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Scot: Okay. Let's talk about COVID now. Woo!

Troy: Yeah. Love COVID.

Scot: Do you really? If you love it so much, why don't you marry it?

Troy: I pretty much have. I feel like COVID has just moved in here and it's joined the family.

Scot: Just sleeping on your couch, will never go away.

Troy: Sleeping on my couch, yep. Just on the couch, just a guest that just does not take a hint.

Scot: The podcast is called "Who Cares About Men's Health," and around here, we like to think of health as the currency that enables you to do all the things you want to do. My name is Scot. I am the manager of thescoperadio.com, and I care about men's health.

Troy: I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah, and I care about men's health.

Scot: And today's show, Troy, Dr. Madsen, is an emergency room physician. And of course, all across the United States, we are seeing new stories that this big, huge wave of COVID is coming. I wanted to talk to Dr. Madsen, because you and I don't necessarily talk about this that much, about what you're experiencing in the emergency room when it comes to this pandemic.

So, first of all, are you seeing a lot of COVID in the emergency room, or do you not really see it there?

Troy: We are seeing a lot of COVID in the emergency room. So anyone who has symptoms where they're concerned about COVID, they're coming to us. They're not really going to a primary care doctor because the primary care doctor is going to say, "Hey, if you think you have COVID, go get tested. And then if you're feeling really sick, don't come to clinic." If the clinic is even open. They're saying go to the ER. So we truly are on the frontlines of this.

We have a dedicated respiratory unit, so an area of our emergency department that is set aside for patients who have COVID or potentially have COVID. And I will say that the shifts I've worked there lately, that unit is full, and we have patients waiting to try and get back in there. So there's no doubt we're seeing COVID, and we're seeing a lot of it.

Scot: And what's a typical patient that comes into the ER with COVID? How bad of a sick is it?

Troy: Yeah. Great question. So, first, to break that down, I would say in our respiratory unit I see three different types of patients. Number one is the patient who comes in who has a cough and fever, who you think has COVID, but is well enough to go home. We'll send the COVID test, tell them it's going to take 24 hours to come back, go home, self-isolate.

Then we get the people who come in who know they have COVID, they're one to two weeks into it, and they feel absolutely miserable. Sometimes they're well enough to go home. Sometimes they need to be admitted, because their oxygen level is low.

And then the third type of patient we have come in I see a lot of are the people who are probably a little bit on the older side, have some medical issues, who come in and are really sick. High fever, maybe their blood pressure is low, their heart rate is going fast.

Some cases, I have had people come in with oxygen levels that I have never seen in a living person or someone who is actually able to walk and talk. I've had people come in with oxygen levels on room air, which is breathing room air oxygen, in the 50s and 60s. Just for reference, normal is greater than 95%. This is down at 50% to 60%. It absolutely blows my mind to see this, but I've seen it on several occasions, people who come in with these unbelievably low oxygen levels. We put them on oxygen. We have high-flow oxygen, all these things we're doing for them to get their oxygen level up. They get admitted to the intensive care unit.

Scot: So then, every shift, are you dealing specifically with COVID, or as an emergency room physician, sometimes you work in the regular ER, sometimes you have to go to the respiratory unit where the COVID patients are coming in? How does that work?

Troy: So probably a third of my shifts, third to a half, depending on the month, are in the respiratory unit. The rest are in the main emergency department seeing all the other stuff we see -- abdominal pain, chest pain, heart attacks, strokes. Obviously, none of that stuff has gone away, so we're still seeing all that as well.

Scot: So how are you holding up mentally as a healthcare professional with COVID? Is this truly unlike anything you've seen before? Is it taking a toll on you in a way that the day-to-day that is very stressful in the emergency department not during a pandemic is?

Troy: Yeah, it's interesting, Scot. I try to be fairly objective about things and try not to overstate things or overdramatize things, but this has been a unique situation. It is unlike anything I've experienced before, and I think it's unlike anything anyone working in healthcare right now has experienced before.

The closest analogy I can have for this is H1N1. And when we dealt with that, that I think put everyone's anxiety up a bit and we're all like, "Are we going to catch H1N1? Are we going to get it ourselves?" But this has certainly been a whole other level of that.

Prior to COVID, I had never sent anyone home on oxygen. We'll have people come into the ER and if they're sick and they need oxygen just to be able to breathe, they get admitted to the hospital for it. But now with COVID, our hospital, we're at capacity. The way we've been able to work with that is people who are under 50 and maybe don't have other medical issues, we're sending home on oxygen and telling them, "Use the oxygen. Try and check your oxygen levels. Turn it up if you're having trouble breathing, and if you can't turn it up more, if you max it out at six liters, come back in and we'll have to admit you."

I've never done that before, but that's a contingency we had to put in place initially to be able to deal with the surge of patients and be able to have hospital beds for the people who absolutely need it. It's a strange situation to be in to be doing that. And as I look ahead, I don't know what the next month or two will hold.

There have been some times when I'm in the respiratory unit and it feels a little bit like being in a war zone, where you've got all these people, they're sick, we're taking care of them, let's get them upstairs. We've got three ambulances coming in. We've got no beds for them. It's been interesting.

And all that being said, I think our administration has done everything possible, has done an incredible job of dealing with this and having contingency plans and surge capacity and everything we can do, but at a certain point, those resources max out. And again, I've always worked in busy ERs, and we've always dealt with overcrowding and all that.

But you asked about from a personal standpoint, I think I went through a phase initially over the first three months where I was very, very anxious. I was very anxious. I would go into work, and I'd be like, "Man, I am going to catch this virus, and this is not going to be good." I think I've settled into things now, settled in the routine, and also, in terms of taking care of this new disease, become much more comfortable with that after seeing so many patients with it and so many sick patients.

I've probably tried to compensate for it just by running more. I think we may have talked about this. As of June 1, I increased my weekly mileage by about, I don't know, 30%, 40%. So I have probably tried to just compensate for it just by running more. And partly, that's just to say, "Hey, the best defense against this virus is being in the best shape you can be in."

Scot: Yeah. Having a strong immune system. And also, you've talked about how that's how you deal with things from a mental standpoint, is exercise.

Troy: Oh, yeah.

Scot: I read something that was really . . . actually, somebody told me that I need to get this book. It was fascinating. It talked about if you find yourself in fight or flight mode . . . which I'd imagine COVID does. That's what stress is for any of us. It's a fight or flight mode. That's what stress is. You have these chemical reactions happening in your body. It's dumping cortisol into your system. The way to get around that is you have to do something physical.

And I'd love to get this book and find out if they talked about why, but on the surface, and this is not the scientific explanation, it makes sense, right? Because if you are in this fight or flight mode, then from a physical standpoint, your body is ready to do that. So if you can do that, then you feel better about things.

It's just the difference is it's not a physical threat like it was if it was a saber-toothed tiger. A lot of times now it's mental threats, but still, the way to get over that is to . . . I also heard getting hugs, so get hugs, but to physically just get rid of it, which I find fascinating.

Troy: Something I've done as well is . . . because I just felt like, "Okay. This is a new disease. I've got these sick, sick patients," and that created some anxiety, but I just thought, "I'm going to hit this head-on. I'm going to hit this head-on, and I'm going to be ready for them."

And every day, every day for the past several months, I have practiced physically . . . talking about taking that physical action. I have physically practiced and I have this lo-fi simulator I've created. I physically practice walking through the steps that I will take when someone comes in and they can't breathe.

And it's not just sticking a tube down their throat because we want to avoid that. We want to keep them off the ventilator. You may have heard some of the numbers on that. It's every step along there. "The oxygen. Okay. That's not working. Add on the non-rebreather mask. Okay. High-flow oxygen. Then we go to CPAP. Okay. Let's get ready to intubate." I walk through that every day physically.

And you would laugh if you saw the simulator I created. Laura saw it. She's like, "What is this?" I would probably be embarrassed to send a picture, but it's essentially my simulator and just some old equipment I've gathered over the years of just stuff I can physically handle, just like putting the oxygen on this on my simulator and putting the non-rebreather mask just so I feel like I'm physically doing this every day. And then, when I've had these patients come in, it's just like that muscle memory is there.

So I think partly, yeah, there's the physical running. There's that part I've done to deal with it, and that I think helps process a lot of things. But just being able to physically walk through this every day and just be like, "Hey, I want to be ready for this, and I feel ready for it," I think that's helped a lot with that anxiety piece as well.

Scot: You are one of the people that I just admire so much because I know that this virus is taking its toll on healthcare systems and healthcare workers all over the place working tremendously long hours, the stress that comes along with it, but you always seem to manage to maintain a pretty good attitude. How do you do that?

Troy: I don't know, Scot. Sometimes I feel like my attitude is not very good. Thank you. Great question. Maybe that is my coping mechanism, to put more of a positive spin on things.

But emergency medicine is inherently stressful, and that's one thing I've accepted over the years, and it inherently has a lot that you take home with you. And I always say emergency medicine keeps you up at night. It keeps you up at night because you work night shifts and it keeps you up at night because you take a lot of it home with you and you think about it.

COVID, I think, has compounded the stress of emergency medicine several times, many times. Just that sense of sometimes feeling overwhelmed. And seeing those cases multiplied many times of . . . the cases that you used to see here and there and that you'd think about a lot, but to see that many times over.

To have someone come in the ER who's about your same age and you're doing CPR on that person and you don't get them back has been a lot of what has been challenging for me over 15 years of practice compressed into about nine months of . . .

Scot: Wow.

Troy: Yeah, just in terms of really tough cases. Tough cases meaning cases where you have cared for people who didn't make it. It's been a lot more of seeing that over this period of time than I've seen in my career prior to this. So that's tough.

I think you're right. I'm probably downplaying things a bit and focusing on the positive, because there is a lot of positive too. I don't want to say there's not, but I think just the teamwork aspect, the way our team has come together to deal with this in spite of their personal challenges and professional challenges, the way our administration has responded has been very positive.

And then to see these people who come in really sick and to be able to care for them at this time is a positive thing, in spite of the challenges. At least you're able to offer something. I can't offer a cure. The treatments we can offer are not great. At best maybe some evidence behind it, but not great, but at least to be able to offer that during such an uncertain and difficult time for them. I think that it's difficult, but it's also empowering.

And while I think so many of us feel like we're stuck at home and there's nothing we can do, at least I do have that where I can feel like, "Hey, I'm doing something. I'm trying to help."

I'm doing some research with COVID too, which hopefully has a bigger impact on understanding COVID and the disease process. So I think at least that gives you a little bit more sense of empowerment, and I am grateful for that, that I do have that.

I think certainly distractions of health. I like listening to these Great Courses. I don't know if you ever listen to The Great Courses on audiobook, but I love listening to that kind of stuff. A lot of science stuff. Some stuff that has nothing to do with my job. I just love listening to that.

And it's funny. I'm actually listening to a book on stoicism right now on philosophy, on the stoics, and certainly relevant to our time. I think that helps as well.

It helps being able to come home to a supportive spouse with Laura, who's very supportive, and I think certainly has faced her challenges with work and with adjusting to working from home as well, but in spite of that, obviously, has a great attitude and is a very positive person.

And coming home to 17 kittens. If that doesn't brighten your day, I don't know what will. We don't have 17 kittens right now. At one point this summer we did have 17 kittens, but we have four little kittens right now that are the cutest little things you will ever see. And when you come home grumpy and you see those little faces, honestly, it's hard not to feel good about things when you see that.

Scot: So COVID is real? It's a real thing?

Troy: Yeah, it's real. It's legit. Yeah, it is real. It is such a weird disease process unlike anything I've seen. When you look at chest X-rays of people who come in with COVID, the best analogy I can come up with would be . . . If you have an X-ray of someone's lungs, on an X-ray, healthy lungs are black. They're dark with some little thin white streaks on it. The chest X-rays of people with COVID look like you took a black piece of paper, put it against a wall, and shot it with a white paintball gun, little white paintballs. There are little splotches all over it. Just really unlike anything I've seen before.

It's just such a bizarre process and just to see the full range of how sick people are . . . yeah, it's legit. It's real. It's a crazy disease. It's challenging to deal with. We're seeing really sick people. The hospital is full. The best thing you can do is the simple stuff: wear a mask, wash your hands, avoid social gatherings, social distance, all the stuff health officials are telling you.

Again, it's something we hear again and again and again, and I don't want to get on my soapbox about it, but as a healthcare system, we certainly appreciate the help and support people are offering.

And a thank you goes a long way. I'll say that as well. It's been funny. We got a lot of thank-yous in the ER. Back in April and May, when we were really not that busy. It was like, "Well, you're welcome."

Scot: Compared to now, right? It's a lot worse.

Troy: I know. Tell your healthcare worker thank you. We're nine months into this. We could use a hug, a socially distanced hug. Pat on the back, a thank you, whatever it is, I think we're all feeling that and we appreciate it when people offer that.

Scot: Time for "Just Going To Leave This Here." It might have something to do with health, or it could be something completely random that we just feel compelled to talk about. Troy, do you want to start with "Just Going To Leave This Here"?

Troy: Scot, I'm just going to leave this here. We just talked about COVID and talked everything about COVID. And obviously, COVID and 2020 have become synonymous. Although it's COVID-19, but it's 2020 that's . . .

Scot: We're on a first-name basis with this thing now.

Troy: Yeah. We don't call it COVID-19. It's just COVID. So I know you have seen me many times pull out my little black planner, and you have harassed me for pulling this thing out.

Scot: You don't use electronic means to keep track of your schedule like the rest of the world. You still have a little black planner that you keep in your shirt pocket.

Troy: Yeah. I am still stuck in the '90s. I have a little black planner I pull out. I just bought my 2021 planner. It has November and December of 2020 in it, and it was such a relief to take that 2020 planner and throw it away and start using this one that says 2021 on it. It filled me with a sense of hope that maybe we're moving into something better.

Scot: Did you burn it? Did you throw it out in the yard and stomp on it?

Troy: Yeah, I should have held some sort of ceremony.

Scot: Just going to leave this here. This might also bring some light to your life. I don't know if you like eating raw cookie dough. So I like eating raw cookie dough. My wife hates it. I don't know where you're at on it.

Troy: I don't know. The raw egg piece of it is kind of . . .

Scot: See, that's the thing.

Troy: There's that.

Scot: There's the safety element. Eating raw cookie dough can be dangerous because you've got the raw eggs, so they tell you not to do it, although that never stopped me. I bought some cookie dough the other day that on the outside it says, "Safe to eat raw." So, apparently, technology has finally given us cookie dough. Somehow, and I don't know how they've done it and I ain't asking questions, they are marketing and put on the package "safe to eat raw."

So, in this time of a pandemic, now at least if you're eating cookie dough, you're not worrying about salmonella. So there you go.

Time to say the things that you say at the end of podcasts, because we are at the end of ours. Troy Madsen, go.

Troy: Check us out on Facebook, facebook.com/WhoCaresMensHealth. Our website is whocaresmenshealth.com. You can reach us at hello@thescoperadio.com or you can call us at . . . Scot, what's that number?

Scot: Oh, that's a good question. 801-55SCOPE?

Troy: 601-55SCOPE. Don't confuse it for the 801, Scot. This is 601-55SCOPE in Quitman, Mississippi.

Scot: Also, we would love it if you would subscribe to the podcast on the podcatcher of your choice. And thank you for listening and thank you for caring about men's health.

Hey everyone, this Margaux from Bundle Of Hers. While we're on hiatus, I wanted to share with you another podcast called, Clinical, which is produced by The Scope Presents, the same network that produces Bundle Of Hers.

Clinical takes you deep into the heart of our institution and to find out what really makes a hospital... a hospital, and looking beyond the stories of just physicians, but into the entire ecosystem of our hospital and all healers that make our hospital work.

Currently, on Clinical, there's a multi-part series called Unit on the Brink: Voices from the COVID Frontline. As a resident, whose been working with COVID patients, I think it's important that we take time to listen to the narratives of the frontline workers in the COVID units. If you love the narratives we share on Bundle Of Hers, I highly recommend you check out this series.

Talking Admissions and Med student life will be back soon with a new format to celebrate our 150th episode.

Until then, I wanted to tell you about a podcast I think you’ll really like.

Clinical takes you deep into the heart of University of Utah Hospital to tell the stories of the people that make a hospital… a hospital.

Clinical’s current series is called Unit on the Brink: Voices from the COVID Frontline. It’s the stories of seven medical professionals and how the virus is impacting their patients, their community, and their lives.

Check it out. And if you like what you hear, you can find full episodes and subscribe at thescoperadio.com/clinical.

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

I'm Mitch Sears, producer for The Scope Radio, and you're listening to episode five of our series "Unit on the Brink." This is a multi-part story told in order. And if you haven't listened to our previous episodes yet, we highly recommend you go back and start with episode one in your podcast app. Don't worry, we'll be here when you get back. And for everyone else, this is part five of "Unit on the Brink."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nurse Brim: I am the keeper of hope even when I know deep down that there is none. I am the keeper of hope when the family and the patient has lost all hope, but I know deep down that there is still hope.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical is part of The Scope Presents Network and brought to you by University of Utah Health. If you liked what you heard, please be sure to subscribe and share with your friends. And if you haven't yet, why not give us a rating on Stitcher or Apple podcast? Those ratings really help new podcasts like ours. and it really makes our day to read them.

And to all the nurses, doctors, admins, interpreters, operators, technicians, and all the other hospital employees out there, we know you're listening and we want to hear from you. Do you have a frontline story or a message for us or for the people in our story? Feel free to share at our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or email us at hello@thescoperadio.com.

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

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

Special thanks to Charlie Ehlert and Jessica Cagle for their work on the companion site. And of course, our heartfelt thanks to the men and women who have shared their stories with all of us and fight to this very day to keep each and every one of us safe.

Hi, this is Scot from Who Cares About Men's Health. Troy and I are going to be back next week with some brand new episodes. Really excited about that. But in the meantime, I want you to check out a podcast that I think you're going to really love. It's called Clinical, and it takes you on a deep, deep dive into the heart of University Hospital and tells the stories of the people that make a hospital a hospital.

Clinical's current series is called Unit on the Brink: Voices from the COVID Frontline. And it's the stories of seven medical professionals and how the virus is impacting their patients, their community, and their lives.

And by the way, you're going to hear a familiar voice on this podcast. Producer Mitch not only produces it, but he's also one of the co-hosts of Clinical along with Stephen Dark, who is an amazing writer and amazing storyteller. I listened to Episode 3 three times, twice because I had to for my job and the third time for me.

Interviewer: Skin infections, when is it the time to go to the ER? We'll talk about that next on The Scope.

Announcer: This is From the Frontlines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: So here's the situation. You've got this redness on your arm. It could be from maybe an ingrown, a cut, maybe an ingrown toe nail. Maybe it's just redness on your arm that starts spreading and taking up more and more of your skin. It could be an infection. Should you go to the ER for that? Dr. Troy Madsen is an emergency room physician at University of Utah Health. First of all, I think it's important to say that infections can be really serious. Like, we tend to forget how bad they can be because we've gotten really good at dealing with them.

Dr. Madsen: That's exactly right. Infections are one of these things where you may look down, again, at your arm or your leg, you see some area of redness, you think, "Oh, it's just going to get better." But we often sort of take for granted that, yes, infections are easy to treat, they don't kill people. But we certainly see cases in the ER of very serious infections. Oftentimes people who have put off going to the ER for whatever reason, where that infection grows, it's a very serious infection, it then leads to sepsis or an infection into the blood stream, and sometimes can be a life-threatening thing.

Interviewer: So that type of an infection, would it ever get better just on its own? Like, if I see that red area on my arm and it starts to spread, and I'm like, "Well, I really don't want to go to the ER. Maybe it'll just get better." Will it get better without treatment? Will my immune system fight it off?

Dr. Madsen: Usually not. The cases we see. . .

Interviewer: Really?

Dr. Madsen: Yes. It's one of these things where once you get that bacterial infection that settles in there, say, in the arm or in the leg or wherever it is and for whatever reason, oftentimes I don't have a great answer for why this infection started. It's typically not going to get better without antibiotics. The exception to that might be if you have a little abscess, so like a little pocket of infection and maybe it starts to drain, that sort of thing once it drains may get better. But if that infection then spreads to the skin around that abscess where you start to get a lot more redness, it's expanding, you see red streaks tracking up your arm, that can be a very serious thing and without at least starting some sort of antibiotic, whether it's oral antibiotics or, in more serious cases, IV antibiotics, it's really not going to get better.

Interviewer: ER or urgent care?

Dr. Madsen: If it's the sort of thing where it's just a local area of redness, maybe not bigger than, say, 3 or 4 inches long, you're probably okay to go to an urgent care. They'll prescribe some antibiotics. But if you're having fevers with it, chills, you see streaks tracking up your arm, I would recommend going to the ER because those are cases where you may need some blood work, you may even need IV antibiotics and admission to the hospital.

Interviewer: Got you. So, if you have an infection and it continues to get bigger and bigger, it's not going to get better on its own, you do need to go talk to somebody, otherwise it could be bad news.

Dr. Madsen: Exactly. Another thing to watch for with infection, there are cases you may have heard of flesh-eating bacteria. It's a scary sounding thing. But there are cases of really serious infections that you need to get to an ER as quickly as possible. And these are infections usually in people who may have some immune system problems, maybe they have diabetes, maybe they have cancer where they're on treatment for that.

But these are infections where it's a very, very rapidly spreading infection, and you feel sick, and you may even push on that area of infection and it feels kind of crunchy, kind of a weird sort of feeling to it like there's air under the skin. This is something that's called necrotizing fasciitis, and this is something where you need to get to an ER as quickly as possible, as that it's the sort of thing that often requires surgery. It's rare, but we see it, something that's worth mentioning with a rapidly spreading infection. So infections, something that may seem simple, but it's not something to mess around with.

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