Symbol of Hope

In the early days of the COVID-19 crisis, Saint John’s used technology, innovation and personalized care to save Michael Chang, who continues to inspire caregivers.

BY MELANIE ANDERSON/PHOTOGRAPHED BY PHILLIP GRAYBILL

When Michael Chang was rushed by ambulance from Orange County to Providence Saint John’s Health Center on April 7, he was sedated, dependent on a ventilator and fighting for his life. By 10 a.m. the next day, he was smiling and eating a few tiny bites of birthday cake in his ICU room—his first signs of improvement since contracting a severe case of COVID-19 in late March.

It’s a birthday that Chang, a Los Angeles Police Department detective, will remember for years to come—even though he wasn’t fully alert at the time. Fortunately, Chang’s care team captured his 52nd birthday celebration on video. Pulmonologist and director of critical care, Terese C. Hammond, MD, and cardiothoracic surgeon Raymond C. Lee, MD, presented him with cake while 20 nurses gathered outside his room singing “Happy Birthday.” Chang’s wife and three sons joined on video chat from their home in Huntington Beach.

“When I watched the video the next day, it tore me up because I didn’t know how bad I had gotten,” says Chang. “I was given my phone, and when I turned it on, it was blowing up with text messages and emails about ‘prayers for you.’ Then Dr. Hammond came in and showed me the video from my birthday—especially when she showed me that my family was watching and almost all the nursing staff in the ICU was part of the celebration—it was really mind-blowing.”

Chang’s stunning turnaround marked a celebrated moment in the COVID-19 pandemic at Providence Saint John’s Health Center. In the midst of the unrelenting spread of the virus, Saint John’s has emerged as a go-to destination for some of the most critically ill patients, such as Chang, who require a treatment called extracorporeal membrane oxygenation (ECMO) that is offered at only a few hospitals in the region—as well as access to investigational medications through clinical trials.

While not every critically ill COVID-19 patient survives, the resources and physician expertise at Saint John’s have heartened the community and Saint John’s caregivers.

“Saint John’s is such a special place,” Dr. Hammond says. “I don’t think what we pulled together at Saint John’s could have happened anywhere else in California. The efforts of so many people were needed. At Saint John’s, everyone pulls together to get these patients through.”

Chang was initially hospitalized in Orange County, where he was put on a ventilator after several days of declining health.“I just looked at it like peace,” says Chang. “I get to go to sleep, my body gets to rest and it doesn’t have to be a struggle of fever, cough—everything I was feeling, which was just miserable.”

While Chang was intubated, a doctor at the Orange County hospital called Chang’s wife, Dana, and told her Chang needed a higher level of care than what was available there. By making a series of phone calls, Dana arranged to have her husband transferred to Saint John’s, where he was taken off the ventilator and placed on ECMO.

ECMO is an advanced life-support system used to provide heart and lung bypass support when those organs are failing. According to Dr. Lee, Saint John’s has the most COVID-related ECMO experience of any hospital in California and rivals or exceeds the experience of other ECMO centers in the United States. By July 13, the hospital had treated 21 COVID-19 patients on ECMO.

LEADERS IN ECMO THERAPY

“When our community needed COVID-19 ECMO, our hospital rose to the challenge,” says Dr. Lee. “Anytime a hospital calls us, we do everything we can to get these patients here and take care of them the best we can.”

ECMO involves placing tubes in the patient’s veins and arteries and/or using a pump to move the patient’s blood to an artificial lung, which removes carbon dioxide and adds oxygen, before pumping it back into the body. “It bypasses the function of the lungs,” Dr. Hammond says. “For some patients, the ability to rest the lungs and give them more time to let their body fight the infection has been lifesaving.”

Dr. Lee and his colleagues believed ECMO would be effective for treating COVID-19 patients because of their past success using the technology to treat patients with flu, H1N1 and other respiratory illnesses.

“It turned out we were right,” he says. “By the time data started coming in from other parts of the world on using ECMO, we had already been doing it for our COVID patients and had the largest experience in the western part of the United States and one of the largest experiences in America. In the international registries, our patient survival was good—just as good based on what we would get with our non-COVID-19 patients.”

Philanthropy has played a key role in sustaining the Saint John’s ECMO program, which involves a highly skilled multidisciplinary team.

“When we evaluate our COVID-19 patients each day, we have a hematologist, surgeons, a perfusionist, nurses, social workers—we have so many different people thinking every which way we can to help get our patients through,” says Dr. Lee. “Ever since we started our ECMO program—between philanthropy, through the foundation and our donors, and the hospital supporting the program—we have never had any roadblock in terms of getting anything we needed to care for our patients.”

Dr. Lee explained to Dana that ECMO wouldn’t guarantee Chang’s survival. “He said it doesn’t mean he’s going to live. We’re in a 50-50 place, but we only have a 10% chance if he stays on the ventilator,” says Dana. “I said, ‘Whatever you’ve got to do, just do it.’”

When Chang arrived at Saint John’s, Dr. Hammond says his oxygen level was “inconsistent with being able to survive,” but the ECMO team was ready. “We got him immediately on ECMO,” says Dr. Lee. “We were able to get his breathing tube out, and he recovered very quickly.”

COVID-19 patients on ECMO must be carefully monitored since their recovery is not always linear. “With COVID-19, we see a lot of fluctuations and unexpected events, a lot of infections, blood-clotting and bleeding events, and just a lot of complex things,” says Dr. Hammond.

She describes Chang’s outcome as the “best-case scenario,” since he improved rapidly and responded to two investigatory medications. One was the antiviral drug remdesivir, which has since been approved for emergency use by the Food and Drug Administration. Since Chang was suffering from overwhelming inflammation, he also received the anti-inflammatory drug sarilumab.

Chang’s high level of fitness and lack of underlying health conditions likely aided his recovery. “Part of it, too, is that the guy is an absolute fighter,” says Dr. Hammond. “He was attached to ECMO, yet he pushed himself to stand up and walk a few steps—to do all of the things that were required for him to survive.”

AN EMOTIONAL SENDOFF

After 10 days at Saint John’s—seven on ECMO—Chang became the hospital’s first critically ill COVID-19 patient to go home. As he reunited with Dana and their sons, he was given a celebratory sendoff by dozens of hospital staff as well as his colleagues.

“I wanted the entire hospital—all the people that you may not be able to say ‘thank you’ to every day who make it possible for us to take care of such sick people—to see that they’re part of something big,” says Dr. Lee. “They’re part of something very special, and because everybody worked so tirelessly, this man got to go home to his family.

”Chang says he was floored by the treatment he received from his caregivers. “I owe them my life,” he says. “The nurses there were outstanding. At the end of the day they were basically my family, because I couldn’t see mine. Dr. Lee and Dr. Hammond were texting my wife and keeping her up-to-date. I’ve never seen anything like that. The care was just remarkable.”

Doctors are still learning about the long-term effects of the virus on the lungs and other organs, but Dr. Hammond and Dr. Lee are optimistic about Chang’s prognosis. “When I got discharged, the only thing I was sent home with was oxygen,” says Chang. “I still use it as needed, whereas when I first got out, I was using it regularly.”

Chang is currently undergoing pulmonary therapy and a multiphase reconstruction of his nose, due to an injury that’s likely related to the ventilator. Overall, he feels healthy and grateful for support from his family and doctors, who remain in touch. He can once again enjoy favorite pastimes, especially surfing.

“Being Hawaiian, I am a true believer of the Hawaiian saying: Ke kahea nei ke kai I na mea a pau me ka uhane aloha. Translation: The sea embraces all things with the spirit of aloha. The ocean is very important to me, and that’s why I love ocean sports such as surfing, paddleboarding, kayaking and scuba diving.”

Saint John’s is at the forefront of COVID-19 clinical research

Remembering Chang’s triumphant recovery helps Dr. Hammond persevere as new COVID-19 patients are admitted. “He represents a lot of hope for us,” she says. “Detective Chang was the first to walk out, and he’s a very important symbol for us to keep on going.”

Saint John’s is at the forefront of COVID-19 clinical research. As the threat of the coronavirus pandemic became apparent, clinicians and researchers at Saint John’s, John Wayne Cancer Institute and Pacific Neuroscience Institute put their heads together to prepare for treating a disease none of them had ever encountered. After only a few weeks of collaboration, Saint John’s began offering investigatory medicine to COVID-19 patients. Today the hospital has a portfolio of cutting-edge clinical trials that Steven J. O’Day, MD, executive director of JWCI and director of Providence Los Angeles Regional Research, describes as “second to none worldwide.”

“The John Wayne Cancer Institute at Saint John’s offers the best of academic and community medicine. We’ve been really lean and mean and very productive in cancer clinical trials in the last few years,” Dr. O’Day said in June. “I basically pivoted our cancer clinical trials team and joined forces with our infectious disease doctors and our critical care doctors who are at the forefront of the clinical management of the patients with COVID. It’s been a spectacular—really an extraordinary—three months of advancement and productivity.”

For Dr. O’Day, a world-renowned melanoma specialist, spearheading Saint John’s COVID-19 clinical research program feels natural. “Clinical trials and research are integrated into every aspect of cancer care,” he says. “There’s such an aching need to advance, and the science has been so spectacular in the last several decades—particularly around immunotherapy—that we’re very comfortable offering our patients the best standard treatments and then layering in the best cutting-edge clinical trial research.

”In fact, Saint John’s participated in the clinical trial that resulted in the antiviral drug remdesivir, gaining emergency use approval by the Food & Drug Administration. Remdesivir is now the standard treatment for COVID-19 patients hospitalized at Saint John’s. Patients may receive additional investigatory drugs, if needed.

“Now we understand this disease so much better—we understand it has a viral component and an immunologic component, which causes inflammation—so we can be a lot smarter early on to understanding what’s happening in each patient,” says Dr. O’Day. “Is it the virus per se? Is it the inflammation, or is it both? And depending on which it is, treat the patient accordingly.”For patients with severe inflammation, Saint John’s is offering three different medications: sarilumab, tocilizumab and an investigational drug from Novartis, known as an IL 1b-IL 18 inhibitor that targets specific proteins that cause inflammation. Saint John’s recently put the first patient in the nation on the Novartis trial.

Research from Oxford “shows that steroids in very sick patients seek to reduce mortality,” says Dr. O’Day. “The fact that off-the-shelf steroids, which are relatively broad-based anti-inflammatory drugs, worked to reduce mortality in advanced diseases bodes well for some of our more sophisticated, antibody-directed anti-inflammatories that we have in clinical trials.”

If therapy beyond remdesivir is needed to relieve the viral infection, patients may receive donated plasma, which contains virus antibodies from recovered patients, or engineered antibodies called spike antibodies.

Early clinical trials at Saint John’s focused on treating hospitalized patients, but the hospital is beginning to enroll outpatients—starting with a clinical trial on spike antibodies—with the objective of keeping them out of the hospital. Currently, about 20% of COVID-19 patients require hospitalization, Dr. O’Day says.

“We are opening trials to outpatients who are at high risk, particularly patients who may not be very sick yet but because of risk factors such as age or comorbidities such as heart and lung disease, obesity and other factors that we know put them at higher risk for bad outcomes,” says Dr. O’Day.

The hospital is also maintaining a patient database that includes a blood biospecimen and outcomes data. That database will contribute to two National Institutes of Health studies—an autopsy study to understand how COVID-19 patients are dying and an endocrine study to understand how diabetes and obesity affects COVID-19 outcomes.

“John Wayne and Saint John’s are not only working to bring the best treatments here, but we’re collaborating scientifically with the best scientists in the world at the NIH around several novel projects.”

Dr. O’Day says it’s a privilege to lead this collaborative research effort. “The cancer team, the critical care team, the surgical team, the infectious disease team—everybody has come together to make this work,” he says. “There are very few hospitals, if any, in the world that have been able to do this in just a few months—and that includes academic centers—because we’re so nimble and focused on what we’re doing.”

Of course, this extraordinary work would not be possible without the support of donors. “There has been tremendous generosity already,” says Dr. O’Day. “We really appreciate our donors and are so grateful for all the support.”