key: cord-0997077-6b2dzghq
authors: Davis, Kimberly A.; Kaplan, Lewis J.
title: Out of Darkness
date: 2020-05-22
journal: Ann Surg
DOI: 10.1097/sla.0000000000004108
sha: b1e10bcc908cd8cc5d76add58d1bd2772be9a4c5
doc_id: 997077
cord_uid: 6b2dzghq

nan

A s Severe acute respiratory failure coronavirus-2 relentlessly spread across the globe, we were collectively unprepared for how the pandemic would devastate the world economy, stretch hospitals to the breaking point, and distort daily life. 1 In 2015, Microsoft founder Bill Gates opined that the world should ready itself for just such a pandemic. He suggested that the World Health Organization, in concert with individual countries, should craft medical response teams that would train in self-contained units, engage in simulated pandemic exercises, and stand ready to surge into pandemic zones to initiate care. That vision was not embraced. As this pandemic unfolded, it became clear that our disaster planning and training, often designed for mass casualty response, was inadequate to address the breadth of COVID-19. 2 Recent experience with other outbreaks -including SARS and Middle East respiratory syndrome-related coronavirussimilarly failed to prepare us as those infections demonstrated rapid lethality over a compressed time frame. By comparison, Severe acute respiratory failure coronavirus-2 is highly transmissible with illness that may persist over an extended course.

As a result, the COVID-19 pandemic has stressed our system in unanticipated ways. We are challenged to deliver supplies spanning personal protective equipment, ventilators, and therapeutics in short order and at unprecedented volume. Innovative solutions surfaced that included 3-dimensional printing of connectors and masks. Protective equipment designed for sport use was reallocated to safeguard frontline healthcare workers (HCW). Hospital systems responded to an influx of critically ill patients by shuttering many aspects of elective care, and repurposing clinical environments. Novel intensive care unit spaces arose from post-anesthesia care units, operating rooms, and acute inpatient care spaces previously used for less ill patient care. 3 When those spaces filled, tents, convention centers, and hospital ships were pressed into service as impromptu overflow sites. The Secure National Stockpile was opened to replenish depleted medications and infuse equipment such as ventilators to save lives.

The call for clinicians to aid beleaguered HCWs in overwhelmed cities like New York City was bravely met by hundreds of volunteers. The critical care community buttressed their colleagues precisely as anticipated -swiftly and selflessly. The panoply of interventions designed to rescue patients and protect HCW from viral infection is now occurring over a protracted period given the long course of care for those with critical illness. Although critical care often engenders episodes of rapid assessment, decision-making, and therapeutic intervention, it is uncommonly coupled with the concerns of personal and family safety that permeate COVID-19 care. In short, our colleagues are embattled. Unfortunately, many of the typical stress management solutions relied upon by HCWs, and the general populace, are no longer available. Social distancing, nonessential business closures, and other containment efforts have derailed the usual social interactions that revitalized many. Furthermore, the anticipated visual cues that provide insight into what people mean when they speak are constrained behind masks previously limited to the operating room and procedure suite. Perhaps most importantly, our ability to provide emotional support through touch is severely limited by requirements for personal protective equipment and safety.

Multiple reports document that HCWs across the world manifest emotional distress as anxiety, insomnia, and depression. 4 Nurses in particular bear the brunt of much of the stress of caring for COVID-19 patients. They spend more time in the room providing direct care than any other HCW. They field phone calls from loved ones distraught over both the patient in the bed and their inability to visit, particularly at the end of life. This is a potent brew for emotional distress and moral injury, which affects all care HCW. 5 Changes in how care is provided including limited room entry, closed doors, and safety precautions such as remote medication administration from intravenous pumps outside of the room further exacerbate the stress of care. All of them enforce distance between HCW and patients. That distancing may persist for some time and seem to be in sharp contradistinction to the resumption of ''normal'' healthcare operations. The impact of reengaging in elective care on an already stressed healthcare force cannot be underestimated and requires careful planning.

Taken together, chronic high stress, emotional and moral distress, and enhanced personal and family risk may lead many to question their longevity as clinicians in critical care. Perhaps not right now -when our HCWs feel deeply tied to providing life-saving care -but in the aftermath, our medical enterprise faces serious threat. Mental health and resilience is under assault. It is incumbent upon facilities and medical professional societies to carefully plan how to identify impacted individuals and rescue them. Maintaining the mental and physical health of our healthcare workforce is no small charge, but a vast task that merits focused attention coupled with thoughtful intervention. Our most precious resources are not PPE, nor therapeutics, nor ventilators. Those irreplaceable treasures are instead our nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, and all the individuals essential for our healthcare engine to function effectively. We must act now, and together, to ensure that what follows in the wake of the COVID-19 pandemic is not a legacy of devastation, but instead a pathway out of darkness.

Critical supply shortages -the need for ventilators and personal protective equipment during the Covid-19 pandemic

Facing 21st Century Public Health Threats: Our Nation's Preparedness and Response Capabilities, Part 1. Written Testimony Senate Health Education Labor and Pensions (HELP) Committee

Turning ORs into ICUs

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

The critical nature of addressing burnout prevention: results from the critical care societies collaborative's national summit and survey on prevention and management of burnout in the ICU