By Claire Sykes
Alejandro Castro loves to swim, hike and cook. But throughout his 299 days at Providence Portland Medical Center (PPMC) as a COVID-19 patient, he couldn’t even breathe on his own, and many times was at the brink of death. Thanks to the hospital’s critical care and respiratory/cardiology department teams -- and its cutting-edge extracorporeal membrane oxygenation (ECMO) machine -- the 44-year-old many call Alex, a husband and father of four, is back home in Sandy, Oregon.
The vaccines weren’t available when Castro and his kids became infected with COVID-19 in early December of 2020. His wife, Amanda Chase, was the only one in the family who was spared, and she took care of them. Their four children had mild cases and soon got better. But after Castro began struggling to breathe, she rushed him in the middle of the night to the nearest medical facility, Adventist Health Urgent Care in Sandy.
A few days later, he was whisked into the critical care unit (CCU) at PPMC and immediately hooked up to an ECMO machine. This invasive, aggressive treatment, around since the 1970’s, is the last resort for patients with severe respiratory distress. ECMO machines do the work of the lungs and heart, hopefully giving the patient’s lungs the chance to heal. Luckily, one of the hospital’s three units, in constant use during the pandemic, was free. Without the treatment, Castro’s care team is convinced he would have died.
The ECMO machine’s tubes, or cannulas, were threaded into the large veins and arteries in Castro’s neck and groin. Through them, the machine continuously pumped blood out of his body, adding oxygen and removing carbon dioxide before returning the blood via the cannula. He was on ECMO in the CCU for 108 days, the longest ever at PPMC. Along with his lungs, heart and liver, Castro’s kidneys also failed, so he was also put on dialysis.
“Every day on ECMO, the risk of dying goes up,” says Tara Tuepker, RN and ECMO specialist, one of a large team of CCU staff who took care of Castro. Fifty of the 130 PPMC critical care nurses are trained on the complex ECMO technology that kept Castro alive.
To avoid muscle atrophy and brain trauma, Alex was not sedated. Javiera Pobanz, a nurse and ECMO specialist, described the routine. “Since before COVID, we’ve been doing what we call ‘awake-mo,’ so the patient can stay alert,” she said. “That helps them keep track of time and process what’s going on, and not get delirious. But it’s risky because the cannulas could move.” The tubing also means a liquid diet, Castro preferring orange sherbet, and milk with protein powder. ECMO patients are susceptible to the occasional infection, and Castro was no exception. The infections were further setbacks to his recovery, but Alex fought them off each time.
Since early 2018, PPMC also had been walking their ECMO patients, a relatively unusual practice in American hospitals. “Those in Europe have been doing it for years and have standards for it, so we thought we should do it, too,” said Pobanz. “Walking helps patients sleep, sticking to a routine night-day cycle. At first it was scary, though, because the cannulas can get pushed in further or pull out. But we researched ways we could ambulate these patients, and we developed a strategy.”
Two to three times a week, Castro gave his all in slow, small steps down the hall, still connected to the ECMO machine. Each walk involved a team of several nurses, a respiratory therapist, a physical therapist, and an occupational therapist.
“Oxygenating blood is exhausting, and there were days he felt fatigued being on ECMO for so long, and he didn’t want to walk or even sit in a chair because, also, he was so depressed,” said Pobanz.
In the beginning of Castro’s stay, visitors weren’t permitted. Staff rallied around him, though, giving him extra support and encouragement, so he wouldn’t feel so alone, isolated in the CCU. “We were his only social connection then,” said Pobanz, who spoke Spanish with the Mexico-born Castro. “I just concentrated on the positive, joking with him about our countries’ soccer teams (Pobanz was born in Chile) to lighten the mood. We all engaged with him, to take his mind off what was going on. And we’d move his bed or turn his chair toward the window, to give him some connection to the outside world.”
Sometimes Castro let down his guard and the tears would come. “I felt privileged in those moments when he was very open and vulnerable, while wanting to be strong for his family,” said Tuepker.
Then, finally, Castro could have one visitor. That was his wife Amanda, who made the journey from Sandy to the hospital in northeast Portland every day. Soon, Castro’s 20-year-old son, AJ, was allowed to visit. AJ would often help with his father’s ECMO walks, urging him to go just a bit further each time. Several times over his long stay at PPMC, Castro’s nursing team bundled him up for a wheelchair ride outside to feel the sun and see his other children, Marielena, 22, Luis, 17 and Yasmin, 14. “There were multiple times I thought I was losing him,” Amanda said in the video PPMC made of her and Castro the day he left the hospital for home.
Doctor Jason Wells, an ECMO specialist in pulmonology critical care at Providence and Castro’s physician, said, “There were lots of ups and lots of significant downs where you know you couldn’t see a path forward for him where he’d make it through.”
That was hard for CCU staff, but they bonded through adversity as they have throughout the pandemic. Pobanz, among the 20 CCU nurses on day shifts and another ten who work at night, said, “I rely on my fellow nurses a lot. We started meeting monthly so we could air out our issues and feelings as a group.” Tuepker adds, “Our team is so tight. And the doctors are right there with us.”
Tuepker says she draws strength from her faith, prayer and her family. Long walks outside also help with her stress. Pobanz took up running after watching Castro fight so hard to build strength. “If Alex can walk while on ECMO, I can do a 5K, so I started training,” she said. “I realized I needed to take care of myself, my body and mind, to remain healthy and take care of patients.”
By March 2021, Castro made enough progress that he was ready for the respiratory/cardiology department on floor 2R. Nurse Erin Robertson-Otis became part of this care team. She said, “When he arrived, he was incredibly anxious. Patients here still have intense respiratory-treatment needs, and they’ve been through so much more than you can imagine. He was quite fearful to leave [the CCU], understandably, even though that means good things.”
The respiratory/cardiology department’s goal is to wean the patient off the ventilator, remove the tracheostomy tube, get them strong enough to move around and, eventually, eat safely. Right across from Castro’s room, a bank of monitors in the nurses’ station constantly tracked his heart rate and oxygen saturation, sending Robertson-Otis into his room several times an hour to increase his oxygen. Two to three times, he had to go back to the CCU, once after only 12 hours on 2R.
“We’ve had so many respiratory patients, but we’ve never seen the massive fluctuations like we did with Alex,” she said. “I’ve never been tried to this degree. I don’t think most of our staff have been taxed in this way before. Their skills are impressive, they save people’s lives, but that’s not the part that’s hard. It’s the emotional part. I felt for a while that I was carrying the emotional weight of the global pandemic, then I realized we can only care for the people here. And that was freeing for me.”
Meanwhile, Castro felt imprisoned by fear when the pandemic compelled the hospital to again bar visitors. “He missed his family so much. It was terrifying for him, because he was utterly losing hope from not seeing them at all,” Robertson-Otis said. “He was on Facetime with them, but if he couldn’t have anyone visit, we didn’t know if he was going to make it. So we asked for special permission to have just his wife come.”
Castro started to improve. By August, about a month before he was discharged from PPMC, he walked the hall twice a day on 25 liters of oxygen, a significant increase from what he could handle when he first arrived on 2R. “Then he had a respiratory event that made him a little bit worse,” said Robertson-Otis. “We were so afraid, after all this time, that he wasn’t going to make it. I told him, ‘You’ve given so much, and we realize you may have little motivation for yourself, but we can’t handle you not making it home.’”
Castro was finally able to, after more than six months in respiratory/cardiology and nearly four months more in the CCU. In the PPMC video, when asked about this next, huge step in his healing, he says, “I feel happy to see all my family. A little scary, but I’m happy to go home,” he says. He had missed his wife’s and four children’s birthdays, Christmas, New Year’s, his youngest daughter’s eighth-grade graduation and the funeral of a friend who died of cancer. But he would be home with his wife in time for their 22nd wedding anniversary.
And what about COVID? “I don’t believe it before, the COVID, but now I believe. I tell everybody be careful, this is scary. I’m scared, very scared,” says Castro. By then, everyone in his family had been fully vaccinated.
The day Castro left PPMC, about 50 nurses, doctors, physical and occupational therapists, the chaplain and almost everyone else who was a part of his life at the hospital lined the hallways. They shouted, applauded and cheered. A patient transporter slowly rolled him in a wheelchair past them and out the door, a black-and-white-plaid fleece blanket on his lap topped with two red roses, as he fought back the tears. Behind him, his wife carried a dozen colorful mylar balloons.
“I can’t express my gratitude, my appreciation, for everybody here,” Chase says in the PPMC video. “The nurses have become friends, or you know, family. They’re closer to us than a lot of people. It’s beyond words how much I appreciate the hospital staff and the doctors who’ve taken such good care of him.”
Castro says he doesn’t remember half of what happened to him at PPMC. But he’ll probably never forget how he felt the day he left. Neither will his care team.
“Watching him leave, I cried like a baby,” says Tuepker. “When Amanda gave me a hug, that’s when I lost it the most. Then I walked by Alex and he reached out and gave me a hug. No words were needed. He was so grateful.”
“That he had gotten better made all the work we did worth it,” says Pobanz. “It can be draining to put in so much effort and time and nothing to show for it. But to see that he got to go home was so rewarding.”
Robertson-Otis feels the same way. She said, “We’ve seen so many people die, and the fact that he made it gave all of us not only hope that we can work hard enough to save people, but also that he is an inspiration for our team about how many times you can want to give up, but you don’t. Real human interaction is one of the things that matters most, and if you can be there for people, what else is there? When they need you and you can give to them, it’s a wonderful honor. It changes you to know someone and have something major happen together with them. As a nurse, I’m a part of something major in someone’s life. And I want to be as present with them as I can, and have an open heart, helping them get to the next stage.”
The man who once proudly held three jobs now turns to his wife and eldest daughter, Marielena, for the family’s income, while AJ takes on the role as his main caretaker. Castro tires easily and still struggles to breathe. He will need oxygen constantly and he may eventually need a lung transplant. He faces a long, difficult road to recovery ahead, but physical and occupational therapy are already helping to bring noticeable improvements every day.
“He’s doing so well right now,” said Tuepker, who has stayed in touch with Castro and his wife. “It’s very unusual for me that a friendship has come of out this. Amanda tells me, ‘I’m still scared.’ And I say, ‘Yeah, you’re probably going to continue to be.”
Today Tuepker pictures Castro at home, which reminds her “to continue to have hope and pass that on to others. There’s a fine line sometimes between hope and reality and sometimes you need hope to push through reality.”