Sunday 12th July 2020
Figures for 11th July
UK COVID Deaths 148 / Total 44,798
James Cook Hospital – Total COVID deaths – 254
All COVID cases within South Tees Hospitals Trust – 5
James Cook Critical Care COVID cases – 1 ventilated
James Cook Critical Care non-COVID cases – 40
Now that things have settled down, I thought I would take the time to write about the impact of the initial phase of the pandemic on my colleagues and I. The surge of cases that began at the end of March affected us all in different ways, both physically and mentally. During the last three months we have been fortunate enough to have members of the Clinical Psychology Team embedded within the ICU in order to help with staff well-being. This is not our usual practice; the hospital’s Psychology service usually offers psychological support to patients and not necessarily to members of staff.
It is well-recognised that an Intensive Care stay can have powerful psychological effects on patients. There is a high incidence of adverse psychological outcomes in patients who recover following their illness and psychologists can help mitigate this. There is clearly a role for their presence within the ICU.
But why might you need a psychology service for the staff rather than the patients? Well, Intensive Care Staff are at high risk of ‘burnout’. Burnout is a colloquial term for a pathological syndrome, first described in relation to warfare nearly 50 years ago. It usually consists of three symptoms: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.
Working within Intensive Care has stresses that may not be present amongst medical and nursing staff working in the rest of the hospital. We are frequently using more technological interventions to maintain life whilst simultaneously caring for a significant number of dying patients. There is an expectation from patients, relatives, other medical staff and even amongst ourselves, that ICU doctors will be perfectionists, always able, whatever the situation, to provide a high standard of care. Dealing with patients’ families who may be upset, angry or have unrealistic treatment expectations can be very stressful. The high mortality rate in the ICU can contribute to feelings of futility and be a huge contributory factor for burnout.
The Psychology team have been present at our hand-over meetings at the end of each shift. This was to ensure that staff who may need help after a difficult shift could have someone to talk to, even if it was just an informal ‘debrief’. Many of us were perhaps initially a little self-conscious when discussing clinical events in front of a psychologist. However, pretty soon any worries about being ‘analysed’ during these meetings evaporated and everyone soon almost forgot that the psychologist was there. They became, simply, another member of the team.
The Psychologists were surprised by how calm the atmosphere was when we were particularly busy. However, they were aware that, at times we were using the handover sessions at the end of each shift to ‘offload’ and to talk through some of the problems we had encountered. They have been surprised at the reassuring, unflappable nature of many of the staff and began to realise that a lot of the difficult situations we encountered due to COVID-19 were not necessarily new to us, it was just that they were now happening continually.
Often the most difficult situations were due to the ban on hospital visiting. Communicating with families by telephone or video call has been much harder than we had initially anticipated, especially when the conversations became more and more difficult. Informing a relative that their loved one is dying is always a hard conversation to have but it is made much harder when you cannot do it face-to-face. Without the family being present, the nursing staff are often the only ones who are with the patient at the moment of death. Many of the aspects of caring for a dying patient are based around the patient’s family being present and their absence means that we have often struggled to deal with these situations.
Despite the difficult working conditions and the heightened sense of anxiety, the feeling of camaraderie within the department was palpable. The phrase ‘nothing brings people together like a crisis’ is a cliché for a reason and the sense of commitment, dedication and perseverance amongst my colleagues was to be admired. Prior to the pandemic we were a large, at times chaotic department that had lost some of the cosy feel of a smaller ICU, the sort I remember from when I first started working in Intensive Care. Dividing us up into smaller teams allowed a return of that feeling and it worked extremely well. Decision-making was streamlined and each team was quicker to deal with the difficult medical problems that COVID-19 brought. As time went on, a sense of loyalty toward team-mates blossomed.
So, how did I cope mentally with the surge of cases that we saw? I am one of the older Consultants within our department and a lot of the clinical situations that presented during the pandemic were not entirely new to me. I was able to draw upon that experience to help with the difficult decision-making and remained more objective than perhaps would have been the case had I been younger. However, I hadn’t realised how much I would be affected by the high mortality rate we saw amongst our COVID patients. As the numbers of patients dying began to rise we all struggled to remain positive. All around the country, Intensive Care staff began to celebrate success in a way that we hadn’t ever done before; the soon-to-be universal practice of applauding and cheering patients as they left ICU was testimony to that.
I found myself worrying about my patients a lot, both whilst at work and when I was at home. This was hardly surprising, given that my patients were horribly sick and more likely to die than usual. This worry may not have been helped by discussions that Nicky and I would have at home over dinner; we were both treating the same patients. One of the manifestations of this anxiety was that I began to notice that whenever I was out and about, I was looking at members of the public and subconsciously estimating their risk of death from COVID-19. It took a while before I realised that I was doing this, but one particular day it dawned on me that I was picturing every elderly person I saw, ventilated on the ICU. This wasn’t especially distressing but it clearly wasn’t a normal interaction with the population.
Despite these anxieties, I still managed to sleep pretty well. I always have slept well; if sleeping were an Olympic Sport there’s a good chance I would qualify for the national squad. I was often getting to bed late, partly through writing the blog, and partly due to the need to unwind and clear my head. However, when I did get to bed I was managing to sleep pretty well until the morning. The dehydrating effect of wearing PPE all day ended up being helpful in this regard as it meant that I no longer had to get up during the night to go to the bathroom.
The psychology team have talked about the types of behaviour that we have used to help cope with the stresses that we encountered. The black humour that they saw in abundance came as no surprise to them. It is well known that such humour can be a valuable coping strategy for people who experience traumatic events in the course of their working lives. It can contribute significantly toward resilience and is certainly a strategy that I use often. However, it is not without its drawbacks. ‘Gallows humour’ can sometimes be misinterpreted by people who do not work in such environments as callous or uncaring behaviour and can be hard for some people to come to terms with.
Of course, another way of attempting to cope with stress is to drink more. I have talked before about my increased alcohol consumption during this time. I don’t think I was drinking to the point of concern but I was certainly drinking every night in order to help me relax. In many respects, using alcohol in this way is socially acceptable, hence the fact that most of the nation appears to have drunk more during lockdown. In the longer term, of course, we all know that continuing to use alcohol in this way can lead to psychological problems of a different nature.
I have found that writing this blog has been very helpful psychologically. In some respects this has been akin to writing a diary, especially the posts that I have written when I’ve finished a shift at work. This shouldn’t have surprised me - there is good evidence that writing can help with processing information and allow for a more ‘healthy’ way of interpreting experiences, aiding reflection and creating reliable memory. There’s even a suggestion that sharing the experience with others can help.
Nicky on the other hand, has not been sleeping well. To be honest she is something of an insomniac so given the situation, she was never going to sleep soundly. She poured scorn on my suggestion that she should try staying up late whilst writing a diary and drinking whisky.
Another thing that has helped has been the support from the public. The encouragement that health-workers have received has been overwhelming and this has helped all of us perhaps more than you realise. One of the cardinal features of burnout is the feeling that you and/or your department are not accomplishing anything and that all your efforts are futile and unappreciated. Whilst I may have been embarrassed by the Clap for Carers events on Thursday nights, your enthusiasm did not go unnoticed by everyone working within the hospital.
We are now in a different phase of the pandemic. The initial surge of cases is over and we are struggling to adapt to a new environment. As I have explained before we are still wearing full PPE in our ‘sealed bubbles’ whilst on each of the ICUs and this is proving to be uncomfortable and frustrating. It hampers your ability to do anything quickly and efficiently, requires more medical and nursing staff to be present and complicates the transfer of any patient outside the ICU.
Our work pattern now involves working fewer hours than during the surge but all of us are tired. We are still working many more evenings and weekends than before and Nicky and I are worried about what this work pattern will be like once the children return to school. We both feel guilty that we have neglected our children somewhat over the past few months; they have had very little time when both of us have been present.
To be honest, Nicky and I are both also feeling somewhat deflated. Many of the positive experiences of working in such a crisis have now disappeared and whilst we now have fewer patients and less of them are dying, work remains difficult at times. Different stresses are returning as the hospital tries to get back to delivering care to non-COVID patients. Problems that were forgotten about during ‘the surge’ are now rearing their ugly heads again. The future seems very uncertain in many ways. We don’t know what work will look like in even a month’s time and none of us feel that we have seen the end of COVID-19.
The psychology team said that we would feel this way after the initial crisis was over and they were right. They have unfortunately left us now but we would very much like to establish a permanent place for them in our department. All of us feel we have benefited from their presence during the past three months.