How Doctors and Nurses Manage Coronavirus Grief
In their own voices, health care workers from across the country reflect on coping with the pandemic
Frontline clinicians have become the face of our pandemic. They represent the best of humanity, rising to treat critically ill patients, as well as the collateral damage from America's fragile health care system and disordered government response. Calling them "heroes" doesn't protect them from psychological trauma, and experts warn that a mental health crisis among health care workers could emerge in the virus's wake. Scientific American asked doctors, nurses and respiratory therapists working in hospitals across the country how they were coping with fear, processing grief and tending to their own well-being. Interviews were conducted in late March and early April, as COVID-19 was rapidly upending life in the U.S. These stories reflect that period of extreme uncertainty and may contain details (such as mask-wearing policies) that have since changed. The essays have been edited and condensed for clarity.
On inequity and moral injury Ana Delgado Profession: Nurse Midwife and Clinical Professor Location: San Francisco, Calif.
There was a lot of talk early on about how this crisis was going to bring us all together. But what it has clarified for me is that we're not actually all in this together. It has laid bare what most reproductive justice advocates already knew: inequity and racism have always been around. I work at the county hospital. The impact of shelter in place has been stark for my pregnant patients, many of whom are undocumented and were already living paycheck to paycheck, and now are unemployed. A patient came in yesterday and burst into tears from her desperation. I feel extremely overwhelmed by the need.
There are a lot of injustices that we as clinicians are aware of and feel powerless to do much about. People call this "burnout," but one of my colleagues talks about how that seems associated with self-blame, like you got something wrong. Most people go into health care because of a deep commitment to supporting the health and wellness of their community. When you actually become a provider, you're thrust into this system that is not really set up to promote health and wellness, and you're constantly confronted with this discrepancy. You can't rationally argue that physicians, who are trained to recognize depression and suicide risk, have one of the highest suicide rates of any profession due to "burning out." The pandemic makes these issues worse, and it's painful to witness. That's not burnout; it's a deep moral injury that people are experiencing.
For me, an example of moral injury is having to send home a patient, a pregnant woman, who was still waiting for her COVID-19 results. Her home is a room in a two-bedroom apartment shared among three families. This woman is terrified that she's going to infect her family; there's no way she can stay six feet away from anyone. Now she's basically imprisoned in a corner of a room. So you can imagine how it felt for us to say goodbye to her at the hospital door and be like, "Good luck!"
This concept of incredible unmet need thrust in people's faces--such as the idea that we have to pick who lives and who dies--seems to be a new thing for white people in some respects, whereas that's kind of normal for many people in communities that have been oppressed. For a black person, leaving the house every day is often a life-or-death proposition. They have mechanisms for coping with this type of continual stress. Is the pandemic different or new? Maybe. But there's a discussion that this is not that unusual, that in many ways it is the next thing in line.
On the flip side, there's this trauma porn that comes out of the health equity space: that black and brown people are downtrodden. But let's also talk about the ways we thrive, and redefine resilience not as survival of trauma but as creativity and drawing strength from our redemption narratives and from each other. People who are extremely capable under these types of circumstances are the ones who have been surviving moral injury for decades.
So yes, I have to go work in the clinic and be exposed to people who might be COVID-positive, and that's scary. Yes, I come home and take my clothes off at the door before seeing my family. But as a midwife, I still get to lay my hands on people, to touch and be with people on a daily basis. Many people aren't able to do that right now. That's part of my antidote.
I struggle a bit with the hero worship of health care workers that's going on. I want to be recognized for my hard work, but I feel like it will swing back to the other side, to mistrust and lack of support. If you think about traditional societies, the position of a healer is very respected, but it is also accountable to the community. In our country we have this tendency toward either worshipping heroes or maligning them. That extreme exists because we don't have a true public health network in this country, a model for developing healers from our communities where there's a sense of trust. If that existed, everything would be different right now.Read audio transcript“From, like, a moral injury standpoint, like, this is kind of a new thing for white people, right? Like, this concept of this incredible unmet need and injustice being just thrust in people’s faces, right? The idea that you would have to pick who lives and who dies. That kind of thing just feels, like, incredibly painful. And yet, in some respects, that’s kind of normal for many people in the community, right? I was talking to a friend of mine who’s Native American and who lives in New Mexico. She’s like, ‘I was always taught by my elders to have a supply of things—necessary things—and to be self-sufficient,’ because the government was essentially bent on exterminating us. So, like, why would I depend on a government to have to save me in a time of need, you know?”
On the guilt of being sidelined John Berk Profession: Pulmonary Critical Care Physician and Associate Professor Location: Boston, Mass.
For providers, there's a really complex psychology to all this. Everyone realizes the importance of what they're doing but doesn't want to be the next person felled by COVID-19. You're grappling with fear of the unknown and your call to duty. In the early days of this outbreak, the hospital had a policy that you couldn't wear a mask unless you were treating a suspected or confirmed COVID-19 case, and that made the anxiety even higher among the staff. You didn't know who could be the lurking carrier. My wife, who is also a doctor, and I have been at this game for longer than we care to admit, and we've never been in a situation where there was a real fear of interacting with patients like there is now.
In mid-March I was three days into a rotation in the medical intensive care unit, ramping up for the inevitable surge, when it was decided that those of us 60 and older would be pulled from clinical duty because of our higher risk of dying from COVID-19 infection. Now I have younger colleagues taking on a huge amount of work, and all of them have young families. There's a significant element of guilt in not contributing. We ancients are currently figuring out how we can provide services to lighten their burden. It's a nice gesture, but it's a complicated process. I'm reading the front page of the Boston Globe today, which is trumpeting the threatened salaries and pay holdbacks that different hospitals are proposing because their revenues have dropped like a rock. That there's going to be pay delays and cuts for people in the emergency room and intensive care unit who are working double time is just a little stunning.
Instead of spinning my wheels, I'm occupying myself with other issues at the medical center. I'm responsible for ongoing research and clinical trials for a rare disease, so I'm trying to figure out how I can protect the study coordinators and patients who are involved and at the same time continue participation of the study patients so they don't lose access to these disease-altering drugs.Read audio transcript“You’re at the hospital. You’ve been exposed. You carefully shed your scrubs, and you put on other clothes. You wash your hands about 4,500 times. Your hands are cracking. And you head home with the concern that you are dragging COVID-19 into your house. You feel a little bit like a leper.”
On feeling a loss of identity Roxy Johnson Profession: Emergency Room Nurse Location: Dallas, Tex.
In late March I was running a low-grade fever and had to self-isolate at my house for several days before my COVID test came back negative. It was so hard to stay away from my family and even harder to stay away from my work, which I love. It felt like punishment, like I was losing my mind. I'll admit that I was drinking more than I ever do. In early April I decided to start staying in a hotel so as not to accidentally bring the virus home to my husband and two kids, who could also spread it to my immunocompromised dad, who helps with child care. For me, the hardest part has been the isolation. I've had an eerie sense of calm and peace about all of this up until now, but recently I've started to feel something inside that is not me. I think it's the separation, the loneliness of keeping everyone at arm's length. Sometimes I get in the car, blast music and just go. I ran out of gas on a joy ride last week.Read audio transcript“I feel like we’ve all been exposed to it, but that’s not our worry right now. Our worry is to just focus and, like, take care of it and treat people. You know, like, that’s the point that we’re at. I just don’t see the point of sitting there and dwelling on it. Like people want to know, ‘Oh, an employee was positive, and I’ve been exposed. Do you know who it is?’ I don’t even know if it matters. What does it matter? They’re looking for Patient Zero to a fault, and they lost sight of what’s really important.”
On just getting through each day Matthew Bai Profession: Emergency Room Physician Location: New York City
I honestly have no idea how I feel. I don't have time to digest any of this. I go to work, and then I go to sleep. Training in emergency medicine in New York, with the speed and number of patients, probably prepared me somewhat for what's happening now. But nothing can prepare you for an event of this magnitude. Everything is in flux. The upside is realizing the level of flexibility that's possible in a hospital. I'm seeing new faces in the ER all the time--nurses and doctors from other departments, even surgeons, OBs and people flying in from all over the country. In the back of my head I'm constantly thinking, Can we manage our resources and keep our staff healthy for however long this lasts?Read audio transcript“I’ve not seen this level of flexibility in the hospital, like, ever. And, like, things just happen so fast now. So that’s, like, the upside of this whole horrible pandemic—is just how quickly a health system can change to handle this. And then, like, I honestly have no idea how I feel. Like, there is no time for me to even digest any of this: Doing things, getting things done, and it’s the end of the day. And then I’m too tired, and I go to sleep.”
On anticipation and humility Patti Marshall Gilpin Profession: Respiratory Therapy Navigator Location: Louisville, Ky.
I educate patients with chronic lung disease. My role right now seems a little silly; I can't educate people about something we don't understand. In a worst-case scenario, I'll go back to doing the critical care with the therapists who are in the trenches. When you read about what's happening in New York and other areas on social media, it's very difficult not to be scared. There's a constant undercurrent of bracing for that potential surge. This huge push to ventilate more than one person on a single machine? Yeah, you should never do that. So we're getting support and ideas from each other about how we'll handle different scenarios.
Because this virus lives in aerosols so long, when a person in severe distress shows up to the hospital, we're currently skipping the process of bagging them with oxygen and going into rapid sequence intubation, which means we have to put a mask on the person to give them high levels of oxygen. It's horrible because it goes against what you want to do when you're trying to resuscitate somebody, which is to give them breaths.
Before this, we put on all this personal protective equipment and disposed of it multiple times a day. I look back at it now and it's laughable that we used it in situations where we probably didn't need it. We always thought we'd have endless resources, and suddenly we don't have any. It feels like a parallel to the planet and climate change.
In the beginning, the advice was nothing is acceptable except an N95 mask. A week later the guidelines changed. Our whole community laughed at the CDC recommendation to wear a bandana. Just be transparent and tell me we don't have enough or that you're saving it for the surge that probably will come. But, I suppose, what good would it do me to know the truth? I'm still going in that room, I'm still going to help the patient breathe, no matter what I have to put on my face.
I think most things like this make you stronger, unless it breaks you. It might scare some people into stepping away from the profession or taking retirement a bit early. This virus is fairly mild overall, but what if the next one is extremely dangerous? In our department the therapists are mentors to future graduates in local respiratory therapy programs. The students I've talked to feel very fortunate to be a part of this--it's good for them to see how we adapt and take care of each other and come up with ideas for how to improve readiness. No one goes through trauma without learning from it.
Everyone in health care wants to do the right thing. It's humbling to see how everyone is at the top of their game, improvising equipment, seeking out knowledge. I've watched transporters take patients from one place to another, interacting with them, being so optimistic when there's this palpable dread all over the hospital. I've seen amazing courage when staff have to do CPR on one of these patients--no hesitation when you have to intubate. But when it's over? My co-workers come into my office to vent and cry; some talk about problems with anxiety. When my shift ends, what do I do with this crap I've been carrying around all day, the things that happened, the things that could happen tomorrow? You can't even name it. Then you go home, and you can't have your typical social release because you fear contaminating your loved ones. Worrying that I'm going to spread this is the worst feeling of all.Read audio transcript“Social media is—you know, it’s our best friend sometimes and then our worst enemy, too. Facebook has horrid stories and a lot of misinformation. I think, for the most part, we that are in the trenches know what we see. And we don’t see a lot of younger patients without underlying conditions. Ones that have passed away have been very sick. But when you read what you read on social media, it’s very difficult not to be scared, because it’s happening in such a horrid way in New York and Louisiana and California and Washington.”
On the perspectives of older patients Suneel Dhand Profession: Internal Medicine Physician Location: Boston, Mass.
To be honest, I wouldn't say I've been anxious about the situation beyond knowing we have to prepare and make sure we are all protected. My organizations have instituted several new initiatives to help with the obvious distress and concern among frontline staff. We have regular check-in morning huddles to discuss where we are and air concerns to the hospital administration. We are also trying to take breaks, doing things such as sitting down to lunch together. That lifts off a huge load, to share stories and feel like we're all going through this at the same time. I do worry about what will happen later, the knock-on effects. But one of the tremendous privileges of being a doctor is getting to talk to a lot of amazing patients in their 80s and 90s who have lived through events like the Great Depression, World War II and the Cold War. It's funny, they have been the calmest out of everyone because they've seen very tough times before and know in the end things will improve, that humans are resilient creatures.Read audio transcript“We see all sorts of other illnesses like Ebola. I’ve done a lot of reading on the black plague. This isn’t like that. It’s not, quote, unquote, ‘a zombie apocalypse.’ It’s a bad illness. It tends to affect some people worse than others. But the statistics are showing over 90 percent of people do fine. They don’t need to go to hospital. I’ve already seen—and this is actually reassured me a lot—just the last couple of weeks I’ve seen 80- and 90-year-olds come through this and be discharged home.”
On blocking out the future to function Adam Levine Profession: Internal Medicine Physician Location: Boulder, Colo.
A couple of weeks ago, when all of this was ramping up and we were seeing floods of patients at other places in the country, I had to ask myself, Can you do this? When I was a resident in the cardiac ICU, I had terrible shifts: getting slammed, people dying left and right, four codes at once. I feel like my training has prepared me for having to make decisions on the fly and having to be OK with those decisions. But when you get into the main event, who knows?
We currently have a dozen COVID-positive patients and many pending, but it's actually been really slow at the hospital. When I was a medical resident in Florida and Hurricane Irma came through, I remember seeing pictures of Tampa's beaches, and the ocean, like, retreated. Everything left. It was so eerie. We're lucky in that we've been able to prepare for getting destroyed.
What has changed is morale and the atmosphere of the hospital. The nursing staff are really the ones that are the most affected because they are in these patients' rooms the most and get the brunt of the exposure. There was a situation the other day where a respiratory therapist was wearing an N95 mask, and they were saying to one of the nurses, "Why aren't you wearing an N95?" The nurse said, "Oh, we're not recommended to wear an N95 unless we're in the presence of an aerosolized maneuver." And the RT responded, "Oh, no, you should wear one all the time." And it just created all this commotion on that floor for two hours: Who should be wearing N95s? Are we safe? Is anyone looking out for us? As the leader of the team, I'm trying to keep everyone calm.
Our workflow has changed a lot, too. I'm a big communicator; that's how care moves along. On rounds we're talking to patients on the phone now to avoid frequent exposure, then calling family separately. It's this whole disjointed process. But I've also been trying to call in to their rooms just to say, "Hey, what's going on, how was lunch?" It takes only a minute, but I think it signals to the patient, "The doctor is checking in on me." Imagine being an old person diagnosed with COVID, being left alone; you're kind of a leper. Being so isolated has got to make struggling with this disease even tougher.
It sucks dying alone in the hospital, whether you're a COVID patient or not. I had a guy the other day who has cancer and has been going downhill. He's not imminently dying, but he'll probably die in the next month or so. Now his wife can't come to the hospital to spend time with him, and it's heartbreaking. I tried to push our administration for an end-of-life exception, but our policy is to not have a lot of exceptions because that's how these rules break down, is what I'm hearing.
I try to separate myself from my emotions when I'm at work. I try not to think about things too deeply. Every day I get a list of patients, and my focus is, I want to take care of those patients. At home I do what I always do to totally zone out: play music. I've bought, like, 15 guitar pedals in the past few months, though, so I guess that's how I'm coping, by playing so much guitar. If I let all this stress and anxiety of the pandemic get to me--if I think about what's going on outside my house, what's going on outside the hospital doors--I'm not going to be able to function. It's an outlook that I didn't choose, but it is what it is.
We had a code the other night on a COVID-positive patient where we had to rush in, and people weren't properly putting on their PPE. Obviously the patient comes first, but I said to them, "Stop, we have to protect ourselves." The patient ended up doing fine. But those sorts of calls are going to be tough. If someone's coding and that extra minute of putting on PPE means they might die, should we risk ourselves? The answer is not clear.Read audio transcript“When you’re a resident, when you’re a doctor, you have bad shifts. I mean, like, as a resident in the cardiac ICU, I had terrible shifts, where you’re just getting slammed. People are trying to die left and right. I was the only one there, and there were, like, four codes at once. Like, shit can hit the fan on a normal day in medicine. So I feel like my training has prepared me for situations where you have to make decisions on the fly, and you have to be okay with those decisions. I’ve been in the shit before, and, you know, this will be deeper shit. But I should be able to manage my way out of it.”
On adapting and letting things go Sarah Bradt Profession: Float Pool Nurse Location: Minneapolis, Minn.
You can never really be fully prepared for a pandemic. Thankfully, nursing is never routine, so we adapt quickly. I'm a float pool nurse, which means I work on almost every unit in my hospital. I rarely feel intimidated by something new. But many of my co-workers have been displaced and are now working in unfamiliar areas or jobs, creating chaos and stress. I've noticed the most tension on the new COVID rule-out floors. Many staff members are scared to even enter the unit and act like anyone working there is dirty. Patients have commented on how they feel like a burden. Nurses working on these floors are teaching everyone who enters a patient's room how to properly put on and take off our protective wear, and I have been on the receiving end of many eye rolls and rude body language when all I was doing was trying to help. Fear of the unknown is certainly putting people on edge. I'm coping by just allowing myself to leave work at work. My dog has gotten more walks in the past few weeks than the whole year combined.