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The day Paul’s friend died of the coronavirus, he still went to work. Paul (some health-care workers requested that we only use first names) is a senior resident at a hospital in South Florida, and all over his ward, he saw COVID-19 patients hooked up to ventilators, their inflamed lungs struggling to combat the severe respiratory failure to which his friend had just succumbed at age 35. “I’m usually the strong, silent type, and I found myself having to go find this little out-of-the-way storage room to hide and cry,” he told me. Each night when Paul goes to sleep, he finds himself racked with nightmares about the virus. “Now you have to fight against the mind frame of: Who else am I going to lose? Am I going to recognize someone in one of those beds? Or is it going to me?”
As the coronavirus crisis swamps American hospitals, health-care workers like Paul are being infected at disproportionate rates. In the past two months, more than 9,000 health-care workers have contracted the virus, and 27 have died, a number that is likely underreported. Beyond the immediate physical risks, many front-line workers who survive the crisis will likely be contending with psychological ramifications long after the U.S.’s curve has flattened. “For medical staff, the repercussions of this months and years down the road are going to be extreme,” said Dr. Peter Shearer, Mount Sinai Brooklyn’s chief medical officer, in his dispatch from New York’s diary of a hospital series. “It goes back to the wartime analogy — people being in World War One being ‘shell-shocked.’ Now you call it PTSD.”
Typically a group known for resilience, many health-care workers say that they are being challenged in unprecedented ways: Beyond the ever-present exhaustion and risk of sickness and death, many are now working in unfamiliar fields. Some feel helpless and without support or resources. “Infectious diseases are much more psychologically toxic than hurricanes or tornadoes, because they are invisible,” says Dr. George Everly, a professor at Johns Hopkins and an expert in disaster mental health, who has consulted on catastrophic events like 9/11, Hurricane Katrina, and the SARS epidemic of 2003. “Research demonstrates that psychological casualties in an event like this far outweigh physical casualties,” he adds. When this nightmare ends, he worries that the public-health crisis may very well be followed by a mental-health crisis.
Doctors and nurses spend years developing the mental fortitude to avoid internalizing patients’ suffering as their own. Yet for many, the unique stresses of the coronavirus pandemic are causing those boundaries to fragment. And while health-care workers are used to dealing with sick patients, many — save those who experienced previous epidemics, such as Ebola — are not used to the risk of becoming patients themselves.
Dr. Elliott Haut, a trauma surgeon in Baltimore, recalls operating on a patient who didn’t have COVID-19 symptoms when he arrived in the hospital, but who tested positive three days later. Sleeping alone in the basement away from his family as a precaution, he tossed and turned all night trying to remember if he washed his hands, if he properly disinfected, second guessing his every move. “The only way to be a trauma surgeon and not be a total basket case is to compartmentalize when you go to work, and then turn it off a little bit when you leave. But now, in the back of your mind, it’s not just the patient in front of you going to die. It’s Am I going to get infected? Am I gonna bring it home to my wife or my kid? You really can’t compartmentalize this, it is nonstop on your brain.”
“There’s this feeling of being vulnerable at the same time you’re exposed to all this stress — like you’re rushing off to war but you’ve left your armor at home,” adds Dr. Albert Wu, a colleague of Everly’s at Johns Hopkins, and the founder of RISE (Resilience in Stressful Events), a peer support group for health-care workers within the university’s system. Wu says that this feeling of being under siege can result in panic attacks, depression, or anxiety. “If you are afraid or you feel threatened, it changes your neurobiology and you are really much more prone to be in this sort of fight-or-flight response.”
For some doctors I spoke to, the fear of getting the virus is secondary to the pain of witnessing a degree of tragedy they have never seen in their lives. Dr. Cleavon Gilman is an emergency medicine resident in New York and was a medic during the Iraq War. “If you would have asked me this two weeks ago I would be like, Yeah, I’m compartmentalizing, I’ve done that through a lot of my life,” says Gilman, who says he grew up poor, in a working-class neighborhood in Lakewood, New Jersey, and lost his stepfather to addiction. Yet eventually, after weeks of ignoring the emotional toll, he broke down. He had to call someone and tell them that their mother had died. “After that, I just couldn’t return back to the shift,” he says. “I had to walk outside and I was in the ambulance bay for like half an hour walking in the cold. I didn’t have a jacket, but I didn’t care. I was just crying and tears just kept coming and I couldn’t stop. And after that shift I just cried all the way home.”
That was two weeks ago, and now he says he can’t even count how many families he has had to call to deliver the same news. The hardest part for him, and many others, is the fact that families aren’t allowed in the hospital. “It feels like that burden has been put on me to be like a family member to my patients,” Gilman says. He used to put up a bit of a guard with patients. Now, he is getting them water and pillows, tucking them in like children.
Health-care workers, especially in the developed world, are used to feeling supported by years of training, as well as cutting-edge technology and scientific knowledge. The coronavirus pandemic, with its uncertain trajectory, high mortality rates, and strain on a finite amount of resources, upends that sense of order. “People who are used to feeling in control suddenly feel like they can’t keep up the high standards that they’re accustomed to,” Wu said.
“When someone does poorly there are very few things you can do for them,” said Kate, a doctor at a hospital in Brooklyn with a large population of very sick patients. “You’re kind of on this uncharted course where you don’t have any tools in your toolbox to deal with it.”
Kate says that compared with workers at higher-end hospitals in Manhattan, she and her colleagues feel like they are being neglected by the government by not being provided with the resources they need to do their jobs. Amid a shortage of PPEs, she and her colleagues have been forced to advocate for themselves, teaming up with charities and launching a GoFundMe to try to get adequate resources.
Seeing how hard her patients — mostly poor people of color — have been hit by the virus has Kate constantly in fits of fury and despair that she finds tough to shake. “The main emotions I feel on a daily basis are deep, deep sadness and anger,” she says. “Sadness because so many people are left to die unnecessarily, and a lot of times I have nothing to do for them. And then angry because a large portion of this was completely avoidable, and just the utter callousness and ineptitude of the government.”
Burnout and depression have long been commonplace for doctors and nurses, but the medical industry hasn’t done much to provide them with institutional support for mental-health treatment. To this day, some state licensing boards will ask prospective doctors if they’ve ever been treated for a mental-health condition; answering yes could damage an applicant’s odds.
But many hospitals around the country recognize the unique strain on their workers right now, and are finally scrambling to put resources in place. For the past six years, Wu has been working to train other hospitals to develop programs like Johns Hopkins’s RISE program. Normally, Wu says, RISE gets one to three calls a week. Since the pandemic began, they’re getting more calls in a single day than they used to in a month, and are working to expand the program’s capacities and provide psychological first aid for the hospital systems. “I hear reports about people not sleeping, worrying, feeling like they have no one to talk to and feeling isolated. So all of these things are the precursors of potentially developing a longer-term PTSD,” says Wu. Still, he is hopeful that by normalizing this sort of staff support structure in health-care institutions, more people will seek help. “I think because this is such a universal experience, people are not so shy about saying, ‘I’m freaking out, I’m having a panic attack.’ And sometimes by talking to us they get enough relief that they are able to go back to work that day.”
Ted, a doctor in New York, has never been an anxious person, but he is right now. He spends late hours reading journal articles about COVID-19, worrying that if he doesn’t have all the information possible, his patients could be at risk. It’s exhausting, grueling work. Yet he has found that speaking to his own therapist has been something of a respite — particularly because his therapist lived through the peak of the AIDS era in New York. “He talked about how easy it is to [ignore] self-care in a time of crisis, and how his own weight dropped down to 119 pounds during the AIDS crisis,” he recalls. While his therapist encouraged him to look after himself — and he did ultimately take a few days off — he says it also helped to talk to someone who doesn’t minimize his desire to be there for his patients at all hours. “He is pushing me to look after myself, but he’s not trying to talk me out of volunteering. He understands the pull to be taking stuff on and trying to be useful.”
At the same time, many health-care workers soldier on without the tools necessary to weather this impossible time. When I asked Paul whether his hospital had offered him any sort of counseling, he laughed. “No. It’s very much a ‘physician heal thyself’ situation. Keep calm, carry on and don’t mention it. And God forbid you actually ask for help.” Last week, he scheduled an appointment with a therapist, and he hopes that the breadth of this crisis will decrease the stigma around health-care workers getting help. “In med school, you feel nearly invincible,” he reflects. “You feel like with your science and research and the application of good medicine, you can take on almost anything. Now, everything that we’ve been taught works is failing.”
“The best way I can think to describe it is you’re standing on a shoreline looking out to sea and there’s a tidal wave coming,” he adds. “You can’t outrun it, and you can’t get away from it, you just have to hope to God you can swim.”
Read the 'Diary of a Hospital' Series
- Working Wave After Wave at Elmhurst Hospital
- How One Brooklyn Hospital Survived Its Deadliest Spring
- Diary of a Hospital: ‘It Felt Like a Calling’