Friday, May 1, 2020

The World Needs To Be Ready

Lorna Breen, MD, Emergency Room Medical Director
New York Presbyterian Allen Hospital

This traumatic episode in history, on a massive scale, will be studied for years to come. We know that after trauma comes the post-traumatic episodes and the world needs to be ready to help those who will need to be mentally supported once the worst is behind us.

― Aysha Taryam

Those of us with an understanding of Post Traumatic Stress Disorder (PTSD) who've been following the news (especially that coming out of Italy and New York) are likely less surprised that Lorna Breen,  a successful ER doctor in New York, died by suicide a few days ago. We are no less heartbroken, but less surprised because we could see this brewing. For those serving on the front lines of the COVID-19 pandemic, there is a perfect combination of the circumstances that lead to PTSD. 

Last month when I first read about what was happening in Italian hospitals, I shuddered. The overcrowding, the lack of beds, supplies, and medical personnel. And the number of people dying from this virus, despite heroic attempts to keep them alive. Doctors were often put in the agonizing position of having to determine who would receive lifesaving measures, and who would not. 

Most doctors go into their field in order to save lives. The Hippocratic Oath, the most basic tenet for medical doctors, states first: do no harm. But here, they were having to decide who they would let (likely) die in order to provide services to someone else. Having to make that type of decision flies in the face of 'do no harm.' This ethical bind alone will shake even the most stoic of medical personnel.

Looking at the causitive factors of PTSD, we can not deny that a pandemic the nature and scale of COVID-19 is going to have a lasting effect on hundreds of thousands of people - if not more. Some have called this pandemic 'the invisible war', Without going into the politics of who said it or why - it seems to be an apt term. Now consider that r
esearch on PTSD has shown that it is caused by certain circumstantial elements. One of the most common is a person's sense of helplessness when experiencing/witnessing a life-threatening or fatal event.

Children get PTSD from traumatic events (especially long term neglect or abuse) because inherently, they are without recourse when it comes to stopping the situation. Those who are physically, sexually, or emotionally abused/assualted are also often victims of PTSD. And for military troops in combat, PTSD runs rampant. In all of the above cases, we can see that a common thread is feeling as though there is a terrifying lack control over a traumatic situation.

Another factor in the likelihood of developing PTSD has to do with a perceived sense of responsibility. Loss that results in survivors guilt has a profound impact on the person suffering. This type of guilt and shame is a significant driving force in the development of PTSD.

For front line personnel in the areas hardest hit by this pandemic, in order to work, their psychological emotions are often in freeze mode. Physiologically they are inundated with a constant stream of stress hormones, specifically adrenaline and cortisol. And while both adrenaline and cortisol serve a purpose, long term exposure can be perilous to physical and mental health. When this happens, the deck for a healthy trauma response is stacked against a person.

If you are thinking that medical personnel should be trained to mentally/emotionally handle this type of trauma and loss, thinking along those lines is both dismissive and dangerously mistaken. Even prior to this pandemic, in the United States doctors die by suicide over twice as often as those in the general population. In the case of the armed forces, military medics represent a significant portion of those who die by suicide. More concerning are studies that have shown that among first responders,  those who indicated being regularly pushed to work past exhaustion and burnout are significantly more likely to die by suicide than their counterparts.

In the communities hardest hit by this virus, the medical personnel who are managing the sickest of those diagnosed with COVID-19 feel helpless when it comes to managing a novel coronavirus with no significantly effective treatment yet available. While many are having to confront the most brutal aspects of this virus, over and over again - they also feel the strain of an expectation that they should be able to comfort and heal patients. Combined, we have the perfect stew for developing a PTSD that leads to suicidality.

How do we help the health care professionals who are in this situation? The first thing to do is to acknowledge that there is very real possibility they are dealing with PTSD and recognize that suicidal ideation can be one of the symptoms of PTSD.

Recognize the increased risk factors, and go from there. Learn the warning signs of suicidal ideation, and learn what to do if you are concerned someone is suicidal.

Treat doctors, nurses, and hospital staff with kindness and caring, always. These are very frustrating times for all of us. Our entire world is dealing with the stress, inconvenience, and pain around this pandemic. If you have feelings of frustration around social distancing, shelter in place mandates, or other pandemic control practices - medical personnel are not the people to take these frustrations out on. Do what you can to support your neighbors and friends who are working in the medical/hospital/emergency services field. Reach out, text, or make a phone call. Ask if you can have a meal delivered to them at home or at work. Communities that are sending lunches and dinners to entire emergency rooms and/or intensive care units, are doing a good job of letting the staff know that they are seen and appreciated. Equally, when people are coming together to make noise to celebrate their medical personnel (virtually at a certain time of day, or in person during shift changes, etc.) there is a profound benefit. When a person feels as if they are seen, appreciated, and cared for, they feel less alone and helpless.

We are confronted with enough loss of life when it comes to COVID-19. Let's not let suicide lend to additional casualties. The world needs to be ready to support the first responders in this invisible war. So, do this today. Tell someone on the front lines that you care, and that you appreciate everything they do. Sometimes one measure of kindness can be the difference between despair and the ability to go on another day.