“Because there will be a next one. This is a warning shot”
Emergency support services for health workers put in place during the COVID-19 pandemic are being reviewed by hospital administrators as the crisis eases to determine which ones should be retained.
So, now is the time for C-L psychiatrists to proactively take the lead in having valuable support services sustained, says Damir Huremović, MD, MPP, FAPA, FACLP, North Shore University Hospital (Northwell Health)—a health care behemoth with 23 hospitals in Metro New York.
Health care workers in pandemic outbreaks are exposed not just to increased risk for infection, but also emotional trauma and traumatic distress.
Their usually safe and controlled working environments may become overwhelmed with patient needs and, inadvertently, hotspots for transmission of the disease itself.
“Their workload is incessant and stressful,” says Dr. Huremović. “They feel they are ‘lambs to the slaughter,’ yet guilty when they are unable to save the lives of families’ loved ones. Their patients in isolation perceive that they are being stigmatized, even by health care personnel. And, alongside concern for their patients, health care workers are anxious about the safety of their own families when they have to return home into communities riddled with fear.”
Health care workers downplay symptoms of anxiety and depression, feeling that they are letting their colleagues down if they don’t stand alongside them.
It is estimated that 20% of health care workers develop traumatic stress; more have at least some symptoms of traumatic stress or depression. In China, during the COVID-19 epidemic, up to 50% of health care workers showed some such symptoms.
Paradoxically, health care workers are more protected from the virus itself because they take necessary precautions (12.2% of health care workers in the New York Downstate area contracted and survived COVID-19.)
At such times, during and after a pandemic, C-L psychiatrists need to deliver psychological first aid for clinical colleagues and actively advocate for their mental health and well-being—what Dr. Huremović describes as ‘meta-liaison’ with hospital administrators.
Dr. Huremović urged C-L psychiatrists to be advocates for health care colleagues in a live ACLP webinar Consultation-Liaison in the Era of the COVID Pandemic—now available on the ACLP website here.
“Remember that L stands for Liaison,” says Dr. Huremović. “It is next to impossible to do tele-liaison for a prolonged period. Your place is next to your colleagues whenever reasonably possible. C-L psychiatrists should consider a more active advocacy role in pandemics because there will be a next one. This is a warning shot.”
But what services should be provided for health care workers and which ones should be retained now the pandemic appears to be subsiding in parts of the US?
Another presenter in the webinar, Vera Feuer, MD, Hofstra-Northwell School of Medicine, described her own facility’s staff support services.
From daily mindfulness and yoga classes, to tranquillity tents, and cafeterias converted to mini-marts for staff, support services were introduced beyond already-established peer support groups, a 24/7 emotional support hotline, and stress first aid. “We are now working on what should be retained,” she says.
More support measures are described by ACLP members in the Academy’s Support for Medical Providers listing, part of the Academy’s COVID-19 listserv service here.
And, among the most recent Annotations, collated by members of the Academy’s Guidelines and Evidence-based Medicine Subcommittee, findings published in a Lancet article describe interventional tactics adopted in a Hunan Province hospital during the height of the epidemic to support medical staff.
Some tactics were initially met with staff resistance, such as reluctance to participate in group and individual psychological treatments offered by the crisis team.
Focus, instead, was put on issues such as lack of protective equipment, safe use of that equipment, and the need for temporary housing separate from their at-risk families. Staff were unable or unwilling to return home for fear of infecting others.
Staff also wanted training on how to manage psychological issues arising in infected patients, as well as ‘decompression’ sessions for staff through on-the-floor counselors.
C-L Psychiatry consults do not arise in a vacuum, says Franklin King, MD, Massachusetts General Hospital, who listed the Annotations extract. “Issues relating to floor acuity, unit morale, and overall team dynamics often play a significant role in the generation of the consult question and requisite needs.
“The unique set of circumstances of the COVID-19 pandemic and the needs of hospital staff will be likely to influence the consultant-consultee interaction. As such, it is important for consulting psychiatrists to be aware of these issues and, when possible, to collaborate with hospital leadership, social services, and staff to assist where appropriate in addressing staff needs.”
Questions about demoralization among health care personnel posed by attendees at the ACLP webinar were answered by panelists:
Can one of you comment on the concern about suicide in frontline health care workers like Dr. Breen [Lorna Breen, MD, New York-Presbyterian Allen Hospital.]
“It is a tragic reminder of how impossibly demanding our job can be, at the crux of trauma, exhaustion, helplessness, and moral injury. Dr. Breen’s premature death helped shed light on some of these challenges and mobilized most health care systems across the country to build programs to facilitate resilience and well-being for their staff.”
Have you incorporated the concept of ‘moral injury’ into the psychological framework of disaster?
“Moral injury in this outbreak is a considerable source of frustration and disillusionment among health care personnel, possibly with more significant fallout than from other trauma (at least, among health workers). Medical professionals tend to not process demoralization and anger very well; I fear those will be turned inwards and processed, leading to a considerable uptick in substance use, reckless behavior, and, likely, suicidality in the longer run (not during the acute phase).”