Search for tag: "pandemic"

Mitch: We're here at the AAMC Learn Serve Lead Conference having conversations about how different organizations within academic medicine are rising up to meet the challenges of the modern world, and what's happening to improve equity, diversity, and inclusion within our organizations.

Today, we are joined by Nafisa Masud. She is a content specialist with University of Utah Health. We're also joined by Natasha Ovuoba. She's from Huntsman Cancer Institute and she is the Associate Director of Equity, Diversity, and Inclusion. As well as Abdulkhaliq Barbaar, who is the Director of Equity, Diversity, and Inclusion at the University of Utah Health.

So one of the things that we wanted to talk about here today is what is life like in our space dealing with burnout after COVID? The novel coronavirus came. It changed everything. We had the Black Lives Matter protests. We had marches and movements. We had press releases. Nafisa, you and I working on those press releases, trying to educate the public about things. It's now been years after that and we're . . . I don't know. For me, at least, it still feels like I'm dealing with burnout. My team is dealing with burnout.

What are you guys seeing in your own organizations? And what are you guys trying to do to acknowledge that experience, move forward? Yeah, let's just have a conversation about that.

Natasha: Yeah, you are not the only person dealing with burnout. An analogy that I like to think of is if you've ever been someone who is trying to zero-scape your yard, so to make it more eco-friendly, use less water, oftentimes you sort of change that grass, some of those flowers to rocks, or to concrete. And oftentimes, it might seem easy to just scrape up the grass and to just lay down some rocks and say, "Okay, I'm done." But then in a few months, especially as the weather warms up, you start seeing that grass, those weeds grow right back up through those rocks.

That, I think, is the moment where we are right now with our burnout. Because we've said, "Okay, we're through COVID. Vaccines are out. Boosters are out. We've got masks available. We're out of the crisis." But we've never laid down the tarp that is supposed to act as that block barrier for weeds to stop growing altogether.

So really, what we're experiencing right now with the trauma of COVID, with the trauma of the racial reckoning, we are experiencing this place of, "We're done. We did it. We hired the EDI teams and directors, and we don't have to worry about COVID." And our clinical staff, our operation staff is all going, "I never laid down that tarp. I never put in the barrier of protection to stop the pain and the hurt from creeping back up through my rocks."

Mitch: Sure. So we're still experiencing burnout. We're still having trauma responses. We're still dealing with those very real raw emotions. How about you, Nafisa? How are you feeling, I guess, after COVID?

Nafisa: Yeah, that's a big question. I think I find myself swinging on a pendulum where it feels like no time at all since COVID first hit, and at the same time, it feels like we've been doing this for years longer than we have.

And I think something that in a strange, twisted way has made me grateful is that COVID has forced me to reevaluate a lot of the practices that I had in place in my workplace. And also, just personally, I think realizing that in some ways the way that we were working, the way that we were communicating, the topics that we were focused on are just not sustainable, or it's not correct, or it's not accurate, or it's not inclusive.

And so that was an interesting awakening for me to realize that I have limitations. I have boundaries. And historically, that's been an issue for me to verbalize and to really put in place.

And then I think as far as the EDI sphere, it really has been an awakening in a lot of ways, not only to the issues that I think as a person of color you're aware of, but that you also now feel a responsibility to make others aware of and to devote more of your time and your communications to covering those topics.

So there definitely felt a greater sense of urgency and meaning to covering those topics. And I think in some ways it's great that we've had that momentum, but it was also a long time coming, and that's the difficult part.

Mitch: You and I both are working on the EDI group within our marketing and communication field, so I've seen some of the stuff that we've been trying to do and some of the great steps we've taken in one way or another.

One of the things I wonder just for you specifically as a content creator and promoter and so forth is what is the biggest shift pre- and post-COVID for you? I mean, we went in assuming one thing about what's going to happen in a pandemic, what's going to happen after a pandemic, and now we're spit out the other side. How has your strategy and your team's strategy changed?

Nafisa: Yeah, that's a good question. I think the biggest takeaway for me really is that our communications are not one-size-fits-all, and our decisions as a healthcare system are also not one-size-fits-all.

I think in the past, when we were rolling out a policy change or a program, it felt very one-dimensional. And in some ways now, I feel like we're more aware of the fact that health issues like COVID are affecting communities in vastly different ways. And it's also highlighting ways that they struggle to access care or be treated equitably when accessing care.

And so I think it's caused me to realize that when I'm creating any form of content, I cannot have just one goal and I cannot have one audience in mind, because it is so complex and so multi-dimensional. And I owe it to those audiences to really tailor our content and center them in a way that they haven't always been.

Mitch: Absolutely. I mean, one of the things that I find interesting is that we're part of a university, right? We're part of the public education arm, and now we're starting to really think and really, really devote time and energy and resources to making sure that everyone can understand us? I think that's a silver lining of everything that happened.

And how about you, Abdulkhaliq? What are some of the things that you've seen pre/post/after COVID? What's going on right now burnout-wise, and what is your group doing to recover?

Abdulkhaliq: Thank you so much, Mitch. And thank you, Nafisa and Natasha, for great points. I think working in the EDI space, burnout is a topic that we should always and constantly discuss with our teams. Because working in the EDI space trying to change policies, procedures, and practices, we are always swimming against the current.

Therefore, checking in with our team, how are they doing, how is the week going, before we even get into work, right? Just checking in, self-care. How are you taking care of yourself? How are you doing? It's critical to surviving in this type of space.

And what we have seen in the community . . . Because we are the bridge, right? I call myself a convener. We are the bridge between the community and the University of Utah Health. And we always constantly hear about how the leadership or the dominant group is advancing academically in health, all of that, compared to the minoritized groups. We hear that and we take that personally, right? So that checking with each other and asking each other how are we doing is critical.

Mitch: Sure. So when you say checking in, making sure they're not getting burned out, are you talking about just with day-to-day life, or with dealing with equity, diversity, and inclusion issues every day for your job?

Abdulkhaliq: Day-to-day life, right? What we do in the community and at home will affect how we perform at work. So we constantly have to check in about, "How is your weekend going?" Then after that, talk about work, right? Sometimes we forget about our other life, right? So that's what I'm talking about.

Mitch: Got you. So one of the things I want to ask the three of you is from your backgrounds, your personal experience, what are some of the good things that you think have happened since after we've come out of this situation and as we are trying to build from the ground up? Rebuild, right? That's kind of the take-home message that we're trying to do with some of these conversations. But what can we look forward to? What efforts are being made now? What are the good things that happened?

Abdulkhaliq: I was at a session today and they talked about how Congress has an act, Health, Equity, and Accountability Act of 2022. That happened because of COVID, I think. Now we recognize the . . . Actually, the silver lining of about COVID is we recognize the disparities in health, disparities in economics, disparities in communities, right? And now, we are hiring more health equity leaders within our universities and community to address those.

We have a long way to go, but now we see the disparities clearly and we are working to address it. We're not there yet, but we are working to address it.

Natasha: I was actually going to speak to a point that Abdulkhaliq said a little bit earlier, which is about finding these moments of significance with those who you're surrounded by.

And something that I have noticed outside of COVID . . . especially because we are still in this hybrid world. But before, we were only on Zoom, we were only on phone calls, and not able to make a lot of those face-to-face connections. Now, whenever I have the chance to be in an in-person meeting and there is that time to just grab a cup of coffee and sort of chat with people and say hi and ask how they're doing, it's given me the opportunity to really break up the mundane, maybe, of our everyday work and sort of just the coming in, clocking in, clocking out, and to be able to see my fellow co-workers as people.

And I think especially for equity, diversity, and inclusion work, especially that inclusion part, that belonging part, there's no way that you feel that sense of belonging if people don't see all aspects of you.

And so being able to connect with people in person now to ask them how they are, how their families are, what color they just painted their nails, whatever it might be, it's just that chance to maybe even move beyond the nurse title, or the researcher title, or the assistant title, and to just be able to connect and find common ground with my people, with my community.

Mitch: I like that a lot. I think that's something that I've experienced myself. It seems like beforehand, I was a content specialist, editor of podcasts, whatever. But we were all kind of forced into extraordinary circumstances, right? And all of a sudden, I care about what your hobbies are, co-worker of mine, because we're both human beings. I think that's really an interesting new foundation that we're building from, and it's very heartening to hear that other people are experiencing that too.

How about you, Nafisa?

Nafisa: I think related to what Natasha and Abdulkhaliq said, we are more . . . I think in our workplaces, we're being seen as more than the work that we do. And obviously, the source of that was not a positive way to learn that, but I think there was this overall focus on resilience and wellness.

The idea that your value does not just lie in the work that you do, and the content you create, and what you produce, but who you are and how you're feeling and how you can contribute to social space and not just a productive one. And so I thought that pivot has been really beautiful to see.

The idea that we see each other as not just colleagues and co-workers, but as friends and as neighbors, as cheesy as that sounds. We're not just productive, but it matters that you're well and that resources and programs are being put in place to ensure that employees and groups are well.

And then I think the other benefit is flexibility and adaptability, the transition to remote work, and allowing for more flexibility for different situations. And I can speak personally. I relocated less than six months ago and moved cross-country. The fact that I was able to do that, it's not something I ever considered . . .

I still have very strong connections with my co-workers, and we've found ways virtually . . . Even though it is so nice to be able to meet in person like this, we found ways to stay connected, to continue to strengthen those bonds and those partnerships without necessarily losing anything over the distance.

Natasha: If I can add in there, I am so glad that you said that because I don't want to sound like that person who sort of says, "Oh, yes, everybody should come back to work, because that's the most engaging way." You know what I mean? We need to do things that are healthy for each of us, because I think that's the way that we are able to show up the best each day in our work.

I think what is really, really important to understand is that even when we talk about right now, in this moment, this is health. I think sometimes we can think, "Oh, healthcare is just at the hospital, seeing the doctor, having the surgery." No. Health is our social health. Health is our educational health. Health is our financial health.

And so to hear moments, like you touching on that remote work and the benefit of remote and hybrid work, that is something that has been helpful. We've heard this across so many voices, across social media, you name it. So many people who have said, "It has been so much healthier for me to be able to work from home. It helps my anxiety. It helps me spend more time with my children because I don't have to spend an hour in the beginning of the day getting ready to leave to sit on the freeway for another hour. It helps me with my disability because, honestly, the building I was in was not quite that accessible anyway. And so now I can just start my day at home, and now I have all of the tools I need to do my job successfully."

I think it really is important to understand that all of our health is so individualized. And so when we talk here about our health and creating healthy outcomes and having health equity in our communities, we need to remember that it's not just who we see as patients crossing the threshold of our buildings. It's what we offer as employers, as professors, as members of our community, supporting other members of our community for their health goals.

Abdulkhaliq: And your children sometimes now will jump into the screen, right? And now we don't feel guilty. We don't feel guilty. Everyone will say hi to the children, right? So that's amazing. And that is another self-care. Feeling guilty eats up on you, but now we don't have to feel guilty about that. It's just liberating.

Mitch: Say someone is out there listening right now who's maybe at the AAMC or just any . . . If you're listening right now, one of the questions that I was wondering is if they're in an organization that is still struggling, if they're in an organization that is still having trouble with burnout and the aftermath of everything that's happened over the last few years, what would be one piece of advice that you would give them that has worked within your own teams, within your own lives, etc., to make sure they can meet that challenge of burnout?

Abdulkhaliq: Michael Good, our leader, last week said, "Organizations don't make change. People do." It's not the building, it's not the organization, it's not the system. People make changes. And we need to value our people. They are more than just workers, right? We need to value of who they are, what they do, the context they live in. We have to look at their supporting structures.

And also, there are two systems that people live in: their nurturing system, and sustaining system. The nurturing system is our family. If we don't have that, we struggle. And the sustaining system is the hospitals, our work, our schools, right? If those two do not support each other, we will struggle. Therefore, we have to look at people from that perspective and support them for who they are.

Natasha: Yes to all of that. I'll add this. And this comes from actually a session that I attended today at the AAMC conference, which was really around being a leader who can help solve problems. And I think to do that, you have to look beyond the obvious and practice a growth mindset. What does that look like looking beyond the obvious?

Sometimes we talk about in the EDI space, we don't have enough people of color, people of the LGBTQ+ community, people with disabilities. They aren't applying for school with us, they aren't applying for our jobs, whatever it might be, right? We talk about not having an adequate number of representation. Look beyond that, right?

If you have a candidate who applies for a job, you have a chance to talk to them, to see them, and you say, "They aren't quite there yet." Instead of just, "Well, we're going to hire the person with the most experience," can you go back to this candidate say, "Okay, you didn't get it this time. Let me help you"?

Or as a leader, if you have a team member who applies for another job, can you say, "Okay, you applied for this job that's a little bit different than what I thought"?

If Nafisa is applying for a job, which I'm not saying she is, but if Nafisa is applying for a job, it's not, "Oh my goodness, she wants to quit." It's, "Okay, I'm seeing a goal that she's showing me that she wants to accomplish." And then that growth mindset. How can I help her get there? Instead of, "Oh my gosh, we're losing a member of our team," it's, "How can I help her grow and get there?"

Or with the jobs when someone is trying to grow, how can I help someone develop the skills they need to get to be a vice president, a COO, a dean? What do I need to do to help them get there? Instead of the, "We can't do it," change that mindset to, "How can we do this? How can we work together for this?"

Nafisa: That's a great point. I think the advice that I would give to an organization that may be struggling with burnout is to focus less on resiliency and more on restoration.

And what I mean by that is many of the resources we got at the beginning of the pandemic, and those resources have changed over the years, focused on "What do you do when you're already past the point of burnout? How do you create wellness for yourself? How do you relieve stress? How do you process?"

That worked in the moment that we were in, but long-term I think we need to focus on the root of the problem and say, "Which of our policies are restoring our employees? How do we prevent the fact that they feel drained and burned down in the first place?"

So rather than fostering resiliency at the end of that process where they're already burnt out, what policies and programs do we have in place that are nourishing and nurturing our employees so that they never reach that point moving forward?

And obviously, speaking now, we have a lot of burnout and a lot of stress and trauma that we're still processing. But long-term looking to the future, how can we avoid that self-care revolution that I think was really necessary and make sure that if we were to enter into a situation like this, or as post-COVID continues, how are we nurturing our employees so that they're not reaching the state of burnout or the levels of burnout that they're currently at?  

Mitch: That is some great advice for I think any organization at any time really. When we're looking at building back after this particular event, we're looking at the end of COVID and what's next.

Abdulkhaliq, Natasha, and Nafisa, thank you so much for joining us. And if you're listening, there are plenty of other discussions here at the AAMC floor from University of Utah Health and The Scope at uofuhealth.org/aamc22. And if you're interested in any other health-related podcasts, talk shows, basic information, you can also hear more of me at thescoperadio.com.

Listen to our other AAMC conversations:
• Rethinking Population Health Care and Education
• Reducing the Distance Between Patient and Provider
• Doing the Work: EDI as a Shared Responsibility
• Personal Identity and the Philosophy of Caring
• The Power of Diversity in Medicine

Interviewer: Ever since the first case of monkeypox was first identified in the U.S. in May of 2022, there's been concern about the virus and its potential to spread. With newsfeeds featuring images of patients with rashes and lesions, as well as the news that by August, monkeypox has been seen in nearly every U.S. state, it leaves some to wonder if this could be another pandemic.

We spoke with two virologists from University of Utah Health to get their professional opinion to better understand the virus, how it spreads, and perhaps most importantly, how to protect yourself.

Dr. Sankar Swaminathan is a professor and the chief of the Division of Infectious Diseases at University of Utah Health. Dr. Adam Spivak is a researcher and physician with the Infectious Disease Clinic.

Dr. Swaminathan, let's start with the basics. What is monkeypox, and how does it impact the body?

Dr. Swaminathan: It's a viral infection caused by a virus that is related to smallpox and causes lesions or sores on the body, and really can be any part of the skin or mucus membranes. That's the inside of the mouth and the genitals. So that's the primary symptom that people have. It can also cause fever and swollen lymph nodes.

The type of lesion can be quite variable, but generally speaking, they start out as bumps, papules, and they can have a little indentation or dimple in the center of that papule. They can become pus-filled, and eventually, they scab over and they fall off, and they can leave a scar. They're fairly deep-seated, so they can be quite painful. And especially if they're in the mouth or genitals or the rectum, these places obviously can cause a lot of pain.

Interviewer: Now, where exactly did the disease come from? I've never heard of monkeypox before until just a month or two ago.

Dr. Swaminathan: It's been recognized in Africa, in various parts of Africa for quite a while, for decades in fact, and there's been very little spread outside of local populations.

Interviewer: And why are we seeing it now?

Dr. Swaminathan: That's a very good question, and I think a lot of people are trying to answer that. Like I said, we haven't seen this sort of person-to-person transmission, particularly in Western Europe, and in the U.S., and other parts of the world, and now it's become essentially a worldwide problem. The WHO has declared it to be such.

And I primarily think it's just found a niche in people who have close contact, particularly sexual contact, and it's spreading in a way that it might not have been spreading before. It doesn't necessarily mean that the virus has changed, although I think that remains to be determined, whether there've been any changes in the virus that's making it behave in a new way.

Interviewer: And speaking of that, when the World Health Organization declared it an emergency, what are these different groups so concerned about with this particular disease, with its spread, etc.?

Dr. Swaminathan: We realized that there's potential for widespread transmission. And how widespread it's going to be or can be, I think, still remains to be determined, but there's enough of a risk that the WHO has alerted everybody to this.

I think it's compounded by several factors. One is I think our capabilities in terms of testing, vaccination, and treatment have all been somewhat limited, which has allowed the disease to spread pretty rapidly in some areas like New York, and I think the concern is that this could happen elsewhere.

Interviewer: So why don't we move on a little bit to talking about how to identify this disease? So we've talked a little bit about that it looks like a lesion, but some of the things I've been seeing online is it looks like an ingrown hair, or it can be really hard to spot. For someone who is concerned or wants to know whether or not they might have monkeypox, what exactly are they going to be looking for before they go and get help?

Dr. Swaminathan: First I think is how likely it is that they've been exposed. It's people who have been in situations, parties, or group encounters, or raves, or whatever, where they are in contact with a lot of different people, so that's the risk factor.

And if you have had recent intimate contact with somebody, and you don't know exactly what their recent contacts have been as well, it's possible that they may have transmitted it to you without your realizing it.

And like you said, some of the especially initial manifestations may not be particularly alarming or severe, so that transmission could occur even though people aren't aware that they are infected.

Interviewer: Do the lesions change over time, how it expresses itself on the skin?

Dr. Swaminathan: Yeah, they usually progress or evolve. Like I said, they'll start out as a bump and then can become more liquid-filled, pus-filled, can become more painful, and they can break down so that they form an open sore. But eventually, they will scab and fall over. And this can take a couple of weeks or more for it to be fully cleared, and for the person then to not be infectious.

Interviewer: So these particular lesions are . . . like you were saying, they're full of the virus. That's a major infection vector, is the lesions themselves?

Dr. Swaminathan: Correct.

Interviewer: Okay. Are there any other vectors for this particular disease?

Dr. Swaminathan: Certainly other intimate contact like kissing and so on could spread it, but mostly it's skin-to-skin close contact. It can be spread by infected or contaminated clothing, bed sheets, towels, things like that. So any time people are living together in the same household, there's a possibility for transmission even if they're not having intimate contact with each other.

And also, we think that droplets . . . This doesn't seem to be a primary means of spread, but droplets from person-to-person who are sitting in close enough proximity that coughing, sneezing, even a lot of talking could potentially have airborne spread in that manner through respiratory droplets.

Interviewer: Now, does the disease impact anything other than the skin, or is it just a lesion-based kind of virus?

Dr. Swaminathan: Like I said, the other systemic manifestations as we call them are that you can have fever, and swollen lymph nodes, and fatigue. There haven't been any deaths in the U.S. that we know of from this, but it can be quite a severe illness in terms of . . . Usually, there's actually spontaneous recovery, but can lead to fairly severe symptoms that would make somebody not want to get up and leave their bedroom.

Interviewer: Would it require people to get hospitalized for any reason?

Dr. Swaminathan: It could, but generally speaking, we haven't seen that. Hospitalization might be required for severe intractable pain, or inability to swallow, eat, getting dehydrated, or secondary infection, an infection on top of the lesions with a regular bacterial infection, for example. Those would be unusual, but possible reasons why people would have complications and require hospitalization.

Interviewer: So how does someone keep themselves safe from monkeypox?

Dr. Swaminathan: So I think avoiding those types of encounters as much as possible is really almost the only way to protect oneself. Having multiple sexual partners and not knowing very much about what their risk has been, what are their habits, and so on.

Interviewer: In my research, I have been finding some really strange ways to protect oneself. We've had people being like, "I know it's hot in the summer, but just wear a long sleeve t-shirt, and you'll be just fine." I've seen, "Put Carmex on your lesions, and you'll be able to prevent the virus from passing to another person." Are there any known ways to prevent the spread of this disease? And is there any merit to any of these?

Dr. Swaminathan: So I think that you can take precautions if somebody in the household is known to be infected. And I think it would be straightforward, even if it wasn't easy, to make sure that there are no shared utensils, and no shared bedclothes, towels, and all that kind of thing, and that those were properly sterilized in the wash and dryer.

However, as we said, because it's not just from the act of having sex, that intimate contact would be hard to prevent with barrier methods. You'd essentially have to encase yourself from head to foot to prevent skin-to-skin transmission. And once you have lesions, there's no question that you should seek medical attention, and you should isolate. Because until those scabs are all gone, you're going to be potentially infectious, and you should really not have any type of skin-to-skin contact with other people.

Interviewer: So if someone does contract monkeypox, if they see those lesions, what is the first thing that they should do?

Dr. Swaminathan: I think if there's a concern that there's monkeypox, they can get tested. And we have started testing here at ARUP. We can generally get tests back in two to three days, and maybe sooner. And hopefully, we can keep up with the demand because I have a feeling that demand is going to continue to increase. But it's very good that ARUP . . . There are many labs that have now been approved to do this kind of testing, and we're not just depending on one or two centralized state or CDC labs.

Interviewer: So Step 1, if you think you've got something, go get tested. If that test comes back positive, what's the next step?

Dr. Swaminathan: Like we said, prevent yourself from giving it to other people. So you would need to isolate and take the precautions, which you can get detailed instructions from a healthcare provider.

And there is an oral treatment, which is approved for smallpox but is not officially approved for monkeypox because it really hasn't been tested in clinical trials against monkeypox, but we think it would work. It works in animals against monkeypox, and it certainly works in the laboratory, and it's a similar virus. So this drug called Tecovirimat, or TPOXX, should work, but it's only approved and can only be given under strict regulations.

So we're restricted in who we can give it to, and it's basically for people who have severe disease. There are various definitions for that, but it has to be severe disease, not just mild, a few skin lesions. And also for people who are at high risk, so people who are immunocompromised, whose immune system is weak, whether it's from cancer, or an organ transplant, or advanced HIV infection, or other immune deficiencies. So those people would be eligible for being treated, and we can treat them if we think that they have monkeypox, or we know that they have monkeypox.

Interviewer: But for most people, the treatment is not necessarily approved for everybody that gets monkeypox?

Dr. Swaminathan: Correct.

Interviewer: So quarantine, what does that look like in a household? Are you closing yourself off in a single bedroom?

Dr. Swaminathan: That would be the easiest way to do it, but that doesn't mean you can't come out of your bedroom. You should probably not share the same furniture as other people until you are over your period of isolation.

Interviewer: And how long is that period?

Dr. Swaminathan: Three weeks or so. All the lesions have to have been essentially healed over.

Interviewer: And how long after they've all been healed over are you good to go?

Dr. Swaminathan: Once all the lesions are healed, you shouldn't be infectious any further.

Interviewer: Is there any potential long-term consequences for a monkeypox infection?

Dr. Swaminathan: Not that I know of, but again, we're somewhat in uncharted territory. But generally speaking, recovery is thought to be complete.

Interviewer: So not super life-threatening, but you might be left with some scars?

Dr. Swaminathan: Yes.

Interviewer: Severe scars? Mild scars?

Dr. Swaminathan: Again, it depends on the number and location of the lesions.

Interviewer: So let's talk a little bit about vaccination. Is there a vaccine available for monkeypox?

Dr. Swaminathan: Yes. So the one that's currently being given is a vaccine that is based on the same virus that's used to vaccinate against smallpox. We don't routinely use that live form of vaccinia of smallpox vaccine because we've stopped vaccinating people against smallpox since the '70s. That vaccine is available and is thought to protect against monkeypox as well, but the incidence of complications with that vaccine is high enough that that older smallpox vaccine is not being used for monkeypox.

What we have is a newer vaccine that's made with a weakened or attenuated form of vaccinia that can't replicate, but it can stimulate the body to make an immune response against smallpox, and monkeypox, and so on. And that is effective both in animals that are challenged with monkeypox as well as in the laboratory. So that's the vaccine that we can give, but it is in somewhat limited supply currently. And like I said, we prioritize people who are at highest risk for it.

Interviewer: Now, speaking to you, Dr. Spivak, one of the first questions I'd like to ask you just to get it out of the way, with your experience researching viruses and treating HIV, is monkeypox a gay disease?

Dr. Spivak: Nope. It's a human disease. I don't know that there is such a thing, certainly not in virology, not in medicine, and not in existence in the world that I'm aware of such a thing as a gay disease.

And by way of background, I'm a physician caring for people living with HIV, very interested in preventing HIV, and I study HIV in the laboratory. Certainly, there's some background to my answer there, as, of course, HIV as a predecessor to this one, this latest outbreak of monkeypox, was often labeled a gay disease.

And just to elaborate a little bit because that, of course, sounds purely like opinion, the number one risk factor for acquisition of human immunodeficiency virus worldwide is heterosexual sex.

Interviewer: Heterosexual sex, really?

Dr. Spivak: Yep. So there are about 75 million people worldwide that have ever acquired HIV infection. Approximately half of them have died of the disease in the last 40 years since we first discovered it. So there's somewhere around 35 million people living today on Earth with HIV. And again, the majority of those folks acquired this disease sexually through heterosexual sex between men and women.

There's a fairly complex and really fascinating story about why HIV is prevalent among gay men, among men who have sex with men, and transgender women in Europe and in the United States. And that has to do with the transmission of the virus as it evolved, as the epidemic spread, where it first originated in West Africa, out to Haiti, and out to the Western world through sex, but also through blood products.

It's a complex story, but in any case, there are some pretty well delineated and well-understood reasons why HIV is more prevalent among men who have sex with men, again, in the United States and Europe. And that, of course, did give rise to this false notion that this was a gay disease, that heterosexual individuals were not susceptible, that this was somehow something that could be attributed to a man having sex with a man, which is entirely untrue.

And I think that the way I try to summarize that for medical students is to say that the disease actually . . . In the case of HIV, of course, it can also be transmitted through injection drug use, but by and large, we consider it a sexually transmitted disease, and that means humans having sex. The disease does not tend to discriminate, but people do.

Interviewer: And so while we are seeing more cases currently in the U.S. among men who have sex with men, that does not mean that this disease is any . . . there's not anything about the disease that specifically impacts one orientation over the other.

Dr. Spivak: No. There is zero evidence of that being the case. It does appear to be disproportionately affecting gay men at present, but the best we understand . . . And again, I think it's worth pointing out that there are a lot of unknowns here, and I certainly would not ever claim to sit here and have all the answers. In any case, the best science now seems to indicate that this virus spreads through skin-to-skin contact. And that is to say contact with your skin against the lesion on someone else's skin. Sex is a fantastic opportunity for skin to meet skin.

I don't think we really have a good answer as to why it is occurring predominantly among men who have sex with men, but as far as we know right now, there is absolutely no reason to think that this could not be spread from any type of skin contact, again, healthy skin touching against skin where there is a lesion. And we all have skin.

Interviewer: So, with that in mind, is this technically a sexually transmitted disease, or sex just happens to be a place where skin-to-skin happens?

Dr. Spivak: Yeah, I think it's a really terrific question because certainly, the biological mechanisms are exactly as you said, that sex is a great opportunity for skin to be vigorously rubbing against skin, and so a great opportunity for the disease to spread. But that's not the only way that we come into contact skin against skin.

When we call something an STD or sexually transmitted disease, that obviously implies a specific route of transmission. I think this could be categorized as an STD. There are also implications for that, around calling something an STD, because of our morals and our discomfort, I think, in our society about talking frankly about sex. That, I think, has given a lot of people in medicine pause about calling this an STD.

And I think we're trying to be sensitive to the fact that there were lessons to be learned, and there are lessons to be learned about HIV. And as I shared with you, sort of a common misconception 40 years into an epidemic that frankly should be controlled, but isn't . . . and I'm talking about HIV . . . there's still this perception that this is a gay disease. As I shared with you, that's just not born out by facts. There's nothing about this virus that indicates that it has any predilection for gay men at all.

Interviewer: So circling back to the state that we're in right now with monkeypox, we see the news every day, it's on the rise, it's scary, it leaves scars, we've done pieces about how it's transmitted, etc., but are there any steps that someone can take to make sure to protect themselves from potentially getting infected?

Dr. Spivak: Yeah, that's a great question. And the answer in some respects is similar to what we've learned, unfortunately, the hard way with COVID, though you could argue the glass is half full there, and I'm getting at vaccines. We have a vaccine against monkeypox, which is pretty remarkable that we actually had the vaccine present before the outbreak. And again, that's the glass half full.

The glass half empty is there's not a lot, not enough to go around. We don't have it here yet. That's largely because the supply is limited, but the Department of Health to their credit acquired vaccine from the federal government and tried to disperse it quickly. The Utah AIDS Foundation led by Ahmer Afroz has done a phenomenal job at getting information out and actually getting vaccine and distributing it.

I think we have a long way to go there, meaning that a lot more folks probably should be vaccinated. And frankly, anyone who wants to be, thinks they may be at risk, should be vaccinated. I don't think at this point, and we're in mid-August of 2022, that we have enough vaccine to go around. And so there have been decisions made about who gets priority, which is unfortunate from a public health standpoint because this is going to allow the disease to spread.

It is a disease that's spread skin-to-skin and spread by touching or coming in contact with these lesions, and so what that means is beyond vaccines, which are preventive, if you think you may have this, you should come and get checked out. We have a great diagnostic test.

And ARUP has been at the forefront. They're a phenomenal lab. They're an international leader, and they came out in end of July with their own monkeypox PCR test. Our clinic managers, and the urgent care staff, and people in the ERs, and people in our primary care clinics have rapidly become aware that this is out there. We're seeing more cases because people are coming in, and then physicians, and physician associates, and APCs are recognizing it. And clinic managers, and nurses, and clinic staff are taking the right maneuvers to sample the virus, meaning there are collection procedures that have to be put in place.

All this happened very quickly, and I think COVID did teach our health system how to be a little more quick to respond. And so that's been really encouraging. Working together, we can recognize this. Led by Jeannie Mayer, a hospital epidemiologist here, we can really as a system start to adapt to a new disease. So that's all encouraging.

I would say that people need to be aware that it's out there. They need to come in and get checked. We have a great test, and we actually have a great treatment. I could keep going on and on, but I'll stop there.

Interviewer: There seems to be a lot of fear out there right now, especially with limited supplies of vaccines, etc. Do you think that fear is founded?

Dr. Spivak: I do. Yeah, I do. It's scary. I've cared for a few individuals with monkeypox, and I'd say one thing. Again, I tend to be a glass-half-full, optimist-type person. It's not COVID. And what I mean by that is people are recovering. We have, to my knowledge, yet to have a monkeypox fatality, and yet it is symptomatic. People experience a lot of pain with it.

I think, obviously, it's to be avoided, but it's not quite in the same ballpark, I think, when we talk about in the intensive care units across the country where there was no vaccine, no treatment, and it was spreading like wildfire. We're really not in that situation.

But on the other hand, as I shared earlier, there are a lot of unknowns here. Maybe this is a mild strain, and we're going to see it get worse, or who knows what. But I don't think so. I think this is going to be a little bit milder.

I think the fear is justified because our public health measures aren't enough. We don't have enough vaccine, and we should be vaccinating everybody that wants a vaccine. We don't have quite enough of this therapeutic medicine to go around. It's a bit of a headache bureaucratically to get it, though I'll say that is part of my job, and we'll do it, jump through the paperwork hoops. That's fine.

The first patient I've treated with this drug called Tecovirimat, which is specifically . . . It's not FDA approved, but they have what's called an investigational new drug application, and that allows us to give it for this indication. The very first patient I've used the drug for had a really exciting turnaround in his symptoms, severe pain, and rash, and within about 48 hours, he got better. Now, that is what we call in science an N-of-1, but no side effects and a great recovery. Obviously, we have a lot more to learn, but that's encouraging.

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.

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.

Pandemic fatigue, we all have it. However, it is affecting children more than adults in many cases.

Pandemic fatigue by definition is the mental exhaustion caused by being in a state of heightened awareness and alertness in the face of COVID combined with the uncertainty of how the pandemic will develop. Parents are struggling to continue to juggle working from home and teaching their kids who are doing online school. Healthcare workers are getting burned out from the stress of working with COVID patients and seeing the numbers of infected patients continue to go up.

Kids are becoming more anxious and depressed, not just about isolation and not seeing their friends, but I'm having parents bringing their kids to me about anxiety over things they've never been anxious about before. This is especially true because just as COVID numbers started to increase locally, we also had a major earthquake. I have some patients who if they get a cold are asking me if they're going to die. I have others who are terrified of germs and think they will get COVID if someone touches their dog or they will change their clothes as soon as they get home from being out of the house, even if they just went to a store.

People are tired of wearing masks. People are tired of physically distancing, of not having normal life milestones being able to be celebrated in the way we have done for years. So since this is not showing any signs of slowing down anytime in the immediate future, how can you help your children do the best they can while dealing with COVID in the long haul?

First, continue to make mask wearing fun. I've said it before, and I'll repeat it again. If the mask is something fun, kids will want to wear them more. Have fun characters on their masks. Let the kids have enough variety in their masks that they can coordinate them with their outfits. That's exactly what my younger son does every day. His teachers comment all the time about his cool masks and how they match what he's wearing.

For hand sanitizers, have seasonal scents. If your child doesn't have eczema and they're not sensitive to different fragrances, let them choose what they want to smell on their hands all day long.

Empower kids. Let them know it's okay to tell family members and friends that if they just aren't masked or they're not social distancing, then your kid can't play with them. It's okay to remind others of the rules. Just make sure it doesn't turn into a daily battle and they don't turn into the germ police.

Let kids connect with friends online. I know we didn't use to be a video game family, but when the pandemic hit and schools went online, I caved. I bought an Xbox for my boys and I let them have a certain amount of time to play with friends every day. It helps them still feel connected to their friends, but in a safe way. It also lets them get a break from school and just play and be kids.

Finally, remember that it's okay for them to be bored and figure out new things to do. It's okay to let them cry, even if they can't tell you what they're sad about. It's okay to have breakdowns and just get angry and need you to hug them until they're screaming turns into crying and then I'm sorrys. As long as your child isn't disrespectful or violent, let them express their emotions. Then, if they want to talk about their feelings, if they don't want to, that's okay. Let them have their space. The bottom line is everyone is feeling pandemic fatigue in one way or another. If we all help each other, then we will get through this together.

Suicide is one of those topics no one wants to talk about, but something that needs to be discussed. This is our topic today on The Scope.

Recently, a longtime family friend's daughter, who my kids have grown up with since they were really little, whom we have known since before our 12 year old was even born, acted on an impulse and took her own life. This podcast is dedicated to her. Her parents know I'm doing this podcast in her honor. During her services, her parents spoke about how important it is to bring awareness to the reality of suicide in teens, to talk about it, to talk to your kids about how they can come to you if they're having thoughts of self-harm, that there might not always be the warning signs that people tell you to look for.

With teens, their brains are not yet fully developed in terms of executive function skills. So they often can't see that while things may be bad right now, there is hope. And often, in time, things will improve. This is true so much this year with the pandemic. Our teens are not able to do normal teenager things like school functions, dances, hanging out with friends, having their first boyfriend or girlfriend. They have been cut off from interactions outside their families. Teens can only see what is happening here and now. And in their minds, it feels like things will never be the same again.

Unfortunately, they're probably right. Things will most likely never go back to the way that they had been. However, there is hope, hope that we are better able to understand COVID and hope that we will be able to bring an end to the pandemic. Hope that within the next year, people can start returning to what we consider normal life.

Knowing someone who has completed suicide will rock you to your core. Sometimes there are signs like sadness, wanting to sleep more, or stay away from others more than teens normally do, grades falling and your teen not really caring about school. Sometimes there is a history of mental illness or self-harm, and it gets the better of them. And sometimes, a teen will struggle in silence. They will appear happy and social on the outside, but be suffering within, until one day that wave of suffering overpowers them, and they act on their immediate feelings with fatal results.

The more I have spoken to teens and parents of teens, the more the subject of negative thoughts seems to come up. More and more teens are having these thoughts. More and more teens are doing self-harm, like cutting or attempting overdoses. I have about a patient a week lately, where I am having this conversation with them. It's real, it's serious. Teens need to know that we are there for them and that they can come to us, that they have options for help. No, we can't make everything go back to the way it was. No, we can't take their feelings away from them. But we can help them work through their feelings, give them options that are safe, and help them to understand that they aren't alone.

We see you, we hear you. You are beautiful and special, and you are loved.

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.