After more than three decades as a critical care nurse at the University of Michigan Hospital in Ann Arbor, Carolyn Lyles has come to depend on her hour-long commute as a refuge from the din of alarming machines and harried voices that awaits her in the ICU. On a typical morning, Lyles, 55, wakes up at 4, prepares her lunch, makes coffee, and grabs a bagel for the road.
She slips out of the house while her husband Steve and three children are still in bed, climbs into her gray Buick Enclave, and drives from her home in Grosse Ile, near the point where the Detroit River spills into Lake Erie, past sleeping neighbors in darkened houses, across the Wayne County swing bridge and past the Chrysler engine plant in Trenton. As she cruises past the red approach lights that guide airliners into Detroit-Wayne County International Airport, she thinks of her 82-year-old mother, Mary, asleep nearby in the house that she grew up in. Mary, who raised Carolyn alone, was a neonatal ICU nurse. The days Lyles spent shadowing her mom at the hospital inspired her to become a nurse herself.
A deeply faithful Catholic, Lyles usually travels the dark highway in silence. She prays that God will deliver her to the patient who needs her most. Working so close to the fragile membrane between life and death, Lyles has always prayed for strength to get through the day. After two weeks of caring for Covid-19 patients, those prayers had taken on a frightening intensity.
On Tuesday March 24, the 20-bed Critical Care Medicine Unit, or CCMU—the only place Lyles has ever worked since she received her nursing degree in 1987, just a year after the hospital opened—was suddenly closed and emptied of patients so that carpenters could install negative-pressure filtration systems for the anticipated deluge of Covid patients. Since Lyles and her CCMU teammates have pulmonary care expertise, they were temporarily reassigned to the Regional Infectious Containment Unit, or RICU, a special negative-pressure ward on the 12th floor of the adjacent C. S. Mott Children’s Hospital that can be activated in emergencies to isolate patients with highly infectious diseases like SARS, Ebola, and now Covid-19.
It was disorienting. “We were all blindsided,” Lyles tells me. Accustomed to working one-on-one with her patients on a floor as familiar to her as her own home, with colleagues she has known for decades and come to think of as family, Lyles was suddenly thrust into a 50-bed unit in an entirely different building, assisting a swarm of unknown doctors, nurses, and technicians swathed from head to toe in protective gear that would have made it difficult to recognize them even if she did know them. “You have no idea where anything is,” she says. “How do I get help? Who do I get help from? Where is everybody?”
Lyles did not have a patient of her own that first day in the RICU, so she served as a runner, fetching medications and supplies for nurses who were tending to patients behind glass doors that remained closed to minimize contamination. Nurses on the inside would write their orders on the glass with dry-erase markers—backwards, to make them readable to the runners—because it was impossible to communicate through N95 masks and glass and over the noise of ventilators and alarms. On the drive home that night, Lyles was exhausted, her back in spasms from the tension.
“I'm not sure I'm ready for this,” she thought to herself. “I'm really scared.”
“We are facing an unprecedented situation that none of us has lived through before. We know this is terrifying for all of us,” reads an email sent to employees of Michigan Medicine—the University of Michigan’s hospital system—on April 2, signed by CEO Marschall Runge and two other members of the executive team. By the time the email hit the inboxes of 28,000 employees—who include about 3,000 doctors, 6,000 nurses, 1,200 residents and fellows, and legions of support staff—Detroit, about 30 miles away, was reeling from an outbreak that had already filled some of the city’s largest hospitals to capacity.
“It escalated really quickly after spring break,” which ended March 8, says Preeti Malani, a professor of internal medicine who serves as chief health officer of the University of Michigan and advises Michigan Medicine’s Covid-19 planning team. “At that point we didn’t have any documented cases, although there probably were some cases that just weren't reported.”
The state of Michigan confirmed its first two Covid-19 cases on March 10. In the three weeks that followed, the number of cases in the state soared to more than 10,000, making it one of the nation’s hot spots. The overwhelming majority were in Detroit and the three surrounding counties—Wayne, Oakland, and Macomb—but everyone at Michigan Medicine knew that the storm was hurtling their way.
By Tuesday, March 17, the medical school had suspended student clinical rotations and moved all classes online, in accordance with guidance from the Association of American Medical Colleges. For many in the Michigan Medicine community, the disappearance of hundreds of medical students from the hospital floors was the first visible sign of a jarring new reality.
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Like a body diverting all of its energy to its immune system to fight an infection, Michigan Medicine concentrated its resources for a long campaign. Things got eerily quiet as the hospital system closed its outpatient clinics, scaled back nonessential procedures, eliminated elective surgeries, shifted thousands of doctors’ office visits to telemedicine appointments, and limited transfers and emergency room admissions almost exclusively to Covid patients.
Department supervisors adjusted staffing to ensure a ready reserve of frontline personnel. One of the most chilling actions was the decision to restrict visitation to only the most dire situations and to limit the number of visitors to one per patient in the emergency room and two per patient during end-of-life care in the ICUs. “It’s a horrific social action to say spouses and children and parents can’t come and visit their loved ones in the hospital,” says Gilbert Omenn, a physician and geneticist who served as CEO of the University of Michigan Health System—now Michigan Medicine—from 1997 to 2002. “It’s terrible, but it's got to be done. And it’s very stressful for everybody.”
Meanwhile, maintenance crews got to work converting as much of the 1,000-bed hospital system as possible into ICU space capable of accommodating Covid patients. Plans came together to add hundreds of beds in case the worst case scenario in the modeling came to pass. “Right now, the focus is on trying to keep the health system intact,” Malani says. “You can’t make a pivot at the last moment.”
For a hospital that runs at about 85 percent capacity on average, this was a monumental undertaking carried out under the unrelenting pressure of time. “It’s a matter of scale and severity and speed,” Omenn, who is also a former dean of the school of public health and a distinguished professor at the medical school, says when I ask what makes the Covid-19 pandemic different from other epidemics. “The notion of going up an exponential curve is really dramatic.”
Outbreaks of highly contagious diseases, including seasonal influenza, can place an extraordinary burden on hospital systems at every level of size and sophistication—including Michigan Medicine, which is ranked 11th in the nation by U.S. News and World Report—pushing the caseload of patients requiring acute critical care up to and beyond capacity. “The difference is that flu is moderated—some years prevented—by the vaccine,” Omenn says, adding that every Michigan Medicine employee is required to be vaccinated against the flu each year in order to come to work, or else wear a mask.
“Here we don’t have a vaccine,” Omenn says, and “the biggest concern both here and nationally is the risk to health care workers, because the system is dependent upon people with extraordinary dedication and willingness to accept some risk, maybe a lot of risk, doing what's necessary for patients who are extremely ill.” Although the hospital system’s existing crisis management plans had been honed by experience with outbreaks—SARS, H1N1 Swine Flu, and H5N1 Bird Flu, among others—Covid-19 was something entirely new, as the term “novel coronavirus” makes clear, and none of the existing plans quite accounted for the maelstrom of logistical, staffing, and safety demands posed by the pandemic.
As it rapidly proliferates into every nook and cranny of human settlement across the globe, there is no way to predict when it will slow down, let alone when it will be over. “We need to get ahead of this pandemic so that the spread of the disease slows and we have time to do what we can for all the people who need acute medical care,” Omenn says, “to get other people recovered, and to not get massive numbers of additional infected people, which we are at risk of if people will not fully cooperate—fully at all levels, starting with individual Americans.”
After lunch on Saturday, March 28, Doug Arenberg settled into a couch in his living room at a safe distance from his wife Karen and his two sons, Clark, 20, and Brett, 18, to watch an animated movie called Spies in Disguise about a super spy who accidentally gets turned into a pigeon. Arenberg, 55, is a Chicago native who came to Michigan as an intern after medical school almost 30 years ago and is now a pulmonary and critical care doctor specializing in lung cancers. He had just finished the first of two weeks of clinical rotations in the CCMU.
During that time, the census of Covid-19 patients under Michigan Medicine’s care swelled from 16 to 76, outgrowing the capacity of the RICU and spilling into the hospital system’s other ICUs. More than a trickle, but still not quite a flood. Not long into the movie, Arenberg’s phone rang. It was Michigan Medicine’s chief medical officer, Jeff Desmond, calling. David Miller, a urologist who is on the Covid-19 response leadership team, was also on the line. As Arenberg left the room to answer, his family followed him with their eyes, disturbed by the look on his face.
“You don't usually get that phone call,” Arenberg says, “and I knew that it was not good.” Arenberg and his colleagues had watched as Beaumont and Henry Ford hospitals in Detroit grappled with a monstrous spike in cases. They had been eager to help, but they were anticipating a surge of their own. Until then, Michigan Medicine’s modeling had presumed that an increasing number of Covid patients from its own region, in and around Washtenaw County, would start showing up at the emergency rooms, but that few of them would require hospitalization and still fewer would require intensive care, maybe five out of 100.
Over time, Covid patients would take over more and more of the hospital until eventually a field hospital might need to be opened, a stage that planners were referring to as phase 4. The modeling gave the planners a crushing timeline of about two weeks to roll out massive adjustments. “How you doing, Doug?” Desmond asked. He and Miller were calling to tell Arenberg that they would have days, not weeks.
“Exactly what was said was, ‘Doug, Beaumont and Henry Ford are being overrun. We can't allow that to happen to them. So we're going to take our old model and throw it out.’ We essentially just said, give us what you got.”
Twenty-two Covid-19 patients would be transferred to Michigan Medicine over the next 24 hours, six of them to the CCMU. Arenberg texted his friend, CCMU medical director Robert Hyzy: “I think the tsunami just hit.”
“There was a flurry of phone calls, and that's when I just kind of sat down and took a deep breath and said, ‘Here we go,’” Arenberg says. “It was the first notion for me that tomorrow is going to be very, very different from today. It's no longer theoretical tomorrow.”
Over the next 11 days, waves of Covid-19 transfers and emergency room admissions broke on Ann Arbor, justifying the extreme preparations at Michigan Medicine. Sirens and the thumping rotors of maize and blue Eurocopter 155 Survival Flight helicopters signaled the arrival of as many as 25 patients a day until April 8, when the number of Covid inpatients hit a peak of 229. As the hospital system mobilized to meet the rising waters, thousands of non-Covid patients became what Omenn would call “casualties of triage,” their procedures and treatments postponed until a date that suddenly seemed unfathomable: the day when the waters would recede and some semblance of normality might return.
Although some operating rooms remain open, Michigan Medicine’s growing non-Covid patient backlog includes people who need procedures as simple as colonoscopies and as surgically involved as hip replacements, some tumor operations, and non-emergency heart valve repairs.
The rationale for temporarily deferring these cases is to prevent healthy people from getting sick in the hospital and to prevent Covid-infected people, including hospital personnel, from bringing the virus in. Additionally, even minor surgeries have the potential to land someone in the ICU with complications. By late March, with Michigan Medicine’s internal modeling anticipating the Covid-19 surge might amount to several hundred or even thousands of severely ill patients at a time, every existing ICU bed—and every potential ICU bed that could be converted—had become a priceless resource. Faced with a towering set of unknowns, the threshold for known and avoidable risks dropped to zero. “There’s a huge human cost to that,” Malani says, but “it’s not about perfection. It’s really about saving as many lives as you can and trying to do the least harm to everybody.”
Even as Michigan Medicine was implementing these tectonic adjustments, the planners knew they might not be enough, so the Covid team worked with the US Army Corps of Engineers to draw up plans for the construction of a 500-bed field hospital at an athletic facility on campus. Michael Mulholland, a surgeon and 32-year faculty member who now serves as executive dean of clinical affairs at the medical school, volunteered to lead the field hospital planning and to run the facility in the event that it has to be built.
At an online employee town hall on April 3, Mulholland delivered sobering remarks about the task before them. “The work will be difficult. For most of us, it will take us far away from our usual comfortable lives. We are used to order and predictability and the luxury of plenty. A field hospital will have none of that.”
Mulholland was referring specifically to the field hospital project, but his words spoke to the anxieties of the nearly 8,000 people listening at home on their laptops or on their smartphones somewhere in the hospital complex. He spoke calmly, pausing between phrases. “I believe this service is best approached with a deep sense of personal humility. Over the coming weeks our work will require courage—courage from all of us in all of our work. This courage will allow us to care for others, knowing that in turn we will be cared for, and our families cared for in the same way, should we become ill.”
“We'll get through this together,” he concluded. “I promise.”
In the era of Covid-19, Ric Eakin’s skills are every bit as vital as the machines he runs. Together with intensivists like Arenberg and critical care nurses like Lyles, respiratory therapists like Eakin are the last line of defense against acute respiratory distress syndrome—the pulmonary complication that is killing thousands of Covid patients around the world. In the most basic terms, the syndrome occurs when any number of illnesses—pneumonia, sepsis, smoke inhalation burns, Covid-19—cause inflammation of the lungs, which in turn causes capillary oozing that fills the lungs with fluid, making them difficult to inflate and preventing the membranes of the alveoli from absorbing oxygen and expelling CO2.
As blood-oxygen saturation drops, other vital organs are starved of oxygen, which hinders their ability to function. The kidneys and liver struggle to filter toxins, and the body’s immune system can turn on itself in a potentially fatal phenomenon, sometimes referred to as cytokine storm. Eakin’s job, in a nutshell, is to use the machines at his disposal to help the patient breathe without damaging their lungs, in order to keep the worst complications of respiratory distress at bay.
When fine-tuning a ventilator, Eakin uses as little pressure as possible to keep a Coke-can-sized pocket in the inflamed lungs from collapsing, adjusting flows to make sure the right mixture of oxygen and air passes over the still-functioning alveoli inside. Italian pulmonologists Luciano Gattinoni and Antonio Pesenti coined the term “baby lung” to describe the tiny zone where Eakin concentrates his efforts—equivalent to the average lung volume of a 5- or 6-year-old child. Too much positive pressure and sensitive lung tissues that are already inflamed can suffer damage, compounding the patient’s respiratory distress with more inflammation; too much sedation and patients can suffer psychological trauma, including delusions and PTSD. “We will give you just enough air to survive and oxygen to survive,” Eakin says. “You won’t like it, but we’ll keep you alive, hopefully.”
Ventilators are a tool of last resort, and the odds of a critically ill patient coming off the ventilator after more than two weeks alive are sobering: about one in two, according to a 2015 review of studies published by the National Institutes of Health. Preliminary data from New York and Wuhan, China, suggest that as many as four out of five Covid patients die after going on a ventilator, according to a report from the Associated Press. But Arenberg agrees with experts who say these high death rates may be correlated to how sick the population of ventilated patients is in a particular place. In New York, where many hospitals have exceeded their ventilator capacity, “only the sickest of the sick will get on the vent,” Arenberg says.
Generally speaking, the chance that a patient with severe respiratory distress will survive declines the longer they’re on a ventilator. Some patients with Covid-related respiratory distress remain on a ventilator for as long as three weeks. “We just can’t get them to turn that corner,” Eakin says.
The “corner” is the point at which a patient has recovered enough for a spontaneous breathing trial, which involves reducing sedation and ventilator support to allow the patient to try to breathe for themselves, a necessary preliminary to extubation. “When we do get them down to that level,” Eakin says, “it’s touch and go to even get them extubated.” According to Arenberg, one of the most vexing aspects of caring for Covid patients is that a patient might appear well enough to extubate, only to have their condition deteriorate rapidly once the tube comes out.
Despite the grim odds, there are small victories that are not so small if you’re the one on the vent. One of Eakin’s recent patients, a man in his sixties, ripped out his own ventilation tube when he awoke in a hypoxia- and sedative-induced delirium and panicked, a somewhat common occurrence. In normal times, a doctor might choose to keep a patient under observation after a self-extubation, but according to Arenberg, experience with Covid cases has “raised the bar on extubation.” Having witnessed how swiftly Covid patients can “decompensate” after extubation, the patient’s care team decided to immediately reintubate him. Statistically speaking, the need for reintubation is associated with reduced chances of survival.
Nevertheless, after a week on the ventilator, Eakin and his team were able to reduce the ventilator settings and put the patient through a couple of days of trials, letting him breathe spontaneously with minimal support. Eakin happened to be standing outside the door when two respiratory therapists and a nurse removed the breathing tube at last and cleaned out the patient’s mouth.
“He's coughing, which is normal, and then I heard Julie, one of the therapists say, ‘Can you give me a smile?’ And the look on his face was like, ‘You got it!’ It was the biggest grin you can imagine. Everybody just started breaking up laughing,” Eakin recalls. “I went in later on that day to get some equipment and talk to him for a second, and he was just so thankful for everything that we'd done and so happy to get off the ventilator and get that tube out.”
For Doug Arenberg, these moments of shared success and joy—however fleeting—are profoundly important. Arenberg has been concerned with the morale of the residents, who are mostly young, new to medicine, and unaccustomed to the onslaught of severely ill patients and relentlessly bad news in the Covid-19 ICUs. “I could tell it was hard on them because when these folks with coronavirus get sick, they get sick and they stay sick,” Arenberg says. “Typically with acute respiratory distress syndrome, if you’re going to die, you’re going to die in the first seven days. It’s pretty dramatic. But if you get people through those first three to five days, you see the trajectory starting to get better. You see a day-to-day feedback, ‘Oh look we did this and now they're a little better.’ So we’re not seeing that. This is a much more protracted course.”
To lift the residents’ spirits, Arenberg charged them with discovering one personal detail about each patient in their daily phone calls with the families. “One thing every day that has nothing to do with them being sick,” Arenberg says. “I wanted something like, do they like to garden? What’s their favorite color? Do they have a dog? Are they dog or cat people?” (“I'm a dog lover,” Arenberg tells me. “If I could, I’d have like 10 golden retrievers, but I’d also be on antihistamines for the rest of my life.” Instead, he has a Havanese named Wrigley. “He’s hypoallergenic.”)
Plus: What it means to “flatten the curve,” and everything else you need to know about the coronavirus.
“I just said, ‘Give us one thing every day,’ and it was really interesting to watch everybody's reaction to that,” he says. “Everybody smiled. Everybody nodded their head and everybody seemed like, ‘Yeah, this is what we need.’”
The next day on rounds, Arenberg learned that one patient liked orchids. “I can’t grow an orchid. I’ve killed every plant that’s ever been in my care. So I made this mental note. Little stuff like that. I don’t know if it’s going to help in the long run, but it was a nice distraction, and it helps people connect to the humanity of this.”
Arenberg and several of his critical care colleagues, including Jack Iwashyna and Mike Mendez, were already looking for ways to “aggressively rehumanize” patients before Covid-19 struck. Now, a ferocious contagion has introduced a new and formidable barrier between patients and healers. The infected person lying helpless in a hospital bed, hooked up to machines and IV bags and sprouting a tangle of wires and tubes, fighting for their life—this person embodies the danger that has seized the entire world. In hospitals everywhere, Covid patients pose a grave threat to the very people who want so desperately to help them. They carry a mysterious and lethal virus that has proven itself capable of slipping through the most robust defenses.
As of April 16, nearly 300 Michigan Medicine employees had tested positive for Covid-19. More than twice that number have tested positive at both Beaumont and Henry Ford hospitals in the Detroit area. The sci-fi-worthy protective gear that medical workers must armor themselves with to care for Covid patients projects sterility and an air of technological mastery over microscopic enemies that our plague-devastated ancestors could not have fathomed, but it also serves as a brutal reinforcement of the isolation born by Covid patients. There is no way to look at a person behind a face shield and an N95—let alone a positive-air-pressure purifying respirator and a Tyvek suit—and not think about who they are protecting themselves from.
In Covid times, the need to rehumanize patients—aggressively—is all the more acute. As before, Arenberg says, that often means taking time to care for patients’ families—educating them about the progress of the illness, keeping them informed of routine activities and changes, comforting them when things turn worse. Unfortunately, safety protocols have made it almost impossible to have families present in the room when they most need to be there, at the moment when a terminal patient comes off life support and begins to die.
“This is such a departure from how we usually do these things. We usually want to make sure that we assure the family that the patient will be comfortable, and then we allow them to fill the room with whoever wants to be there. Sometimes five, six, seven, eight people in these small rooms, with a respiratory therapist and a nurse and a ventilator and maybe sometimes a dialysis machine that we get out of there,” Arenberg says.
On a recent shift, Arenberg had to lay the foundation with the sister of one Covid patient, a woman in her early 70s, that things were not going well. In a phone call, he explained that the patient had multiple organ failure and would never again survive without the artificial measures that were maintaining her vital signs. Arenberg gently told the sister that they were no longer prolonging life, but prolonging death. He recognized the moment when the woman on the other end of the line realized she would not be at her sister’s side at the end.
“You could hear and feel the agony on the other side of the phone because she didn't want her loved one to die alone, and so we assured her that she wouldn't,” Arenberg tells me. “I promised that somebody would be able to hold her hand and be with her, and we made sure that there was somebody in the room,” he says. “We kept that promise.”
After the patient died, a resident who had spoken to the sister previously called to tell her that it was over and that it had been painless. The two women cried on the phone together. As he tells the story, Arenberg himself starts to cry.
“You can't do the job without putting a distance between you and the patient, but you also can't do it without trying to empathize with the person in the bed and the person on the other end of the phone,” he says, pausing to collect himself. “I think part of it is that you have to be willing to acknowledge that this affects you … I think people need some freedom to go close the door and cry.”
“I see the turmoil in my colleagues' eyes when we talk about this. That’s the moment where you start to think, ‘Well, that’s not going to happen to me.’ And obviously I don’t want to die, but the most important thing is I don’t want to bring this home to my family. So a lot of us are getting apartments and staying in hotels. And if you feel sorry for yourself because you’re alone in a hotel room, you remind yourself, it could be worse—you could be alone in the ICU.
“So I think the reason I’m so emotional now is I’m thinking about some of these residents and respiratory therapists I’m hearing about in the news locally that are dying from this. Nobody goes into medicine and writes in their application essay, ‘I want to deal with a global pandemic.’ But everybody says they want to be part of something important. So we feel like we’re part of something important, but we’d like to be able to know that we didn’t put our families at risk.”
I ask Arenberg what he thinks of the hero language currently being directed toward hospital workers. “My plea to everybody has been, if you stay home, you’re just as much of a hero as anybody else, because you not getting sick means we have that much more of a chance to take care of that person who didn’t have a choice,” he says. “If you end up in our ICU, and my nurse colleagues and respiratory therapy colleagues have to expose themselves to the possibility of getting this virus to help you survive, we want to know that you didn’t have a choice. I want to know that you didn't go out and go to a party … I guess the short answer to your question is, if you really want to thank a health care worker, just stay home.”
On Wednesday, April 1, a week after her first shift in the RICU, Carolyn Lyles parked in one of the outlying lots, walked the half mile or so to the hospital in the dark and began her fifth 12-hour Covid shift. She resumed her previous day’s assignment, caring for a patient who was hooked to a dialysis machine and suffering from multiple organ failure.
Throughout her Monday shift, she had struggled to keep the dialysis lines clear so that the machine could filter the patient’s blood properly. She would no sooner leave the room than an alarm would go off and she would have to gown up in full protective equipment again to run in and adjust the dressings around the IV access and restart the machine all over again. Tuesday was no better. “I remember the dialysis nurse standing outside the door, and the machine kept alarming and I kept resetting it, and she’d just look at me, and I’d be like, ‘I got this. I’ll fix it.’ Just, you know, ‘Don’t come in,’ trying to manage it without their help,” she says.
After hours at the patient’s bedside, Lyles finally got the catheter and lines to lay just right, and the machine was filtering properly at last. She stepped out of the room, meticulously removed her protective gear, and sat at the desk, looking through the window at the patient. “I wasn’t there for more than five minutes. I was going to try and chart some things, and the patient’s blood pressure started dropping,” she says. So I jumped up and went over, and I started getting dressed. And by the time I got dressed and got in the room, the patient’s heart rate was half of what it had been.”
Lyles ran to the machine, turning the dialyzate down so that she would not pull any fluid from the patient. “The patient’s heart rate at this point was 20. I’m panicking in the room thinking this patient’s going to code and die. I can't fix this.” Guided by tens of thousands of hours of experience, Lyles pulled a sedating medication out of the pump and replaced it with a blood pressure medication. She cranked up the flow, then ran to the other side of the bed, squeezed herself between the equipment and pushed the code button, alerting the code team that her patient was on the verge of cardiopulmonary arrest.
By the time the code team donned their PPE and got into the room, the blood pressure medicine that Lyles had initiated had started working. “He came back,” Lyles says, “but it was within seconds. He would have died. And it’s probably the scardest I’ve been in many, many years.”
The patient’s family members—just two of them, as per the restrictions—donned protective gear and came to the room while he was still heavily sedated, barely clinging to life. “I just wanted to hug them, and I couldn’t,” Lyles said. “I just felt horrible.”
Two days later, Lyles’ husband, Steve, showed her a picture of a nurse from Henry Ford Hospital, 54-year-old Lisa Ewald, who had just been found alone in her home, dead from Covid-19. “He was scared. He said, ‘It reminds me of you. She looks like you.’”
It was April 3. Lyles was two days out from the RICU, but she was still exhausted. “I wasn’t sure if I was just tired because I’d just worked three 12-hour shifts, and it's long days, or if I was starting to come down with something,” she says. “So I took it easy that day, and then the next day I still didn't feel like I had any energy. I slept most of that day. I was coughing, and that evening I had a fever,” she says. “So I called my manager, because it was a Friday, and I was supposed to work on Saturday. I told her I had a temperature of 102.”
Under ordinary conditions, Ric Eakin’s job requires precision and focus, but like Arenberg’s and Lyles’, it also requires a willingness to bear witness to tragedy and to offer sympathy to frightened patients and grieving family members. Over the past two weeks, the staggering volume of severely ill patients and the hypervigilance required to maintain proper PPE and decontamination protocols have added new dimensions of mental and physical fatigue to an already taxing workday.
When Eakin and I last talked, on April 9, there were 17 Covid patients on ventilators in the CCMU. Hospital-wide, there were 152 patients on ventilators. Arenberg says the number of patients on ventilators in the CCMU where he, Eakin, and Lyles work is not unheard of. “Sometimes all 20 beds are full with patients on ventilators,” he says, but having to care for so many acutely ill patients under the strain of mounting paranoia about personal safety is incredibly stressful. “I know exactly how many doorknobs I have to touch on the way to my office,” Arenberg says. It’s not meant to be funny. (The answer is four. He doesn’t count his office door because he opens it with a key.) “You have to watch out for the burnout,” Eakin says. “It creeps up on you real quick.”
The insane operational tempo has not been as difficult as watching patients die alone or watching people awkwardly struggle to put on gowns, masks, face shields, and gloves so they can stand at the bedside of a family member who is actively dying. “I do feel for the families, because there is no way right now to make this comfortable. We try our best to make it as respectful as you can, but you’ve got HEPA filters that are blowing air out of the room through the windows, because of the way they've had to retrofit, and it's noisy. The door is closed. There’s only so many people, there’s no other visitors around,” Eakin says. “You see them FaceTiming with family, being creative and struggling to figure out how to communicate the grief and what they’re feeling, because nobody’s there with them, and that is very difficult on your soul, because, but for the grace of God, it could be your family.”
Forty years ago, Eakin left his own tight-knit family in Greenwood, South Carolina, and traveled north on the heels of a Michigander named Brenda Eppler. While Brenda went to school at Eastern Michigan University, Eakin completed a respiratory therapist course at Washtenaw Community College, which landed him a job at the University of Michigan, where he has worked ever since. Eakin and Eppler eventually married and had two sons, Tom and Chris, who are now 20 and 25. Eppler and Eakin divorced eight years ago, but they remain on friendly terms and they care for Tom, who is on the autism spectrum, together.
Eakin and his boys are very close, but now that Eakin is working four 10-hour shifts a week in a Covid unit, he has to keep his distance from the boys to minimize the risk of contamination. Eakin comes home every night to an empty apartment. “I’ve gone for walks with them, standing four feet away. I feel like if I gave it to them, it would just be a horrendous experience,” he tells me. “It would very much traumatize me.”
At 59, Eakin never imagined that his profession and the main tool of his trade—the ventilator—would become central discussion terms of the worst global pandemic in a century, alongside “N95 respirator,” “wet market,” and “social distancing.” But such public recognition comes at the cost of punishing loneliness, and Eakin would happily fade back into professional obscurity if it meant the end of the crisis and relief from the terror of passing the virus on to his friends and his sons.
Being unable to hug Tom has been especially difficult, because hugs are one of Tom’s most important forms of communication. “You hug him and it’s like getting a hug from a grizzly bear. You know you’ve been hugged,” Eakin says with a laugh. Then his voice falters. “I looked at him the other day and I said, ‘I need one of your hugs so bad it’s killing me.’” Tom shook his head to show he understood and said, “I know, Dad.”
When Lyles called her manager to tell her about her fever, the manager took Lyles off the nursing schedule and instructed her to contact the employee health department to arrange an appointment for her at a drive-thru testing site in Canton, about 45 minutes from her home. On Saturday, April 4, Lyles slid up to a white tent outside one of the university’s satellite clinics. An attendant directed her to pull past the safety pylons, where she waited with the windows closed while a nurse put on her mask, gloves, and gown and readied a testing kit. As she prepared to plunge a small swab on a long, thin dowel deep into Lyles’ nasal cavity, the nurse warned Lyles about the discomfort. “I’m one of those people that have to do those swabs. I understand,” Lyles says. “I told her, ‘You do what you have to do.’”
As Lyles drove home, there was no doubt in her mind that her test results would come back positive. “I knew when I was going that I had it,” she says. “I worked in the unit. I knew that no matter how much you try to not expose yourself, there’s a chance that you’re going to be exposed. You’re talking about an organism that you can’t see. How do you fight against something that you can’t see? It’s everywhere.” When her test results came back the next day, they confirmed her instincts: She was Covid-positive.
She worried that her prediabetes and asthma—two conditions thought to be associated with the worst Covid outcomes—might make her symptoms so severe that she would have to be hospitalized. But mostly she worried about her family and about her coworkers, left short-handed by her absence. Over the next few days, her fears of infecting her family grew as her symptoms worsened. For four days straight, she had a severe headache and coughing fits so intense that she could not catch her breath. She could not eat and subsisted only on water and tea with honey and lemon, which she drank to try to soothe her throat. She was so exhausted that she could hardly get out of bed. Through it all, she sequestered herself from her family, obsessively washed her bed linens, and wiped down everything she touched.
When her fever finally broke, Lyles had to face a new fear: returning to work and to her normal life. Something as simple as making a run to the grocery store to buy fish for Good Friday dinner became laden with anxiety. “Am I a carrier now? Am I shedding? Do I still have the virus? Because I’m still coughing,” she says. “I don’t think they know enough about Covid-19, and I don’t want to be responsible for causing someone else sickness, heartache, and death.” She decided to skip the grocery store.
When we talk by phone on April 11, Lyles says she’s slated to return to work in a few days, and she’s anxious about whether she can handle the long hours in her depleted state. “It’s so physically, mentally, and emotionally draining,” she tells me. On top of her concerns about her own capacity, Lyles says she does not know what to expect back in the CCMU. During her sick leave, Lyles kept in touch with her friends in the unit. “Different people have texted me every day. ‘How you doing? How you feeling?’” she says.
Her colleagues have also leaned on her for support. One of her best friends, a nurse she’s known for more than 30 years who had just come off of a few days of shifts, cried on the phone with her for an hour. “We hold ourselves to such a high standard of care. And when you feel like you are falling short of that because you don’t have the resources to do what you feel you’re supposed to do, it’s overwhelming,” Lyles says. “And I think that’s how she was feeling. She was just feeling very overwhelmed.”
Being unable to directly support her colleagues has been almost unbearable for Lyles. “She was in my wedding, I was in hers. We’ve watched our kids grow up together,” Lyles says of the friend who broke down on the phone. “I still feel guilty. I feel horrible. I know that they’re there, battling every day, and I’m here and I can’t help them.”
Everyone I spoke to for this story, Lyles included, expressed ambivalence about being called heroes. In most cases, they flatly rejected the label. “I don’t think I’m anything special. I am not a hero. I’m a regular person like everyone else, and I’m just as scared as everyone else,” Lyles says. “I think I’ve been given a gift to try and help people, whether it’s to live or to die. But it is not my power or my will that will save someone,” she says, reflecting the humility that Mulholland called for in his April 3 address. “As a nurse, I take care of that person in that bed as if it were my own family member, with my whole heart and soul,” Lyles tells me. She describes her profession as a calling—a vocation in the truest sense of the word. Talking about her fellow nurses, she says, “They answered the call. They do it because they love people they don’t even know. It’s hard to love someone that you don’t know, but these people truly care.”
“We work in a special area. We watch people die all the time, so you think this would be easy, but it’s not,” Lyles says. “The CCMU has the highest death rate in the hospital usually. When most people die, they die in an ICU. Most of those patients that we watched die prior to Covid-19 were more or less planned. We knew that they were sick, we knew that they were dying. The families had time to grieve. We gave them that time to grieve, and it doesn't feel like with Covid-19 that we get to give them that time. These people are dying alone, afraid, and scared. And when their families come in to say goodbye, they have to say goodbye through the glass. They don’t get to hold their hand. They don’t get to caress them. They don’t get to hold them and reassure them that they’re going to be OK.”
As she tells me this, Lyles begins to cry. “In all my years of being a nurse, you know, I used to say there’s something worse than dying, and that is suffering. And if there’s any bright side, at least these people who are dying from Covid-19 aren’t suffering. They’re passing away quickly, and they’re not lingering for long periods of time suffering.”
Lyles, Arenberg, and Eakin, who have almost a century of critical care service among them, work at the margin where the throbbing pulse of human life—beating to the rhythmic wheezes and beeps of life-support machines, scored on a digital display in the angular, peaking and plunging notation of the electrocardiogram—brushes up against the void.Their days in and outside of these ICU rooms are punctuated by the shuffling feet of highly trained professionals working in synchrony, alarms that trigger spontaneous, concerted action, and the occasional frantic bursts of human voices, wails of grief and muted sobs.
There is laughter, too, because they share their lives together. Some days, they spend more time with each other than they do with their own families. They have come to value, respect, and even love each other as something much more than colleagues, and their prolonged, intense exposure to the ultimate tragedies and joys of human life—the kind that you find only in the places where death hovers close, claiming one soul only to let another live, and giving no explanation—has not numbed them. It has made them wise, humble, and selfless, but it has not made them immune to the pain. They are no more immune to the pain than they are to the virus that has invaded every aspect of their lives, within and outside of the hospital. Covid has caught them off guard, shaken them, and demanded everything they can give—but they are facing the challenge together.
At 4 in the morning on Wednesday, April 15, Lyles gets out of bed and folds the heated blanket in the guest room where she has been sleeping. She gets dressed, makes coffee, and steps out into the chilly morning air. She walks down the driveway, past the handful of Ford F-150 pickups her husband keeps, parked two abreast, to test the aftermarket products his small business manufactures. Thinking for a moment, perhaps, about when her husband’s business might be able to reopen so that he and his 11 employees can get back to work—one of them is her 21-year-old son, Brad—Lyles climbs into her Buick Enclave and pulls away from the house.
Driving west toward Ann Arbor and the hospital where she has worked for her entire adult life, Lyles prays, as always, that God will guide her to the person who needs her most that day. Now, she adds a line: She asks that God protect everyone she comes in contact with—to protect them from her. She savors the walk from the parking lot, a few minutes of quiet and calm to psych herself up for the day ahead. Her small feet carry her up East Medical Drive, toward the lights of the fortress of healers above the Huron River, besieged, for now, from the inside.