Stephanie Innes | Arizona Republic (CNT) City News Talk #arizona
When she first woke up on Sept. 11, Reyna Lopez thought it was still June.
She had no idea that she’d been sedated through the entire summer — she’d missed the Fourth of July, her fifth wedding anniversary and Labor Day. Her newborn was about to turn 5 months old.
She did not know that more than once, her husband, extended family and providers at the Mayo Clinic Hospital had braced themselves for her death.
After spending more than four months in the hospital for COVID-19 — most of that time attached to an artificial lung — 31-year-old Reyna Lopez went home Friday for the first time since June 12.
All told, Lopez spent 88 days attached to an artificial lung and was in the ICU for 119 days.
Lopez set a record at the Mayo Clinic Hospital in Phoenix for the length of time she spent on what’s known as ECMO — extracorporeal membrane oxygenation, a last-ditch high-level treatment that works like an out-of-the-body, artificial lung.
ECMO adds oxygen to the blood, removes carbon dioxide and buys time for extremely ill patients, like Lopez, whose lungs need to heal.
Lopez, a Tempe mother of three, is still incredulous at how long she was ill.
After being discharged from Mayo Oct. 23, she spent a week as an inpatient doing rehabilitation at Banner Baywood Medical Center in Mesa, where she began working at walking and performing daily tasks like writing and putting away groceries.
“I can’t really write, but I try and write at least every day, and I’m keeping track of it so at the end I can see a difference. But most of it is walking,” she said last week.
Every day she sees progress. On Oct. 28, she went from walking 75 feet to 200 feet. She gets winded easily, she explained. Now that she’s home, she’ll continue rehabilitation as an outpatient.
Her husband, Rodolfo Lopez, 29, is taking a leave of absence from his delivery job for a local beer distributor to help his wife as she recovers.
“Take precautions, be mindful of others. Just because you might not get infected as bad, some people get it worse, like Reyna,” Rodolfo said last week while visiting his wife at Banner Baywood. “This virus doesn’t discriminate. It doesn’t care if you are only 31.”
Nearly 5,000 Arizonans between the ages of 20 and 44 have been hospitalized for COVID-19, and 342 in that age group are known to have died of the coronavirus, the Arizona Department of Health Services’ data showed on Monday.
‘I’m surprised I got it’
The Lopez’s youngest son, Noah, was 11 weeks old when Reyna first became sick with COVID-19. The couple has two other children, both girls — Damia is 4 and Luna is 2.
Lopez is not certain how she, her husband and Noah became infected with the SARS-CoV-2 virus that causes COVID-19.
Both Lopez and her husband say it could have been at a swap meet they attended June 7, a little more than two weeks after the state’s stay-at-home order expired.
“I think we opened a bit too early. People went out and our people in charge said it was OK, and we did, too,” Rodolfo said. “I feel like that’s when we got sick. When we started to go out and feel safer.”
The number of Arizonans who became sick with COVID-19 spiked after the state’s stay-at-home order ended. In the two weeks between June 1 and June 15, the daily average number of COVID-19 cases in Arizona jumped by 151%, according to a recent report from the Arizona Department of Health Services published by the Centers for Disease Control and Prevention.
Reyna Lopez has underlying health conditions — asthma, lupus and rheumatoid arthritis, which made her more vulnerable to infection. For that reason, she had been careful throughout the pandemic to follow federal guidelines from the Centers for Disease Control and Prevention on social distancing, hand sanitizer and wearing a mask, she said. Her husband was, too.
“I’m surprised I got it,” Lopez said. “I never really believed I would get it.”
Not everyone at the crowded swap meet they attended was wearing masks, they said. It wasn’t until June 17 that Arizona Gov. Doug Ducey said local jurisdictions could put their own mask mandates in place.
The weekend of the swap meet the couple’s daughters were with relatives, and they never got sick. Reyna, Rodolfo and baby Noah all became ill and tested positive for COVID-19. Neither Rodolfo nor Noah developed serious sickness, but Reyna’s illness took a different course.
Lopez became ill just 48 hours after the swap meet, which would have been a short incubation period. So that’s why she can’t be sure where she contracted the virus.
Typically, a person develops symptoms five days after being infected, the Centers for Disease Control and Prevention, says, though symptoms can appear as early as two days after infection.
On Tuesday, June 9, she went to her job managing a title loan company but was feeling off. She felt nauseous, lightheaded and dizzy. She was also coughing, had body aches and later in the day developed a fever. She ended up hospitalized for two nights and was discharged June 11.
On June 12, she took a turn for the worse and went to a standalone emergency room, where emergency personnel transferred her to Banner Desert Medical Center Mesa, she said.
“I couldn’t breathe,” she said. “My inhaler wasn’t working for me.”
Medical providers gave her external oxygen via a facial mask, she said, but that wasn’t helping, either.
Lopez, who by that time had received a positive COVID-19 diagnosis, remembers telling her providers she was going to pass out. That’s the last thing she could recall before she woke up in the Mayo Clinic Hospital in September.
The ventilator wasn’t helping
Though Lopez has no memory of it, her COVID-19 illness progressed quickly on June 12, and frontline health workers scrambled to get more oxygen into her lungs.
Medical providers try other methods of oxygenation before the more invasive process of putting someone on a ventilator.
A ventilator requires a tube to be inserted into the windpipe in a process called intubation. The tube is what’s attached to the mechanical ventilator, the machine that helps the patient breathe, which can also send oxygen concentrations at higher-than-normal pressure to help keep the patient alive.
By June 17, Lopez wasn’t getting better, and other methods of giving her oxygen weren’t working. Providers at Banner Desert made the decision to intubate and put her on a ventilator, Rodolfo said.
But after eight days, he recalled, the ventilator wasn’t helping his wife, either.
On June 25, officials at Banner Desert Medical Center called Rodolfo Lopez and told him his wife needed more support than what a ventilator could offer, he said this week.
If a patient’s lungs get so damaged that they don’t work, even with assistance, some hospitals have the ability to use an external lung machine known as ECMO. The Banner Health system in Arizona has nine ECMO machines, which require a team of expert staff to operate.
“It was really bad,” Rodolfo said. “ECMO was the last option.”
During the COVID-19 spike in June, Banner said publicly that it had reached its capacity on its nine ECMO machines. At the time, state health officials said Arizona had a total of 27 ECMO machines.
But just because a hospital has an ECMO machine doesn’t mean it always has the highly specialized medical expertise, a 24/7 medical team to monitor the patient on ECMO, and a program that’s coordinated to manage patients who are on ECMO for extended periods of time. During a crisis, those resources can be difficult to come by.
“Not every hospital can provide ECMO,” Rodolfo said. “Fortunately enough she was able to get into Mayo. Without it, she wouldn’t be here.”
ECMO is not a common COVID-19 treatment
The Mayo Clinic Hospital typically has the ability to have five patients on ECMO at one time, and it’s a major decision whether to connect a patient to one because there are risks involved, said Dr. Patrick DeValeria, who is chair of the division of cardiac surgery at Mayo Clinic in Arizona as well as medical director for its ECMO program.
“We only use it in these very specific situations where we feel that the patient has not had something in their underlying disease process that has prevented them from having a good chance of recovery,” he said.
If the the lungs have been irreversibly damaged, putting a patient on ECMO to buy them time is not going to do any good, DeValeria said.
“ECMO doesn’t cure anything. It basically keeps the patient oxygenated and allows time for the patient to heal,” he said.
An international nonprofit consortium called the Extracorporeal Life Support Organization is maintaining a registry of COVID-19 patients who use ECMO worldwide. As of Monday, it had recorded 3,062 patients with confirmed and suspected COVID-19 who had used ECMO, including 1,982 in North America, although because the registry is voluntary it could be an undercount.
“We have 43 million patients across the world who have been infected with COVID … Even if it captures just 50%, there’s only been 3,000 patients across the world that have been put on ECMO for COVID,” DeValeria said.
“She (Lopez) was one of those special situations where she did not have a lot of other issues …It’s a small window of people. That’s something many people don’t understand.”
Lopez’s doctors say there’s no question that ECMO saved her life.
‘Why is this happening to us?’
Lopez was a good candidate for ECMO because she had not been on a ventilator for very long, and she was young and did not have other significant health issues, Dr. Ayan Sen said. Sen is the head of critical care medicine at Mayo Clinic in Arizona and was involved in Lopez’s care throughout her stay.
Sen was part of the six-member medical ECMO transport team that went to Banner Desert, surgically connected Lopez to ECMO by placing large catheters into blood vessels in her legs and then transferred her by ambulance to Mayo. The team includes a perfusionist, a surgeon and two ICU nurses.
DeValeria said the catheters function to remove the blood, run it through the ECMO membrane to perform the typical job of the lung, and then return the blood back to the body with carbon dioxide removed to an appropriate level.
“The body can then use that oxygenated blood to keep the patient healthy, and keep the patient’s organ systems healthy and buy them time for whatever other therapies they need,” he said.
Sen said the survival rate for patients using ECMO is 50% to 60%, and major risks for the treatment include significant, life-threatening bleeding, blood clots, stroke and infections.
DeValeria said. “When you take people that are already extremely sick and then you add to it that now they have to be heavily sedated and immobilized, many people are not in a position to recover from such a trauma to the body.”
While his wife was on ECMO, Rodolfo tried to stay strong. He took Noah to Missouri to stay with his mom and did his best to think about what his wife would want.
“I looked at my little girls and used them as motivation to get through the day,” he said. “Reyna is such a planner, an organizer and a goal-setter. I knew she wouldn’t want me to mope around. I knew she’d want me to make plans for whatever the outcome may be.”
Still, there were dark times, he said.
“It was tough. It wasn’t easy juggling the kids, there was some financial trouble and then on top of that work, and then on top of that talking with doctors,” he said. “I know no one is exempt from pain, but at a certain point I was just, ‘Why is this happening to us?’ We are really just starting out … It was a nightmare for sure.”
‘The first thing she asked for was to see her kids’
Medical providers at Mayo say a key to Lopez’s survival was the consistent support she received from her family. Her husband called multiple times per day, and even though she wasn’t responsive the family held Zoom calls with her every morning and night.
Lopez’s recovery has been a bright point for many Mayo Clinic health providers, said Stephanie Blakeman, an ICU nurse and coordinator of the ECMO program at the Mayo Clinic in Arizona.
“The reason we are so attached to her and her story is there were times when it was extremely bleak for the whole care team,” Blakeman said.
“I took care of her once myself when she had an extremely acute event that required her to go to the operating room. You hear the calls the doctors are making and they are basically telling the family, ‘This is the last thing we can offer.'”
The longevity of her time on ECMO was unusual, but at the same time there was no frame of reference for COVID-19, Blakeman said. She said that Lopez began to turn a corner at about Day 60 on ECMO.
“As soon as we were able to lighten her sedation and wake her up, she was so motivated, and that motivated the whole team further to really see if we could make this happen for her,” she said.
While she was connected to ECMO, Lopez was hooked up to a ventilator, although it was no longer in her mouth. Surgeons performed a tracheostomy, where a breathing tube attached to a ventilator was inserted through a hole in her neck. Eventually, after she woke up, a speaking valve was attached to the tracheostomy tube.
“She did great with that. The first thing she asked for was to see her kids. The second thing she asked for was for some food, which was such a fond and light moment,” Blakeman said.
“She progressed so quickly and so while while she was here she was able to get the tracheostomy out. And when she left she was able to breathe on her own with no breathing tube whatsoever.”
An unclear path ahead
The median length of time for a COVID-19 patient to be connected to the type of ECMO that Lopez was on, called veno venous, appears to be two to three weeks, Sen said. But like all other aspects of COVID, medical providers are learning as they go.
For Lopez, the issue was waiting for her lungs to recover well enough that they could take over the workload of the gas exchange of oxygenating blood and removing carbon dioxide, her doctors said.
When Lopez was discharged from Mayo Oct. 23, the staff threw a socially distanced celebration and sendoff for her. Many had been rooting for her all summer, Blakeman said.
The road ahead for Lopez is unclear. There are a number of long-term effects of COVID-19 that are being reported, including cognitive, heart and lung issues. Sen said Mayo Clinic doctors will be tracking Lopez as she recovers.
“How much the lungs heal and how much of a normal lung function capacity the patient recovers, I think that’s yet another one of those things from COVID we’ll have to figure out,” DeValeria said.
“People can have long-term damage from any kind of pulmonary infection, whether it be viral or bacterial, where the lungs never quite recover to their pre-infection state. We’re learning that about COVID still.”
Lopez has always been a positive person and that has not changed with COVID. She’s upbeat about improving.
“I’m back to me,” she said, smiling.
“Somehow everything worked out,” Rodolfo said. “Against all odds.”