Robert Carver recalls being in church one Sunday morning and speaking with an elder mother when the subject of the 91st Psalm of the Bible came up.
That’s my favorite scripture, the woman told Carver. I’ve always leaned and depended on that scripture.
From its beginning, Psalm 91 advises people to put their trust in God as a “refuge and a fortress.” These are far more than words for Robert and his wife of 24 years, Chalice.
“The psalm speaks to how God puts you in a secret dwelling place and protects you from all hurt, harm and danger,” Robert said. “That’s the gist of the scripture. We live by that foundation.”
COVID-19 challenge
In late March, Robert and Chalice found they needed that foundation more than ever, as the novel coronavirus threatened to sweep the ground from under them. With blurring speed, the virus attacked, bringing Robert to the brink of death. That he survived is a tribute to the medical providers who cared for him and to his own determination, the strength of his family and the faith that sustains them.
The odyssey began innocently enough with a Sunday golf outing. The previous day, Robert, then 49, had developed a cough, but he didn’t think much of it. As he chipped a few balls onto the greens, though, a sudden gust of wind coursed through him. In that instant, his seemingly mild illness took a vicious turn.
“I felt sick,” he recalled. “I felt it in my body.”
A day later, on his daughter Chelsea’s 13th birthday, Robert was so feverishly ill he couldn’t make it to the bathroom unassisted. Chalice rushed him to the emergency department at UCHealth University of Colorado Hospital on the Anschutz Medical Campus, where providers saw his oxygen levels plunge and put him on a ventilator. He tested positive for COVID-19, the disease caused by the SARS-CoV-2 virus.
ECMO lung treatment for COVID-19
“He came in with full-blown respiratory failure,” said Dr. Muhammad Aftab, assistant professor of Cardiothoracic Surgery with the University of Colorado School of Medicine. Over the next three days, Robert’s condition declined further, and he developed acute respiratory distress syndrome (ARDS), which occurs when the tiny air sacs in the lungs called alveoli fill with fluid, preventing oxygen from flowing to the body’s organs.
The ventilator could no longer sufficiently support Robert’s breathing. Aftab took a final step to save his life, connecting him to an ECMO (extracorporeal membrane oxygenation) machine that functions as an external lung. It was the first time providers at UCH used ECMO lung treatment for a COVID-19 patient.
Aftab and his team inserted a tube with two separate channels in Robert’s neck vein. One tube sucked the blood out of his still healthy heart into a machine with an oxygenator. The oxygen-rich blood then returned through the second channel to the heart, which pumped it to the lungs and the rest of his body.
Meanwhile, Robert also remained hooked up to the ventilator, but at a very low setting. This allowed his lungs to continue to inflate and deflate, but very gently, so as to avoid further trauma and help them heal.
“ECMO acts as a bridge to recovery,” Aftab said.
But would Robert recover? Aftab told Chalice he put his survival chances at 50-50. She went to the hospital, gowned up in protective gear and went into his ICU room to see him, perhaps for the last time.
“I could do nothing but pray for him,” Chalice said.
A sound ECMO program
Robert had both spirit and science supporting him. Aftab noted that in the past five years, the ECMO program at University of Colorado Hospital has treated some 150 patients like Robert with lung support therapy. (Others have received ECMO that supports both the lungs and the heart). The multidisciplinary team includes surgeons, critical care physicians and nurses, cardiac and pulmonary specialists, and perfusionists who operate the lung-heart machines that supported Robert Carver.
The experience has paid off in helping providers recognize as early as possible patients who need ECMO and select those who are most likely to benefit from it. For example, patients with serious underlying medical conditions and multiple system failures are not good candidates for the therapy, Aftab said. The result: a survival rate that Aftab puts at 65%. That’s in keeping with centers around the nation that specialize in ECMO therapy.
Relatively healthy before the COVID-19 strike, Robert still spent eight days supported by the external lung and deep in a medically induced coma. After Aftab disconnected him from the ECMO machine, he remained on the ventilator for another 11 days. He breathed for the first time on his own on April 14, just over three weeks after entering the hospital.
Resurfacing after EMCO lung treatment for COVID
As his lungs gradually strengthened, Robert swam through layers of sedation into confused consciousness. Where was he? What time of year was it? His freedom-from-the-ventilator day rang a welcome bell. April 14 was his mother’s birthday. Finally transferred from the Intensive Care Unit to a medical floor, he restlessly tried to come to terms with what had happened to him – all the while painfully isolated from Chalice, daughter Chelsea and sons Donovan, 20, and Nathan, 18.
“I spent a lot of long nights staying up, talking to God, talking to the nurses, saying I didn’t come here to die,” Robert recalled. “I tried to stay awake to see the sun rise again, just knowing that I want to make it through the night, to see one more day.”
His spirit was willing, but his flesh was weak after weeks on a ventilator, immobilized and sedated. A robust 6-foot, 275-pounder before the illness, Robert struggled to hold a fork to his lips and to sit on the edge of the bed in the early days after the ICU. He needed a sit-to-stand manual lift to get to the bathroom. He gradually worked up to moving around his bed with a walker.
“It was a journey just to do that,” he said.
The road back from EMCO and COVID
But after two weeks, he had toiled on to the next stage: intensive inpatient rehabilitation therapy. Robert worked for another 10 days with physical and occupational therapists to regain enough strength to return home and reunite with his family. That meant relearning to dress and feed himself, rebuilding his core strength and walking a continuous six minutes.
Patients like Robert who have survived extended periods on a ventilator face a tough recovery time, said Dr. William Niehaus, assistant professor of Physical Medicine and Rehabilitation at CU.
“In that scenario, people aren’t using their muscles and a significant amount of atrophy happens,” Niehaus said.
The deterioration can lead to critical illness polyneuropathy and myopathy, which weaken nerves and inhibits them from firing movement signals to the body. The challenge is to simultaneously help these patients rebuild muscle mass and increase their stamina while protecting their lungs and hearts, Niehaus added.
Like other patients recovering from long ventilator stays, Robert’s recovery consisted of “stepwise” therapy aimed at restoring his ability to perform independently the activities of daily living, Niehaus said. He had a long way to go. Robert recalled that on his first attempt at a six-minute walk, he managed only about two-and-a-half minutes before his body gave out.
With steady effort, Robert improved, moving from his wheelchair to a walker to unassisted walks of increasing duration. He fortified his core with squats and other exercises and slowly built strength by hefting weights – starting at a modest 2 pounds.
Near the end of his rehab stay, he completed the six-minute walk without stopping and managed a few steps in the stairwell. The effort pushed him to the limit.
“I was wiped,” Robert said. “It was a really hard day.”
Homeward bound
On May 7, a little more than six weeks after he arrived at the hospital in a downward spiral, Robert was able to leave. His caregivers lined the halls of the Rehabilitation unit and cheered for him as he rang a bell to signal his departure. Out front, he tearfully reunited with Chalice and his family.
Robert’s recovery continues, with moments both positive and challenging. One big source of joy was seeing his son, Nathan, make a “virtual walk” to celebrate his graduation from Overland High School in Aurora. Aided by his walker, he’s getting out of the house for short jaunts. But he’s also been slowed by nerve pain. Returning to work as an account manager for business products sales with Staples is a ways off. Progress is frustratingly slow.
“I’m still not even close to where I was,” Robert said. “The whole experience has been humbling – doing the little things that we take for granted, and then waking up in the hospital and not being able to do any of them. You can never imagine, if you haven’t been there, how humbling it is to start from the beginning at 49 years old.”
Grateful thanks to his providers – and vice versa
He knows how much help he had along the way. Chalice was left alone to keep the home together while he recovered. She and the kids all pitch in to help him as he recovers. And he’s very grateful to all his providers, whom he refers to as “angels.”
“Everybody goes to work and does something, but to go in and help people who can’t help themselves, that’s a different level of dedication to the human race,” Robert said. “The whole experience at UCHealth was top-notch.”
For his part, Niehaus said he and other providers on the Rehab unit drew strength from Robert. The necessity of isolating COVID-19 patients from their family and loved ones has made recovery even more difficult and stressful than usual, Niehaus said. Yet Robert rose above the challenges and strengthened not only himself but those who worked with him every day.
“He was a breath of fresh air,” Niehaus said. “He was all in and ready to work every day. That helped to fuel our providers for the rest of the day. He helped to fill your cup up.”
A first, but not the last to have ECMO treatment for COVID-19
Robert Carver was the first COVID-19 patient to recover with the assistance of ECMO and leave the hospital alive, but many have followed. Aftab said that as of mid-June, he and his team had placed 22 patients with the disease on ECMO. Robert is one of 14 who are now home. Four more are recovering, but still in the hospital – a survival rate of 80% that offers a strong measure of hope.
The experience of these patients could yield more understanding of COVID-19, Aftab added. He noted that University of Colorado Hospital and four other institutions – Washington University in St. Louis, the University of Utah, New Mexico Heart Institute and the University of Nebraska – are pooling data on COVID-19 patients treated with ECMO therapy and will use it to study outcomes, develop treatment strategies and figure out ways to improve care. One unique characteristic of COVID-19 that has already emerged, Aftab said, is that patients with the infection seem to be especially vulnerable to blood vessel clots.
Niehaus, too, said that rehab specialists have noted that COVID-19 patients recovering from extended ventilator stays differ from those with other critical illnesses that tethered them to the breathing apparatuses.
“After a typical critical illness, patients make a slow, progressive recovery,” Niehaus said. By contrast, COVID-19 patients’ recoveries have tended to move forward in “chunks,” he said – significant improvement, followed by plateaus of several days, then another leap forward, and so on.
“It has seemed like steps,” he said. “Their lungs and hearts needed to recover from what we were putting them through, then they would catch up and make a big change.”
The answers to these and other questions about the present-day scourge lie ahead. For Robert and Chalice Carver, their path forward has long been lit by the words of Psalm 91.
“Robert and I read 91 together before he went to the hospital,” Chalice said. “It was telling us that God will put angels around you. That’s what we stood on.”