Code Blue for Caregivers

Critical care providers face acute threats to their physical and mental health as they aid patients during the pandemic. How medical professionals are coping.

Jason Wittmer, M.D., is the respiratory medicine section chief at Broadlawns Medical Center. When working with patients, medical professionals typically “rely on the family a lot for a sense of who these people are,” he says. “That humanity is important as you try and care for people. COVID divorces you of that.”

Writer: Chad Taylor

Even in the best of times, critical care work is grueling; it’s a physically and mentally demanding job that requires long hours, little rest, and the ability to mingle with tragedy and death in a particularly intimate fashion. But even for the most experienced health care workers, this pandemic has been uniquely overwhelming.

While Iowa has been spared the extreme situation faced by health care workers in New York City, where COVID-related illnesses and deaths devastated that city’s hospitals earlier this year, the number of positive cases— and related deaths—in the state has been steadily climbing since March, with an alarming spike happening at press time in mid-September. This has meant more hours and more work for medical professionals, creating an unceasing drain on their mental, emotional and physical stamina.

“Burnout is a real concern,” says Breanna Young, a licensed mental health therapist and supervisor of the MercyOne Psychiatry Residency Outpatient Clinic. “We have FURI (fever and upper respiratory infection) doctors who are dealing with patients every day, plus we’re asking them to clean their own rooms to limit exposure, so they’re changing PPE 50, 60 times a day in some cases.”

“When you get ready to go into a room, you’ll have your N95 and your respirator or face shield. You’ll have on an impermeable gown, two sets of gloves,” explains Jason Wittmer, M.D., respiratory medicine section chief at Broadlawns Medical Center. “Taking all that off is a time when you can potentially infect yourself if you’re not careful.

“Some hospitals that have significantly larger staffs have created a kind of ‘dirty doc’ position, where all that doctor will do is deal with COVID patients,” he adds. “But we don’t have that kind of staff, so all of us are seeing a mix of COVID and non-COVID patients.”

There’s precedent for concern. In a pair of studies from 2016 and 2017 on the SARS and MERS outbreaks, respectively, the National Center for Biotechnology Information found that epidemic outbreaks have a significant effect on the mental well-being of health care workers, and that those effects can be long-lasting or even permanent.

“It’s horrible,” Wittmer says. “I think everybody in my department has the expectation that it’s going to get much, much worse. I don’t know what the inciting factor is going to be—school, fatigue regarding masking—but all of us have this sense of impending doom.

“I don’t think people have any idea how fragile the capacity of the health care system is to deal with this,” he continues. “If we get a large number of sick people, we will run out of ICU beds quickly. And even if we can put you in a bed, there are only so many of us who are ICU-trained.”

That kind of frustration takes its toll on even the most resilient providers. Those interviewed for this article, some of whom asked to remain anonymous, spoke of insomnia and bad dreams, being more argumentative with family and co-workers, a lack of appetite, and crying fits. They said that while their training had prepared them for things like facing death and the uncertainty of new illnesses, a pandemic creates unique challenges, primarily because of its scale.

“Being in critical care, you never really know what’s going to happen to your patients,” said a nurse with seven years’ experience at MercyOne, who requested her name not be used in this article. “Sometimes, [ICU patients] turn really quickly. So I was kind of prepared for that. But something like a pandemic? I guess I never really thought I would experience it like this. I never really prepped for it. I thought it wouldn’t happen to me.”

A Different Kind of Death

In addition to dealing with the long hours, an uncertain future, and an influx of sick and contagious patients, health providers face another singularly awful challenge with COVID-19: watching people die from it.

Due to the highly contagious nature of the disease, hospitals across the nation and in Iowa have shut down visitation hours, especially in ICU and critical care wards. This leaves patients frightened, gasping for air and bereft of loved ones, all of which puts even more pressure on nurses, doctors and respiratory therapists to pick up the emotional slack and provide what comfort they can, through all the PPE and other health protocols.

“Normally, we rely on the family a lot for a sense of who these people are,” Wittmer says. “That humanity is important as you try and care for people. COVID divorces you of that. So now there’s a physical barrier with the PPE and a psychological barrier. And, frankly, you’re scared of them. You’re scared of your patients.”

“A lot of our COVID patients aren’t just coming in today and dying tomorrow,” MercyOne’s Young says. “It’s taking a week, two weeks sometimes, and there’s no family allowed. The only family these dying people have are your nursing staff. So providers go above and beyond to help these patients feel some kind of peace as they’re moving towards the end of their lives.

“Our nurses are constantly having to share bad news and see tears all day long,” she adds. “I had one nurse tell me, ‘I had to talk to another family today, and they begged me to let [them] come hold their loved one’s hand for 30 seconds and I couldn’t do it.’ ”

A Silent Killer

In the final week of April, New York City—then the hottest of COVID hotbeds—served as a harbinger for a different kind of health care crisis, as two critical care workers died by suicide within days of each other. The first, 23-year-old John Mondello, shot himself after just three months on the job as a Bronx EMT. Then, two days later, Manhattan doctor Lorna Breen died from self-inflicted injuries while recovering from COVID, which she contracted at work. In a New York Times article, her father, also a doctor, was succinct: “She was truly in the trenches of the front line. She tried to do her job and it killed her.”

Even before the pandemic hit, a 2019 study by the National Center for Biotechnology Information found that physicians and nurses were nearly one and a half times more likely to commit suicide than a member of the general public. Female health care workers are particularly at risk, being almost twice as likely as the average person.

Across the national health care community, “we’re screening higher rates [of suicide],” Young says. “The likelihood of suicide has gone up tremendously in the first six months [of the pandemic]. I think things will start to plateau moving forward, as this becomes more of a ‘new normal,’ and we can focus on things like a potential vaccine.

“Of course, nationally, if we start seeing hundreds of deaths per state every day again, we might start seeing those suicides spike again.”

COVID also has limited the number of outlets health care providers have to release their pent-up stress, given the isolation that comes with social distancing and mandates closing or limiting social events, restaurants and bars.

“People just go home at night,” Young says. “We have [health care workers] who are normally fairly social people, but they’ll go home and shower and they can’t go out with their friends because they’re isolating. They have those feelings of fear that they’ll expose friends and family.

“So they have time to sit home and stew with thoughts of anger and depression,” she adds. “And when that goes on long enough, you start to consider things that you’ve never considered before.”

Battling Stigma

Des Moines’ medical centers have support options available for health care workers feeling the strain of the pandemic. But the stigma of mental illness shows up even in health care settings.

“Some of the feedback that we’ve gotten is that nobody wants to be seen as the weak link,” Young says. “If they reach out for services and are seen talking to someone regarding behavioral health, they’re afraid of being viewed as unreliable. One of the biggest problems that we face is that nobody wants to be the one who says, ‘I need help with this.’ So instead we have higher call-in rates, higher resignation rates.”

To combat this stigma, hospitals have made mental health care as accessible as possible. Professionals can seek treatment from therapists outside of their own medical centers and have those expenses paid; they can also speak anonymously. Some health centers have phones set up in special “quiet rooms,” where providers can contact mental health professionals in secret.

At MercyOne, health care professionals and hospital staff can take advantage of the Colleague Care Circle, which tries to actively engage with hospital staff at all professional and seniority levels, intentionally sounding people out for stress and exhaustion levels, addressing fears related to job uncertainty or COVID-related stresses like infection and sending children back to school.

“I think we’ve kind of all pitched in and helped one another through this,” says the MercyOne nurse. “We’ve come closer together as units. We’ve had nurses who had never worked together before becoming closer, and it’s really brought us together more as a whole.”

“I have some colleagues that I talk to about the stress and the way it’s affecting us,” Broadlawns’ Wittmer says. “None of us have any better idea of how to handle it than the other, but there’s some value in talking about it. There’s value in understanding that everyone is going through the same things.”

Long-term Effects

That kind of fraternal communication undoubtedly will become increasingly important as the pandemic drags on, as several of the health care workers interviewed said they worry about the long-term effects COVID will have on their job performance.

“There’s no light at the end of the tunnel,” Wittmer admits. “Even in the best-case scenario that I can come up with in my mind, we’re still doing this [at] this time next year.”

Moving forward post-COVID “is something that I’ve talked about with my colleagues and wife a lot,” he adds. “It will leave an indelible mark on how you deal with people. I don’t think I’ll ever feel as free with people. Staying further apart in exam rooms. Shaking hands—I don’t know that I’ll ever be able to shake someone’s hand without feeling weird about it. It’ll never be the same.”

“The long-term effects are that people are going to leave the field,” Young predicts. “For the workers that are seeing the worst of the worst, there may be some PTSD, dealing with these horrific cases over and over again.”

Keeping tabs on the mental and emotional health of providers is always a concern for any hospital’s in-house therapists, but under the current circumstances, keeping tabs on the people most at risk has become a priority, experts say. And that’s when all the work hospitals have already done in building strong, personal ties with their staffs pays off.

“At Broadlawns, we’re a pretty small community. We all know one another,” says Teresa Dolphin-Shaw, D.O., chair of the psychiatry department at Broadlawns Medical Center. “We take care of each other. We’re always telling people that we’re here for them. And they know that I’m not trying to analyze them; they know that I’m asking as a friend.”

Rx for Health Providers

When health care professionals speak to their mental health counterparts, much of the day-to-day advice hasn’t dramatically changed since COVID hit.

“We’re still saying some of the same stuff,” says Teresa Dolphin-Shaw, D.O., chair of the psychiatry department at Broadlawns Medical Center. “Exercise. Step back and take time for yourself. Those are things we all should do for ourselves, and health care workers are very bad at that because the nature of our jobs is to help others. But most importantly, don’t beat yourself up. If you need help, go.”

“Put down the news,” adds Breanna Young, a licensed mental health therapist and supervisor of the MercyOne Psychiatry Residency Outpatient Clinic. “Turn off the TV, shut off alerts on your phone, do as much as you can to disconnect when you go home. Reengage with old hobbies. Find something to do that is non-COVID related. Exercise, conversations with family, online courses. Finding and engaging in distractions. And, by all means, if you need to talk to someone, reach out. Talk to somebody.”

As the certainty of COVID-19 continuing deep into 2021 becomes more crystalized, finding safe, responsible ways to take care of one another could ultimately wind up being more meaningful to health care professionals than any round of applause.

“I think all of us want to be appreciated,” says Jason Wittmer, M.D., section chief of respiratory medicine at Broadlawns Medical Center. “Early on, there was a lot of ‘come into Starbucks and get your free coffee.’ It makes you feel valued, sure. But I also saw someone on Twitter the other day say, ‘I don’t need a free cup of coffee. I need you to wear a mask.’ That’s the biggest thank you that we can get.”

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