Abbreviations and Acronyms:COVID-19 (corona virus disease), HPA (hypothalamic–pituitary–adrenal axis), IL (interleukin), PPE (personal protective equipment), PTSD (post-traumatic stress disorder)
“With that many sick people, what are we supposed to do? ...if we stop working, we’re classified as traitors. Right now we’re just waiting to die….working like this, we’re tired to exhaustion.… infection is much more horrible than it’s reported on TV…. we have 10 doctors here, and each doctor has treated more than 100 infected patients in just one day.…the patients were begging us desperately, but we couldn’t do anything. They’re dying right in front of our eyes.”Staff at Wuhan Hospital, Wuhan, China
“There have been so many deaths, and this is destroying us because we think we aren’t able to do what we are here for. The reality is, we see them dying, and we die inside, too…. I go home for a few hours at night and just collapse on the sofa. I am sleeping but not sleeping because I wake up every hour with nightmares. My husband and daughter wait for me at home. They try to talk to me, but I can’t even hear them. They ask me if I’m listening to them…but I can’t.”Carla Maestrini, Intensive Care Coordinator, Cremona, Italy
“A medical war zone…. Every day I come, what I see on a daily basis, is pain, despair, suffering and health care disparities…. We need gowns, we need gloves we need masks we need more vents…. We need psychological support as well. It's not easy coming here when you know what you're getting ready to face.… Certainly no physician wants to be put in a position where they have to triage treatments based on resource availability…. I don't really sleep that well at night…. I’m worried about my family, I worry about my safety. I worry about my colleagues. I worry about how the shift is going to be the next time I come. I worry about if a family member is going to come and be patient as well.”Arabia Mollette, Emergency Physician at Brookdale University Hospital, New York City
- Marquez M.
- Moghe M.
- Mays H.
- Yeung J.
- Gupta S.
- Luhby T.
- Moghe S.
- Chen N.
- Wright J.
- Salles A.
- Gold J.
Physiological Effects of Stress on Health and Disease
Physiologic and Clinical Impact of Emotions
- Talbot S.
- Dean W.
Unintended Nocebo Effect
- Johnson J.
- Edwards E.
- Hillyard V.
- Ely E.W.
- Ely E.W.
Implications of Psychological Milieu for Critically Ill Patients and Their Providers
- Jahangir K.
|Resilience techniques||Take advantage of diaphragmatic breathing between patient interactions. Diaphragmatic breathing involves contraction of the diaphragm, expansion of the belly, and deepening of inhalation and exhalation, which decreases the respiration frequency.|
91Breathe this way until your stress level can come down to 4/10 on a 1-10 scale with 10 being the highest.
92Diaphragmatic breathing triggers body relaxation by reversing the frontal lobes when in deep HPA activation, and normalizing noradrenergic activity in the locus coeruleus, which is increased during stress.
|Meditate to improve sleep quality,|
94mediate physiological markers of stress,
95improve a sense of well-being,
96and reduce anxiety, depression,
97and negative affectivity.
98There are many readily available public resources to help you start your own journey in this area.
|Practice self-care: Little steps are more important than “fixing” everything at once. Adequate sleep restores immune system function and can reduce infection risk/improve infection outcome.|
99Nutrition also plays a key role in multiple immune system pathways.
100Exercise improves cognitive function and memory, psychological functioning, and benefits the immune system.
|Look at green plants. It helps to restore cognitive skills, especially attention. Nature and green for most of us — especially those who are working in highly technical environment —means being away from work stress and reminds us of pleasant, relaxed times.|
|Use the APPLE technique to manage uncertainty. Healthy coping approaches involve “leaning into”, rather than “running from” anxiety. The APPLE technique stands for:|
|Recognize that it is likely that at some point we will transition from an acute to chronic crisis mentality. This can be a difficult transition because it can feel like defeat. It’s not.|
|Remind yourself daily that you are the one who is the best trained to deal with this situation, even if the challenge sometimes seems bigger than your coping potential.|
|Schedule “worry time” — write down all the things you worry about. Then decide on when you’re going to address each of the items. If you notice yourself worrying, remind yourself that you will address it at that time. Recognize that many of these anxieties are chronic in nature and will still exist after the current pandemic is over — they can be addressed again then.|
|Stay connected with your loved ones, including digital methods if necessary. Turn to your colleagues, friends, or team leader for social support — your colleagues may be having similar experiences to you. If you need help and support from others, be very clear and specific about what your needs are.|
|Zentensivism — Focus on what is relevant and important. Born in social media as a parody opposite for the professional role of the intensivist, #zentensivist has touted a voice of reason highlighting multiple iatrogenic threats that have emerged due to fear during the pandemic, and advocating for a measured, compassionate, best supportive care. In the absence of clearly effective treatments, delivery of best evidence-based resuscitation, supportive critical care practices with early de-escalation, prevention of iatrogenic complications, and appropriate palliative care approaches remain the key tools to achieve best possible outcome.|
|Brush up now on the skills you consider outside, but proximal to, your normal scope of practice. You don’t know where you may be needed.|
|Remember your bandwidth — Our working memory is only able to hold in mind 7±2 pieces of information, and so much right now is preoccupied with COVID-19. Take your time with big decisions. It might take longer to think things through if you are feeling overwhelmed. Also, consider your psychological energy levels — you will need to “fill up” with rest, rewards, and positive experiences after “emptying the tank” at work.|
|Seek information updates at specific times during the day once or twice. The sudden and near-constant stream of news reports can cause anyone to feel worried. Get the facts.|
|Maintain a positive mindset||Reflect on positive aspects of what you experienced — Actively find positive moments (teamwork, collegiality, patient not dying, supportive tweets, etc). Positive self-reflection can reduce stress,|
106whereas negative rumination (repetitive focus on symptoms of distress and the causes and consequences of one’s predicament without improving the ability to solve the problem at hand) exacerbates feelings of distress.
|Use positive self-suggestions such as “I am able and will manage it,” “I have strong reserves,” ”I am strong and quiet deep inside,” — this can increase problem solving under stress.|
108Do this particularly when you feel like being critical of yourself.
|Have a positive future image that represents what the future holds when we are over this difficult time. Recall this image in moments of especially high tension (eg, when you are back home, sitting in an armchair, drinking wine/whisky, etc).|
|Recall moments of “love” and “being loved” and treasure the times of human connection throughout the day. This may lead to an increase in central oxytocin, which reduces stress, tension, pain, and anxiety.|
109“Hearty laughter is a good way to jog internally without having to go outdoors” — Norman Cousins.
|Be proud of yourself. You are providing very important service for mankind. There is a great meaning in the work you do. As Nietzsche said, if we have our own “why” of life, we shall get along with almost any “how.”|
111and increase central oxytocin.
|Practice the golden rule||Praise your colleagues for their assistance, use the word “thank you” and “please” as frequently as you can. Lack of appreciation exacerbates work-related stress, and feeling recognized decreases psychological strain at work.|
115Feelings of gratitude can also decrease the levels of stress and burnout, improving a sense of well-being.
|Say “sorry” if you were rude or aggressive with someone (colleague, patient). Briefly, simply. This way we can prevent the accumulation of tension, resolve any potential interpersonal conflict, and replace negative unforgiving emotions with positive other-oriented emotion.|
|Techniques to reduce patient distress||1. Practice mental hygiene in parallel with physical one (during hand washing, donning/doffing). The concept of “mental hygiene” is a historically “loaded” term that refers to the mismanagement of patients,|
119but it can have a different application in the context of critical care. Clearing your mind of previous patient interactions before entering a new patient’s room is important, recognizing that a patient’s perception is primarily affect-based
|2. Promote sleep and movement within the constraints of the environment. Physical therapy can and should still happen.|
|3. Limit television news reports in patient rooms — Excessive information, and the risk for (mis)information can heighten fear or fight or flight response.|
|4. Do not cease the most basic forms of human contact and touch despite PPE.|
|5. Ask about how the patient is feeling when you can, and don’t rush to make them feel better — acknowledge the validity of difficult feelings. As Martin Gabel put it, “Don’t just do something; stand there.” And we might add, “…and listen.”|
|6. Acknowledge normalcy of their fear — try to understand the drivers of fear/anxiety.|
|7. Maintain authentic dialogue with the patient. It is still ok to talk to them, particularly about non-medical topics, their interests, or families.|
|8. Thank the patient for bearing with their isolation, honoring their altruism as we express how grateful we are for their helping others remain safe.|
|9. Understand that you may become a confidante — in select circumstances, a patient may have no one else in the twilight of life.|
|(Positive) communication||10. Use “Get to Know Me” board. Adapted from palliative care medicine,|
120it is a poster that introduces information about the patient’s routine life, including hobbies, activities, accomplishments, favorite books, movies, food, and other information (Figure 1). Even without the pandemic, vulnerability of the critically ill to the loss of respect, dignity, and anonymity is heightened
121and can result in erosion of trust in providers, communication breakdown and feeling violated.
122This simple tool can aid providers in seeing the human in the patient, someone valuable, unique, and an individual.
|11. Tell one thing about the patient as a person on rounds daily.|
|12. Positive communication and awareness of language — Say “good morning,” “sleep well,” or parting with the words, “have a nice day.” There is a sharp negative connotation if we stop saying these routine phrases to a human being who is alive (even without active contact with their surroundings, such when comatose or sedated). Use the words “please” and “thank you” as frequently as you can (eg, “Open your mouth, please…”).|
|13. Reassure when able. For the patient who is feeling lonely or fearful in COVID-19 isolation, provide communication either at necessary interval visits, or at other times via digital devices. Reassure that we are prepared to help and take care of them. Explain, even if the patient is sedated, each time a procedure or intervention is being done to help them, such as performing a nebulizer treatment, bronchoscopy, or even just turning or cleaning them. Reassure that they are safe. Reassure that they are not alone in this process.|
|Connect with team, family and friends||14. Post printed pictures of the team caring for the patient with descriptions of who they are so patients can see faces, not just the masks, and know who their team members are.|
|15. Communicate messages by families to patients, even if the patient is sedated. It’s a “delirium factory” out there due to isolation, lack of family presence and PPE; do not forget the ABCDEF bundle|
124and the importance of environment and family on patient’s mental health outcomes.
|16. Hello, my name is… — Emergency physicians have recently designed a simple poster that can help connect with the patient and their family (Figure 2).|
“I Am Not Touching That Coronavirus Patient!”.
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Grant Support: This publication was made possible by grant K23 HL146741-02 from NHLBI. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Potential Competing Interests: The authors report no potential competing interests.