COVID’s Hidden Toll

By Gretchen Eichenberg

The mental health needs of medical professionals

Drained physically and emotionally.

That’s how local pulmonologist Maydee Rosario, M.D., said she feels when she gets home from a rotation in the ICU of Ascension Providence Waco, where her focus over the past 10 months has largely shifted to caring for patients suffering from COVID-19.

“It is overwhelming,” she said. “In the last 21 years of practicing medicine, this is the most draining disease I’ve ever treated. On a normal day I would make rounds on maybe 25 patients, which is a busy day for me. After that I would make a plan for my patients and go on with my day. Now you can make a plan, but three hours later you may have to change that plan because it’s not working, and you have to try something else. COVID has completely taken over the system. And by system, I mean hospitals, doctors, nurses, respiratory therapists, custodians, pharmacists and every service that is there to provide care for the patients.”

With a rising number of urgent hospital admissions, the struggle to understand a deadly new disease and advocate for terrified patients and their loved ones who aren’t able to be at the hospital, health care professionals also must worry about their own health and safety. All this — plus the community’s reluctance to comply with safety protocols — have created a crushing pressure that is the perfect storm for anxiety, burnout and depression among some of the people we need the most right now.

Dr. Randy Hartman, M.D.

“Most of us, myself included, are feeling significant fatigue that this pandemic is causing,” said emergency physician Randy Hartman, M.D., who serves on the board of the McLennan County Medical Society. “It’s frustrating and heartbreaking, seeing so many patients ill from this disease and knowing as we’re admitting them to the hospital that they may not make it. Every day the numbers of COVID patients in the hospitals grow, the numbers that die in our ICUs increase, and we can see the toll our colleagues bear.”

As the weight of the pandemic bears down on the sick, a mental health crisis has emerged as health care workers clock longer hours under unthinkable conditions with what seems like no end in sight.

“All of us rely on physicians to listen and respond to our health care needs with clarity and confidence,” said clinical psychologist Don Corley, Ph.D., of Waco Psychological Associates. “We often, literally, put our lives in their hands. We expect them to always have the answers to a very fluid situation with COVID. There is new information coming out every day that they are trying to assimilate at the same time that they are working to responsibly care for our needs. The pandemic has not only increased the frequency of anxiety, depression and social isolation for us, but also placed a greater burden of care on the physicians caring for us.”

One of Corley’s physician patients described it this way:

“The physical toll is real. Health care workers involved in the care of COVID patients are stretched thin. [We] are taking care of more patients with higher acuity and wearing more gear, which is hot and exhausting in and of itself, with the same implied expectation and self-imposed expectation to provide the same standard of quality care. The emotional exhaustion is the more profound, now chronic, change — especially for those in the emergency and critical care settings. Patients are dying long slow deaths with high clinical care needs throughout their stay. They are sick and alone, and the outcomes are grim. The nurses, techs, respiratory therapists and physicians are not only the people keeping those patients alive, but also they are their only available support system. It only takes seeing one or two completely healthy patients deteriorate and die over 20 days to contemplate that there is little to keep that from being someone you love. Fear attacks the already present exhaustion.”

The experience that physician is describing is known as secondary trauma, the personal trauma an individual bears when dealing with someone else’s catastrophic illness or event, Hartman said.

“Months and months of caring for and watching our community suffer and die from this disease has been especially hard on our friends and caregivers,” he said. “We are all very anxious for the vaccination program to progress and be successful.”

Strange and deadly new disease

It was around July when Waco hospitals began to see a spike in emergency admissions, and health care providers embarked on a desperate attempt to deal with a strange new disease.

“This disease is not predictable, and that’s emotionally draining,” Rosario said. “You can have a 27-year-old on a ventilator and a 75-year-old who gets sick but recovers. This is a different beast, and it doesn’t behave the same way every time. Even with cancer there are patterns, and a family can know what to expect. With COVID someone can come into the hospital with pneumonia and be talking, and four hours later they are on a ventilator. You are on your toes every moment. You’re gowned up and in all your PPE [personal protective equipment] and making decisions about what is best for a patient, whether that’s a ventilator or something else. And when you have 20 families with someone in the ICU, that’s 20 families who are waiting and hoping and wondering.”

Providence ICU nurse Mackenzie Adams remembers when the reality of the pandemic hit her. She normally works three 12-hour shifts a week, taking care of COVID and other critically ill patients.

“I think the first time I realized that [this] was real is when we received our very first COVID patient in the ICU,” she said. “I wasn’t even taking care of the patient, but I remember thinking, ‘Wow, this is really real, not just something we’re hearing on the news.’ Back in July when cases really surged, I was working four shifts a week because we were so understaffed. I was very overwhelmed on all four shifts that week. I remember thinking, ‘How long is this going to last? This has to get better, it has to. I don’t know how, but it has to because I can’t keep doing this every week.’”

As new information about the disease came in, patients continued to die. And doctors like Baylor Scott & White family physician Charles Stern, M.D., are left with questions and concerns. He has treated COVID patients in the clinic and seen some of them go on to the hospital and some even die.

“I could not help but wonder if any of these deaths could have been avoided,” Stern said. “I have felt sad at times. Other times I have felt frustration. Everyone who dies from COVID-19 has a life story and has had an impact on those lives they touched.”

Patients frightened and isolated

As hospitals shut down to visitors in order to stop the spread of the disease, doctors and nurses have had to fulfill the role loved ones would usually play — sitting at the bedside, listening to reports, making decisions, comforting family members and communicating with people waiting for news by phone.

“Not having family members at the bedside is really hard,” Rosario said. “As a human being, emotionally, not being there drains anyone who cares for anyone. The families are relying on us to be there and take care of their loved ones. When you tell them that something isn’t working or the patient is not responding, it’s hard. And since they can’t be there, they have to be wondering if someone is really taking care of their loved one. It’s human nature to want to make sure they are not treating my loved one as just another 82-year-old patient.”

Jana Beyer, a respiratory therapist in the Providence COVID ICU, agreed that the absence of family members makes it hard on both the patient and the caregiver.

“When you see these patients that are on a ventilator or are about to be, it’s very emotional. They are alone. It’s very scary for them. They have no one else in that room but you and the nurse and the doctors who come in and out. You just grab their hand and tell them who you are and what you are about to do,” she said. “Just yesterday we were about to intubate someone. He was crying, and we were crying, and he just said, ‘Please tell my family that I love them.’”

Working at the bedside of terrified patients who gasp for air and cannot not see the faces of the doctors and nurses caring for them due to all the protective gear adds to the providers’ feeling of helplessness.

“We don’t realize how important human contact really is,” Rosario said. “I’m somebody that for the last 20 years, a patient hasn’t come to my office without getting a hug from me. It’s been tough not to be able to hug someone and instead just put your hands in your pockets.”

While nurses like Adams are happy they can be there to comfort patients who are alone and scared, it’s also difficult.

“We have seen so much death,” she said. “It’s even harder when you develop a relationship with a patient before they have to be put on the ventilator, and then you slowly watch them die. I try to place myself in the family’s shoes: ‘What if this were my loved one?’ We sometimes have to slow down and realize that even though it is another terrible death, it was also somebody’s loved one, their parent, spouse or child.”

Personal risks and community defiance

You’d be hard pressed to find a doctor, nurse or therapist who puts their own health and safety above a patient’s, but worrying about personal risks from the disease is a new level of stress, even for those who are accustomed to working in critical care scenarios.

Corley, who has been counseling physicians over the course of the pandemic, shared the thoughts of another physician patient.

“You are in the room for hours trying to save a life, knowing that every minute you are performing CPR, listening to breath sounds, adjusting the ventilator, could put you at risk too. All hospitals do drills and preparations multiple times a year for a mass casualty. I have been involved in a real-life mass casualty. This is a yearlong mass casualty situation with no end in sight for safe resolution, and oh, by the way, the threat remains in the hospital room with you. There is no way to prepare for that. Even people with the strongest coping skills, emergency preparedness and clinical compassion are frustrated, burned out and overworked,” he said.

At first routine procedures became worrisome to clinicians, but as more PPE became available, it helped ease some of the concern.

“Something as simple as an endotracheal tube, which is something a pulmonologist can do in their sleep, was a risk,” Rosario said. “Any time you open a circuit in a respirator, there’s a chance of getting infected. And at the beginning you really didn’t know how much it would take to become infected. So I remember the first time I did that, I really did not breathe through the whole procedure. Then you start trusting the PPE, and now I’ve gotten my vaccine. There’s peace of mind in that.”

Beyer agreed.

“At the beginning we were all scared to death because it was the unknown,” she said. “Then the hospital provided us with respirators. We have the proper gear, and I feel safe. It’s still scary, but we do not run into a room without all our gear on.”

As health care professionals risked their own lives to care for others, they also faced backlash from community members who fought against mask orders and continued gathering in groups. Seeing what they see each day, the idea that people would not take personal measures to stop the spread of the disease was nothing short of demoralizing.

“Another frustrating thing for us is all the miscommunication in social media,” Hartman said. “Most of us see our friends, family members or social contacts saying things like this, ‘This is a disease that
99 percent will completely recover from.

This isn’t a big deal at all.’ However what is not realized is that 1 percent of everyone — as everyone is susceptible — is an enormous and significant number. Assuming Waco has a population of 200,000, 1 percent is 2,000 individuals significantly affected by COVID or dying from it. That’s a devastating blow to our community.”

Stern said he was dismayed by the responses he saw from some in the community.

“My wife, who is also a physician, and I could sense the magnitude of the impending impact of the pandemic back in April,” Stern said. “We knew that our nation’s inconsistent public health approach was going to be problematic. We have tried to be positive messengers, encouraging people to adopt sound mitigation measures so we can blunt surges of the disease.”

Rosario feels the frustration as well.

“Something that makes me really emotional and upset is when I see people on Facebook without masks and getting together,” Rosario said. “To me, that’s so irresponsible, and it makes me angry because [I see] the way the hospitals are so tapped right now in terms of capacity. That may mean if your grandmother has a stroke, there may not be a bed for her in the hospital. And it’s because there are people in the community who are not following the guidelines.”

Barriers to mental health and wellness 

Doctors, nurses, therapists and everyone in the health care trenches of the pandemic are at some level of mental health risk.

Don Corley, Ph.D.

“Physicians are not immune to the same life challenges as the rest of us, but they often don’t take the time to care for themselves,” Corley said. “Our world is in a chronic state of crisis, and health care workers are the ones that take on the full weight of that crisis day in and day out.”

Physicians and other health care personnel share an innate desire to be present and prepared at all times, and especially when patients need help most, said Baylor Scott & White family physician Bill McCunniff, M.D., and president of the McLennan County Medical Society.

“As with anybody, one’s mental, emotional and physical health are all woven together,” he said. “As the time passes since the pandemic began, physicians are faced with an internal struggle about whether to take time off for personal health and well-being versus to be working in the office or at the hospital, where our patients are seeking care for COVID or other medical ailments in unprecedented numbers.”

McCunniff said health care professionals are seeing issues revolving around the effects of isolation, leading to loneliness, anxiety and depression.

“As physicians we feel the same pressures and anxieties as we try to help our parents and children have some normalcy in their routines of life and extracurricular activities while dealing with the implications of social distancing and COVID-19,” he said. “The effects of this pandemic will be felt long after the new cases have ceased.”

COVID has led to an increased level of anxiety and concern in many communities among people of almost every age, particularly around issues of disease management and preventing the spread of infection, McCunniff said.

Hartman agreed and said frontline health care workers are no exception.

“It is critical for health care providers to seek mental help if they need it,” Hartman said. “However, we are usually the last and the least likely to seek it. We like to believe we’re strong, we can handle it and don’t need any help.”

And like anyone needing mental health services, there can be a stigma attached.

“Some physicians may experience an external pressure that they need to have it all together. This stigma may potentially inhibit someone from seeking mental health services, as though they are a failure or are incapable of following their own advice. I’ve also heard from some physicians who might not seek mental health services simply due to the lack of time. As with our patients, the months of social isolation and restrictions from visiting family and friends can begin to take a toll on physicians as well,” McCunniff said. “Unfortunately mental health services are underutilized and overwhelmed at the same time.”

Concerns over medical licensing or renewal could also be a barrier to physicians seeking the mental health services they need.

“There is a strong disinclination to seek mental health care because of the real fear that if the medical board or governing bodies discover that a clinician or provider is depressed or receiving psychiatric care, they will have their license suspended or taken away,” Hartman said.

But Corley said he thinks that stigma is changing.

“I think there is less of a stigma for any professional to seek mental health services than in previous years,” he said.

And Stern said getting help is vitally important.

“First, doctors need to be cognizant of symptoms of burnout, depression and anxiety,” he said. “Turning to available mental health resources can help guide them through stressful times.”

One such resource is LifeBridge, a wellness program launched by the McLennan County Medical Society last August. Any member of the society can contact the LifeBridge liaison, and that person will contact Waco Psychological Associates to schedule an appointment at a convenient time. The physician can meet with a mental health professional for four sessions to focus on any issue that is causing personal or professional distress.

“LifeBridge was created as a potential outlet for physicians to access free, confidential psychological services for the physician members of our local medical society,” McCunniff said. “The early stages of implementation began in 2019 due to well-documented issues with physician burnout. However COVID-19 expedited the need to provide immediate support for our physicians who may be struggling with concerns of burnout, anxiety, depression, loss and other issues.”

A benefit of the program, which is funded by donations from both Baylor Scott &White – Hillcrest and Ascension Providence, along with a grant from the Texas Medical Association Foundation and private donations, is that it removes several barriers that physicians would encounter previously when seeking an outlet, McCunniff said.

“The program allows each physician member to have four counseling sessions a year with licensed local psychologists via in person or virtual visits. It is based on self-referrals and not meant to be punitive or compulsory,” he said. “It is meant to provide support and therapy to those who may be struggling with processing or coping with the demands of our profession. LifeBridge is about having a safe harbor to empower and equip physicians with the tools needed to take care of themselves as they take care of patients.”

Baylor Scott & White also offers a Self-Care program that is available to all its employees and includes a spiritual support hotline, a behavioral health access support line and a peer support hotline, as well as a Meditation Mondays program — all designed to provide outlets of support for those in crisis or who just need a listening ear. Providence also offers counseling services for its employees, Beyer said, but she has not used them yet.

Corley said health care professionals need a safe place in order to be vulnerable and process what they are going through and deal with feelings of helplessness.

“Helplessness is one of the most debilitating emotions for ‘can-do’ people,” he said.

Self-care and mitigating stressors

Everyone processes stress and anxiety differently, but it’s important to find ways to decompress, especially on dark days.

“There is a great deal of empirical research that points us to a very simple but powerful truth: The best thing we can do in any situation in which we are out of control is to first focus our time and energy on the things over which we have complete control,” Corley said. “This allows us to restore our sense of confidence and well-being, which then allows us to take on the tasks or situations over which we have less control.

Rosario said these last months she has not wanted to talk about her day with her husband. And neither does Adams.

“I have a 30-minute drive home, so I usually reflect on my shift during that time,” Adams said. “I don’t like to bring those emotions home to my husband, so I try to use my drive home for that. He typically knows when I’ve had a hard shift because I am very quiet when I get home.”

When a spouse is not in the health care field, it is often hard for them to understand what a day in the ICU is like. Beyer said she leans on her coworkers instead.

“I used to talk about my day, but now I don’t want to talk about it,” Beyer said. “Now we have a rule that we don’t talk about work. I try not to think about it until I get up the next morning and get ready to go again. I just talk with my coworkers.

I lean on them, and that’s how we get through it.”

Corley said there is good research to indicate that most of our daily stress comes from responsibilities that we cannot dutifully dismiss.

“So in order to mitigate the daily stressors, we need to add things to our day that are uplifting. The majority of uplifting activities are things that we do in relationship with others. This has been compromised by the social distancing recommendations and restrictions. But there are other ways to add brief moments of joy or positivity throughout our day, like listening to music or a podcast, taking a walk, reading something inspirational, engaging in a hobby or interest, reading for pleasure, planning an outing.”

Both Hartman and Stern said spending time with family is important to their well-being.

“I used to feel like I lived to work,” Stern said. “As you grow older and wiser, you tend to transform your focus more on the blessings in your life. Spending time with my family and sharing stories and fellowship brings such joy to me and allows me to be free of stress.”

On days when she’s not at work, Beyer said she likes to sit alone in the sunlight in her backyard and enjoy the quiet.

“When I’m at work, it’s constant ventilator alarms going off and IVs going off,” she said. “It’s hectic and noisy. So peace and quiet is good.”

For Adams, it is faith that gets her through.

“To find peace I have to remind myself quite often that God has a plan, and his plan is always greater than ours,” she said.

Rosario said she relies on faith and the support of others.

“Science can go far, but I believe in a higher power, and we have to turn to that,” she said. “And also having supportive people in your life. This is how you get through a crisis. You need people in your life who will listen and tell you it’s going to be OK.”

Lasting effects and looking forward

Secondary trauma from all these experiences and the isolation from family and friends will likely take a lasting toll on health care professionals.

“I think a lot of us are going to have some emotional issues to deal with when this is over. We see death a lot more than we should be seeing it,” Beyer said. “My family lives three hours from here, and I don’t get to see them. I used to go home all the time; now I can’t do that. I’m ready to get back together with them. And I’m going to have to put myself back together. Right now I feel very alone.”

Corley said medical professionals are permanently changed as a result of the pandemic.

“We are likely to lose some health care workers who are burned out, disillusioned or no longer find their call to serve as valued by those they have worked to serve,” he said. “One physician said, ‘Hearts are hardening, and compassion is being replaced by survival.’ Physicians and health care systems will have to find a way to rebuild their focus on the delivery of quality and compassionate care, which has historically been at the very core of their existence and, for many individuals, at the very center of their calling into the profession.”

But Corley is quick to point to positives as well.

“Some of the positive changes,” he said, “will include systemic changes in health care, the sharing of information and scientific processes and creativity, shorter meetings and the use of electronic means of communication that we have had to create or utilize in a new manner, more flexibility in how to get things done, greater emphasis on healthy lifestyles, a new appreciation for social gatherings as well as an appreciation of the fragility of life and the importance of healthy relationships now, instead of some other day in the future.”

Beyer said an unexpected gain is the close relationship she has developed with her coworkers.

“We have grown so close with each other,” she said. “When patients are getting worse, and we’re about to have to intubate, no one has to ask questions anymore. We all know what everyone wants and needs and what
to do. One day we lost three people in one shift, and we just sat there and cried together. It’s brought us together as a family.”

Moving forward, the health care community is looking at how to change its approach to each and every day.

“Living ‘one day at a time’ should not be considered a trivial cliche but rather a way to focus our time and energy on meaningful and purposeful endeavors today,” Corley said. “We can ask ourselves the question, ‘What can I do? What do I have control of today?’ and that will begin to restore our sense of personal order in a world of chaos.”