protocol of donning and doffing of specialized protective equipment.

Megan: We had to change our scrubs and you had different shoes that you would wear. And there were certain protective equipment, and then there are different zones that you stand in. It was like, "In this zone, you have to take this thing off and wash your hands like this." So it turned into . . . it was an interesting start because we hadn't done that, but they had been preparing for it.

So we started doing this code bio thing, and we would have two nurses for one patient and another person back there to help read the steps of when you put everything on and take everything off. And it was eating up a lot of our staff because you have to have, like, three nurses for one patient.

Stephen: As the first COVID-19-positive patients came in, so protocol changed.

Megan: We probably had, I don't know, 9 or 10 patients come through that we put in those rooms, and then the CDC changed their recommendations of what kind of precautions to be on. And so we put the wall back up and put all the other stuff away, and then it was just regular droplet and airborne precautions. So it started out really weird with the code bio stuff, but it felt really intense.

Stephen: COVID-19 required new protocol for personal protective equipment. Those policies would change each time the Center for Disease Control issued new guidelines.

As more COVID patients occupied MICU beds, Cat Coe found her initial assumptions that the virus was another form of influenza immediately challenged. Suddenly, the personal stakes for staff felt much higher.

Cat: We started to get our first few, and one of them is fairly young and no past medical history, and that really worried me. I was like, "Oh, okay. This is . . ." because I think leading up to that, I thought, "Oh, it's like another flu. If we get it, we get it, but we'll just basically have the flu." And then I saw this patient that was incredibly sick. Very, very sick.

He very quickly went from having classic upper respiratory infection signs and symptoms to going into ARDS, so acute respiratory distress syndrome. And seeing a young person with no past medical history going to ARDS from a virus that I previously thought was like the flu was a game changer for a lot of us in the ICU and the way that we thought about coronavirus.

Stephen: Along with the stress of seeing patients inexplicably deteriorate, nurses like Megan Diehl also had to deal with seemingly constant changes in protocol when it came to PPE and patient care.

Megan: There are so many things that change all the time with what are you supposed to wear, and who's going to be in the room, and this, and that. And so it's been . . . I think it's just stressful because so much changes, and we want to make sure that we're protected, but we want to be following the rules and doing the appropriate steps. And it feels like the steps are always changing.

Stephen: The virus has impacted her professional life in so many ways, whether in terms of trying to conserve PPE or handling how she enters her home after each shift.

Megan: I definitely have changed my work kind of routine. We were changing scrubs . . . most people still change scrubs when they work with those patients into the hospital scrubs. At the end of the shift, I put my scrubs in a bag and I have shoes that I only wear at work. And then I change shoes and change clothes before I go home. And when you get home, you put your bagged clothes into the laundry. It feels like we're doing the right things, but there's always kind of in the back of your mind, like, "Well, what if I were to get it?"

Stephen: Some didn't want to care for COVID-19-positive patients, not out of concern for themselves, but because of responsibilities at home.

Megan: I know a lot of my coworkers have kids at home and they're worried about bringing it to their kids, or they live with family that's immunocompromised and they're like, "Well, I don't want to have those patients because I don't want to take it home to them." And that makes sense.

And so I feel like some of us feel like we should have those patients more because we are not in contact with other people that would be hurt more by it. And we have 2 nurses too that are over 60, probably. I don't know how old they are actually, but we always try to put them on the other side of the unit or not let them take care of those patients because there is a risk.

And so you think about it, but I feel like our management team has been really great at getting us prepared and making sure we have what we need. And I fall back on that, I think, of being like, "No, we're prepared. We're ready. We'll be fine. We're taking all these steps." But you still shower when you get home right away. Some people even shower at work and then shower again when they get home. So it's changed a lot of things.

Stephen: Recollections of H1N1 inevitably haunted some of the healthcare workers. And when nurses like Barker drew comparisons between H1N1 patients and the symptoms and fate of the first COVID-19 patients, their sense of apprehension only grew.

Alisha: Oh, god. Similarities are the acuity of the patients. They're very sick and time-consuming, and the risk . . . I remember feeling, especially when I was pregnant, just very frightened every time you put on your PPE and you think about it. You think, "Okay. I hope I don't get infected with this." And then you're taking it off and you're making sure that you're wiping things down and sanitizing your hands. I think that attention and that pressure that you feel when you're taking care of these patients, that is similar.

However, COVID, the patients . . . the death rate is higher and there's more fear around it. And maybe it's because I'm a more seasoned nurse and I know more. During H1N1, I was two years into my nursing career, where I knew enough, but I wasn't as well-rounded as a nurse as I am now.

Stephen: Barker found comfort in her wealth of experience as a nurse. She felt like she and her colleagues were akin to a medical version of the Navy Seals when it came to fighting the virus.

Alisha: It's a bit of dread like, "Oh, here we go," but then also realizing, "Well, we take care of these types of patients all of the time who need these respiratory . . ." We're wearing this PPE. We're very used to wearing this PPE anyway. And so I almost feel like we're kind of like . . . it sounds cheesy to say, but almost like the special forces of this. We practice this all the time. We're very good at it. We're the experts at it.

Mitch: Coming up next on "Unit on the Brink," the staff at the University Hospital MICU are some of the most well-prepared individuals to help save the victims of a global pandemic, but all of their protocols, all of their training, and all of their experience was about to be tested.

Man: We do start off with breaking news tonight. Late this evening, Utah becoming the latest state to have a confirmed case of the coronavirus.

Woman: A Summit County man is believed to be the first person in Utah to have contracted COVID-19 through community spread.

Mitch: As the number of infected individuals rose in Utah, the unit began to see a rise in the severity of the illness in some of their patients, and in turn, the medical staff had to escalate to more extreme measures to fight back against the virus and save their patients' lives.

Woman: When you're on a ventilator with ARDS, typically what we'll do is, yeah, put people into a coma by sedating them as well as . . . often, we'll paralyze them, pharmaceutically paralyze them.

Dr. Keenan: I always tell patients, particularly before I put a breathing tube down or any time, that we're here to take good care of them. And I always tell them what the plan is for the day so that they know, and I tell them how they're doing, if they're doing the same, and I tell them in my world stability is a great thing.

Mitch: Join us next week for Episode 3, "Isolation Protocol."

Clinical is part of The Scope Presents network and brought to you by University of Utah Health. If you liked what you heard, please be sure to subscribe and share with your friends. You can also help others find us by leaving a review on Stitcher or Apple Podcasts. Those reviews really help out new podcasts, and we really appreciate them.

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

And finally, if you want to see the inside of the MICU and the faces of the brave professionals in our story working to save lives, you can visit our podcast companion site at thescoperadio.com/clinical. Click on "Voices from the Front Line." There, you can find bios and pictures from the frontline healthcare workers, bonus content, and teasers for future episodes. That's thescoperadio.com/clinical.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Music by Ian Post, Yehezkel Raz, and collective artists. Audio clips from CSPAN, CNBC, and KUTV. Special thanks to Charlie Ehlert and Jessica Cagle for their work on the portraits and companion site. And, of course, a heartfelt thanks to the men and women who have shared their stories with all of us, and fight to this very day to keep each and every one of us safe.

Interviewer: By focusing on the opioid epidemic, are we missing the bigger problem? We'll talk about that next on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From the University of Utah Health Sciences, this is The Scope.

Interviewer: Mark Ilgen is an associate professor at the Department of Psychiatry at University of Michigan, and much of his current work focuses on improving treatment outcomes for patients struggling with substance abuse disorders that are also complicated by co-occurring problems like chronic pain. Dr. Ilgen, when you say that to really solve the opioid problem that the conversation needs to be about a bigger issue, can you tell me what you mean?

Dr. Ilgen: The topic of opioid use and opioid overuse has received a lot of attention in the national media. You often hear about what's often called the "opioid epidemic" as something that's grown within the last 5 or 10 years, but prior to even the last 7 to 10 years, there was still the problem that many individuals with pain were not functioning well. And a large portion of those individuals coped with their pain by misusing or overusing substances, and that's not limited to opioids.

Someone can drink too much to manage their pain, use marijuana to manage their pain or overuse marijuana to manage their pain, or use either street or prescription opioids. And so the broader issue of pain management has, in some ways, been lost. And there's really a lot of concern that in our conversation about, "How do we keep people safe from opioids," that we might also be losing sight of the fact that many people still have chronic and poorly-managed pain. And those individuals are often left without a lot of very attractive treatment options.

Interviewer: So what can you do? What is the bigger solution to the problem?

Dr. Ilgen: I think that pain management as a topic is one that I think we need to be giving more attention in our health care system, so it's a difficult topic for a lot of treatment providers to discuss. And I think a big part of why opioids became the problem that they are now is that they presented or were, in some ways, billed as a solution and as an easy solution to the problem of pain. And so that was appealing to primary care physicians and other treatment providers because they felt like they could do something to help someone who was struggling with chronic pain.

But a true, honest conversation about chronic pain requires going into more depth, understanding what the patient's going through, getting better diagnostic information about the pain, and then coming up with coping strategies that are more comprehensive that go beyond what you can usually achieve with a medication.

Interviewer: What are some of the solutions that you're seeing out there that are offering some promise?

Dr. Ilgen: Well, the hard thing with . . . it's a very complicated issue, and the solutions to pain are going to look very different, depending on the nature of the chronic pain. So again, unfortunately, for a long time, the solution to chronic pain was often pitched as opioids, and those were applied across a number of chronic pain conditions, from fibromyalgia to migraines to lower back pain.

But in fact, the different solutions to the pain conditions often really vary substantially, depending on what the presenting problem is. So a first step in doing something about the pain is just to make sure you get an accurate diagnosis, and in many cases, that means going to a pain specialist and getting a better sense of what's actually going on.

And for a lot of individuals who have musculoskeletal pain, they need forms of treatment that focus on their physical functioning as well as their pain level. And most effective treatments for long-term, let's say, back pain involve both helping the person manage the pain in the moment, but also helping them remain active in their life, get physical therapy, in some cases get certain pain-specific types of psychotherapy that help them cope with their pain and better adapt to the pain condition.

Interviewer: And to some extent, I would imagine one of the challenges, too, is helping us, as patients, overcome this notion of the easy solution of the pill, like the pill or the painkiller is the ultimate thing. Because physical therapy and staying active, all that stuff take commitment and work, and people can also be skeptical that that's actually going to do anything.

Dr. Ilgen: Exactly. I think managing expectations around what is or isn't possible is very important, so unfortunately, often the case, that you don't have an easy solution to the pain. Instead, you're looking at scaling back on the pain from a level that really is impairing to a level that's easy to cope with. But it often doesn't go away. It's just at a lower and more manageable level.

Interviewer: Yeah, so as a patient, suffering from pain from a particular condition, it sounds like your recommendation be, first, make sure that I have an accurate diagnosis of what's causing that pain. So then that would lead to the ability to come up with a plan to help manage that pain, which comes back to your concept of it might not go completely away, but you do what you can do. And then, at that point, just realize that it's a process, and it's going to take some time, and maybe that's a good trade-off for the downside of a potential addictive substance that could ruin your life.

Dr. Ilgen: Yeah, and I don't want to overstate the potential downsides of opioids. So there's a lot of controversy in the field about whether opioids are ever an effective and appropriate treatment for chronic pain, and then, if so, at what level? And I think those decisions are just made on a case-by-case basis with a treatment provider.

What we see that's problematic is when someone is taking a moderate or high dose of an opioid and not getting a lot of relief and then ends up escalating and needing a higher dose to get some relief and then even that's not working, that's when someone's kind of going down a path towards not getting a lot of return on the medication. It's not really giving them a lot of pain relief, and the risk for side effects is going up.

And that's when you really want to be concerned and be careful and to stop and have a really frank conversation with your treatment provider about, are you on the right path here? Or are you really getting greater and greater physical dependence on the medication for either continued not-very-good or maybe, in a lot of cases, a worse degree of pain relief than you did initially?

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Interviewer: Are concussions more serious than people think? We'll find out next on The Scope.

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Interviewer: Dr. Greg Hawryluk is a neurosurgeon at University of Utah Healthcare. It seems like there's a lot in the news and in popular culture about concussions nowadays, and we're starting to learn that maybe they're a little bit more serious than we first thought. It feels as though at one point, if you got a concussions somebody would go, "How many fingers am I holding up?" If you passed the test, great. You're okay. But it's a little bit more serious than that, we're starting to learn.

Dr. Hawryluk: That's exactly the case. First off, what I can tell you is that it's probably an epidemic. There's probably way more concussion out there than we've ever really known. We're only now starting to see a lot of people coming to doctors with their concussion.

Interviewer: So how serious is a concussion in terms of the damage caused to the brain?

Dr. Hawryluk: The problem there is that we really don't know. We don't think that a concussion implies a structural injury to the brain. We still think that it's probably sort of a chemical imbalance. But there's no question that we do think it puts you at risk for ongoing damage to the brain, perhaps over the rest of your life. We are seeing something we call chronic traumatic encephalopathy, changes consistent with Alzheimer's disease in the brain. It really is suggesting that athletes need to be a lot more careful in terms of avoiding concussions and having them treated by a doctor, than has been the case in the past.

Interviewer: So a concussion is when your brain actually hits your skull. Right? So it's not a physical bruise in terms of like what a muscle is. But it causes a chemical imbalance. Explain that.

Dr. Hawryluk: Yeah. There's a few misconceptions about concussion. So one is that you don't actually have to hit your head to have a concussion, and you don't have to lose consciousness. Really, all that has to happen is your brain sloshes around inside your skull. The hallmark is that there's at least a temporary change in brain function. But in fact, we don't see bruising of the brain. We think that probably it's a chemical imbalance that leads to the brain dysfunction. If it gets to the point where there's actually bleeding in or around the brain that is an even more serious condition.

Interviewer: What does that chemical imbalance look like? What's going on there?

Dr. Hawryluk: It's something we really don't understand. It's something that's hard to study. What's really funny to me as both a neurosurgeon and as a scientist is that we haven't made more progress in this field. We can put people on the moon, but we really don't understand what's going on. In some senses, we're sort of at square one with concussion. The important thing is that we're recognizing the significance of it. But there's an awful lot more work to do to figure out what's going on and how to best treat these.

Interviewer: If I understand correctly, a single incident can be bad, can cause symptoms and damage. But it's the multiple incidents without recovery time that you're really worried about.

Dr. Hawryluk: Well, that's absolutely true. We're concerned about both cases. One concussion is certainly a concern and has to be appropriately treated. These days, we certainly advise that every concussion should be seen by a doctor. But our level of concern as physicians goes up quite a bit when we start to see multiple concussions. The worst case scenario that we worry about as doctors is basically a repeat head injury before the first concussion is fully resolved.
The reason that that's so important is because we actually see people die from that. There's something called "second impact syndrome." So if a player, for instance, goes back to playing football before their first concussion is resolved, some of those patients have died. We know that there's a tremendous amount of brain swelling that can occur in that instance, and that's one of the biggest things that we're trying to avoid and get word out to both players and coaches. That once you've had a concussion, you need to sit out and be seen by a doctor.

Interviewer: Outside of football is that the case, say for example, I was skiing and took a hard hit and got a concussion. Could the same thing happen if I got a second concussion as a football player?

Dr. Hawryluk: That's absolutely the case. One of the challenges with concussion is that a lot more things can cause concussion than I think a lot of people realize. Football is one that we would all think of. But I always tell people, I remember a time when I was younger and when I was on a roller-coaster, and I'm pretty sure I had a concussion on that roller-coaster. So, really anytime that you're jarring your head around that's a big issue.

Interviewer: If I get that one-time concussion, whether I'm playing a sport or in an accident, or something like that, should I be super-concerned above and beyond seeing a doctor?

Dr. Hawryluk: Well, the biggest thing is to see a doctor. The biggest change of concussion management over the last 10 years has been the idea of rest and graduated return to normal activities. We do think that we've learned that that leads to the best recovery from a concussion. After any sort of a concussion, the minimum amount of time it takes to fully get back to what you were doing before in terms of activities is about a week.
Some recommendations say that in children it should probably take twice that long to get back to normal activities. So, that needs to be medically supervised. There's usually six steps that we talk about as people go back to their normal activities. The good news with concussion is that the vast majority of people have a resolution of their symptoms and ultimately do quite well. There are, however, a minority of patients, maybe 20% that even six weeks out from a concussion are still having trouble, something we call "post-concussion syndrome." But the good news is that fortunately that's a minority of people.

Interviewer: Are there long-term repercussions to concussions then?

Dr. Hawryluk: Well, there certainly can be. So we think that at some level there is a brain injury, and we certainly worry about the accumulative effects. We are starting to learn, again with these professional athletes that perhaps these seemingly minor blows to the head when they're accumulative can lead to depression and behavior change. In fact, we think that maybe even some suicides have been linked to this.

Interviewer: Which comes back to that chemical imbalance [inaudible 00:06:16].

Dr. Hawryluk: That's exactly right.

Interviewer: That makes total sense.

Dr. Hawryluk: Yep.

Interviewer: What's the future hold? What do you think we're going to find in the next 5, 10 years? You said it's in its infancy. Where are things going?

Dr. Hawryluk: Yeah. It's a time where the concussion field is advancing in a lot of different directions. We're learning more and more about the basic science of the condition. We're learning more about how to treat these patients and how to manage them in terms of their sporting activities.
One of the things that is something I think an awful lot about is people that are participating in contact sports. I'm hearing a lot of parents these days with reservations about having their children play hockey or football. I think to a certain extent that's reasonable. But if I look back on my own life, the lessons that I learned playing sports with other kids is so important for socialization and it's important to be active and to be healthy.
So I just have a bit of concern that the way this conversation seems to be going is should kids be participating in some of these sports? What I always counsel my patients and their families is that I really think participation in sports have so many benefits that I hate to see kids pulled out. I think really what's important is encouraging safe play. The reality is that most concussions we think are probably preventable. Teaching players to treat each other with respect, to obey various rules for safety, I think those are the key. Again, I just worry about kids not participating because of some of these fears.

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