Last March, in the early days of Covid-19, when cases were mostly confined to New York and a handful of other cities, I called a friend and fellow ICU doctor in Detroit. His hospital was inundated with critically ill COVID-19 patients. As he shared tips, I became fearfully aware that the work I do could kill me. But I was galvanized in my commitment to fight the virus. Then the first COVID-19 wave hit us in Rhode Island. In the coming months it rolled slowly across the country and did not stop. Wave after wave. In time every nurse, physician, respiratory therapist, pharmacist and hospital janitor in the United States found themselves awash in COVID-19. What I did not know then was how much health care would change during the pandemic, nor how much it would change me and my fellow health care workers.
In the beginning there was solidarity among the frontline workers and a shared sense of valor in our cause. Anesthesiology helped internal medicine; surgery and neurology managed cases that wouldn’t traditionally fall under their care; and emergency medicine was, as always, the tip of the spear. A grateful public turned out for us. The yard signs and 7pm cheering lifted us. We had adrenaline on our side. When the hospitals were flooded, administrators halted elective surgery and fresh reinforcements flew in from far-off places like Texas and Colorado.
To beat the virus, America needed a moonshot. We needed a massive testing campaign, universal masking, and coordinated and collective sacrifice based on a shared set of facts. What we got was rugged individualism and an undermining of science encouraged by the highest levels of our elected leadership. This, combined with a health care system better designed for profit than for public health, proved deadly for patients and demoralizing for health care workers.
By the end of March, we could already see signs that the American health care system was failing patients and relying too heavily on the goodwill of its health care workers.
It started with the system failing to protect its caregivers. Doctors and nurses reused N95 masks, if any were available, until the white linings turned dirty and brown. Desperate health care workers resorted to bandanas and trash bags. Some who spoke out were threatened or fired.
As tragic as it was predictable, a year into the pandemic a joint investigation by Kaiser Health News and the Guardian found more than 3,300 American health care workers have died of COVID-19 so far. In a third of cases, the health care workers who died had expressed a concern about inadequate PPE.
The death of health care workers only compounds the national tragedy that has left more than 460,000 Americans dead and will likely eclipse the 620,000 lives lost to the Civil War. A lack of federal leadership produced a patchwork and calamitous response. If the nation had implemented a unified plan, avoided the politicization of science, and attained mortality rates similar to Washington state, at least 220,000 fewer American would have died in the pandemic’s first year.
While health care workers fear for their own lives, and grieve the losses of their fellow workers, they are also bearing witness to previously unimaginable patient fatality rates. Few patients die of COVID-19 at home, so nearly every one of the 460,000 Americans who have died were treated by a team of health care workers. Bearing witness to so much suffering and death has put an enormous additional burden on doctors and nurses. The resulting long term psychological trauma is incalculable.
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Last summer I cared for an otherwise healthy young man who had developed respiratory failure from COVID-19. I had known him for a week in the ICU and his lungs were slowly getting worse. I looked in his eyes, as we prepared to put him on a ventilator, and told him not to worry, that we would get him through this. Three weeks later he died, alone in our ICU. I’ll never forget him or that I underestimated a foe we do not fully understand.
This scenario plays out again and again for a countless number of doctors, nurses, and other health care workers across America.
A close emergency medicine colleague of mine, who is always sharp with his clinical judgement, unflinching, and a person who embodies a child-like enjoyment in the practice of medicine recently told me, “I used to think I would work this job forever. After we get through with this pandemic, I’ve had enough.”
Now in the dead of winter, health care workers are battle-hardened and exhausted. Relief isn’t coming in from out of state because the entire nation is on fire. We’ve had some successes but mixed among them are too many losses. The losses stick with you. Nurses and doctors walk around the ER and ICU looking dazed and distant, walled off in protective numbness.
One of the most pernicious consequences of the last year is the strained relationship between clinicians and patients. It has been difficult for doctors and nurses to watch some patients turn from the cheerleading in the spring to adopting anti-science and anti-public health beliefs this fall and winter. As health care workers, our devotion to our patients gets us through the grueling education and training, endless hours, missed family events, and sleepless nights. What happens to that devotion when patients flout mask wearing and social distancing? Or when patients who are dying of COVID-19 deny that the virus even exists? When those counterfactual beliefs and choices – like refusing to wear masks – endanger frontline workers and their families, they open a crack for nihilism to creep in.
Over the next six months we must do everything we can to stop an exodus of health care workers and to make sure that we fully support those who remain. We desperately need all Americans to embrace collective action over individualism. This means universally wearing masks, practicing social distancing, ordering takeout, avoiding indoor gatherings, and getting vaccinated. Elected officials must champion science over politics in their messaging. What they say has an outsized impact upon what their constituents do. We must reject public policy where reopening commerce comes at the price of continuing the high rates of COVID-19 hospitalization. Hospital administrators, for their part, must focus on the long term health and sustainability of their most valuable resource, their health care workers. Prioritizing health care worker safety, autonomy, and reaffirming their value has never been more critical. There is nothing like walking the hospital halls to feel the effects of administrative decisions, and for understanding the profound moral and ethical dilemmas frontline workers face. The strain on the workforce is immense. Without these efforts, the damage to health care workers may be irrevocable. For too many it already is.
Dr Corl acknowledges Wendy Dean, MD, for critical assistance in developing and shaping this work. The views expressed here are those of the author.