My sister, Virginia, is a surgeon. As a breed, surgeons aren’t sissies. And that’s true for Virginia, too. She was a resident at St. Vincent’s Hospital in Greenwich Village, NYC during the peak of the AIDS epidemic. She has cared for and continues to care for hundreds of first responders in the immediate aftermath and for more than two decades now following 9/11. She is on the frontlines again with COVID-19.
When I asked her how she was doing the other day, she broke down and cried. “Kathy, it is bad. Everyone in the hospital is scared. Doctors and nurses, techs and aids – everyone on the frontlines – we are stressed in a way that I have never seen before.” And then she described these five stages of her emotional and psychological journey thus far.
1. Fear. Never has Virginia felt so scared. Never has she seen her colleagues be so scared. Never before have they said aloud that they are scared. “It’s the fear of the unknown. That you’re not going to know what to do for your patients. And then that you are going to get sick and get your family sick, and then you really are not going to be able to take care of your patients when they really need you.” Fear is a normal reaction to high risk situations, but it’s meant to be an alarm for an acute situation. Our COVID-19 crisis is like an alarm that won’t turn off. “Our fears are turning into anxiety and triggering psychosomatic symptoms in our patients and ourselves. I am seeing people whose tinnitus is worse. They are getting headaches. They are coming in for common colds because they are scared. My colleague described terrible chest pain the other day. Another feeling sick to her stomach. I felt my heart racing out of control the other day. Nobody is getting sleep.”
2. Anger. Healthcare providers are being sent to war. Our hospitals are the trenches and our healthcare workers are on the front lines. Like all physicians, Virginia has taken an oath. She is committed to care for her patients and do no harm. But she is angry that she and healthcare workers across the country have been sent to the frontlines unprepared. Rationally she knows this is an unprecedented crisis, so it would be unrealistic to expect to be prepared, but she is still angry. “How did this land in our laps? Why don’t we know what to do? Why are we are not ready? These conditions make us angry, but there is no place to direct it. To make us feel better, we direct our anger at the lack PPE, the science taking too long, and the response being too slow- whether that is the case or not. Really, even if all these things were in place, we are not able to save everyone from this nasty virus that turns the lungs into slime, and that makes us angry in some abstract way that might not be logical, but the feeling real.”
3. Guilt. When people arrive at the hospital, they are sick. Really sick. Without established treatments, healthcare providers are having to create protocols based on previous experience with other illnesses, but this illness is different. “When I get a protocol sent to me, and it’s different from yesterday, I feel a knot in my gut. OMG. Last week we did diagnostic nasal endoscopy without thinking about it. And now I find out I was doing things that may make the virus worse.” Virginia is joining group texts to share what seems to be working in real time. “As a healthcare profession, we collectively feel like we are failing our country. We are healers. And individually, I keep wondering if I could have done more. And then I feel guilty because I am not in the ICU. I get to wear my N95 mask. I am not the nurse at the bedside all day or the respiratory therapist. Do I even get to feel this way?” How could our healthcare providers do any better than they are doing right now? This virus is not their fault. But they took an oath to first do no harm. They feel responsible. Guilt eats away at us and can lead to terrible bouts of despair and depression.
4. Grief. Virginia is a beloved doctor. Usually she has a high sense of agency and derives tremendous satisfaction from her work. Not now. “I am going to lose people. Families can’t even be in the room with their loved ones when they are dying. Physicians are going to have to tell family members that their loved one died. And they didn’t even get to be with them in the last moments to say goodbye.” And all indicators are that it is only going to get worse. In this context of repeated experiences of loss and grief, our front line workers are at high risk of succumbing to compassion fatigue. This extreme state of tension and preoccupation with the suffering of those being helped can lead to secondary trauma for healthcare providers. Desired isolation, excessive blaming, sadness and apathy, or even poor hygiene are symptoms of compassion fatigue.
5. Acknowledgement. “I know Kubler Ross would move to acceptance as our fifth step. But I am not accepting this. Acceptance does not feel right. I will acknowledge it. It is pounded into us during our training that there is so much we don’t know or understand in medicine. But this is like swallowing a horse pill of not knowing. Scientists are still going full bore to develop treatments. The current situation leaves us to acknowledge that we can only do what is within our ability. And what we can always do is care. And by caring we will fight together to come up with the best protocols, best treatment, and best way to be empathetic. We can acknowledge that there is something so much greater than any one of us and even all of us collectively. Acknowledging that is the only thing that gives any sort of peace.”
As Virginia winds her way through fear, anger, guilt, grief and acknowledgement, her coping skills are tested, her resilience is drawn down, and her mental health is put on trial at every turn. All the self-care recommendations that are being circulated are great for those safely sheltering-in-place. Not so much for those on the frontlines working double shifts or around the clock.
All week, I have been wanting to support Virginia, but have felt helpless. It finally occurred to me, I could just ask her what would make a difference right now. Here’s what she choked out through her tears, “People need to know that, as healthcare providers, we are trying to do our best. When you are angry that we fail you, please know it is not for lack of caring or trying. When I see people expressing their gratitude, it is everything for me. And the other piece is support from colleagues. Extraordinary stress can destroy teams and pit people against each other, but we need to support each other. Words of support. Expressions of care. Knowing I am not alone. A simple text, ‘thinking of you’ does it for me.”