For Dr. Joseph Herrera, the past eight weeks have seemed like a lifetime.
Herrera used to spend his days treating sports injuries as chairman of rehabilitation medicine at Mount Sinai Health System. Then the number of Covid-19 cases started to rise. Hospitals reached capacity in a matter of days as an invisible enemy stormed emergency rooms.
Herrera, a 47-year-old father of three, was deployed to the front lines—and he hasn't been the same since. He tends to patients young and old on a Covid-19 inpatient floor. The past two months have been the most challenging of his career. The work is physically grueling, but that's not what troubles him.
"I don't think anybody can ever prepare you as a physician for the amount of grief and death that's happened here during the pandemic," Herrera said. "The worst day on my watch, we had four deaths. We're running in there, running to codes, doing chest compressions to save the lives of the people we're caring for."
Far too often, nothing works.
"One of the toughest things," Herrera said, "is then calling family members who haven't seen their loved one in weeks because they haven't been allowed to come into the hospital and sharing their grief when you tell them their loved one has passed away."
He worries about his own family as well.
"My kids are 12, 10 and 6," he said. "My wife is also on the front lines; she's an anesthesiologist intubating patients."
Herrera fears he will bring home the virus. He strips down in his garage, then gets straight in the shower. He agonizes over refusing to see his mother, who had a stroke in August, as she recovers with other family members. But he wants her to live.
His fears are not unique.
Some frontline workers have been staying in hotels to protect their family. The isolation can be difficult to bear.
"There's not a single person I've talked to who's been on an inpatient unit who hasn't felt a little bit to a great deal overwhelmed by the experience," said Dr. Andrew Brotman, executive vice president and vice dean for clinical affairs and strategy at NYU Langone Health, as well as its chief clinical officer.
Although much about the novel coronavirus remains unknown, it has proved a tactical opponent that compounds stress for frontline health care workers.
"The nature of this situation is different from others because there's no clear end," Brotman said. "It's happening every single day. There is a great deal of uncertainty. The amount of death on inpatient units is about tenfold the usual amount, and the number of people who have transferred into roles they didn't previously have is very, very high. It's much like the anxiety of an active military battle."
As the number of Covid-19 patients has begun trending downward, doctors and nurses have fleeting moments to reflect on the war they've waged. The death toll has been hard to handle, and there's no time to rest.
Outsiders might think frontline health care workers will receive extended breaks after marathon shifts, but it's not that simple. Patients still need care—and workers have to get back to their everyday routine.
In recent weeks hospitals have started to bring back online some surgeries and other services that were put off to add Covid-19 capacity. Such services bring in much-needed revenue for facilities. Returning to this version of normal means transitioning doctors and nurses back to their pre-Covid-19 roles. To do so, they will have to help staff head off mental health concerns before they lead to burnout or have grave outcomes.
"The goal is to keep people as safe and supported as they can be," Brotman said, "so they stay in the battle."
Shawna Townsend, a clinical nurse leader at the Hospital for Special Surgery, oversees care for patients with underlying conditions when they have orthopedic surgery.
Townsend, 38, is used to complex patients, but the Covid-19 cases she and her team took on to help ease the strain on other hospitals were different.
"When you see a patient who is struggling to breathe because their lungs are being invaded by this virus, that's not an easy thing to see," Townsend said. "Even having a conversation is a luxury they don't have.
"We're not used to patients dying at HSS," she added.
It's been overwhelming at times. "I've cried," Townsend conceded. Talking to her team members and being there for them in return has helped.
"We want our health care workers who have had to be redeployed to the front lines to feel good physically and emotionally to go back to their prior responsibilities," said Dr. Dennis Charney, a psychiatrist and dean of the Icahn School of Medicine at Mount Sinai. "These workers are critical to providing care to so many millions of people."
Sustaining critical levels of personnel will mean getting ahead of serious mental health conditions, burnout and suicide.
"We know that post-traumatic stress disorder comes in many different forms," said Dr. Jeanie Tse, chief medical officer at the Institute for Community Living, a nonprofit behavioral health provider. "I think a lot of those folks who have seen people die without their families, and die so rapidly and in such large numbers, will have the potential to lead to the symptoms of PTSD."
That can include re-experiencing traumatic events, a numbing of emotions, a shortened sense of the future and nightmares, Tse said.
Even behavioral health care workers—particularly those in residential facilities—have experienced stressors and exposure from the crisis.
"My concern is that this is going to leave us with a group of staff members who are going to have eventually some form of PTSD," said Dr. Mark Jarrett, chief quality officer and deputy chief medical officer at Northwell Health. "If we don't try to rectify that now and there's a resurgence [of Covid-19], it will only make it worse."
Providers who are stressed, burned out and overtired can unintentionally make mistakes.
"This is as much a quality and safety issue as it is a human issue," Jarrett said.
Dr. Eric Wei, vice president and chief quality officer at New York City Health and Hospitals, agreed.
"When people were saying, 'What happens when all of your health care workers are out sick, contagious with the virus? Who's going to be standing ready at the emergency department doors, in the ICUs, to treat patients?' The same thing applies for mental health."
Wei, who has personally cared for Covid-19 patients, says he'll never be the same from a clinical or leadership perspective.
"This is definitely unprecedented in my lifetime," he said. "I know others have compared this to the HIV/AIDS epidemic. Working in the [emergency department] during this surge, there were things I never could even have dreamed of in my worst nightmares. It just felt like drinking out of a fire hose—waves and waves of sick patients coming in and a feeling of hopelessness."
He said he has received extensive training to diagnose and treat all manner of patients, but some Covid-19 patients kept getting worse and worse no matter what was done.
"They would be talking in full sentences and then, a few hours later, be intubated," Wei recalled.
He said he knows his colleagues feel the same way.
"I think my biggest fear is not just losing our health care heroes to the virus," he said, "but losing them to the emotional and psychological trauma of that."
At Health and Hospitals, a Covid-19 relief fund for frontline health care workers has raised more than $20 million. It's being used to provide clean scrubs, meals and hotels for staff members who don't feel safe returning home. It's also being used to bolster the health system's existing Helping Healers Heal program, which provides in-house services and referrals for doctors and nurses dealing with traumatic events.
Dr. Bonny Baron, an emergency department physician at Kings County Hospital, said just knowing workers from the program have been present at the facility has been comforting.
"At one point we were in the middle of a surge, and the liaison for the program just walked in with water," she recalled. "That's all we needed at that point in time."
Baron recently lost several of her longtime colleagues—whom she calls her family—to the virus in a single week.
"We just got an email from [Dr. Mitchell Katz, president and CEO of Health and Hospitals] about a program with the Department of Defense that will use combat stress-management techniques for us," she said. "People are going to suffer from PTSD. It's prolonged stress; you can't identify acutely how this is going to affect people later."
At Northwell Health, Jarrett said mental health support will be a priority of the health system's recently assembled recovery group.
Additionally, the health system has brought in volunteer staff from the University of Rochester and Intermountain Healthcare in Utah to provide relief to frontline workers.
"Having them come here was emotionally and physically what our frontline staff needed," said Dr. Nancy Kwon, vice chairwoman of the Department of Emergency Medicine at Long Island Jewish Medical Center, which is part of the Northwell system. "You can't even explain what [frontline staff] have carried on their shoulders and seen over the last two months. This has been analogous to a war that we are fighting, and it does at times feel like that."
Break rooms and outdoor spaces where doctors and nurses can rest free of their personal protective equipment for a few minutes have helped. So have the presence of psychiatrists in the emergency departments and the availability of confidential Zoom sessions.
"The support has been amazing," Kwon said, "but I think it's going to be [important to be] checking in with people and recognizing at some point what is going to be the long-term impact of all of this."
Mount Sinai has created a new center aimed at addressing the psychological impact of Covid-19 on frontline health care workers. It will focus on screening, treatment and research, the health system said.
Charney said the center is being funded by philanthropy as well as by the health system and medical school. He said it's a substantial investment but declined to provide the exact dollar amount.
New York–Presbyterian, which recently experienced the suicide of an emergency department physician who had taken a leave of absence after treating many Covid-19 patients and contracting the virus herself, has been offering virtual mental health services to all its employees at no cost. Services include screening for stress, anxiety and depression; referrals to additional resources if needed; and 24/7 access to psychiatrists.
The expanded access is expensive, said Dr. Philip Wilner, senior vice president and chief operating officer of the New York–Presbyterian Westchester Behavioral Health Center and a professor of clinical psychiatry at Weill Cornell Medicine. To date the services have been dependent on volunteerism. But there is a commitment from leadership to sustain them.
NYU Langone's efforts have included virtual team meetings and screening for those staff members who need care.
"Everything we're doing at this stage is intended to minimize stigma and build resilience but at the same time provide a safety net for the small minority of people who are so overwhelmed that they need some sort of psychiatric care," said Dr. Charles Marmar, professor and chairman of the psychiatry department at the NYU School of Medicine.
Research has found that influenza-like viruses can trigger depression. Therefore health care workers who have contracted Covid-19 themselves might be at added risk.
At SUNY Downstate Health Sciences University, Dr. Ayman Fanous, chairman of psychiatry, said efforts have focused on engaging frontline doctors and nurses and helping them deal with times when they've had to do things that run contrary to what they believe in and that they found hard to deal with.
During the current crisis, doctors and nurses have been told not to allow family members to visit patients in the hospital and in nursing homes, for example.
And often their efforts to save patients have proved futile.
"Our very best isn't necessarily reflected in the patient outcomes, and that's something we're not used to," said Dr. Mafuzur Rahman, vice chairman of the Department of Medicine and the director of palliative care at SUNY Downstate. "It's devastating."
Care during the crisis goes against what nurses have been trained to do, said Jacqueline Witter, SUNY Downstate's associate administrator and director of nursing education and research.
"Patient-centered care. That's what is embedded in our daily routine—patients and patient families," Witter said. "That's what's been taken away."
Witter, Rahman and other members of leadership have been working hard to engage frontline doctors and nurses in virtual group support meetings.
One important aspect, Witter said, is cultural background. Many of SUNY Downstate's frontline workers are from the Caribbean, like Witter, and many others are African American. Some have been hesitant to partake in psychological support—traditionally not sought in some segments of the black community—relying instead on family members and prayer.
However, it's important to involve all of the institution's frontline workers and inform them of the importance of group support meetings, Witter said. SUNY Downstate is offering one-on-one virtual support sessions with therapists and a 24/7 hotline for those feeling emotional concerns or distress.
"These are the people who are actually doing the fighting," Fanous said. "I view us as the medics to help them heal, so they can get back in the fight."
Far from over
Wilner of New York-Presbyterian pointed to a recent study from Wuhan, China—where the virus emerged—as a precautionary tale.
The study found that, when conditions started to improve, 25% of the overall workforce didn't return, Wilner said.
Hospitals will need to figure out how to rest their frontline workers, Wilner said. Doctors and nurses will have to be re-energized and ready to go back to normal work.
"We don't know when this is going to end, and that weighs very heavily on everybody," Wilner said. "This is my new normal? My new life? My new career? That is very hard to bear. That sometimes leads to despair, and we have to try and keep people from despair. That's the big challenge now: to keep people from despair."
Townsend of Hospital for Special Surgery—who hasn't seen her mother, sister or nephew since the crisis started—likened her personal experience to being on a roller coaster. She tries to brace for the downs and hold on to the ups as long as she can.
"The beautiful part is when you clap them out," she said of the send-offs for patients who have recovered, which are marked by applause from the full staff. "The patients love it."
"This was truly a war zone."
This article originally appeared in our sister publication Crain's New York Business.