The coronavirus patient, a 75-year-old man, was dying. No family member was allowed in the room with him, only a young nurse.
In full protective gear, she dimmed the lights and put on quiet music. She freshened his pillows, dabbed his lips with moistened swabs, held his hand, spoke softly to him. He wasn’t even her patient, but everyone else was slammed.
Finally, she held an iPad close to him, so he could see the face and hear the voice of a grief-stricken relative Skyping from the hospital corridor.
After the man died, the nurse found a secluded hallway, and wept.
A few days later, she shared her anguish in a private Facebook message to Dr. Heather Farley, who directs a comprehensive staff-support program at Christiana Hospital in Newark, Del. “I’m not the kind of nurse that can act like I’m fine and that something sad didn’t just happen,” she wrote.
Medical workers like the young nurse have been celebrated as heroes for their commitment to treating desperately ill coronavirus patients. But the heroes are hurting, badly. Even as applause to honor them swells nightly from city windows, and cookies and thank-you notes arrive at hospitals, the doctors, nurses and emergency responders on the front lines of a pandemic they cannot control are battling a crushing sense of inadequacy and anxiety.
Every day they become more susceptible to post-traumatic stress, mental health experts say. And their psychological struggles could impede their ability to keep working with the intensity and focus their jobs require.
Although the causes for the suicides last month of Dr. Lorna M. Breen, the medical director of the emergency department at NewYork-Presbyterian Allen Hospital, and John Mondello, a rookie New York emergency medical technician, are unknown, the tragedies served as a devastating wake-up call about the mental health of medical workers. Even before the coronavirus pandemic, their professions were pockmarked with burnout and even suicide.
On Wednesday, the World Health Organization issued a report about the pandemic’s impact on mental health, highlighting health care workers as vulnerable. Recent studies of medical workers in China, Canada and Italy who treated Covid-19 patients found soaring rates of anxiety, depression and insomnia.
To address the ballooning problem, therapists who specialize in treating trauma are offering free sessions to medical workers and emergency responders nationwide. New York City has joined with the Defense Department to train 1,000 counselors to address the combat-like stress. Rutgers Health/RWJ Barnabas Health, a New Jersey system, just adopted a “Check You, Check Two” initiative, urging staff to attend to their own needs and touch base with two colleagues daily.
“Physicians are often very self-reliant and may not easily ask for help. In this time of crisis, with high workload and many uncertainties, this trait can add to the load that they carry internally,” said Dr. Chantal Brazeau, a psychiatrist at the Rutgers New Jersey Medical School.
Even when new Covid-19 cases and deaths begin to ebb, as they have in some places, mental health experts say the psychological pain of medical workers is likely to continue and even worsen.
“As the pandemic intensity seems to fade, so does the adrenaline. What’s left are the emotions of dealing with the trauma and stress of the many patients we cared for,” said Dr. Mark Rosenberg, the chairman of the emergency department at St. Joseph’s Health in Paterson, N.J. “There is a wave of depression, letdown, true PTSD and a feeling of not caring anymore that is coming.”
Screw all of you now I see exactly why the only thing left to do is suicide. — a Facebook post by a St. Louis paramedic in April
After Kurt Becker, a paramedic firefighter in St. Louis County, saw that post, which included a profanity-laced screed of frustration and despair over the job, he sent a copy to the man’s therapist with a note saying, “You need to check this out.”
“I’m reading this, and I’m ticking off each comment with, ‘stress marker,’ ‘stress marker,’ ‘stress marker,’ ” said Mr. Becker, who manages a 300-person union district. (The writer is in treatment and gave permission for the post to be quoted.)
The paramedics are part of a “warrior culture,” Mr. Becker said, which sees itself as a tough, invulnerable caste. Asking for help, admitting fear, is not part of their self-image.
Mr. Becker, 48, is himself the grandson of a bomber pilot and son of a Vietnam veteran. But his local has been hit by a dozen suicides since 2004, and he has become an advocate for the mental health of its members. To maintain his equilibrium, he works out and sees a therapist.
“The virus scares the hell out of our guys,” he said. “And now, when they go home to decompress, instead, they and their spouses are home schooling. The spouse has lost a job, and is at wit’s end. The kids are screaming. Let me tell you: The tension level in the crews is through the roof.”
Many besieged health care workers are exhibiting what Alynn Schmitt McManus, a St. Louis-based clinical social worker, calls “betrayal trauma.”
“They feel overwhelmed and abandoned” by fire chiefs who, she said, rarely acknowledge the newly relentless demands of the job.
Many paramedics, she added, are “aggressive and depressed. They are so committed to the work, they are such good human beings, but they feel so compromised now.”
Brendan, who asked for his last name to be withheld to protect his privacy, is a 24-year-old paramedic firefighter who works 48-hour shifts on the tough north side of St. Louis. His unit has been so busy running calls that he goes for long stretches without showering, eating or sleeping. He is terrified he might infect his fiancée and their daughter.
“We got a letter from our chief saying that there’s a national shortage of gloves, gowns, masks and goggles because the public is taking them,” he said. “Then we walk into Walmart and see that 90 percent of the people have better masks than we do.”
With no end in sight to the crisis, Brendan sought out a therapist.
“We are a lot quicker to be angry with each other,” he said. “Any little thing sends us over the edge. But among the older guys in their late 30s and 40s, it’s not OK to talk about things. So all anyone talks about is alcohol.”
“They were coming in very sick and deteriorating so fast. I was carrying a lot inside me, and I was very sad when I came home. I was feeling like I wasn’t doing a good job. My mother-in-law is a nurse, and she saw I needed help so she connected me with a therapist.” — Kristina, a nurse at Long Island Jewish Medical Center in Queens
Therapists around the country, many affiliated with the Trauma Recovery Network, which includes a large New York team, have been lining up to offer free treatment to medical workers. But the number of requests for help has been modest.
“People are nervous that if they pause to get treatment, they’ll crash, ”said Karen Alter-Reid, a psychologist and the founder of the Fairfield County Trauma Response Team in Connecticut, who has treated disaster-relief workers at school shootings and hurricanes.
The reasons to offer front-line workers specialized trauma therapy now are both to forestall destructive symptoms from settling in long-term, and to patch up depleted people so they can keep doing their jobs with the intensity demanded of them.
Since mid-March, Dr. Alter-Reid’s group has been treating dozens of emergency medical technicians, doctors and nurses. What distinguishes this pandemic as a traumatic experience, she said, is that no one knows when it will end, which protracts anxiety.
Medical teams, she noted, keenly miss the familial, visceral contact. They are used to hugs, backslaps, and sharing beers after a rough shift. Now, safety strictures have shut all that down.
Through Zoom group therapy, the crews have been regaining some semblance of solidarity as they unburden with each other, unmasked, through a computer screen, hearing everyone talk about similar struggles: Living away from families, to keep them safe. The smell of disinfectant in their clothes and hair. The clumsy haz-mat gear.
As they tap, which can sound like group drumming, she asks them to recall a challenging case when they each prevailed, and to share it.
Through these sessions, she tries to help them subdue memories of fear, failure and death so they can summon their innate resilience: Remember what you can do.
I have nightmares that I won’t have my P.P.E. I worry about my patients, my co-workers, my family, myself. I can’t turn my brain off. — Christina Burke, an I.C.U. nurse at Christiana Hospital, Newark, Del.
A nagging detail sticks in Christina Burke’s mind like a burr. Not only is hers the last face that patients see before they die, but because of her mandatory mask, all they glimpse are her eyes.
Her identity as a compassionate nurse feels diminished. She longs to lift up her mask and reveal her full self to patients.
At 24, Ms. Burke has already worked in an intensive care unit for three years. She has loved the connections she made with patients and their families, but those experiences are now largely gone.
“I can’t imagine one of my relatives on their last breath with a stranger,” said Ms. Burke, who is close to her own family but hasn’t been able to visit them for two months.
One recent day, overcome with sleeplessness and despondency, she contacted Bridget Ryan, a member of the hospital’s peer support program. In Ms. Ryan’s office, she tearfully unloaded.
A March study in JAMA Psychiatry looked at the psychological impact of the epidemic on health care workers in 34 Chinese hospitals, reporting that nurses, especially women, carried the heaviest burdens. They had elevated rates of anxiety, depression and insomnia.
The prevalence of burnout and suicide among medical professionals has been widely studied. As the pandemic invaded the West Coast earlier this year, Stanford psychologists gathered focus groups in their medical system to explore how to shore up mental health.
Researchers flagged workers’ limited capacity to manage Covid-19; their fears of contaminating family members; the moral code-bending decisions about when to use limited, life-saving resources. But much distress could be headed off if hospital leadership created a proactive, supportive culture that included ways for workers to express concerns and feel heard, the researchers wrote in JAMA.
ChristianaCare, a four-state health system, began assembling such a protocol five years ago. The program provides group support and daily inspirational texts. Twice a week, doctors and staff meet senior leaders. It set up designated “oasis” rooms, outfitted with low lights, massage chairs and meditation materials, where stressed workers take a breather.
“We’re trying to provide them with psychological first aid,” said Dr. Farley, an emergency medicine physician who directs ChristianaCare’s Center for WorkLife Wellbeing.
Peer counselors are quickly available. “No one else understands what we’re going through,” Ms. Burke, the I.C.U. nurse, said. “It doesn’t sound like much, but that program has changed the world for us.”
At the end of her meeting with Ms. Ryan, the two women, both in surgical masks, shared a social-distance-defying hug. Ms. Burke said she emerged refreshed. For the first time in two months, she slept through the night.
To address safety fears, ChristianaCare offers disposable scrubs, which workers tear off at the end of a shift. It also has a gratitude program, in which former patients return to thank their healers. At a time when so many Covid-19 patients are dying, such exchanges, said Dr. Farley, reconnect demoralized staff to “why we do what we do.”
Dr. Farley and her team check on hospital crews, pushing carts loaded with hand lotion, anti-fog lens cleaner, protein bars, chocolate and solace.
Every time, Dr. Farley said, “There is someone crying with me, and it’s 3 a.m. They’re exhausted. They need this.”
I see all these people coming in to the hospital now who are really sick, and I’m wondering, could this be me one day? There are a lot of unknowns. And the anxiety is amplified, knowing what happened in my household. — Dr. Andrew Cohen, an emergency medicine physician at St. Joseph’s University Medical Center, Paterson, N.J.
When Dr. Andrew Cohen, 45, is working his shift at the hospital’s emergency department, he is fine. He has the thick emotional skin characteristic of his high-octane profession. He dons his gear, turns his adrenaline up to a quiet, steady hum and focuses on saving lives.
But hours before the shift starts, he becomes foggy, anxious, hesitant. And as soon as it ends, he performs a cleansing ritual that even he labels “over the top.” That is because he has discovered, in a brutal manner, that he cannot leave the job behind.
For nearly a decade, Dr. Cohen and his wife shared their home with her parents, a practicing pulmonologist and a retired nurse, who often babysat for the Cohens’ children, now 8 and 11. But in March, both in-laws became ill with Covid-19 and were admitted to the hospital within a day of each other.
Dr. Cohen’s mother-in-law, Sharon Sakowitz, 74, died first.
On the day of her funeral, the hospital called the Cohens: now the father-in-law’s organs were shutting down. The Cohens rushed to the hospital. Dr. Barry Sakowitz, 75, died that morning. A few hours later, they buried Mrs. Sakowitz.
Still mourning, Dr. Cohen wonders, “Did I bring this virus into my house?” As he prepares to go to work, “My son says, ‘Daddy, be very, very careful,’ and I know what he’s thinking.”
The guilt threatens to swamp him. What if he is the third person in this household to die?
After the shift, Dr. Cohen photocopies his notes, so there’s no risk he leaves with paper that might have coronavirus on it. He cleans his stethoscope, pens, goggles, face shield and the bottom of his sneakers with antimicrobial wipes. He does a surgical hand wash, up to his elbows.
He changes into a clean set of scrubs, putting the dirty ones in a plastic bag, and walks through the hospital parking lot. Sitting in his car, he sprays the bottom of his shoes with Lysol.
At home, he removes his sneakers and scrubs, leaving them in a box in the garage, and heads to the shower. Only after will he allow himself to embrace his family.
How long will Dr. Cohen march through this meticulous ritual? When will fear loosen its grip?
“We’ve always been told to suck it up and move on,” he said. He wonders: When his own emotional crash comes, when colleagues start unraveling, “Will there be people there to help us?”