Doctors Want Masks, Not Wellness Modules
Healthcare workers are distracted by worry about shortages of PPE.
The stress is unbelievable, say healthcare workers on the frontlines of the coronavirus outbreak. COVID-19 has brought unprecendented suffering, and teams are trying to peform under extraordinary levels of stress. But as doctors and nurses are increasinlgy unable to protect themselves with personal protective equipment like masks and gowns, job performance may suffer.
Doctors are getting sick.
Dr. Nicole Battaglioli, Assistant Professor of Emergency Medicine at Emory, is an ER attending at Grady Hospital in downtown Atlanta. During a shift, she was pulled to see the “COVID screeners,” patients who had been flagged by the triage nurse for possible infection with COVID-19.
She did her best to keep her distance. The current guidance is that if both patients and doctor wear surgical masks, the doctor is protected from exposure. “I found myself in a basic surgical mask. You see people coming in and they’re given a mask and it’s like half on their face, under their nose and falling down. You have to keep reminding them, ‘You know you can’t take your mask off while you talk to me. That’s the purpose of the mask, you have to leave it on.’”
A few days later, Dr. Battaglioli developed symptoms and was quarantined at home. She developed sore throat, chest tightness, cough and shortness of breath, all symptoms that characterize infection with COVID-19. Her fatigue was impressive. “This fatigue and shortness of breath reminded me of like the worst parts of first and third trimester pregnancy. It was fatigue like I could sleep forever,” she said. But the shortness of breath surprised her most, “You climb a flight of stairs and wow.”
When she considers her return to work she says, “I think many have shared the sentiment that we have never been so afraid of our own safety to go to work.” She repeated a fundamental teaching of emergency medicine, “There is no emergency if you’re not prepared.” It means you don’t enter the emergency until you are prepared. She always makes sure her team has their protective equipment on before working on a patient, as a matter of course. “You would never expect a surgeon to operate without gloves on. They don’t just go in there with their bare hands and do whatever.”
Performance is impaired when people feel unsafe.
Feeling under threat is a problem because it distracts, creating an attentional bias toward information about the threat. Normally, that’s a tool doctors use, directing attention toward the threat to the patient. But what happens when the doctor feels their own life is threatened? As their attention is pulled toward the threat, it takes tremendous energy to redirect it to problem-solving for the patient.
Not only does lack of personal safety distract, it reduces problem-solving ability. Intense stress decreases cognitive flexibility, which is essential for decision-making, problem-solving and multi-tasking. All of these skills are irreplaceable in the setting of a pandemic response. Health care workers must move fast, keep track of details on multiple patients and manage a constantly shifting clinical situation in multiple patients.
More specifically, performance suffers because “ worry interferes with the transmission of signal from action-monitoring to post-error adjustments, which leads to unimproved behavioral performance.” In other words, worried workers don’t learn from their experience or their mistakes. Yet, in a the setting of a pandemic with a new virus whose treatment we don’t yet fully understand, learning from experience is essential.
The desire for safety is nothing new.
During the medieval period in the West, plague doctors had their own version of personal protective equipment. Their bird shaped masks and full coverage gowns are now popular at costume parties.
Medieval people did many things to protect themselves from disease. According to Professor Jennifer McNabb, Department Head of History at the University of Northern Iowa, people believed pilgrim badges and relics from holy shrines warded off contagion.
But it was the monastic orders who did most of the sick care. Jean de Venette, a Carmelite friar wrote that “a healthy person who visited the sick hardly ever escaped death. In many towns and villages the result was that cowardly priests took themselves off… The saintly sisters of the Hôtel Dieu, not fearing death, worked… A great number of sisters were called to a new life by death and now rest, it is piously believed, with Christ.”
“Isn’t it amazing and chilling? The plague was considered a path to martyrdom for the pious,” McNabb commented.
Why don’t healthcare workers have equipment?
Iraq war veteran and former marine gunner Matthew Groth, now an ICU nurse, calls the fact that we don’t have enough PPE a “head scratcher.” He feels let down by the national leadership. “I don’t understand how nobody could have semi-prepared for this. You know, you guys could have seen this coming and up some production. You could see the problems China was having.”
He’s not the fearful type. “This situation doesn’t overwhelm me, what I saw in combat was so much worse. I’m not feeling anxious.” He explained the the marine corps trained him to be a “bullet sponge,” but they also taught him that team safety is critical to a successful mission.
His reaction to the idea of using a bandana or wearing the same mask for a week? “That’s a terrible idea. You’re just staring down the barrel of a rifle.”
The announcement that government restrictions on the use of construction N95 masks for healthcare were lifted, brings small relief. With rates of COVID-19 rising daily, it will take precious time for those supplies to reach the health care workers who need them now. Based on the projected numbers, that supply will still fall short.
There is real concern that healthcare workers can’t sustain the supernormal performance levels required by the COVID-19 pandemic when they feel unsafe. The obvious solution is to make them feel safer. “I think the system is failing us,” says Dr. Darria Long Gillespie. “There’s so much talk of wellness and we are given more modules on wellness. The reality is this is just giving me more work. So how about you take those funds and redirect them?”
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Originally published at https://www.forbes.com.