The COMEBACK Is Always Stronger Than The SETBACK!

It’s Time to Air Our Dirty Laundry: Moms Who Are Working on The Front Lines.

I am asking for all of you to take a deep look into our current situation of COVID-19. We need a REAL conversation regarding how we will re-structure within our current work force in emergency medicine. We will ALL need to come to the table on this one to develop an action plan on how we will continue. This needs to be a united voice. We must consider all populations that comprise our work force. The older clinicians, the younger and unexperienced clinicians, and the working parents who must teach distanced learning are a few to consider. We also need to consider the immunocompromised (such as one with lupus), those taking care of their own parents in their homes, those who are going through chemotherapy as well as the other tough life events such as a divorce, the loss of a loved one, and all the stressors that are managed once our shift is done.

I know that the last few months have not been easy on any of us. I know that we have been tested in ways we did not imagine for 2020. First, it was only the whisperings of a “virus”. Sure, we have been through this before. HIV, MERS, SARS, and now it is COVID-19. Even the flu of 1918 compares rather well to the situation our nation now is facing. This entire predicament rapidly shifted from back burner conversation and murmurs to front page daily news. COVID-19 is now standing center stage in my home, now in our units of the emergency department, and affecting all aspects of our lives. Many of us are facing some of the greatest challenges in medicine in our lifetime.

I can compare this trauma, a pandemic, to other traumas. Because many of us do not realize, this is trauma. Repeated trauma. For those of us working in the medical community, even those who have done this for years, these times are rattling. We, the ones in emergency medicine, who aren’t easily flustered, who show up to battle for every shift, staying late or coming in early, we have been shaken. I can only speak to my personal testament of trauma. But this is not my first ride in a rodeo called disaster.

In August of 2005, I was an upcoming second year resident, just finishing my intern year, when Hurricane Katrina blew in from the Gulf. I was called into shift on a “Code Grey” for a category 5 Hurricane to work at Tulane Hospital. I was caring for patients when others ran away. I was working in a hospital while its facilities lost power, backup generators failed, flooding occurred, with gas fires, sniper fire, looting, and loss of life. I watched the city of New Orleans flood, while being stuck inside a hospital without power or water for several days. I was stuck living and sleeping on a garage rooftop, evacuating patients, and caring for many who were in dire conditions. I was rescued out by a military helicopter, known as a chinook on day 6, after all the patients had been evacuated.

I have also lived through the death of my brother, who was brought into the same hospital where I was faculty. I had to face my colleagues as a family member with a Level 1 Trauma Activation on a Saturday night when he did not survive his motorcycle crash. We in emergency medicine are a tough breed. But these traumas occurred acutely, with the ability to process and heal as the timeframe was limited. COVID-19 is ongoing and will remain that way. We are resilient and we are strong. Many of us have seen the face of trauma and disaster, so why, why is COVID-19 so difficult on us all in emergency medicine? I will answer this from an angle you may not have considered, but I will answer this as a mother who works as a pediatric emergency medicine physician.

The reason is this, the lesson of COVID-19 has a difficult and silent heaviness we must bear. It is a continued trauma. It is affecting us ALL. This global pandemic, by definition spans worldwide. And no one’s world has gone without shake. No one has been spared. Economically, physically, emotionally, and mentally, it is taking its toll. You may have been sick, or a family member, or lost a patient, or a parent. It is quite literally everywhere.

Personal traumas daily have been repeated. We put on our masks, all our gear, and we suit up to fight this virus. We have dealt with the discomforts of wearing our masks, glasses fogging, ears burning, as well as all the wear and tear on our faces. We have struggled with the beehive suits (CAPR and PAPR’s). The wipe down of our areas. The dehydration, hunger, and discomforts of daily N-95 use with donning and doffing. Teaching new airway protocols, creating negative pressure pathways, and discovering ways to combat aerosolized generating procedures.

Thankfully, my institution was able to purchase top line equipment to be prepared when the talk of not enough PPE was top news. I know in other institutions; this was not the case. We saw people fired for speaking up regarding this. We continue to read the stories of the hard-hit areas, monitoring social media, staying up to date on all of the literature, and following the COVID-19 list-serves. We have stayed on top of this for months. We are counseling our friends, counseling our neighbors, and our families to keep them up to speed with the progress and management of COVID-19. We are encouraging masks and social distancing, which gets more difficult with each passing day.

But while I am showing up in other areas for duty, I leave behind two small boys. Two boys I was put on this earth to protect. This is what I want others to understand. I do not mind the sacrifice. I love hard work, and I love doing what I do for patients. But while we are out saving the day for others, we need a balanced response to our cry for help as parents.

We have made an incredible oath to take care of patients. Compassion and caring are what we do in medicine. We have dedicated our lives to this mantra. Many of us have given up our 20’s and 30’s studying, working, with intense training to master skill sets to serve others (while we were accruing loads of financial debt). We have prepped for this. We are ready. We are dedicated and devoted to the “patient”, whomever that may be. But now, more than ever, this calling to serve on the front lines with a virus that has taken so many lives, has left an internal dialogue that I have never faced. It is as though an internal boundary has been crossed. My family or my patients? I have always had both, and never saw them competing. But now I do, and this struggle is ongoing. Those of us living on the frontlines have continued fear that we will bring this virus home. Fear that our significant others may get sick, or worse, that our children could be infected and may not be part of the lucky who recover unscathed. This is terrifying and it is real fear.

I have spoken to many health care workers who are all feeling this incredible burden lying on their shoulders. I think the cartoon depictions of the physician who has the world on their back could not bear more truth. Now consider the physician parents: They also should be depicted putting out a fire, while pedaling a tricycle, doing a puzzle, while prepping a nutritious meal, and monitoring a first-grade zoom class.

This is affecting us all in healthcare. Not only are the physicians being taxed with extra stressors, but all who work the long hours such as our nurses, medics, respiratory therapists, and all on the front lines. Think of our trainees who may have just entered their careers in emergency medicine as well as their families. The medical students and the college students who desire to work in clinical health care fields.

But let it marinate, this idea of full-time physicians and all health care workers who are also parents. It comes in the changes we had to quickly digest without much choice, and it was survival. I am talking about the division of labor in our homes and our pressures to continue the fight at work, many falling in most homes to the mothers. It is the laundry, the groceries and constant meal prep, the daily clean up and dishes, each bedtime, changing diapers, tantrums, and now we add in classes on a distanced learning escapade? The obvious hardship for most was the school shutdowns and the homework expectations. Children will be home 24-7, without any real breaks. But the adults? We will still be working. Holidays, weekends, and night shifts as the emergency room is never closed. Are we really wondering why some working healthcare parents cracked? We were still asked to show up to work, some teaching if in academics, and some of us working extra for those that were pulled off schedules or quarantined. The day and night shift with kids, and teaching was living a personal circadian hell. And, I know I am one of the lucky ones. My household has two working parents who can feed our family, who have access to computers, and all that is needed to thrive.

Not only did schools shut down, but many of us had daycares shut down. Others who had the financial means, may have hired help to cope with these changes such as a nanny, babysitter, or tutor. Even those with some help had to examine even the risk in that undertaking. Many were younger (maybe in school themselves being encouraged to return home) or older and in fear of infection. Some were suddenly no longer able to do the job if they had been previously employed. Others who may have been able to remain employed, may have wondered if they even wanted to be in our homes? The younger aged caretakers of children are often in crowds who may not be practicing “social distancing”. Older caretakers were aware of the risks staying in a home of a health care worker. So who is your backup when you are working, and school or daycare is closed? A grandparent? Sadly, no, not an option for many in COVID-19 if they too are at risk. Yet another thing that differentiates COVID-19 from our usual weather closures, illnesses, or family emergencies. Some of us looked to our partner for this relief. And some felt the guilt of this too, the continued ask of our partners. This has to be addressed. Many of us cannot remain on this hamster wheel. It is unrealistic and will leave us all broken.

Many of us experienced the closure of so many things that not only left us burdened, it left us isolated. Not being around other parents, other children, or any of the activities that served as a retreat. It wasn’t just the closure of schools. It was the closure of our many outlets such as the gym, dinners out with friends, date night at a movie theater, or even a church function that gave us reprieve and refilled our cup. The pop-off value is gone. This impact of a heightened workload, increased home demand with more child-rearing, (now with home schooling), and our incredible jobs in the ED is in one word, depleting. Do not misunderstand. I love my job as an emergency medicine physician. It is beyond fulfilling, but yes, it also depleting.

Now the cycle is rarely able to reset. The old “work hard, play harder”, left us with no play at all. We have been on this continuous cycle for months. Not to mention the pay cuts, withheld bonuses, and cancelled vacations. Some physicians have been furloughed, or if they become sick and unable to work, they simply will not be paid. We cannot apply our current RVU model in these times. With this “second wave” (or is it?), we are again going to be asked to do more within our work force with a horizon very bleak for returning to some of those things we were hopeful for in fall.

Many are treading water still. Some have already sunk. Some need a life jacket now. My ask is this…More Compassion. Yes, I know we all have compassion fatigue. We have PTSD, and burn out, and some of us are getting crispy. I know we are all tired. But I need you to come to the board room ready to talk about what we can do to support one another. How do we re-vamp our home and work lives to be more equitable? Our colleagues are our most powerful resources. Parent physicians, older physicians, younger physicians, and immunocompromised with all in this work force need to be supported. We need an innovative action plan. Flexible scheduling? Shorter shifts? Stacked shifts with periods off in between? A new pay structure to reflect our current landscape? Telemedicine? An assignment for some to be a resource to trainees outside of the ED that imposes less risk? Our upper administration and contract employee managers are not going to do this for us. We need to ask our colleagues how we can best re-structure and we need to listen to them. We need to allow all the opportunity to speak, to feel empowered to say no, and to kindly decline anymore tasks in this pandemic. Let’s navigate our limits and set them firmly. We are human and yes, we are also strong. No one entered emergency medicine because they are not capable. We can stay motivated and present a creative united platform. We are the MacGyver’s in medicine. Let’s encourage those who are lost, struggling, or have been weakened in the fight. Our careers, our lives, and our children are dependent on our upcoming responses. Repeated trauma. The time is now to urge your department to look at the individual demands on each of us, as our demands are all different. Support one another. Let’s begin to re-structure for us all to be successful.

We WILL COME BACK stronger, and WE CAN COME BACK STRONGER THAN THE SETBACK!

Cristina M. Zeretzke-Bien MD