ROCHESTER, Minn. — On New Year’s Eve, Mayo Clinic's COVID-19 intensive care unit was buzzing about patient Gabe Pastores.
A few days earlier, when nurse Kari Giersdorf left for some time off, the 56-year-old Pastores had been deeply sedated, receiving the highest level of care any hospital can provide to a patient fighting a severe case of the virus.
But by the time Giersdorf returned, he had turned a corner.
“I told him that I thought I was his black cloud because, when I left, he wasn't doing as well,” said Giersdorf, who has been part of Pastores’ care team since he arrived at the unit in late November. “But when I came back, he was doing so much better. And he laughed at that."
A laugh, a smile, a thumbs-up from a patient — it’s what health care providers like Giersdorf live for. They're little glimmers of hope that their patient might some day walk out of Mayo Clinic.
Pastores' road out of the hospital has already been a long one, fraught with setbacks and buoyed by tiny victories.
He landed in Mayo’s ICU almost nine months into Minnesota’s fight against COVID-19 — one among hundreds of patients his doctors have treated since. But in that time, in the midst of the global tragedy the virus has wrought, those medical teams have learned in real time how it operates — and how to prevent more people from dying from it.
There isn’t a cure — and there’s often no predicting how it will tear through one patient’s body over another’s. But it turns out that they’ve had the tools they need to fight the virus, all along.
Elite equipment with a simple job
In Pastores’ room, Giersdorf turned on the radio, tuned to a classic rock station — his favorite.
Between the steady beeps coming from a small army of machines that are keeping Pastores alive, B.J. Thomas’ 1969 hit “Raindrops Keep Fallin’ On My Head” piped out of the speakers:
“I'm never gonna stop the rain by complaining. Because I'm free. Nothing's worrying me.”
As the old year turned into the new, Giersdorf and her colleagues were coming off their busiest — and deadliest — weeks of the pandemic: A November and December when new COVID-19 cases, hospitalizations and deaths soared.
Pastores was one of 12 patients in Mayo's entirely full COVID-19 ICU over the new year. Additional COVID-19 patients were being treated in other parts of the hospital Mayo is using as overflow.
Though caseloads seemed to be tapering off, Giersdorf said she is always prepared for a difficult shift — like one she experienced just a few weeks earlier.
“I think we had six deaths within 24 hours,” she said. “That's like half the floor. It's just so difficult."
But finally, as the weeks inch forward in 2021, COVID-19 fatality rates are actually falling across the state, nation and globe.
It’s not because there’s a cure for COVID-19. Instead, physicians have had a year to learn how to tailor back-to-basics critical care to patients with severe forms of the virus.
And even at Mayo Clinic, one of the most elite medical centers in the world, doctors and nurses have learned that the best way to help a COVID-19 patient survive the ICU is to use the tools that they already have on hand to stabilize the patient’s virus-ravaged body so it can heal on its own.
For weeks, Gabe Pastores was one the sickest patients on Mayo's COVID-19 wing; his lungs are severely damaged from the virus.
But he was also among the patients with one of the best shots at fighting through the disease: He's relatively young, otherwise healthy — and the virus has remained in his lungs. It hasn’t attacked other organs, a situation that can dramatically hamper a patient's chances of survival.
That's why Dr. Kyle Bohman said Pastores was a good candidate for ECMO treatment — extracorporeal membrane oxygenation — a highly invasive procedure in which a patient is connected to a machine that does the work of the lungs by oxygenating the blood.
"We use very, very large IVs, sometimes up to the size of a garden hose, to remove blood, and run it through our ECMO machine, which has an artificial lung in it,” he said.
After the blood is oxygenated, it cycles back into the body. The whole process is meant to take the pressure off the patient’s lungs, while their body works to heal.
Bohman said ECMO is the most intense form of physical support doctors at Mayo can offer COVID-19 patients — above and beyond a ventilator. It's helped two-thirds of Mayo's patients survive the virus.
Bohman's colleague, Dr. Mark Wylam, said that medical teams here are orchestrating a highly coordinated dance — tweaking medications and treatments, constantly scanning patients for other complications like infections, and coordinating care among dozens of providers.
But “it still remains that much of the care is supportive,” he said. “We're stabilizing the patients and allowing their natural recovery to take place — if it's going to."
‘We followed science’
Like so many of the medicines and devices doctors have used to treat COVID-19 patients, ECMO isn't new. It's a tool doctors have used for years to support patients, keeping them alive through the worst of a disease.
"For COVID-19, we don't have a curative treatment. There’s not an antiviral that stops the whole process,” said Dr. Amesh Adalja, a Johns Hopkins infectious disease and critical care doctor. “What makes a difference is how well the ICU care is delivered."
Adalja said that bringing together old tools — ECMO, ventilators, existing drugs like remdesivir and steroids — to treat a new virus that behaves so differently from others has been a significant challenge.
One early, confounding discovery: COVID-19 seems to cause blood clotting in some patients.
"Early on, when someone would crash in the middle of the night, you might say 'Is it because they got worse because of their pneumonia? What's causing this?’ ” he said.
And while clotting remains a challenge, medical teams now know to prepare for it — and to watch for it.
"And that became something that changed the way we took care of these patients,” Adalja said.
Meanwhile, things like monoclonal antibody treatments — proteins created in a lab that, if administered in the early stages of COVID-19, help a patient fight off the worst of the virus — have helped keep more people out of the hospital.
University of Minnesota Medical Center’s director of medicine, Dr. Andrew Olson, said researchers and physicians have had the advantage of studying the disease in real time, test-driving treatments until they have honed their arsenal of tools specifically for COVID-19.
“It’s tempting in the unknown to just try stuff,” said Olson. “What we did right is [that] we didn’t just try stuff, we followed science. We said, ‘How do we approach other problems like this? What works there? Might this work here?’ And we studied it.”
Inching toward recovery
Back in Mayo's ICU, Giersdorf dialed up Pastores' wife, Cindi, on a video call. She was at home, 45 minutes north in Cannon Falls, with their 16-year-old shih tzu/Lhasa Apso mix, Snoopy.
Gabe couldn’t talk, because he had a tracheostomy — a tube through his throat, directly into his airway, that helps him breathe through the ventilator — but he could wave, and gave a thumbs up.
“You look good today, babe,” said Cindi Pastores.
A few days later, in the first week of January, they got to be together in person, for the first time in more than a month. Gabe Pastores was admitted to the hospital on Nov. 30 after, Cindi Pastores believes, he contracted the virus while working at a local grocery store.
He was still in the ICU when Cindi Pastores visited. But he was getting better — and was no longer contagious, which allowed for the visit.
"Today was my first day to get see him, and it was so good,” Cindi Pastores said. “It was really good just to be able to hold his hand.”
Things, she said, were looking up.
"They're just keeping an eye on [him], now that his lungs are starting to heal, to figure out how to adjust all the equipment in the room,” Cindi Pastores said.
In the days and weeks after that visit, Cindi Pastores returned often to see Gabe Pastores in the hospital. He was weaned off the ECMO machine. He stood up. He took a few steps. He and Cindi Pastores had longer and longer conversations as his ability to speak returned. He ate his favorite dessert, chocolate pudding.
And in late January, after nearly two months, he was moved out of the ICU to a floor reserved for people recovering from COVID-19.
Meanwhile, back at home in Cannon Falls, Cindi Pastores continues to document all of these milestones, small and large, in a journal, counting the days until she can walk her husband out of the hospital's front doors.