‘Into the Covid ICU’: A New Doctor Bears Witness to the Isolation, Inequities of Pandemic

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Al Letson:	From the Center for Investigative Reporting and PRX this is Reveal, I’m Al Letson. Half a million people have died in the US from COVID-19. We’re going to spend the whole show today looking at the pandemic through the eyes of one young doctor, a doctor who’s been finding her footing on the frontlines of one of the greatest public health disasters in the century.
Paloma Marin-Nevarez:	[foreign langauge] Good afternoon graduates, families, faculty and staff.
Al Letson:	Back in June 2020, Paloma Marin-Nevarez spoke at her virtual graduation ceremony at Stanford med school.
Paloma Marin-Nevarez:	Let’s be real class of 2020, this is absolutely not the way that we envisioned medical school ending.
Al Letson:	Paloma is one of more than 30,000 new doctors who started medical residency last year, heading out to hospitals and clinics across the country to learn the basics of how to be a doctor just like they do any year except now, those hospitals and clinics were being overrun with a virus.
Paloma Marin-Nevarez:	This is a lot of pressure on you. And I will be the first to admit that this is scary.
Al Letson:	When Paloma graduated, there was still so much we didn’t know about COVID. The first wave of infections was slowing and a second larger wave was about to begin.
Paloma Marin-Nevarez:	As the first graduating class of physicians in the middle of this pandemic, I have no doubt that you will work tirelessly and often at the expense of your own well being. You cannot do everything perfectly and you cannot do everything alone.
Al Letson:	We teamed up with Kaiser Health News and spent the past eight months checking in on Paloma as she started working in a community that’s been devastated by COVID.
Paloma Marin-Nevarez:	We’re graduating to confront systems that have historically failed the poor and failed people of color.
Al Letson:	COVID-19 has been deadlier for Native American, black and Latino people compared to white people. Latinos are more than three times as likely to be hospitalized and more than twice as likely to die from the virus. As a doctor in a predominantly Latino part of California, Paloma will confront these disparities firsthand. Reporter Jenny Gold from Kaiser Health News picks up the story just as Paloma is about to start at one of the hardest hit areas in California.
Jenny Gold:	I started talking to Paloma right before she started residency. It’s been clear to me since those very first conversations that she’s a superstar; Stanford graduation speaker, first doctor in her family, former eighth grade science teacher. So can you start just by introducing yourself telling me a little bit about you.
Paloma Marin-Nevarez:	Yeah, so my name is Paloma. Paloma Marin-Nevarez, I have two last names. And I have two last names because I was born in Mexico where people typically[inaudible]
Jenny Gold:	when Paloma was nine, her father died suddenly of a heart attack. And her mom decided to move her and her two siblings from Durango, Mexico to Los Angeles, California, were they packed into a one bedroom apartment.
Paloma Marin-Nevarez:	So that meant that my mom had to raise us as a widow and pretty much as a single mother after coming to the United States.
Jenny Gold:	Paloma grew up in an almost entirely Latino neighborhood. Her mom, Hortensia worked two jobs, one at a supermarket and another at a 99 Cent store. And the whole American Dream thing it paid off, Paloma and her siblings they all earned college degrees.
Paloma Marin-Nevarez:	The moment I stepped into Williams College, I realized that I was really poor compared to like my extremely wealthy classmates. And that’s when I realized that there’s a ton of social inequity.
Jenny Gold:	She sees medicine as a way to heal some of that inequity. So when it came time to pick where she would do her residency, she thought about where she could make a difference. And she thought about her mom who doesn’t speak English.
Paloma Marin-Nevarez:	When she goes to the doctor, she’s worried about what might be wrong with her health wise, but she also feels this incredible shame in not being able to speak the language and she feels she’s a burden. I feel patients should never feel that way. All they should worry about is how the doctor is going to help them feel better.
Jenny Gold:	Only 6% of doctors in California are Latino compared to nearly 40% of the state’s population. And nationally, Latinos are twice as likely to be uninsured.
Paloma Marin-Nevarez:	I wanted to go to a place where I was needed first and foremost. This was the patient population that I wanted to take care of and so it is my privilege and my pleasure to come to Fresno.
Jenny Gold:	Fresno is a majority Latino County. It’s part of California’s Central Valley, a vast area of farmland in the middle of the state that supplies about a quarter of the nation’s produce. This region often has a hard time recruiting health care workers. Paloma went to one of the top med schools in the country. She probably could have had her pick of residency programs, but she wanted to go to Fresno. She was so certain that she bought the sweatshirt before she even found out she’d gotten in.
Paloma Marin-Nevarez:	All right everybody.
Jenny Gold:	She recorded this Instagram video in March when she got the news.
Paloma Marin-Nevarez:	Congratulations, you have marched into UC San Francisco Fresno.
Jenny Gold:	When she finishes med school a few months later, Paloma packs up her apartment, gets in the car and starts driving toward Fresno, leaving the Stanford campus gleaming in the rearview mirror. She’s leaving one of the richest communities in the country, Silicon Valley for one of the poorest. One in three children in Fresno County lives below the poverty line. Many of the people who pick the crops in this area are low wage migrant farmworkers and they keep coming back to these fields day after day despite the risks of COVID.
Paloma Marin-Nevarez:	Entering Fresno, the first thing that I noticed was just green, a bunch of green, lots of farms and then eventually the farm start to become grape vines and then you know you’re really in the Central Valley when the Trump signs start to come up.
Jenny Gold:	California Central Valley is a republican stronghold and the Fresno County Sheriff refuse to enforce the governor’s mask mandate. By June 2020, it’s been four months since the first COVID case was recorded in the US and already more than 100,000 people have died.
Speaker 5:	Tonight the country has reached another sobering milestone in the coronavirus pandemic surpassing 2 million cases and this warning sign hospitalizations are surging in many states.
Jenny Gold:	When I speak to Paloma over Zoom, she’s just settling in to her new apartment in Fresno. So I see behind you all your walls are blank.
Paloma Marin-Nevarez:	Yes.
Jenny Gold:	Well, totally white.
Paloma Marin-Nevarez:	Yes.
Jenny Gold:	When did you move in and how’s the unpacking going?
Paloma Marin-Nevarez:	I moved in about a week ago, the unpacking’s been good, it’s been really exciting.
Jenny Gold:	It’s the first time she’s had a place of her own and she adopts a kitten to keep her company.
Paloma Marin-Nevarez:	He’s just really adorable, very playful.
Jenny Gold:	What’s his name?
Paloma Marin-Nevarez:	His name is John Charleston Oliver.
Jenny Gold:	Wow.
Paloma Marin-Nevarez:	His given name is Chuck.
Jenny Gold:	Paloma is about to start training to be a fully fledged ER doctor, something she’s been working towards for years.
Paloma Marin-Nevarez:	In emergency medicine, we talk a lot about being the people that run into a burning building. When things are breaking down and when things are chaotic, we’re the ones who run in there and try to figure things out. All right, I pull my cat. How are you doing this morning?
Speaker 6:	I’m doing good [crosstalk]
Jenny Gold:	On June 26th, 2020, Paloma has her first shift in the hospital.
Paloma Marin-Nevarez:	There you go. Have a wonderful day, take care.
Speaker 6:	You have a good one.
Jenny Gold:	Paloma is working at community Regional Medical Center in downtown Fresno. It’s big, 10 storeys high and 685 beds. It’s a safety net hospital that serves lots of low income and uninsured patients. And it doesn’t take Paloma long to notice how different things are here compared to Stanford.
Paloma Marin-Nevarez:	I’m starting to see just how the shortage of medical providers really translates to patients waiting a very, very long time for care. The waiting room starts to fill up quickly in the day, there’s a hallway where patients wait for care and it’s really hard to see them waiting.
Jenny Gold:	For the most part, Paloma’s first few weeks aren’t so different than they’d be any other year. She’s in charge of her own patients, taking their medical histories, performing exams and coming up with a plan for care. And on a moment’s notice, her supervisor, the attending doctor, could quiz her about pretty much anything. Like tell me the name of every nerve in the hand.
Paloma Marin-Nevarez:	So it’s almost like you have this ginormous hat and it’s just full of facts. And you just have to pull five random facts out of this giant hat. And then sometimes you’ll get it, like wow, this was actually relevant. And sometimes they won’t.
Jenny Gold:	Was there a moment when you were like, “I don’t feel like a doctor, I’m falling on my face.”
Paloma Marin-Nevarez:	Oh, all the time. Like literally, I call myself the CEO of hot mess central. I feel like a train wreck all the time.
Jenny Gold:	Reality check here. When I interviewed Paloma supervisor later, she told me Paloma is super organized, definitely not a train wreck.
Paloma Marin-Nevarez:	And I’ve been told that I’m really harsh on myself, it’s how I cope. I feel like making fun of myself is how I get through things.
Jenny Gold:	Early on, Paloma’s program tries to protect residents by keeping them away from COVID patients, but that will eventually change as the pandemic gets worse.
Speaker 7:	California hospitals are rushing to make room as they prepare for a surging COVID-19 patients.
Speaker 8:	What we are seeing a dramatic spike in cases in California over the past 24 hours.
Speaker 7:	The White House Task Force advising hotspots to buckle down.
Jenny Gold:	This is the beginning of the second wave of COVID cases in the US, as infection rates climb, the virus catches up with Paloma’s personal life. On July 7th, 2020, during one of our regular check ins, she breaks the news to me.
Paloma Marin-Nevarez:	Actually, my mom just got COVID.
Jenny Gold:	What?
Paloma Marin-Nevarez:	Yeah, so my mom tested positive last week. My mom doesn’t like to tell me anything, she doesn’t want me to worry. And I told her, “Hey Mom, I need you to talk to me and to tell me the truth.” And she finally did. And the moment when she said, “I’ve lost my sense of taste.” I said I am diagnosing you with COVID right now, I need you to go get a test ASAP.
Jenny Gold:	Her mom’s case is fairly mild, but back at the hospital in Fresno, more and more patients are coming in with severe cases of COVID. PPE is in short supply.
Paloma Marin-Nevarez:	I have been getting the emails from management to always be very thoughtful about the PPE that we’re using, asking us to be very thoughtful about the tests that we’re ordering so that we can conserve supplies. But it does make me wonder what is it going to look like a month from now?
Jenny Gold:	Three weeks in, Paloma gets a day off before she rotates into the ICU. She goes for a hike, but out on the trail, she can’t stop thinking about COVID partly because so many of the hiker she’s passing aren’t wearing masks.
Paloma Marin-Nevarez:	I have this dissonance between me going into work knowing that we have this incredibly contagious virus and we’re respecting it and doing our best to stay safe in the hospital and then the general public just frankly doesn’t really seem to care. That I think that’s been one of the most disheartening things.
Jenny Gold:	In July, protesters organized an anti mass rally that takes over a city block in Fresno. They hold signs that read, honk for Trump.
Speaker 9:	We’re here to protest the tyrannical rules that Governor Gavin Newsom has placed on us.
Paloma Marin-Nevarez:	People just gathered without wearing masks and with their signs that are like end the tyranny.
Speaker 9:	He said the number one priority was to flatten the curve, the curve has been flattened.
Paloma Marin-Nevarez:	And I’m like, “I hope I don’t see you at the hospital people.” I will now begin dawning my PPE.
Jenny Gold:	On July 20th, 2020, Paloma has her first shift in the intensive care unit, just as the second wave of COVID is nearing its peak.
Paloma Marin-Nevarez:	I’ve got my board down.
Jenny Gold:	The ICU is where the very sickest COVID patients end up and many of them are on ventilators.
Paloma Marin-Nevarez:	I’m already wearing my N95 mask, putting on my goggles, I’m ready to go in.
Jenny Gold:	Just a few days and to Paloma’s time in the ICU, hospital in the region are so overwhelmed that the Air Force deploys teams of health care workers to help, Paloma works beside them.
Speaker 7:	The central valley is now the state’s hotspot for COVID-19 as it’s seeing more than double the statewide positivity rate.
Paloma Marin-Nevarez:	Today is the last day of July and it is the 12th day in a row that I’ve been working since I started my ICU rotation. I have been working for two weeks straight without a break, I’m absolutely exhausted. I’m so tired.
Al Letson:	By the end of July, the total number of COVID deaths in the US reaches 150,000, the most of any country in the world. For first year residents learning to deal with death is a part of becoming a doctor, but this year, death is all around them. Paloma has been a doctor for just five weeks, and is already taking care of some of the sickest patients on the frontlines of the pandemic, and things are about to get even harder.
Paloma Marin-Nevarez:	There are so many patients here who have COVID; 70 year old patient with COVID, 80 year old patient with COVID, 50 year old patient with COVID. It’s just everywhere.
Al Letson:	That’s next on Reveal, from the Center for Investigative Reporting and PRX.
Maria Feldman:	Support for Reveal comes from wondrous American scandal. The latest season of American scandal uncovers the story of how Bernie Madoff created the greatest Ponzi scheme of all time, and the shocking ways authorities finally caught him after almost 20 years. In 2008, Wall Street mogul Bernie Madoff was arrested by the FBI and charged with multiple counts of fraud. He would soon be known as the mastermind of the greatest financial scandal ever. Listen to American Scandal on Apple podcasts, Spotify or listen ad free in the Wondery app. Wondery, feel the story.
Al Letson:	Hey, hey, hey, it’s time for another installment of Al’s podcast picks. Today, I want to tell you about through the Cracks, from WAMU and PRX. Through the Cracks investigates gaps in our society and the people who fall through them. In this first season host John Quillin Hill looks into the unsolved disappearance of Alicia Rudd. In 2014, the second grader disappeared from a Washington D.C homeless shelter and it took 18 days for the city to declare her missing. Listeners will learn about how safety networks including family, school and shelters don’t always protect our most vulnerable. Subscribe to Through the Cracks wherever you get your podcasts.
	From the Center for Investigative Reporting and PRX, this is Reveal, I’m Al Letson. Anyone who’s ever seen an episode of Grey’s Anatomy has an idea what medical residency is all about. Working long hard hours for not a lot of money, while carrying an average of $200,000 in medical school debt, getting dropped in the deep end, making mistakes and learning fast and doing it as a team, a cohort.
	But that’s not what it looks like this year. New residents like Dr. Paloma Marin-Nevarez are battling COVID in some ways alone. She can’t hang out with other new doctors because of social distancing and it’s hard to connect with someone new when you can even tell one person from another. Wearing her hospital scrubs, mask and other PPE, colleagues sometimes don’t recognize her. Paloma says that stings a little since she’s at the hospital all the time, working an average of 80 hours a week. It’s isolating. Reporter Jenny gold of Kaiser Health News has been following Paloma for the last year trying to understand what it’s like to be a brand new doctor staring down this pandemic.
Jenny Gold:	By early August, Paloma is in the middle of her ICU rotation. COVID is surging in California Central Valley, and many of the sickest patients are coming to Paloma’s hospital in Fresno.
Paloma Marin-Nevarez:	I’m here’s sitting in the cafeteria, I was luckily able to sign out early today and rare occasion because it’s been a long time since I have been out the hospital and been able to see the sunlight.
Jenny Gold:	In the ICU, Paloma’s usually in charge of five patients at a time, which is a lot. An older resident tells her that in non-COVID times, she probably would have had just two. She monitors her patients’ ventilators and heart monitors and checks in on them constantly.
Paloma Marin-Nevarez:	It’s really hard to say no to families that they can’t come visit.
Jenny Gold:	Families usually spend a lot of time with loved ones in the ICU. They play music, offer prayers and ask questions of the doctors and nurses. But these days, the ICU is a lonely place.
Paloma Marin-Nevarez:	There’s a very strict policy right now that the only people who are allowed to visit their loved ones is if they’re actively dying.
Jenny Gold:	So it falls to Paloma and the other hospital staff to bridge the gap. At the end of every day, she steps into an office and calls her patients families to give them an update. The news is usually not good. And these conversations are complicated by all the misinformation that’s floating around at this point.
Paloma Marin-Nevarez:	There was this one particular interaction that I had with a patient’s family member asking me a lot of questions about different treatments that have been on the media. So things about hydroxychloroquine.
Donald Trump:	Many doctors think it is extremely successful, the hydroxychloroquine[inaudible]
Jenny Gold:	Throughout much of the last year, former President Donald Trump promoted hydroxychloroquine even though study after study found that the drug is not effective at treating COVID. It was just one example of many where the President helped push dangerous misinformation, feeding skepticism about masks, making Paloma’s patients question what she was telling them.
Paloma Marin-Nevarez:	After I let the family member know that the patient had COVID, the family member let me know that they didn’t really think that COVID was a thing. It makes me sad that people have to wait until COVID hit somebody that they love for them to start believing in it.
Jenny Gold:	Brand new doctors like Paloma face a catch-22. On the one hand, they’re needed now more than ever, but on the other, they’re still learning and only have so much to offer. In the ICU, Paloma is seeing more and more patients who don’t make it out. Just to keep calling families to tell them their loved ones aren’t getting any better day after day, it’s exhausting and I can hear it taking a toll on her.
Paloma Marin-Nevarez:	If there is one thing that I can do well right now as an intern of the pandemic is connecting with the families. And I find that to be a really, really important responsibility. I might not have all the answers, but I can make time to give them an update.
Jenny Gold:	Sometimes Paloma stays late volunteering to call the families of other doctors patients so she can speak to them directly in Spanish without an interpreter.
Paloma Marin-Nevarez:	There was this family who I spoke to who told me that they hadn’t talked to a doctor in a while and of course, there were Spanish speaking family. And just at the end, when I’m about to hang up, the patient’s wife just asked me, “So what was your name again?” and I just said, “I’m Dr. Marin [foreign langauge].” And she was like, “I’m so grateful that you’re taking care of my husband.” They’re not a patient who I can confidently say we’ll be able to make it and I am so afraid of having to talk to this person and give them bad news after they said that. I’m afraid of this patient’s family being grateful for a doctor who doesn’t know what she’s doing.
Jenny Gold:	I wanted to know what it’s like to be a family member on the other side of the line with Paloma. Denise Munoz agreed to talk to me. Her dad is a truck driver, 69 years old, and he’s actually the only COVID patient Paloma treated, who she remembers getting off of a ventilator and out of the hospital. A recent study found that about half of COVID patients on ventilators don’t survive.
Denise Munoz:	Thank you again so much for doing that. I know you just must be incredibly busy right now.
Paloma Marin-Nevarez:	More than I anticipated.
Denise Munoz:	Yeah, I can imagine.
Jenny Gold:	When I reached Denise, she’s at home taking care of her dad. She happens to be a nurse in a COVID unit in Southern California. She knows how busy things are, so she was even more impressed by Paloma’s calls.
Denise Munoz:	For me her voice just brought me comfort. She told me that she would call me every day that she was assigned to my dad to give me an update and follow through. She called me every single day which was just amazing to me. I just knew okay, I’m going to get a call from Dr. Marin. Doesn’t matter what time, she’s going to call me.
Jenny Gold:	Denise says she didn’t get to talk to her dad much in the hospital and she wasn’t allowed to visit. Paloma became the lifeline for her and her family, especially when they had to make difficult decisions about his care.
Denise Munoz:	When she called she said that my dad was going to be intubated. It was a scary conversation for me when I hear ventilators like, “Oh, no, this is bad.” She presented it in. “This is not a bad thing. He’s getting worse, but this is going to help him.” And that’s exactly the same thing I told my sisters, which I think brought comfort to them as well.
Jenny Gold:	Her dad needed to be part of these conversations too and he doesn’t speak much English, so having a Spanish speaking doctor like Paloma was critical.
Denise Munoz:	I don’t really know that he would understand if somebody spoke to him in English about medical stuff that was going on. So for her to speak Spanish, there would be no confusion or him saying yes to something that he didn’t really understand.
Jenny Gold:	The ways that COVID has disproportionately hit communities of color has exposed the vast inequalities that have long defined this country. Many of Paloma’s patients in the ICU like Denise’s dad are Latino.
Paloma Marin-Nevarez:	For me, it’s really hard to witness my people just getting absolutely destroyed by COVID, knowing that often were the ones at the frontlines.
Jenny Gold:	More than half of Latino workers in California are in jobs that have been deemed essential during the pandemic.
Paloma Marin-Nevarez:	So it’s hard to see us working so hard and then paying the price for it.
Jenny Gold:	In the ICU, Paloma is on the frontlines of dealing with these inequalities. And she’s the one who has to talk to patients and their families when it becomes clear that the patient isn’t going to get better. It’s Paloma’s job to walk families through really difficult decisions about when the medical interventions used to prolong a patient’s life have started to cause more harm than good. And whether it’s time to shift away from aggressive treatments to focus instead on giving the patient comfort as they die. She sometimes rehearses with her team ahead of time about what she’s going to tell a family. I called her to ask, what do you say?
Paloma Marin-Nevarez:	There’s a very tricky shift that needs to occur. We want them to understand that at this point the their health of their loved one and their prognosis is so poor that us continuing to do invasive things like ventilating them through a machine, injecting them with medicines is not doing good anymore and is causing harm. And so it’s a lot of pausing, it’s a lot of listening, it’s a lot of giving the family the space to cry. It’s my job and I come in and I do this multiple times a day, but for them, it’s an incredibly significant event in their life.
Jenny Gold:	Did you learn this in med school? Did they teach you this? Or is this stuff you’ve just figured out on the job?
Paloma Marin-Nevarez:	No. No, they don’t teach you this in medical school.
Jenny Gold:	Paloma remembers a one hour seminar, but that’s about it. I spoke to Paloma’s mentor at Stanford and he agreed that medical school spent a lot of time on topics like molecular biology, but not enough on issues like talking about the end of life.
Paloma Marin-Nevarez:	I think that we need to improve our fluency in discussing emotions. We need to improve our skill in sitting in a room with someone in silence and just letting them cry and letting them grieve.
Jenny Gold:	Medical residents like Paloma almost always have to confront the death of a patient at some point in their training but because of COVID the number of deaths is just overwhelming. Paloma often finds herself witnessing a patient’s last words or their final breaths.
Paloma Marin-Nevarez:	I hold in my memory one of the last interactions that this person had with someone on earth.
Jenny Gold:	One day she helps interpret a conversation for a Spanish speaking patient who then dies just hours later. Paloma was the last person to speak to them in their native language.
Paloma Marin-Nevarez:	It is a gift but it’s also a gift that I wish that I hadn’t received really. I wish that I would have been able to provide those last moments to the family.
Jenny Gold:	Every time I talk to Paloma during her month in the ICU, she tells me about another patient she’s lost, another grief stricken family. She’s working almost non-stop. One week she clocks 87 hours in the ICU. I can tell she’s feeling rundown. And I’m starting to worry about her a little. Her mom, Hortensia is also concerned.
Paloma Marin-Nevarez:	And I woke up to about five texts from my mom who’s worried because I haven’t called her in a while, so I’m going to do that now.
Hortensia:	Hello.
Paloma Marin-Nevarez:	Mommy.
Hortensia:	[foreign language]
Paloma Marin-Nevarez:	[foreign language]
Hortensia:	[foreign language]
Paloma Marin-Nevarez:	[foreign langauge]
Jenny Gold:	Hortensia does her best not to show it but Paloma tells me that she knows her mom worries about her.
Paloma Marin-Nevarez:	She’s just text me a little blessing every day. My mom’s very religious.
Jenny Gold:	Will you read me one of her blessings.
Paloma Marin-Nevarez:	Uh, sure, they’re in Spanish. Okay, so what she’s saying, she’s like [inaudible], that’s how she calls me. [foreign language]
Jenny Gold:	And what does that mean?
Paloma Marin-Nevarez:	Just means, I hope that God gives you wisdom in your work and that I hope you don’t have to stay for too long. I hope that He protects you and takes care of you and everybody is well, God helps you as you guys help people.
Jenny Gold:	And she sends you one of those every day.
Paloma Marin-Nevarez:	Mm-hmm (affirmative)-hmm.
Jenny Gold:	Wow, that’s pretty lovely.
Paloma Marin-Nevarez:	And she’s blessing all the other doctors and the nurses. And it’s so cute. And there was one day when she forgot to do it. And the day was really busy and I joked with my team. “You know why guys, is because my mom didn’t send her blessing.”
Jenny Gold:	Maybe it was. Everyone I’ve talked to who knows Paloma tells me she’s an extrovert, which makes this time feel even more isolating. She doesn’t know anyone in Fresno. She’s trying to make friends but it’s hard when she can’t even hang out in person with her fellow residents. It’s not like they can just grab a drink or go out for brunch.
Paloma Marin-Nevarez:	I feel pretty disconnected from people right now honestly. And I’ve had to call my therapist and call my old friends just because I just don’t really feel very connected to people right now. And it’s nobody’s fault, it’s just the pandemic.
Jenny Gold:	Well, I hope you’re getting some quality time with the kitty at least.
Paloma Marin-Nevarez:	Yeah, actually my mom ended up taking him for a bit.
Jenny Gold:	Oh really.
Paloma Marin-Nevarez:	I was not home at all to take care of him. I was feeding him and cleaning his litter box but he was getting really anxious and he was not playing so my mom took him.
Jenny Gold:	Now that Chuck the cat is gone, Paloma is all alone when she gets home. I can tell she’s worn out and lonely. So many healthcare workers are struggling right now. All over the world, people are trying to cheer them on calling them heroes. Back in the spring of 2020, when the first wave of COVID cases hit New York, there was a nightly ritual where people clapped for healthcare workers banging pots and pans. Every day when Paloma heads into the hospital, she walks past these signs, a superman silhouette wearing a mask and the world’s heroes work here. It bothers her.
Paloma Marin-Nevarez:	I don’t feel like a hero. That’s not me. I’m not doing the impossible. I’m not bringing people back. Of course we’re doing the best that we can but at the end of the day people are still dying. There’s so much that I wish I could give to my families, like the ability to visit their loved ones. The ability to have those moments that I have taken with me of seeing their loved ones last words, last interactions with the world, last to opening up their eyes on their own. I wish that I could give that to them, I wish that was my superpower.
Jenny Gold:	By September, Paloma finishes her ICU rotation, she gets a much needed vacation and drives down to LA to see her family for her birthday. She stays in an Airbnb to keep them safe.
Paloma Marin-Nevarez:	Is nice in some ways that my mom had already recovered from COVID and so it didn’t feel socially irresponsible to go see her. They got me a really nice tres leches cake. My mom made me pull solei, it was awesome.
Jenny Gold:	It was a big one, she turned 30.
Paloma Marin-Nevarez:	I grew up in a Mexican household with a lot of soap operas. And that was the measure of a woman success, is finding a man and having children. And I guess only thing I’ve done in my life is get a doctorate and I have no partner and no children. So according to Mexican soap operas, I would be a failure. But that’s okay.
Jenny Gold:	When she gets back to the hospital, she stops by the ICU to check in on her former patients. She has a list of people she’s been wondering about.
Paloma Marin-Nevarez:	I went back to look at the ones that I had taken care of and go down the list and see deceased, deceased, diseased, deceased, deceased, all of them except one had died.
Jenny Gold:	On September 22nd, 2020, another milestone 200,000 Americans have died of COVID. But the second wave of infections has finally flattened and things seem to be turning around. Around the same time, Paloma gets a little space from the virus. She begins rotating through departments where COVID is less prevalent. And she sends me audio dispatches along the way.
Paloma Marin-Nevarez:	Testing, testing.
Jenny Gold:	First, she heads to the trauma ward, where she works the overnight shift.
Paloma Marin-Nevarez:	I’ve been running around, responding to a bunch of pages. It is just a matter of time before I get another page. I’m currently, there’s the page. I know it was just a matter of seconds.
Jenny Gold:	In October, she moves to anesthesiology, where she learns how to intubate a patient.
Paloma Marin-Nevarez:	Big deep breaths sphere. We want to fill your lungs with oxygen, okay?
Speaker 10:	[inaudible]
Paloma Marin-Nevarez:	There we go.
Speaker 10:	There you go.
Paloma Marin-Nevarez:	The other tube.
Jenny Gold:	In November, she works with kids at a pediatric clinic.
Paloma Marin-Nevarez:	All right, let’s see what care cap am I going to go with dinosaurs or whales today? Let’s go with whales for mammal Monday.
Jenny Gold:	Gathering one new skill after the next is exhilarating.
Paloma Marin-Nevarez:	My brain is just swelling with knowledge and it’s really amazing to see the growth. I’ve only been a doctor for a few months. And so just to think that I’m going to continue to have this incredibly steep curve of learning is pretty exciting.
Jenny Gold:	But by November, COVID cases has started to climb again. On November 18th, the US records 250,000 COVID deaths. Then come the holidays.
Speaker 7:	Millions of Americans ignoring warnings from the CDC not to travel to-
Speaker 5:	Officials are seriously concerned Thanksgiving gatherings are going to amplify an already overwhelming problem.
Speaker 8:	The Thanksgiving surge experts feared is now here and just beginning to cripple states like California.
Speaker 11:	This morning the Coronavirus accelerating through the holiday season, another million more infections added in the past six days.
Jenny Gold:	Public health officials pleaded with Americans to please stay home over the holidays but millions didn’t listen. Across the country, this is the beginning of the third wave and it’s the one that hits California the hardest. Daily cases in the state double then quadruple.
	It’s hard to describe just how much worse the situation is by December compared to July when Paloma was in the ICU. Looking at the graph of the surges, the summer wave looks like a tiny molehill compared to the Mount Everest of the winter wave. And once again, Fresno is a hotspot.
Paloma Marin-Nevarez:	COVID is wiping the floor with the United States of America. Right now on the emergency department the entire what we call the red zone where they take the absolute sickest patients has been turned into a mini ICU. And so patients are spilling out. The hospital is bursting at the seams.
Al Letson:	By mid-December, the US hits 300,000 deaths. In Fresno, they’re just a handful of ICU beds available in the entire county. That’s when Paloma gets the email.
Paloma Marin-Nevarez:	One of the emails that I got today was from my program director letting us know that they need backup in the ICU since some other residents have started to get symptoms.
Al Letson:	The hospital is looking for residents to go back into the ICU just as cases are at their worst. When we come back, Paloma makes a very big decision. That’s next on Reveal.
	From the Center for Investigative Reporting and PRX, this is Reveal, I’m Al Letson. Healthcare workers have made enormous sacrifices this past year. Kaiser Health News and the Guardian found that at least 3,400 health care workers in the US have died from COVID-19, nurses were hit the hardest making up nearly a third of all deaths, and two thirds of healthcare workers who died were people of color.
	This week, we’re riding shotgun beside a brand new doctor, a first year medical resident as she finds her footing on the frontlines of COVID. When we left off, it was December and Dr. Paloma Marina-Nevarez had a big decision to make. She just got an email asking if she’d be willing to volunteer to go back into the ICU. At this point, her hospital community Regional Medical Center in Fresno is overflowing with COVID patients.
	The medical ICU usually takes care of up to 20 patients, right now, they have nearly 60. They’re short staff and the team needs help fast. So Paloma has a decision to make. Jenny Gold, a reporter with Kaiser Health News brings us the rest of Paloma story.
Jenny Gold:	It’s December 15th, 2020, when Paloma gets that email asking her to go back into the ICU. She’s in her apartment staring at her computer screen trying to decide should she go back into the breach.
Paloma Marin-Nevarez:	I took approximately 45 seconds before replying to this email saying that I was happy to go back to help.
Jenny Gold:	At this point, it’s been four months since Paloma was last in the ICU. She’s still trying to process all the deaths she saw there. It’s a big risk to go back emotionally and physically. And Paloma could be weeks away from a vaccine. Going back into the riskiest place in the hospital is scary, but it’s exactly where she wants to be.
Paloma Marin-Nevarez:	When I am a faculty member, hopefully one day in medical school and my students asked me, “What did you do in the 2020 pandemic?” I wanted to be able to have an answer that I felt proud about. That email that my program director sent was my answer.
Jenny Gold:	December 21st, four days before Christmas, it’s Paloma’s first day back in the ICU and it’s a long one. She crawls into her car at the end of a 13 hour shift.
Paloma Marin-Nevarez:	Oh my God. And finally take off the mask.
Jenny Gold:	The ICU was busy the last time she was here in August but it’s so much worse now.
Paloma Marin-Nevarez:	When I came into the ICU, God I don’t even remember how long ago that was. There were only two teams. And now there’s five. It is absolutely bursting at the seams. It is so full, it is so busy.
Jenny Gold:	These are not good conditions for doctors or patients. A recent study found that when ICUs were at their most crowded during the pandemic, COVID patients were twice as likely to die. But there’s not much doctors and nurses can do. They’re just scrambling, trying to provide the best care they can to the most patients.
Paloma Marin-Nevarez:	Today’s Christmas Eve, December 24th, 2020, just coming home now. Today was rough, I was probably done at around 5: 00 p.m today and I stayed an extra two almost three hours.
Jenny Gold:	Paloma gets her first dose of the vaccine that day, and she stays late in the ICU. There’s a patient there who Paloma has been taking care of, who’s already lost her family member to COVID. Now she’s sick to. All the patient wanted was to go home and spend Christmas with her dog, instead, she’s dying in the hospital.
Paloma Marin-Nevarez:	I followed this patient’s wishes and I did not allow them to die alone. I was there and the patient’s bedside nurse was also there and she was so sweet. She was brushing her hair and lightly touching her on our head as if she was comforting her. I got very emotional and I cried, and I allowed myself to cry at the moment because it was overwhelming. And I think it was culmination of a very long week.
Jenny Gold:	It might not sound like much, but I’m starting to notice a change in Paloma. In the past, she’s given herself a really hard time for crying. But this time, she doesn’t beat herself up. Paloma seems like she’s figuring out how to protect her own mental health even as the pandemic rages around her.
Paloma Marin-Nevarez:	I’ve had to be very strategic about my own self preservation. If I run into a burning building and I burn myself and then I become another casualty, then that’s not helping anybody.
Jenny Gold:	On our next call, I asked her if things feel different this time in the ICU.
Paloma Marin-Nevarez:	I felt like this power where I could advocate for my patients versus before this rotation, I was like, “Well, I’m just an intern. I’m really scared.” And I was just like, “No, I’m going to handle it. I’m the doctor now.”
Jenny Gold:	Gosh Paloma, hearing you talk about this just feels completely different than the last time you were in the ICU.
Paloma Marin-Nevarez:	Yeah.
Jenny Gold:	You have confidence. You are confident as a doctor.
Paloma Marin-Nevarez:	Yeah, yes.
Jenny Gold:	What do you think changed?
Paloma Marin-Nevarez:	I don think that I have some skills. I remember a lot of things that I learned in my first rotation on how to take care of patients with COVID. I usually would ask my attending, “Do you want an X-ray for every day for a patient so that you can track the progress over time?” I didn’t do that anymore. I asked myself that question. I said, “Do you Dr. Paloma Marina-Nevarez, do you need the X-ray to figure out what’s going on with the patient?” And pushing myself to do those things.
Jenny Gold:	On January 3rd, 2021, the US hits 350,000 deaths from COVID.
Paloma Marin-Nevarez:	Oh, this is my second dose.
Jenny Gold:	A few days later, Paloma wraps out her time in the ICU, and she’s able to get her second dose of the vaccine.
Paloma Marin-Nevarez:	Let’s do the left side.
Speaker 12:	Okay, just try and not move your arm.
Paloma Marin-Nevarez:	Yep.
Jenny Gold:	Daily COVID cases in California are still at an all time high.[crosstalk]
Speaker 12:	Feeling okay?
Paloma Marin-Nevarez:	Yep.
Speaker 12:	All right, you’re good. 15 minutes on your timer, okay?
Paloma Marin-Nevarez:	Sure. Over there on those chairs? Perfect, thank you so much.
Speaker 12:	[inaudible]
Paloma Marin-Nevarez:	Awesome, thank you very much.
Jenny Gold:	I’ve been talking to Paloma for the past eight months. I’ve witnessed firsthand the challenges she’s faced and the risks she’s taken on throughout the pandemic. The vaccine is a glimmer of hope. Thinking about all the people like Paloma, who’ve risked so much it made me think again about something Paloma told me back in August, about her discomfort with being called a hero. I wondered if she sees it any differently now. I wanted to play you some tape of yourself from earlier on and have you reflect on it and then I’ll ask you a question.
Paloma Marin-Nevarez:	Sure. I don’t feel like a hero. That’s not me. I’m not doing the impossible. I’m not a superhero. I’m not bringing people back. Of course-
Jenny Gold:	So Paloma following you as you’ve been on the front lines, you’ve done a lot of heroic things, not the least of which has been talking a lot of families through end of life issues. I wondered how you think about this idea of heroism now?
Paloma Marin-Nevarez:	Uh, this pandemic was a catastrophic failure. And there’s almost 400,000 people who are dead in this country because we expect that the job of taking care of others lies only in those who get paid to do so. And by calling other people heroes, we’re separating ourselves from that job. What if every single person had seen themselves as a hero and thus said no to traveling during the holidays? Or had said no to throwing a wedding during a pandemic? Or had said no to having a party, or to have a get together, or to give something up? What if everyone had thought of themselves that way. And I’ve said, it is also my job to take care of others. And we’re all doing what we can as physicians, as nurses, as social workers, as custodians, as everyone who works in a hospital but what the fuck is everyone else doing?
Jenny Gold:	Paloma tells me that by calling healthcare workers heroes, it’s like the rest of us get to let ourselves off the hook. We get to absolve ourselves of all the things we could have done differently to protect one another.
Al Letson:	Half a million Americans have died from COVID-19, more people than any other nation in the world by a longshot. Paloma is one of 12 emergency medicine residents at Community Regional Medical Center in Fresno. When that email went out asking for volunteers to go back into the ICU, all of them signed up. By now Paloma has only been a doctor for eight months, but she’s thinking about doing an extra fellowship in palliative care to help people with end of life treatment.
	We don’t yet know what the long-term impact of this experience is going to be on her and her generation of doctors but some older physicians, especially those who trained during the height of the HIV/AIDS epidemic tell us they think it’s possible that Paloma’s generation will become leaders in changing the way we deal with death. Even though the pandemic has been so grueling for health care workers, it also appears to be inspiring others to take up the call. This year med school applications are up nearly 20%, an all time high.
	This week’s show was a partnership with Kaiser Health News. It was reported by Jenny Gold, [inaudible]produced the episode, Brett Myers edited this show with help from Deborah Angelou and Taunya English at Kaiser Health News. Thanks to Dr. Atul Grover, at the Association of American Medical Colleges, to doctors Tocci Jiwei, and Samantha Godley, whose experiences helped inform this story.
	Thanks also to Heidi de Marco at Kaiser Health News who took photos of Paloma which you can see on our Instagram ad Reveal News. Victoria Baranetsky is our general counsel, our production managers is Amy Mostafa. Score and sound design by the dynamic duo J. Breezy, Mr. Jim Briggs and Fernando my man Arruda that helped this week from Brett Simpson and Amita Ganatra.
	Our theme music is by Comarado lighting, support for Reveals is provided by the Riva & David Logan Foundation, the John D. and Catherine T. MacArthur Foundation, the Jonathan Logan Family Foundation, the Ford Foundation, the Heising-Simons Foundation, the Democracy Fund and the Ethics and Excellence in Journalism Foundation. Reveal is a co-production of the Center for Investigative Reporting and PRX, I’m Al Letson and remember, there is always more to the story.
Automated Voice:	From PRX.

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