Overwhelming volume and acuity, an alarming lack of PPE, the anguish of seeing your patients die alone, the jarring incongruence of layoffs and salary cuts - COVID-19 brings with it a major threat to your wellbeing. Your colleagues in Psychiatry want you to know you're not alone, and there are some tips to care for yourself and your team in the midst of this storm.
A usual day in the ED requires the entire spectrum of emotions as-is: compassion, joy, frustration, anger, courage, sadness, and the list goes on and on. This is even before COVID-19 changed the physical and emotional demands on you in ways you could have never imagined. It was hard to include yourself in this equation to begin with, in a world of competing priorities, let alone the one you're experiencing now.
We see you. We see the long hours, the difficult decisions, the sleeping away from your families and loved ones, the worries about getting sick, the getting sick, and the valid and even proven fears of your own mortality. We also see the anticipatory grief of those of you in the equally difficult place of waiting—of not knowing when, if, and how this pandemic will reach your hospital, your loved ones, and your communities. All that you are feeling and thinking right now is completely OK. We are giving you permission to scream, cry, laugh, yell, or simply...breathe.
Though different from the EM definition of it, when the word "trauma" is used in psychiatry, one definition used is this: Too much changing too quickly. This definition fits the current situation in health care almost exactly. Working in the ED, especially right now, only exaggerates this: You have no time, a limited ability to protect yourself, your patients, your family, and you are confronting a crisis of unprecedented impact in modern history. Whatever comes up for you, whether in named emotions, quick or harsh reactions, or somatic sensations of high stress is, first and foremost, normal. This is the way a human reacts to threat or threat prediction. We are evolutionarily made to be anxious. In acknowledging that, this article is not written to offer you a solution to the incredible situation you're bravely serving in, to minimize it, or to wrap it neatly up in some sugary and reductionist wellness cliché. Instead, we offer you a bandage for now to allow you to keep going, and help you better plan for the long-term to tend to the injuries you may sustain during this unprecedented moment.
Let's start first with the acute response, or what we can consider a psychological bandage. We want to use what we can consciously change to impact the way our nervous system may be reacting to the experience in the moment. In other words, how can we help you get through during the shift, before shift, or after shift, the heightened emotions that you are feeling? Some, but not a complete list of answers include: meditation, breathing exercises, and mindfulness. These tools are not perfect, and may perhaps seem a bit too simple or touchy-feely to you, but they work (and the evidence and data are there, too). The Army uses these practices, professional athletes use them, and many studies show they can aid in times of high emotional stress and processing that stress. This is not to say that awful events will no longer be awful, but rather that these tools may be a way to help you through it.
- Progressive Muscle Relaxation: An exercise of intentional tensing and then relaxing muscles throughout the body to de-stress the mind.
- A free, longer practice, perhaps for when you get home from your shift. A free, shorter practice, when you don't have much time. Sometimes, things like stress putty and stress balls can help with this as a similar form of tension relief and you can leave them in your locker or the dashboard of your car to help. If you want to use it as a bonding activity, you can even DIY some stress putty at home with your kids.
- Grounding Meditation: A practice of paying attention to different stimuli in one's environment rather than to thoughts, worries, hyperventilation, etc. Often used to reduce panic.
- A classic and short sense-oriented grounding meditation, one for practice in the hospital via washing your hands, or a helpful self-soothing
- Headspace is an app on your phone for this, and it is free for health care providers right now. The Calm app also has bedtime stories, which may sound cheesy, but are quite nice.
- Sometimes, more concrete practices are helpful as well, like naming all of the colors you see in the room or all of the objects of a certain color in a room, or listing your favorite cars or television shows. You might even be able to ground yourself by listing the steps to a surgery or your child's bedtime routine (They showed this on Grey's Anatomy!).
- Self-Compassion: A practice of a disposition towards oneself of kindness that one would have towards a friend in the same situation, away from a posture of judgment and censure.
- An exercise for allowing whatever emotions are coming up for you, and other exercises for cultivating self-compassion. You can even put just a positive affirmation on the mirror- or a quote you like- and that can help.
- Breathing exercises: A great tool that can be used to consciously tap into the parasympathetic nervous system.
- Find one for anxiety here and another for health care providers
- Journaling: Set a timer for 20 minutes and write down all of your worries, thoughts, or emotions and then set them aside. This can help you get them out and not have them consume you, but also put boundaries on them
As you know from your own word, acute injury—especially if repeated—can lead to a chronic problem. It is important to plan for the longer term to protect your mental health with good coping, as this is a marathon and not a sprint. We need to keep you going and your mental health is one aspect of that.
- Self-Care: This can include taking time for yourself with relaxation and bubble baths, but self-care, in its true and most uncommercialized sense, is tending to the needs you have as a mortal being living in a very human body. This means, when possible, prioritizing sleep, regular wholesome meals, and movement when you can get it. Your brain is part of your body, and thus your emotional state is impacted by what’s going on with the rest of you. In other words, your mind and body are very much interconnected (whether we sometimes like it or not). This is basic, but it is something we all need reminders to take care of, especially right now.
- Sleep: Sleep hygiene is very important. These are the best tips for trying to stay up with it. You can also consider using an app on your phone to help you with your sleep like the CBTi coach which is good and has evidence to help you with your sleep.
- Eat: It is really easy to forget to eat when you are working shifts and on your feet all day and at odd hours. Try to remember to bring snacks and prioritize food. Try to remember to hydrate.
- Exercise: Exercising is great for your mental health and wellbeing. You can still get outside and walk with social distancing, but there are a lot of online (even free!) classes being offered. Check out: Nike Training Club, Daily Burn, YogaSource, Peloton, Mile High Run Club. There are more Well-Being resources here.
- Vulnerability and connection: Vulnerability, including sharing your fears, emotions, worries, and concerns with your loved ones and friends even though it might feel terrifying actually brings you closer together. Right now with everyone feeling such heightened emotions allowing these feelings to be shared will build stronger connections between teams both at work and at home. Try to be creative and disciplined about seeking and giving support. This might mean that you make space for this and have open discussion worries or what is on everyone’s mind, or it might mean signing up for support type groups to discuss it with others (many hospitals are offering these!).
- You also need to give space to socialize in relaxing, non-COVID ways to distract yourself and there are lots of fun ways to do that, even with social distancing, including watching movies.
- Hope and Self-Efficacy (derived from disaster psychological first aid): In times of crisis, it is important to focus your attention on what you can change and to try to shift your priorities and expectations to accommodate this understanding. This might mean you have to shift what your baseline is or what you define a “good day” as, or might mean you problem solve and set achievable goals each day. But, it is always important to keep a long term perspective. You should try to practice gratitude and look to identifying and building strengths (in yourself and your team). You also really need to be kind and patient with yourself, which though hard, is essential.
Warning Signs
Just as there are things you look for in your own patients that must be ruled out or are reason for immediate alarm, mental well-being red flags exist in this way, too. These are those things to watch for over the marathon ahead of us, both in yourself and your colleagues.
- Social Withdrawal: This is a complicated one since we are all essentially isolated right now, but there are still ways to stay connected. If a person is not wanting to engage at all, this would be a warning sign.
- Coping with substances, including alcohol: It may seem that everyone is having "just one drink" after work right now. But not everyone can have just one drink and sometimes just one drink becomes 2 or 5, and is used to numb emotions and feelings and can really become an issue.
- Not sleeping or eating
- Not being able to function in day to day activities: Although our schedules are disrupted, we still have things to do and people who rely on us. If our anxiety or mood is interfering with these relationships, interactions, or plans, it is becoming worrisome
- Suicidal ideation, hopeless, wishing you never woke up or died instead of someone else:
- Crisis text line specifically for frontline providers: Text FRONTLINE to 741741
- Suicide Prevention Hotline: 800-273-8255
- Mental Health Support: Get help if you need it (or want it) and don't stop getting help if you have it. This can be therapy or medication or both. But, help is here for you. A couple of options specifically for healthcare workers right now include:
- Project Parachute: https://www.eleos.health/parachute
- Physician Support Line: physiciansupportline.com
Ultimately, this is not easy and maybe not what you signed up for, but we are grateful for your hard work and everything you are sacrificing each and every day. We are proud you are our colleagues and friends. And remember, "Vulnerability is not winning or losing; it's having the courage to show up and be seen when we have no control over the outcome. Vulnerability is not weakness; it's our greatest measure of courage." - Brene Brown, PhD
Margaret Duncan is a third-year medical student at Washington University, intending on applying into psychiatry residency in the coming year.
Jessi Gold, MD, MS, is an Assistant Professor in Psychiatry at Washington University at St. Louis. She can be found at @drjessigold on Twitter and Instagram.