By Leah Sheppard, BSN, RN

Content warning: // Death, illness

The U.S. is entering a new phase of the COVID-19 pandemic: vaccinations are readily available, and restrictions are lifting, but cases are rapidly increasing in some areas as the Delta variant takes hold. For healthcare workers who’ve been on the frontlines of the pandemic, the shift in restrictions as well as the pockets of surging cases around the country are bringing up challenging memories and concerns for the future.

“I’m constantly on my toes,” Kaitlyn McDow, a nurse at the University of Washington Medical Center, says. “I’m always scared another wave is going to hit. Other people are saying it’s over, but it’s never going to be over for me.”

Kaitlyn, a former colleague of mine, graciously shared the story of her time in the COVID trenches with me. As I listened, I began to recognize just how intensely the pandemic has impacted frontline healthcare workers. Kaitlyn had been working as a nurse in an Intensive Care Unit (ICU) caring for patients after surgery for a year and a half when the pandemic hit. When elective surgeries were paused in March 2020, the number of patients in Kaitlyn’s ICU dwindled.1 Almost overnight, her unit was converted into a COVID ICU: rooms were outfitted with negative pressure to contain the airborne virus, and staff were told, “Get ready!”

Kaitlyn describes the COVID ICU as intense and overwhelming. Once she entered a patient’s room she remained there for hours, administering medications and working with respiratory and physical therapy. And those hours were physically uncomfortable: staff wore special gowns over their scrubs, double layers of gloves, and powered air purifying respirators – or PAPRs – over their heads. When they finally left a patient’s room, staff were drenched in sweat. They’d change out of sweat-soaked scrubs, chug water as quickly as possible and start the process over again. “How dark was your pee last night?” became a common question among nurses as they arrived for their shift.

Harder than dehydration and discomfort, though, was the human aspect of watching patients die and families lose loved ones. Since families couldn’t visit in person, they provided family photos to display in patients’ rooms. Often, patients were unrecognizable in their “before” pictures – now with tubes down their throats, overloaded with fluid, sedated, and delirious, the people Kaitlyn and her coworkers cared for were shadows of the healthy people they had been. The ICU staff carried the burden of sharing the statistics with families: if patients were unable to breath on their own and needed to be intubated, there was an 80% chance they would die.2

A remembrance board was set up with pictures of the deceased. One or two pictures joined the board weekly. By the end of the first peak of COVID in June 2020, there were over 30 photographs.3 Kaitlyn recalls thinking every day, “I hope my patient is still alive. I hope they didn’t die in the night!” Many of them remain vivid in her memory: her first COVID patient, an elderly gentleman who remained on the unit for over 6 weeks. A young 22-year-old who died a painful death less than 24 hours after arriving. An elderly couple, husband and wife, admitted together. The wife survived. Her husband did not.

As the pandemic progressed, Kaitlyn’s ICU converted back into a surgical unit, but sometimes she still cares for COVID patients. The strain of everything she’s experienced haunts her. When pandemic restrictions began lifting in Washington, a friend told her she was going to a party, and Kaitlyn was struck with dread. All those people gathering seemed like a breeding ground for the virus, and Kaitlyn describes having a mental image of all the party-goers still and dead. “It feels irrational and dramatic, but I still have so much anxiety about my family. I pray my parents never get COVID. It’s horrifying to watch someone suffocate; slowly die every day”. She says she ruminates a lot, worrying she didn’t do enough to save her patients. She has constant anxiety that it all might happen again, and that she’ll be thrust back into the same nightmarish situation. Kaitlyn feels she’s just becoming aware of all the emotions and fears she compartmentalized during the peak of COVID, and that it’s going to be a long journey working through them.

The guilt, fear, and anxiety Kaitlyn is experiencing fall well within the parameters of Post-Traumatic Stress Disorder (PTSD), as do her intrusive thoughts and fearful memories.4 5 People suffering from PTSD often have flashbacks of painful events, heightened emotional states and depressive thoughts.6 PTSD begins with an exposure to a traumatic event, described by the American Psychology Association as a disturbing experience that leads to feelings of fear and helplessness, and disrupts people’s normal behavior.7 Experts have easily classed the COVID-19 pandemic as a traumatic event, citing its exceedance, by orders of magnitude, the normal human exposure to illness and death.8 A second criteria of PTSD requires the exposure to the trauma to be either personal, or repeated and extreme exposure to other’s trauma while carrying out professional duties – which, when considering the experiences of COVID ICU nurses like Kaitlyn and other healthcare workers caring for COVID-19 patients – is highly applicable.9

Previous infectious disease outbreaks, like Severe Acute Respiratory Syndrome (SARS) and Novel Influenza A (H1N1), have a history of associated mental health crises among healthcare workers.10 A study of COVID frontline workers in 2020 found that of 1,257 doctors and nurses evaluated, 71% presented with symptoms of PTSD; to a severe level in nearly half.11 Those who suffer from PTSD are two to five times more likely to contemplate, attempt, and complete suicide.12 It is alarming to consider the long-term impact COVID-19 is likely to have on frontline healthcare workers like Kaitlyn. The numbers are staggering: there are an estimated 290,000 ICU nurses in the United States, and there are hundreds of thousands of doctors, respiratory therapists, physical therapists, and social workers, all vital to ICU patient care, who have faced horrors over the pandemic.13 14 Many thousands will carry mental scars for life.

That is not to say every frontline healthcare worker will experience PTSD, but few have been left untouched. While it’s not always clear why similar circumstances lead to PTSD in one individual but not another, the National Institute of Mental Health suspects it may be differences in past personal experiences and different coping mechanisms.15 However, even those who have not been burdened with PTSD still have experienced terrible psychological stress.

Take, for example, Dr. Jared Harwood of the Shenandoah Valley Orthopedics and Sports Medicine Clinic. Dr. Harwood, another former colleague of mine, is a Navy Reserve physician. Most of the time, he works as an orthopedic surgeon in a civilian hospital, but when the Navy Reserve asked for help with the COVID-19 crisis in spring of 2020, Dr. Harwood answered. He was deployed to the North Central Bronx Hospital in New York, as part of a 13-person medicine support team. He arrived just as New York was becoming the epicenter of the COVID-19 pandemic in the U.S., and remained there, treating COVID patients, for two and a half months.16

Dr. Harwood is not an ICU doctor. But because of the extreme needs of the pandemic, he staffed one of the COVID ICUs at North Central Bronx. Dr. Harwood describes the scene that met him as uncanny and overwhelming: the hospital was designed to hold less than 10 ICU patients, but when he arrived, there were more than 130 COVID patients present; sedated, intubated, and fighting for their lives. Rooms meant to hold one patient housed three or four. He and the other staff worked continuous rotating 12 hour shifts.

Dr. Harwood feels he was deeply impacted but not necessarily traumatized by his time on the COVID-19 frontlines. He says he feels enlightened by the experience, and that it forced him to re-evaluate previous priorities and deepen his appreciation for things he used to take for granted. “I’m actually glad I went,” he muses. “However, I have no desire to return!” Dr. Harwood made friends with other staff while he was there, and together, they adapted to the bizarre and constantly changing world they found themselves in. He adds, “I was fortunate enough to stay safe the entire time. It brought my family closer together. I don’t like that we had to go through the experience at all, but we did, and we’ve come out better on the other side.”

For Dr. Harwood, although the events he faced were terrible, they impacted him in ways more akin to psychosocial stressors than traumas. Psychosocial stressors are situations that, like traumas, create unusual or intense levels of stress that may contribute to mental disorders, illnesses, or negative behaviors.17 But unlike trauma, a psychosocial stressor does not lead to PTSD – though it can lead to anxiety, depression, and serious health issues like insomnia, irritability, hypertension, difficulty concentrating, and excessive fatigue.18 19  For COVID frontline healthcare workers like Dr. Harwood, while they may not experience the intrusive thoughts or horrific fear of PTSD, there can still be terrible repercussions with no clear end in sight.

So, what are people like Kaitlyn, and Dr. Harwood, and the thousands like them, to do? Thankfully, there are resources. For some, a network of supportive friends and family may help buoy them. Dr. Harwood, for example, says, “my family and colleagues have been very, very supportive. I feel well and adequately cared for.” Others may benefit from additional resources, like NAMI Frontline Wellness. Here, resources for Healthcare Professionals, as well as Public Safety workers, can be found, including access to professional support, peer support and peer stories from other frontline workers, and videos and articles on resiliency and healthy coping mechanisms. The Mental Health America site for COVID-19 frontline workers also provides a wealth of aid. It offers articles on topics such as emotional health while caring for dying patients and healing from the stress of COVID. Mental health screening, crisis response lines, and worksheets helping process negative emotions are available, too. And traditional therapy is always a positive resource for individuals struggling with psychosocial stressors and PTSD. Kaitlyn shares that she just started working with a therapist a couple of months ago, when she first started to recognize that she was experiencing PTSD symptoms. “I’m so happy I reached out and got some actual therapy,” she says. “It’s helping quite a lot. I don’t quite know how to feel yet, but it’s definitely helping”.

NAMI Seattle operates a mental health referral and information Helpline to connect callers to the support and resources that they need.

Call or Text: (425) 298-5315

Leah Sheppard is a nurse in the Seattle area with a passion for education around mental health. De-stigmatizing and creating awareness around mental illness and the ways in which we can find health and healing are topics she loves to explore. In her free time, Leah enjoys hiking, knitting, spending time with friends and family, and playing with her kitties.