March 16, 2022

Teamwork returns man with severe post-COVID complications to his life

A multidisciplinary team at Vanderbilt helped José Ontiveros cope with a long list of severe complications arising from his COVID-19i infection.

José Ontiveros, center, and his wife, Isela Morales, to his left, are surrounded by some of the team members who helped save his life as he battled post-COVID complications, including from left, infectious disease specialist Karen Bloch, MD, MPH; interpreter Eleazar Jimenez; orthopaedic surgeon Amir Abtahi, MD; infectious disease specialist Christina Fiske, MD, MPH; and otolaryngologist Sarah Rohde, MD, MMHC.
José Ontiveros, center, and his wife, Isela Morales, to his left, are surrounded by some of the team members who helped save his life as he battled post-COVID complications, including from left, infectious disease specialist Karen Bloch, MD, MPH; interpreter Eleazar Jimenez; orthopaedic surgeon Amir Abtahi, MD; infectious disease specialist Christina Fiske, MD, MPH; and otolaryngologist Sarah Rohde, MD, MMHC. (photo by Erin O. Smith)

José Ontiveros of Manchester, Tennessee, had been in the hospital for nearly two months for COVID-19 in September 2020, intubated during much of that time. When he was sent home in late November, he and his wife, Isela Morales, thought surely the worst was over.

But then he began experiencing severe back pain that radiated down his arms. His symptoms rapidly escalated. Soon he could no longer empty his bladder or get out of bed.

“He was clear from COVID, but this was just not right,” Morales said. “He was feeling so bad, and he was crying.”

Morales called her husband’s primary care physician and was told to get him to an emergency room immediately. He was soon on a LifeFlight helicopter enroute to Vanderbilt University Hospital (VUH).

“They told us he had to get to Vanderbilt if he was ever going to have a chance to walk again,” Morales said.

In December 2020, Ontiveros’ second desperate battle for life through a cascade of complications began. He was 51 years old. He operated a thriving concrete business in Manchester alongside his adult son. His family, also including an adult daughter, twin 17-year-old daughters and three active grandsons, was always together. He had a lot of living left to do.

“When I first saw Mr. Ontiveros, he had only slight sensory function preserved in his arms and legs and no motor function in his lower extremities, so on the spectrum of where patients come to us with neurologic compromise, that is very close to the most severe,” said Amir Abtahi, MD, assistant professor of Orthopaedic Surgery. “With his presentation, the prognosis is usually very grim.

Morales remembers that hour-long, anxiety-filled drive to Nashville with her son to join her husband. What she didn’t know was that a VUH Critical Care Outreach Team had been called to Radiology shortly after his arrival. During diagnostic imaging, Ontiveros had become hypoxic (dangerously low blood oxygen) with an altered mental state. The rapid response team provided immediate life support and moved him to the Surgical Intensive Care Unit (SICU). He was found to be in multiple organ failure due to sepsis, the body’s extreme response to infection.

Imaging revealed an abscess compressing his spinal cord, leading to his partial quadriplegia. Once there are neurologic deficits related to spinal cord compression, there is a brief window of time during which these might be reversible, Abtahi said.

The abscess was due to an injury to his pharynx or throat, likely related to his intubation at an outside hospital. The injury allowed bacteria that normally live in the upper airway to escape and infect the adjacent tissue, a rarely seen but potentially fatal complication.

Morales was told her husband needed immediate surgery.

An orthopaedic spine surgery team led by Abtahi carefully drained the abscess and completed a cervical spine fusion to stabilize Ontiveros’ neck. Surgical repair of the pharyngeal defect — clearing dead tissue and closing the large hole while protecting his airway — was performed by Sarah Rohde, MD, MMHC, associate professor of Otolaryngology-Head and Neck Surgery.

Following the surgery, Morales, who along with her husband speaks limited English, met yet another vital member of his care team, Eleazar Jimenez, a senior interpreter with VUMC’s Interpreter Services.

“After surgery, I had to tell Isela the hard news that it was possible he was not going to walk again,” he said. “She remembers when I told her that and said it was a very tough time for her. She couldn’t even tell the rest of the family about it at the time. She was massaging his feet and just hoping and waiting to see if he would have some movement.”

VUMC’s infectious diseases team, including Karen Bloch, MD, MPH, professor of Medicine, and Christina Fiske, MD, MPH, assistant professor of Medicine, were already working to rapidly address his infection with appropriate antibiotics. Cultures revealed he had four different bacteria attacking his system.

“He completed an eight-week course of IV antibiotics and then, because he has spinal hardware that was necessarily placed into the site of infection, he has remained on oral suppressive antibiotics since that time,” said Bloch. “I continue to see Mr. Ontiveros in the Infectious Diseases Clinic, and he continues to improve.”

His post-operative recovery was not in any way easy. It was complicated by meningitis (inflammation of the lining of the brain and spinal cord), a deep venous thrombosis (blood clot), critical illness myoneuropathy which causes limb weakness and difficulty weaning from ventilation, and apnea which required a repeat tracheostomy.

When he was medically stable, Margaret Jones, MD, MPH, a spinal cord injury specialist and assistant professor in Physical Medicine and Rehabilitation, began working with him to coordinate care so he could continue his rehabilitation.

He was uninsured, and the family could not afford to pay for a specialized wheelchair; the type he would require can cost $30,000-$40,000. Jones began making phone calls, and a vendor generously donated a gently used chair for Ontiveros.

“Between the acute care occupational therapists, the vendor and the patient, I don’t think there was a dry eye there the first time he was able to go over to the window and realized he wasn’t going to be stuck in a bed for the rest of his life,” Jones said.

Ontiveros was discharged from VUH on Jan. 18, 2021, to begin a two-week rehabilitation at Vanderbilt Stallworth Rehabilitation Hospital under the direction of James “Woody” Morgan, MD, an assistant professor of Physical Medicine and Rehabilitation specializing in the care of patients with spinal cord injury and spinal cord disorder.

The Stallworth team focused on continuing to build Ontiveros’ strength, and to teach him as well as his family about tracheostomy care, respiratory management, bowel and bladder management, pain management, safe use of mobility devices, nutrition and other concerns.

Morgan credits everyone at Stallworth who worked with Ontiveros for his continuing recovery.

“We have a huge, multidisciplinary team,” Morgan said. “It’s not just the physicians. It’s the physical therapists, occupational therapists, respiratory therapists, nurses, case managers. We also have the internal medicine co-management doctors checking in on these patients.

“Our goals are always to maximize people’s function and maximize their independence, regardless of what recovery looks like. If there’s a lot of recovery, that is phenomenal. If there’s minimal motor return, we usually still improve their function, often with equipment or other adaptations. One of the most important things about any kind of traumatic injury, whether it be brain injury, spinal cord injury or severe illness, is that there’s still life after the illness. It may look a little different, but there’s a lot of life worth living.”

“Over the course of the year following his discharge, he has made a pretty astonishing neurologic recovery to the point where he can now walk with an assistive device and function somewhat independently,” Abtahi said. “If you had asked me back then whether I thought he was going to be able to walk, I would have said, ‘No.’”

“Mr. Ontiveros’ recovery is a testament not just to the multidisciplinary team who cared for him at VUH and Stallworth but to his indomitable spirit and his incredibly supportive family,” said Bloch. “He is always cheerful and upbeat at clinic visits, with a ready smile. Every visit I am amazed by his progress, and he serves as an inspiration that recovery from these catastrophic infections is possible.”

Lisa Weavind, MBBCH, the SICU attending physician who oversaw the rapid response team when Ontiveros arrived at VUMC, was overjoyed to hear of his continued recovery.

“That is absolutely wonderful news,” she said. “We love to hear from our patients and would love for him to come and visit us in the SICU. These stories fill our hearts with happiness and give us the resolve to come back into work the next day.”

Ontiveros returns to VUMC regularly for follow-up appointments. He is eager to have his tracheostomy tube removed so he can regain a stronger voice and be able to eat.

“I’m hopeful that with all the progress he’s made, in terms of his overall strength and the fact that he’s swallowing saliva better and his vocal cords are moving, that we will be able to correct all of those issues for him,” said Rohde.

His wife wanted to send one message to those at VUMC who fought through every challenge with her husband: Thank you.

“He is able to get up on his own and get on his bike for his exercises,” Morales said. “I still help with the medications and things like that, but it’s just so much better now. He’s recovered his life and I’ve recovered mine, too.”