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After 15 years as an emergency doctor, Anand Swaminathan was familiar with the traumatic experiences that came along with his job – treating victims of shootings, stabbings and terrible incidents of domestic violence. But it was the relentless, months-long influx of patients during the Covid-19 pandemic that made him seek therapy for the first time. “It was very difficult [on] every shift seeing that the patient you took care of the day before is still in the emergency department but is worse today than they were yesterday. The next day, they’re a little worse. And then the next day, they’re on [their] deathbed,” says Swaminathan who is an associate professor of emergency medicine at St. Joseph’s Hospital in New Jersey. With no proven drugs to prevent or treat Covid-19, mechanical ventilators were the last resort to pump oxygen into patients whose lungs were failing.
As coronavirus cases started to surge in mid-March, overwhelmed hospitals in the US raced to convert their wards into intensive-care units for patients requiring ventilation. By April 14, 1,700 critically ill patients were on ventilators across New Jersey’s hospitals. There was nothing else anyone could do for them. More than 50 per cent of people reporting to St Joseph’s Hospital had to be admitted during that time – up from the usual ten to 15 per cent – with critical patients being placed in the emergency department while they waited for ICU beds to become available. For A&E doctors like Swaminathan, who are used to treating patients for a short period of time before admitting them to hospital or sending them home for recovery, this meant watching helplessly as their Covid-19 patients deteriorated over the following weeks and months.
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Hospital staff are trained to deal with whatever comes through the door, but the Covid-19 pandemic has delivered an unprecedented shock. Doctors, nurses and paramedics live with the constant fear of contracting the virus and transmitting it to their families – about ten per cent of infections globally are among healthcare workers, according to the World Health Organisation. These fears were compounded by frustrations about the shortages of personal protective equipment (PPE) and inadequate staffing levels to care for seriously ill patients.
It is no question that all healthcare workers have rough days with poor outcomes for their patients, but during the pandemic, these days have been piling up. “The fact that I’m running these cases in my mind over and over again, isn’t necessarily a bad thing for my ability as a physician to take care of patients, but it’s probably not a great thing for my mental health,” says Swaminathan. Dealing with Covid-19 patients has added a whole new layer of stress and emotional trauma to these workers that, if left untreated, could leave a deep and lasting scar on their mental health.
Although the condition is most often associated with combat veterans, around one in 20 people have post-traumatic stress disorder (PTSD) at some point in their lives. PTSD can occur in people who have experienced or witnessed a distressing event, such as serious injury, death, natural disaster, childbirth, sexual or other violent assault. While it is not clear why some people develop the condition and others do not, the duration and severity of the trauma both influence the risk of PTSD and so does an individual’s history of mental health issues. “Being on the frontline in a pandemic would obviously involve not just one incident of seeing someone die or being put in very difficult situations and having your own life under threat, but would involve that being repeated. So that would definitely elevate the risk of developing PTSD,” says Elizabeth Woodward, an NHS psychologist. PTSD appears to be more common in doctors, nurses and paramedics, with one in six reporting symptoms.
Sufferers tend to feel anxious or frightened, even when they are not under threat. Seeing, hearing or smelling something that reminds them of the trauma can be enough to trigger nightmares and flashbacks, disrupt sleep, cause “brain fog” and create feelings of isolation, sadness or anger. Many people will have some symptoms after a traumatic event, but for most, these will go away. It’s when they persist for at least a month that PTSD is clinically diagnosed.
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Being a healthcare worker is a stressful job under normal circumstances. But the little evidence we have is suggesting that symptoms of mental health problems such as anxiety, depression and PTSD are on the rise among those dealing with Covid-19 patients every day. It is not just the rising death tolls and crushing workloads due to low staffing levels that make this an unprecedented public health emergency. As the UK’s number of new infections grew exponentially in late March, coronavirus left one in four NHS doctors off sick or in isolation because a family member or housemate was ill.
Many workers are facing ethical and personal safety dilemmas due to the lack of experience in providing palliative care, redeployment to another unit, and inadequate PPE. A nurse who specialises in bladder and bowel health in the West Midlands told WIRED she was placed within a district nurse team, without notice or training, to cover for staff that were off sick or shielding and to care for elderly and disabled people in their own homes during a time when coronavirus tests were only performed in hospitals. Although the nurses had been given appropriate PPE, the carers and family members who frequently visited the patients had not.
For Agustina Sanzone in London, the last few months have been especially difficult for her mental health. The paediatric nurse was forced to self-isolate for a month after catching the virus, at a time when the hospital she works at was flooded with coronavirus patients. “Honestly, the fact that I’ve had it helps me a little bit. It keeps me a bit more calm,” she says. It took four swabs and an antibody test to show she could safely return to work. Her ward no longer treats adult patients, but in order to prevent a Covid-19 outbreak, she has to wear full PPE when caring for children needing inhalers or any devices that could generate aerosols, even if they test negative for the virus. This makes Sanzone’s anxiety come roaring back. “When I wear it, it brings back memories of the time when this was all we knew,” she says.
Many healthcare workers will also have experienced situations that go against their values and moral beliefs and that hinder their ability to provide the same level of care for patients and their families during this crisis. Having to decide who gets one of the 120 ventilators was particularly difficult for Swaminathan’s team in New Jersey. They had to prioritise patients that were most likely to survive the illness and whose lungs would not be further damaged by the mechanical ventilation. Having to inform their family members, who were not permitted in the overstretched hospital, about the decision over the phone made the dilemmas even worse.
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Situations like these can cause moral injury, a human response that researchers have studied for years among military personnel and veterans. Unlike PTSD, moral injury is not a mental illness but rather a psychological inner conflict associated with intense feelings of guilt, shame, or loss of trust in oneself or others. Sanzone had a feeling of shame when she heard her neighbours clapping for the NHS and other frontline workers on Thursdays, knowing that her hospital colleagues were overwhelmed with work while she was off sick with Covid-19.
It feels like a betrayal when a doctor or nurse has to compromise on what they know is right in high stakes situations, such as life and death, but there just isn’t enough staff and equipment to care for patients. Should they volunteer to help out on the frontline even if they don’t have the necessary skills? What if they contract the virus and bring it home? This violation of moral code can inflict lasting emotional and psychological damage. “We know from previous work our team has done that moral injury is linked to PTSD, depression and suicidality. Whilst not predicting a tidal wave of cases, it would be inconceivable that there will be no increase in mental ill health amongst healthcare staff,” says Neil Greenberg, professor of defence mental health at King’s College London.
It is difficult to predict the pandemic’s psychological toll. Evidence from previous disease outbreaks, particularly after quarantine, indicates that close contact with infected patients is linked with mental distress. In a study of 549 hospital staff responding to the 2003 severe acute respiratory syndrome (Sars) outbreak in Beijing, China, ten per cent reported symptoms of PTSD. This figure was even higher in studies from Taiwan and Singapore that focused purely on frontline staff. A review of 59 studies – which included Middle East respiratory syndrome (Mers), Ebola as well as bird and swine flu outbreaks – pointed out that female staff, those with less work experience, or with infected family members were more prone to acute and post-traumatic stress.
It is possible that healthcare workers associate their memories from previous outbreaks with the current pandemic. Preliminary data collated during the Covid-19 outbreaks in China, Singapore, India, and Italy suggests doctors and nurses are already feeling the trauma. In China, for instance, staff reported symptoms of depression (50.4 per cent), anxiety (44.6 per cent), and insomnia (34 per cent). One of the main concerns is that they do not have the time to decompress properly after a long and tiring shift and, because of the stigma attached to mental health problems, are suffering in silence. “In many high-risk occupations, people enter into them in order to help other people. When they feel that they can’t do their job, sometimes it comes with guilt feelings,” says Talya Greene, a trauma and mental health researcher from the University of Haifa in Israel and University College London.
To make matters worse, some may be hesitant to seek mental health treatment because they fear it could have a negative impact on their careers. In the US, for instance, some licensing boards still ask applicants questions about their mental health history, which is inconsistent with the Americans With Disabilities Act (ADA) that states questions can only ask about current impairment.
Greene helped set up the Covid Trauma Response Working Group in the UK. The academic group, which includes wellbeing experts from the NHS Trusts, is examining the impacts of working on the frontline of the pandemic and has drawn up guidance on offering psychological support to what appears to be a high number of healthcare staff experiencing stress. “It’s quite common during a crisis phase that the rates of anxiety and depression-type reactions are high. The question is will these persist as we enter transition and recovery phases,” says Greene. “For healthcare workers, it may be the case that mental health issues do recover a little but there may also be a lot of anxiety around the potential second wave. Many don’t feel this is over, they feel this is the calm before the second storm.”
There is some evidence to suggest psychologists shouldn’t intervene with formal treatment during a crisis. “Debriefing” individuals immediately following a traumatic event appears to be ineffective and in some cases to actually worsen PTSD. Instead, workplaces can put in place informal support that give staff the feeling they can access help when needed and an opportunity to share experiences with their peers. The NHS launched a mental health helpline and series of online talks and group chats hosted by psychologists and psychotherapists at the end of March, with more than 6,000 staff accessing the resources to date. “We think that later down the line people may need some more individualised support, or they may need some support in a group of people who have been through what they’ve been through. So that’s maybe when we move into the more therapeutic stage, but right now, it’s just really about connection,” says Lucy Warner, chief executive of NHS Practitioner Health, which helped set up the programme.
Swaminathan feels the weekly therapy helps him deal with the sleeping problems and anxiety he has recently experienced before the start of a work shift. “I think there’s still leftover trauma from what actually happened, you know, seeing so many people dying, so many sick people with so little to offer, having your systems and your colleagues overwhelmed,” he says, adding that confronting these traumatic memories will put him in a better position to mentally cope with a second surge in coronavirus cases. “It’s not post traumatic stress disorder. The trauma is still going on. I think there is this hangover from that time, it just lingers with you.”
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