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Mitch: From 91�鶹����ֱ�� and The Scope Presents, this is Clinical.

I'm Mitch Sears, producer with The Scope Radio, and you're listening to Episode 6 of our series "Unit on the Brink." This is a multi-part story told in order, and if you haven't listened to the previous episodes yet, we highly recommend you go back and start with Episode 1 in your podcast app. For everyone else, this is Part 6 of our story, "Unit on the Brink."

For many, summer is a season of rest and renewal, a time for vacation and travel, to get outdoors and enjoy the warm weather. And inside the University Hospital Medical Intensive Care Unit, the summer months are typically their offseason, with low numbers of critical patients. MICU staff would lend a hand to other units that see an increase in patients during the summer, like the neuro and burn units.

Summer was always a few months to take a breath and collect themselves before flu season begins in the fall. The MICU is the unit tasked with taking care of the most severe cases of influenza during their "on" season. Typically, the unit will see an increase in influenza hospitalizations starting in October, with cases usually reaching their peak in February. By April or May, the unit can finally relax as the rate of flu infections tapers off, and they can clear their beds of patients with life threatening respiratory complications.

But the summer of 2020 proved to be completely different. The coronavirus pandemic persisted through June, July, and August. And in Utah, the numbers of COVID-19-positive patients climbed even higher than what we had seen earlier in the spring, and the hospitalization numbers were following suit.

While many of the patients arriving to the unit eventually do get well, heal, and leave, only returning for the occasional clinical visit, the unit is dealing with many more severely sick patients than they are used to treating this time of year. This summer, rather than a few months' reprieve, the unit found itself dealing with many more severely sick patients than they were used to treating during the season.

This year, it was the MICU that was in need of reinforcements from other units in the hospital during the summer. And on top of that, flu season was fast approaching. What would this winter look like in the unit if a wave of influenza patients were to come, if COVID cases were still filling their beds?

Throughout our series, you've heard the raw tales of the healthcare workers holding the frontline against the novel coronavirus. But the stories that you've heard so far, they were from interviews conducted in April and May of 2020, the early months of COVID-19. After six months of treating the victims of the global pandemic, how were they holding up?

Three nurses from the unit agreed to discuss what happened over the summer. Veteran charge nurse Alisha Barker, nurse Megan Diehl, and nurse Juan Paulino Rodriguez, who joined the unit on Halloween 2019. The three sat down in a 91�鶹����ֱ�� conference room on a Wednesday morning in early September, Rodriguez fresh off the night shift. Over three hours, they revealed to us what it's like being at one of the medical epicenters of COVID-19 in Utah, during a peak in the virus crisis, discussing their fears, anguish and frustration, along with their love for the profession.

The conversation has been edited for length and clarity. Presented by Clinical and written by Stephen Dark, this is our sixth and final episode of the season, "Waiting to Exhale."

Stephen: On July the 26th, newly appointed charge nurse Cat Coe wrote an email about how much had changed at the University Hospital Medical Intensive Care Unit since early spring. Back then, the first suspected COVID-positive patients, some struggling with acute respiratory distress syndrome, or ARDS, had started trickling in to await diagnosis. But by the summer months of June and July, the MICU was being hit harder by COVID-19 than at any prior point in the pandemic.

Cat: The beginning of this pandemic was very different from what it has become in the MICU in the last six weeks. Nurses, HCAs, and some doctors are getting very tired and burned out. We have seen so much death this summer both from COVID and other things. And the MICU is full every day, which never happens in July. Many patients are getting proned, and I've never seen so many people with such bad ARDS all at once.

Stephen: Nurse Megan Diehl agrees with her 1,000%.

Megan: We can put our PPE on in like 10 seconds now. It's impressive the change of just easy . . . like, putting on your PAPR and tying everything. So the mentality has changed a lot, and we are exhausted, burnt out. There's a lot of people that, you know, "I can't. I just can't come in today." And so they'll call off work, or they'll talk to our management and be like, "I just can't deal with it today." And that totally makes sense. We're feeling a lot of the burnout from it, because we've been doing this the whole time. And people are just like, "Well, I'm tired of COVID."

Stephen: It's not just COVID-19 they're tired of.

Alisha: And it's been a lot. It's just a lot of death lately.

Cat: Mm-hmm. It's hard.

Juan: Yeah.

Stephen: Summers before COVID were quiet enough for MICU staff to unwind, to float to other units, Barker says. But with the spike in cases in June and July, they never seemed to turn a corner, to have a chance to recharge.

Alisha: It's just a constant feeling of being tired, but knowing that you have to keep going. And it's almost like it's . . . again, it's kind of like this destabilizing feeling in the pit of your stomach, where you know you're okay because you know what it looks like. We've been working in this environment for several months now, and we're accustomed to it. However, there's not really an end in sight that we know of. And so it's just not a comfortable feeling. But we're all getting accustomed to being out of our comfort zone. But that's exhausting.

Stephen: Before the pandemic, death was a more sporadic visitor to the unit. But with the virus, its presence was painfully more evident. Nurse Juan Paulino Rodriguez recalls a day when the unit experienced three or four deaths in just one shift, including one just as exhausted nurses and doctors were handing over their patients to the next shift.

Juan: There were these lulls where, yeah, you would lose a patient, but then you would have so many recover, and then you'd have another patient that you would lose, and then you would recover because you would get to see other patients go home. But with COVID, it's constant.

Stephen: Diehl recalled one shift change where a young nurse blamed herself for a patient's death, even though she had fought as hard as she could in that patient's corner.

Megan: She had been fighting for this patient all day, and she's such a good nurse. And she just broke down when the patient started coding. And I was trying to talk to her, and there were a bunch of us trying to comfort her, because she felt like she had failed. Like, she had been working with this patient all day and trying to get, "Can we try this? Can we do this?"

Stephen: Whether new or veteran, the number of deaths of COVID and non-COVID patients exacted a brutal price on already exhausted staff.

Megan: You see it wear on everyone. I mean, someone that's been here for 7 years or, I don't know, 15-something, some crazy amount of years that Alisha has been here, but even for this just brand-new nurse, the constant death just really gets to you.

And even with our non-COVID patients, we've had a really solid amount of people that are not COVID patients but are dying in very traumatic ways, or they come in and they're so sick and it's not something that we usually experience during the summer.

Stephen: And when multiple patients die during one shift, it's overwhelming, Barker says. Yet somehow, the mind finds a way through, at least at the moment.

Alisha: Just speaking from many years of experience, when shifts like that happen, you feel disconnected. And I think it's almost like a coping mechanism so that you can survive and that you can continue to function and complete your shift. You have to turn yourself off so that you don't break down and cry.

And I have had those shifts where I have broken down and cried, and I've had to go in the locker room and try and get myself together in the bathroom stall. And it's even worse when someone comes and checks on you to see if you're okay. The moment someone shows you compassion or gives you that look or touches your arm, you just like break down again, so you're like, "Don't talk to me. Don't. Don't."

And then you've got to go home from your shift and you've got to be that person who you are at home when you're completely wrecked. I've had shifts where I've called my husband and I've said, "It's been a terrible day. I can't come home right after work because I can't help you put our daughters to bed. I can't do that. And so I need you to put them to bed and then I will come home."

Stephen: She drives to a park by her home.

Alisha: I will just pull into the parking lot, and I'll just sit there. And for me, personally, again, where I have to turn it off so that I can still function at work. I sit there, and I try and turn myself back on again so that I can feel it. I try to cry, and sometimes I can, and sometimes I can't. So I literally just sit there and I try and conjure up the feelings. I think through the shift, and I'm trying not to berate myself of where I thought I failed.

Because when your patient does code, you think back and you're like, "What could I have done differently? How could I have prevented it? What did I miss?" And so you're trying to not beat yourself up about it so that you can return to work again, and do the same thing the next day or whenever you have to go back to work.

Stephen: And when those setbacks happen, exhausted nurses have to confront their own emotional limits. Diehl talks about an extremely healthy male patient, who when she had to start turning up his oxygen, knew immediately what that meant and broke down.

Megan: And then I got a patient who had COVID, looks pretty healthy. I mean, I had to get a different blood pressure cuff because his muscles were so big in his arms. He was a healthy guy. And taking him as a patient after that death, and then starting to have to turn his oxygen up, he started crying, and I went into the hallway and just cried, because I couldn't . . . I was already . . . you're like already broken down, and then the littlest thing can just push you and just knock you over into a place where you're not in a good headspace.

So it's just . . . it's like you feel one thing, and then even if something slightly bad happens, or your patient cries, and you have to be strong for them, and you can't . . . I don't know. It was a really hard day.

Stephen: When patients experience those first moments when the virus' hardest truths start to hit home, Barker tries to fortify them by shifting their attention. "Focus on what matters to you," she tells patients battling to comprehend what they may face with the virus. She recalls one scared woman who missed her husband and was waiting to be determined COVID negative or positive.

Alisha: I could tell she was very scared, and her husband couldn't be with her and her family couldn't be there. And I just remember looking her in the eye and just being like, "I am going to take excellent care of you. You are in the right place. And I need you to stay in a mental-positive space. I need you to try and just think about your loved ones and your family. And you're going to be okay. It's going to be okay."

And I hate saying it's going to be okay when you don't know if it's going to be okay or not. In the end, I believe it's going to be okay for all of us, whether which way it goes. But I just make sure that they know and that they believe we are going to take excellent care of you. But I just tell them the patients who are able to stay in a more positive mental space are the ones that I see that do better.

If you can hang on to the reason why you want to get better . . . and sometimes I'll make them. I'm like, "Tell me why you want to get better. Tell me what you're grateful for in this moment right now. Tell me who you're going to get better for." So if I can get them to make that switch versus out of panic mode and into this moment where, like, "Yes, I'm going to make it through this," then I feel like it just changes a little bit. It changes the atmosphere for, who knows, maybe only five minutes, but in that moment, I have them with me and I'm like, "We're going to take care of you."

Stephen: If some patients break down as they realize the severity of what they may face, others refuse to accept it at all. Barker brings out the reinforcements in such cases, namely her voice.

Can you give me an example of that voice? I know it's hard.

Alisha: Stephen, your oxygen is 82% right now. I need to put this mask on you. If I don't, your oxygen saturation could drop more, and you might stop breathing. So I can put this on you now, or we can see if you stop breathing later. You decide.

That's my sort of mom voice.

Stephen: And has anybody actually not done what you've told them?

Alisha: It usually is like, "Uh, okay." I don't remember a point where someone didn't do what I wanted them to do when I was talking to them in that way.

Stephen: A change in tone of voice is not the only tool a nurse can brandish from their professional toolbox. For some MICU staff members, there's a sense of almost vocational renewal in the simple act of holding an iPad so relatives unable to visit the unit can communicate with their loved one, even if the latter can't speak.

Megan: Then you're like, "Can they see them? Am I tilting the right way?" I have so many other things that I can be doing, but you're bringing the family comfort by going out of your way and adding a step to your day so that they can FaceTime with their loved one and say prayers or talk or even just look at everything that's happening so that they can grasp, with the treatment that we're doing, how sick this person is, and that they can just actually visualize their loved one that you're taking care of.

Alisha: Yeah, it's a chance for them to see their loved one and everything that they're going through and everything that we're doing. Yeah, I do love when the patients are able to converse with the family on FaceTime. I love FaceTiming with patients and families. I will stay in the room and hang out and FaceTime with the patient, with their family, just because their eyes light up and the families are just so happy just to be seeing them and talking to them.

And I do, I find myself even when I have other things that I have to go be doing, I'll be doing stuff in the room just so I can be a part of that energy. I find that little things like that and little things that we do that the patients would like or find comforting, I really focus in on those things, and I try to be mindful and present when those things are happening, because those are little things that get me through a shift or a difficult time, or when I'm feeling stressed or pressured. It's those little things that help to relieve me and to remind me why I love being a nurse.

Stephen: The pressures of a climbing COVID-19-positive patient census have demanded a new approach to how many sick patients nurses need to care for each shift. Typically, a MICU nurse would have two patients to care for, one very sick, the other stable. But as more COVID patients filled up negative air pressure rooms shifting the majority of patients from non-COVID to COVID, Diehl found herself caring for two extremely ill patients at the same time.

Megan: Usually, those patients would be . . . if you were having a really sick patient, you would pair them with someone who is pretty stable, pretty okay. But when we had as many COVID patients as we did, it was, "You've got a patient that's paralyzed and proned and tubed, and things really could go wrong at any minute. And your other patient is kind of on the borderline of maybe being intubated, and that might not go very well either."

So you had this sense of stress and just peaking, and then also kind of a sense of dread because your workload had completely changed, and then you were responsible for two really sick patients. And the rest of the unit was pretty much the same way.

And so, even if you needed someone to help you, there were so many times, and I know all of us have felt this, where you're in your room and you just kind of stick your head out because you don't want to take off all your PPE and go out of the room, and there's no one outside at the nurse's station or anywhere around that could help you. And you're like, "All right. Well, I guess I'll figure it out."

So we had lots of COVID, and then we didn't have enough nurses, and then everything changed. And it was just COVID peaked and our stress level peaked too.

Stephen: There was a keen awareness of some colleagues who weren't faring as well as they would like.

Alisha: The sad side of this is that while we're laughing and trying to do things together outside of work, and people are going hiking together, and all these other really good things that are happening, we also know that there are staff members that are really struggling. Our manager will say, "I've got a couple people on my radar that I'm trying to keep tabs on, that I know they're in a dark place."

Stephen: As the MICU staggered towards the end of July, staff concerns inevitably began to include the impending influenza season. As Diehl talks through the implications of what flu and COVID might look like in the fall, despite the brightly lit room, it starts to feel claustrophobic.

Megan: And really, sometimes it feels like in the MICU lately these waves are coming and are literally just crashing into us over and over and over. And the winter is our busy season. Each ICU, I think, has a season that is busy for them. And so it'll be really interesting to figure out how to have all these COVID patients, and then also have the flu, and then the regular stuff that we usually get in the winter.

Juan: And I just see the whole rollout process too. "Is it the flu? Is it the COVID? Is it both?"

Alisha: I know. It's just precautions for everyone.

Juan: Everybody, yeah.

Stephen: What would both look like?

Juan: I have no idea.

Megan: A patient that has both?

Stephen: Yeah.

Megan: I'm terrified to think about that.

Juan: Yeah, because just seeing what COVID is doing and then . . .

Alisha: And then having . . .

Juan: The flu on top of it . . . We've already seen what the flu can do just on its own in healthy individuals too, so . . .

Stephen: If public support had helped keep spirits up in the unit through the first and easy months of the pandemic, once the MICU's walls echoed with rooms full of struggling COVID patients, that same support seemed in some quarters increasingly muted. Indeed, the days of the lockdown when they had experienced so many public displays of gratitude, Rodriguez says, had by then faded away to something that felt at times almost unpleasant.

Juan: At the start of this, like I . . . because working nights, you just get off, you go to the store, you're still in full uniform. At the beginning, it was like, "Oh, thank you for everything you do. Thank you for everything you do," to now when people see . . . I don't like going to the store anymore in my scrubs, because now when they see you, people will give you that stare, they'll step back, or they will go to turn down the aisle when they see you, and then they're like, "Nope," and then go the other way. And it's like, "Whatever. I don't want to talk to anybody right now anyway."

Alisha: I'd be like, "Thank you for socially distancing."

Juan: Yeah, exactly.

Megan: But we're so much safer at work than we are anywhere else.

Alisha: Oh, yeah.

Megan: I feel so much more comfortable in a COVID room than I do out in the public.

Alisha: At the grocery store. Yeah.

Stephen: Some wounds of rejection, particularly those experienced by colleagues, by those standing on the frontline with you, hurt the most, remain the most incomprehensible.

Megan: There's one person in particular who had found another hobby, another source of joy other than just being at work, and COVID happened and everything shut down, and this person couldn't go do that anymore. And then once things started to reopen, he was able to go back to that place. And once they found out that he worked in the COVID ICU, they asked him not to return.

And I think it's people . . . people look at us and they take a step back when we say we work in the COVID ICU. And we feel safe. Other people don't always feel safe around us, and I think people need to recognize that that hurts. And the implications that it can have, and how it makes us worry about someone that we may not have been super close with before, but we're looking out for each other. I'm so doing so poorly with this.

Alisha: No, you're doing great.

Megan: It's so hard. People don't get that, and they put us in this box, this COVID box, and this possible infection and all this. We're still people who we need an outlet. And for the people that don't have that, we are worried about them. And it's hard. I don't know. There's a couple people in our unit that are having those experiences, like, "Hey, my friends are getting together, but they don't want me to come." And that sucks.

Stephen: So you are you are being discriminated against by some.

Megan: I would say yeah, in a sense.

Alisha: Yeah, I worry about that with my . . . I have two school-aged children, and the parents, they . . . I mean, for the most part, it's been good, but I worry about that, that they're being left out of things because they live with me and because of what I do.

Stephen: Barker has struggled to find a nanny for her children. No one she talked to was comfortable coming into her home given where she worked. At the same time, she was also nervous at the thought of hiring a stranger who might bring COVID into their family.

Barker told her mother about her problem. Five days later, her mother called back. "I'm calling to apply for your open nanny position," she said. A relieved Barker was so moved she couldn't speak and cried for several minutes. Rodriguez had similar problems.

Juan: Yeah, even on the medical side, I have a niece who has a brain tumor and we've been dealing with it for the last three years, and she was very young. And when COVID started, the clinic that she goes to, they asked her, "Do you have known exposures?" to my sister. And she was like, "No, but my brother, he's a nurse. He works in the COVID ICU, and he hasn't been around often, and we do everything that we need to." And they basically like, "Okay, well, you need to do your appointments virtually now." And it's like how can you do this virtually? The exposure risk is minimal. Like, it's . . .

Megan: Frustrating. It's frustrating.

Juan: Yeah. When she told me, I'm like, "So what? I can't go around her? Is that what the hospital is saying? Is that what they're telling you to do?" It's frustrating, yeah.

Megan: It's because people are telling us that we're heroes. And at the beginning, it was, "Oh, you guys are such heroes. This is so great. Thank you for all that you're doing," but like, "Don't be around me, and I don't want you around people that I know," or, "You can't come here because you're such a hero."

It's a weird thing. We were supported, but it's support from afar. Or we were supported, and now we're kind of being put in this other bubble. So it's a weird feeling. It sucks.

Juan: Yeah, it does.

Megan: But it's sucks together. I mean, we all have that where we've had these experiences, or we know someone that has, and it's really affected us too. And so we share in that together, and we'll still get together outside of work because we're not afraid to be around each other.

Stephen: MICU staff try to support each other, whether it's organizing a staff exercise meet in Sugar House Park or taking time to check in on personal projects. There's a table designated for sharing, where staff like Barker can simply visit, chat, and ask questions.

Alisha: You see some people sitting at the share table, you go and you sit, and you're like, "Okay, what are we talking about? What's going on?" You'll get little clues as to how your coworkers or how people are doing just by what we share at the share table, what we talk about. And so often there we just try and say . . . like, we talk about personal things.

Stephen: Barker will ask Diehl how work is proceeding on her new home.

Alisha: Like, "Hey, how's your house renovation going?" or . . . yeah.

Megan: It hurts me inside.

Alisha: Yeah.

Megan: But that's exactly it. We lean on each other, and we know when someone's had a hard shift, because usually we're right there with them, or we've been stuck in our rooms all night and we're like, "Man, I haven't seen you this whole time and I know you've had just as crappy as a night as I have." So we're I think really good at talking about how things are going and really good at making each other laugh. We really support each other, I think.

Stephen: By the end of a summer unlike any other in living memory, Utah had experienced not only the ebbs and flows of a global pandemic, but also hurricane-force winds battering the streets of its capital. With no end in sight to the crisis, staff wearily steeled themselves for the days to come.

At the end of September, the Beehive State hit its highest ever daily infection numbers for the pandemic, over 1,400 cases. In the MICU, after a brief lull in the run up to Labor Day, numbers yet again began to climb.

As nurses, healthcare assistants, and providers rallied once more to treat the rising number of cases, they drew on each other for morale and support along with their own resources, histories, and quirky personalities. Tired and burned out as many were, they needed all they could find, as the virus laid siege on their patients day after day after day.

Charge nurse Alisha Barker's disciplined, unflinching approach was seeded on the softball fields of Central Utah when she was an ace pitcher coached by her devoted father.

Recently appointed charge nurse, Cat Coe has her years of mountaineering and guiding with all the fear and stress she learned to negotiate to steady her resolve before the onslaught of extremely sick patients.

If healthcare assistant Cornelio Morales' loving approach to caring for patients with disabilities and their loved ones was ingrained in him from the many years he and his wife have cared for their bedridden daughter Cathy, there was also his 11 years working at this unit to guide him.

Unit respiratory specialist Lynn Keenan, MD, had both her family's deep ancestral roots in medicine and 5:00 a.m. jogs, when the peace and promise of Salt Lake's morning streets awaited her.

And if nurse Megan Diehl had thought that a business major would have been too stressful for her, nursing through a pandemic brought to the fore her compassion and her natural qualities as a leader.

And for the very worst cases this unit would face, they can always rely on reinforcements from the CV ICU, professionals like nurse Rebecca Brim, who has walked the gray line of life and death for most of her long career and will do whatever she can to help bring her patients back from the brink.

None of them, however, have faced quite the emotional vortex that consumed nurse Juan Paulino Rodriguez when his grandfather, a man he called Appa, was diagnosed with the virus and cared for by his own unit. Rodriguez was quarantined for most of Appa's time at the unit, only to be there in his last hours to say goodbye and hold the iPad so that many of his relatives might also say their farewells. We'll tell that story in a future episode.

But however long this pandemic would run, whatever the fate of the unit's patients and their committed staff, they remained unbowed before the brunt of COVID's relentless pressures.

The MICU staff knew they had each other to rely on as they confronted the virus' wrath and worked towards the end of all this, whenever that end would come.

Mitch: And that brings us to today, the first week of October 2020. The pandemic continues. The frontline workers at University Hospital are still fighting every day to save the lives of some of the very sickest members of our community. In the past week, we've seen record high numbers of new positive cases in the state, and the overflow unit at the hospital has been reopened.

This has been a story of loss and the pressure that this pandemic has brought to bear on those tasked with treating the sick. But it has also been a story of bravery, dedication, and the saves that make the job worthwhile. A tale of the grace and strength of those who devote their lives to healing others. The story of one state, one hospital, one unit, and the ordinary people facing extraordinary circumstances, coming together and supporting one another through these unprecedented times.

While this may be the conclusion of our first season, this is not the end of our story. We'll be staying in touch with the medical professionals and provide updates as they happen.

And be sure to stay tuned. The Clinical team has been hard at work on a series of "Unit on the Brink" specials coming out over the next few months that aim to share other perspectives of this story, such as the way the virus has impacted Utah's Latinx community, the perspective of a COVID-19 patient themselves who came back from ECMO. And we'll hear from the resiliency center, the people that helped take care of the mental well-being of our frontline workers.

Stephen and I want to take a moment to thank the people who, without their help, this series wouldn't be possible.

First, the professionals who were willing to share their often difficult stories with all of us and helped give a voice to the experience of those in the unit working to hold the line against the virus -- Alisha Barker, Rebecca Brim, Catherine Coe, Megan Diehl, Dr. Lynn Keenan, Cornelio Morales, and Juan Paulino Rodriguez.

A thank you to MICU nurse manager Naydean Reed, for her assistance and guidance on this project.

Our gratitude to the support of the rest of our team -- Cathy, Scott, Chloe, Alex, Charlie, and Jessica.

And of course, thanks to you, our listeners. Without your support, none of this would be possible.

Clinical is part of The Scope Presents network, and brought to you by 91�鶹����ֱ��. If you liked what you heard, please be sure to subscribe and share with your friends. And if you haven't yet, why not give us a rating on Stitcher or Apple Podcast? Those ratings really help new podcasts like ours, and it really makes our day to read them.

And to all the nurses, doctors, admins, interpreters, operators, technicians, and all the other hospital employees out there, we know you're listening and we want to hear from you. Do you have a frontline story or a message for us or for the people in our story? Feel free to share at our listener line at 1-601-55SCOPE. Again, that's 1-601-55SCOPE. Or email us directly at hello@thescoperadio.com.

And finally, be sure to visit our podcast companion site at , and click on "Voices from the Frontline. There, you can find bios and portraits of the professionals in our story, see what it looks like in the MICU, as well as bonus content we hope enhances your podcast experience. Again, that's , and click on "Voices from the Frontline.

Clinical is produced by me, Mitch Sears, and Stephen Dark. Be sure to check out the rest of The Scope's growing catalogue of shows at , including and .

Music in this episode by ANBR, the David Roy Collective, Ian Post, and Yehezkel Raz.

And of course, a heartfelt thanks to the men and women who have shared their stories with all of us and fight to this very day to keep each and every one of us safe.