• Russell Hill

Healing One Another

To read part one False negatives and true recovery click here

“I just want to go home Dr Hill,” Priscilla told me with tears in her eyes. “I know I may not quite be ready yet, but I am anxious to get past this and move on with my life.” 

She had been in the hospital for three weeks and it was emotionally wearing her down.  I was on duty the night she first came into the ER. A few hours after her arrival, Priscilla looked at me sincerely and asked if she was going to be okay. In a matter of 36 hours she went from stable, breathing well on her own to the ICU on a ventilator. Priscilla teetered on survival in the days that followed.  At first, her lungs worsened. Despite the ventilator’s support, day by agonizing day she deteriorated. Then, suddenly, she rallied. A few days after her remarkable turnaround, she was able to come off the ventilator. She began regaining her strength and earlier optiminism. Then, unexpectedly, she had a setback and her weakened lungs needed the ventilator’s support once again. Going back on the ventilator was an unexpected reversal. It weakened her emotionally and physically. She hated this seesaw routine.  During the next three days on the ventilator, her lungs once again made steady, measurable progress and soon she no longer needed the ventilator.  Everyone involved became cautiously optimistic that she had turned the corner for good.  When I visited with her after she had been weaned from the ventilator, her relief in being awake again and eagerness to move forward energized me. Finally, she was stable enough for discharge from the hospital. It was Pricillia’s victory, but it was ours as well. Outside the hospital, people are tentatively recovering from the long night of the coronavirus nightmare: getting back to work, heading to the beach or mountains on the weekend, talking to neighbors rather than avoiding them.  We all want the same thing Pricialia wants: to go back to the way things were, to return to normal, to move on with life. But there may be a “new normal” for the foreseeable future, a cautiousness at churches, in sports arenas, at schools, and on airplanes regardless of how loudly protestors clamor to eliminate restrictions or how quickly government officials drop them. 

Priscilla and her family for a while may observe stay at home directives, follow social distance suggestions, wash their hands regularly regardless of government requirements. They’ve seen COVID-19 too directly, too personally to ignore it’s haughty power. Her neighbors, friends, and attending healthcare workers may not be as loud as the protestors because their battle may not be over with the disease. Given the long incubation period of the coronavirus, none of them know if they will be next in the ICU, hooked up to a ventilator, fighting for their lives.

This global pandemic with its ever changing rules threatens every frontline healthcare worker to a point where some of us may never fully recover. Last month an experienced New York City ER doctor committed suicde after toiling for weeks to save as many lives as possible. Scarce supplies and protective equipment, a harsh medical climate, and something called “moral injury” likely all played a part in Dr. Lorna Breen’s decision to give up the fight. Not to get up another day. Not to face the barrage of demands, dilemmas, and difficulties that no doubt seemed never ending to her.

Hundreds of thousands of healthcare providers can relate to Dr. Breen. She was not burned out. She was morally wounded. She was asked one time too many to ration resources  for dying patients while continually putting herself, her family, and her co-workers in harm's way. Despite being at a tipping point, she kept coming to work. It was her duty and she would not shirk it. Until she could no longer resolve her conflicting demands. 

Moral injury is a wound to the soul that affects healthcare workers' consciences and relationships with friends, family, and society. I first read about it in an article written by two physicians, Simon Talbot and Wendy Dean. It was a mental game changer for me. I recognized its effects on my own psyche, on coworkers, and on friends I care about. It gave a name to our disquiet. 

I realize now how it has affected me. In my case, little by little the challenges and time commitments of medical training and medical practice have isolated me from friends and family. The shift has been subtle, I hardly noticed it, and over time attributed it simply to a rite of passage in becoming a doctor. But now, I see it for what it is. 

Moral injury was first used to describe the dilemma some soldiers faced with taking the lives of others during war. For health care workers, moral injury is akin to a stress disorder due to not being able to provide quality of care to underserved patients. Like other stress disorders, it is difficult to predict or even notice who is affected. Just as two soldiers may face the same horrors of war and one relives atrocities while the other is seemingly unaffected, so frontline providers working side by side may respond differently to the almost daily dilemmas they face. 

 The current complex medical climate--the pressure for profits, the administrative demands, and punitive measures for sometimes minor mistakes--amplifies this widespread moral injury. There are so many healthcare imperatives that conflicting priorities are inevitable. 

Moral injury is not confined to physicians. Nurses, paramedics, respiratory therapists, LPNs, pharmacists, advance care providers, and non-clinical staff can suffer in a climate of high stress, uncertain or rapidly changing protocols and isolation from their families amplified during times such as this current COVID-19 pandemic.  

“As ER nurses we are built to be tough and critically think through anything. The biggest difference for me right now at home and at work is questioning if I did everything right. Did I do everything I was supposed to do to protect myself, my patients, my work family, and my kids at home. I’m confident in my skills, I’ve been doing this for 13 years. I’ve never questioned my skills before, and now it's the simple act of gowning up and off with each risk of exposure that I falter,”  said Jessica Waycaster RN. 

Some of those most at-risk providers in a hospital during the current pandemic are respiratory therapists (RTs). Treating patients in a COVID specific ICU today is like stepping onto another planet. There are no families present, IV pumps are placed in hallways to allow adjustment without entry to the room, and RTs enter each room knowing the patient has a highly contagious, serious disease.   RTs manage ventilator tubing, adjust critical ventilator settings, take arterial blood samples, and respond to cardiac arrests. Getting  assigned to a COVID ICU can feel like being asked to sweep for mines in a field with a blindfold: you’re not quite sure if there is a mine or not and you must feel your way more by instinct than by sight.  

 “Before the COVID pandemic, my job was more routine. I simply helped people who had difficulty breathing. Now, every time I put on my scrubs, I carry so much responsibility for my co-workers and my patients that my shoulders feel weighted with bricks. I don’t like wondering if this will be the day I inadvertently make a wrong decision and carry this virus to another coworker, patient, or my family.” said Angela Hayes, RRT

Some frontline workers face increased isolation even as they struggle with decreased hours, and compensation all while fighting an ever present invisible threat. Again this type of uncertainty isn’t new, but magnified during a pandemic where they now have to face the fear of a second wave of infections.

“A lot of the time we don’t know if a patient has a contagious infection like meningitis, or is an overdose victim with used needles in their clothes, or a gunshot victim that could bring more violence into the hospital. We worry about the growing pandemic and constant daily exposure that eventually adds up. But constant exposure to unidentified risks-- knowingly or not --are always there.” Graycen Clark, RN explains.

Facing the future with courage and fortitude in the face of uncertainty is what defines us. But like any injury, it takes time and the right medicine to heal.  Priscilla’s personal recovery offers so much hope.  Many aspects of national recovery seem well within reach.  But only if we are willing to continue to put the general interest above our own personal interests.

Throughout the past year, protestors have picketed the hospital where I work following major policy changes imposed by a multi-state hospital system that acquired our regional hospital system. The newly formed larger system streamlined, eliminated, or revised dozens of local practices and community services. Long time residents were angry and vented in front of the hospital, far from the daily view of the administrators making the decisions. Instead it was the healthcare workers who passed them each day. 

The first day that I drove in early to have some extra time to see Priscilia the protesters were gone. In their place, dozens of community members lined the street near the hospital with homemade signs thanking healthcare workers. Swords had been beaten into plowshares. 

Additional homemade signs thanking healthcare workers showed up near the hospital appeared lining the streets. Much like Prsicilia who improved, faced setbacks, and then improved again during those several weeks, their homemade signs and encouragement helped me think that maybe, we can replace vitriol and anger with support and inspiration.  Even as we fight the pandemic with everything we’ve got, maybe it can help heal us. Maybe things don’t have to go back to the way they were. Maybe they can be better. Maybe when the caregivers face the aftermath of moral injury supporters can rally behind them just as they do now.

These weeks of isolation in our country have amplified fears and threatened too many lives.  Without the right support, isolation can make normal tasks difficult and any adversity seem intolerable.  But together, at home or as government restrictions ease, we can recognize we are  all essential and all bound together: adept healers, anxious sufferers, and appreciative supporters.

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