This Is Our Fire, This Is Our Inferno
The COVID-19 pandemic poses unique challenges to healthcare workers.
Posted Apr 26, 2020
“People in the medical field shouldn’t complain because they knew what they signed up for.”
For most healthcare workers providing acute care on the frontlines during the COVID-19 pandemic, this and similar sentiments seemingly undercut the fear, grief, and incredible stress many are feeling. Yes, we are trained to fight this type of disaster, however, the current pandemic has placed frontline healthcare workers and staff in fear-inducing, unpredictable, chaotic, and heartbreaking situations and has radically shifted the way we provide care and may lead to lasting changes.
“The flood gates have opened.”
The sheer number and rapidity with which COVID-19 patients present to the hospital, develop critical illness, and pass away is something most healthcare providers have never experienced. Most healthcare workers involved in the care of patients in the critical care units have experienced unexpected patient deaths and while often difficult to process, these episodes are typically few and far between. This allows most practitioners the opportunity to process such experiences before the next such episode occurs.
This end-of-life process typically involves multiple face-to-face discussions between team members and the patient’s family members along the way. This process is humanizing and often cathartic, allowing team members the opportunity to prepare for these unfortunate outcomes. Now we are confronted with losing multiple patients with generally limited time to process these events before the next begins.
Additionally, due to how easily the virus can spread within a hospital setting, patient visitation has been extremely limited or even eliminated, which while necessary, discussing these situations with patient’s families over the phone as compared to at the patient’s bedside is daunting and heartbreaking.
“It's always in the back of your head — will I bring this home to my family, to my children?”
The COVID-19 situation presents a very unique problem in that each COVID-19 patient represents an immediate risk to each healthcare worker they contact. When caring for a patient with terminal cancer, we often reflect on the fact that “this could happen to me one day,” but there is no chance that my interaction with that patient will lead me to develop cancer. Even with other communicable diseases like the flu, nearly all of us in the healthcare field are immunized year-after-year, building up some degree of immunity and providing some degree of protection. The COVID-19 situation is quite different as this is a novel or new virus strain and almost no one will have any meaningful protection. And while only 1-2% of patients that have COVID-19 will pass away as a result, this chance alone induces significant fear.
“It only takes one mistake.”
We have developed clear and detailed guidelines for how to protect ourselves when taking care of these patients, but the process of putting on and taking off protective equipment is actually complicated and must be done with great care each and every time you enter or exit a patient’s room. This requires constant vigilance and can be quite draining day after day, week after week. We have already seen healthcare workers who have died as a result of COVID-19, which never escapes your mind. Additionally, this creates a significant barrier to taking care of patients, which is again quite demoralizing. Imagine an ICU nurse who enters and exits a patient’s room probably on average 10 times an hour. Making a mistake one of those 10 times can put yourself, your colleagues, other patients, and your family potentially at risk for getting COVID-19.
“Are we going to have to choose who gets care — who lives or dies?”
Finally, and perhaps most significantly, is the potential lack of resources. This ranges from a lack of providers (nurses, physicians, respiratory therapists, pharmacists, nutritionists, custodial and engineering services, patient transporters, laundry services, meal services, etc), to a lack of equipment and supplies (ventilators, ventilator supplies, IV tubing, screening tests, nasal swabs) to a lack of personal protective equipment (masks, gowns, gloves). This is anxiety-provoking for many reasons. Obviously, this causes concern about not being able to care appropriately for our patients or protect ourselves, but more importantly, that at some point we, as a healthcare team, are going to have to practice rationed care — in effect deciding who will receive life-sustaining therapy and who will not.
The only area of medicine where we have experience with this is the world of transplant, where such decisions regarding who will get an organ and who won’t are decided by large panels of experts, in which no particular individual has to shoulder the blame for those who do not receive organs. Unfortunately, with COVID-19, these decisions are falling on the shoulders of much smaller groups of physicians who have less experience making such decisions.
“This is our fire. This is our inferno.”
The COVID-19 pandemic has not occurred in isolation. The patients we would normally see for other medical problems in the hospital and ICUs are still being admitted and these patients must be cared for as well. And for every healthcare worker that gets quarantined, someone must take their place. This “next man up” approach means people who don’t have specialized training in critical care may need to step in. There is no shelter-in-place for healthcare workers, just as there is no shelter-in-place for police during riots or for fire personnel during fires. This is our fire. This is our inferno. This certainly confounds the ever-present issue of burnout that pervades the medical community.
“We cannot shelter-in-place so you need to.”
The primary concern is not the fact that we have to care for patients with COVID-19 — this is the profession we chose — but rather the rate at which patients are presenting to the hospital and ICUs. This is the critical factor, and why physical distancing is so important. Relaxing the public health measures that have allowed us to slow this pandemic must be done systematically and guided by data so that we can continue taking care of these patients with a degree of order and sanity. Please don’t pour more gasoline on our fire.