Front-line fatigue: COVID resurgence leaves ICU docs feeling 'heavy in the soul'

Editor's note: This is the second in a series of stories looking at front-line fatigue among health care workers in Utah.

SALT LAKE CITY — A COVID-19 patient lies on a hospital bed with tubes coming out of their mouth and nose and chest. They have large IV-catheters on both sides of their neck. Their body is so swollen that their face looks disfigured and hard to recognize. Their fingers and toes are bruised and black.

The medical team — in respirator hoods and full protective gear — hold up a phone with the patient's family on FaceTime. The doctor has to tell the family on the phone that because they had a family party without following public health guidelines, their loved one will not be coming home and will likely die in the next few minutes.

The family spends the final few minutes of their loved one's life telling the doctor that COVID-19 isn't real.

The patient dies. The family is overwhelmed with grief, but medical staff is already clearing the bed for another critically ill COVID-19 patient, and the cycle begins yet again.

And the doctor acknowledges the elephant in the room: This death was preventable.

These are the jarring, everyday moments from Dr. Brian Poole's life as an intensive care unit doctor that he says he wishes everyone could see. These are the hopeless, sorrow-filled scenes that he can't get away from — even in his dreams.

He and his colleagues at University of Utah Health say they have had this experience in various iterations innumerable times since the pandemic started.

He has had to tell patients' families that their actions effectively killed their family member. He has had to tell teenagers that they are going to lose one or both of their parents.

"I think if people could witness that firsthand like we have so many times since (the pandemic) first started, they would have a whole lot more empathy. It would diffuse tensions about politicized things. After all, who wouldn't want to wear a mask if the other option is telling a 15-year-old that both their parents are dead?" Poole said.

Dozens of surveys and studies have demonstrated that dealing with this level of death and sorrow day in and day out has resulted in a still-increasing spike in post-traumatic stress disorder and mental illness in doctors and health care workers, sometimes even resulting in suicide. Dr. Michelle McOmber, CEO of the Utah Medical Association, said that doctors working in emergency rooms and ICUs are the physicians hit the hardest during the pandemic.

She said that after hearing from the families of physicians who died by suicide, she found that the factors that contributed to the decline in the mental health of health care workers include hospitals being beyond capacity, physicians having to work extra hours, people dismissing medical expertise, the widespread refusal to be vaccinated and/or wear masks and the fear of bringing the virus home to their loved ones.

All of this occurs on top of typical work-related stress, which is demonstrably higher in health care professionals and ICU doctors in particular, according to pre-pandemic research.

A missed miracle

The very first day that the vaccine was distributed to health care workers at Poole's hospital seemed like a miracle, he recalled. The health care workers were in tears, seeing a finish line for the trauma they had all been through — caring for COVID-19 patients for so long, working extra shifts and putting everything else on hold.

"We did what we had to do. We had no choice. And then the vaccine was so much more effective than anyone had hoped for, with a greater than 90% efficacy," he recalled. Watching his co-workers finally get this protection was "honestly indescribable," and "it seemed like everything was headed in the right direction."

But it wouldn't last.

Poole very clearly remembers a work meeting just before the Fourth of July weekend when the case numbers had started picking up and experts gave a forecast of how the numbers would increase. At that point the hospitals were already full of patients who had delayed medical care during the early part of the pandemic, to the point that they were now in critical condition. There was already a nursing shortage and a blood shortage.

"I remember just the horrible, awful feeling I felt. Almost like a PTSD reaction, that this is coming back, we're going to have to do this again," he said. "It's kind of like this almost pit-in-your-stomach feeling. Just the sorrow and despair of it all. An overall feeling of resignation that this is reality and this is what we're going to deal with."

Dr. Sam Brown said he was one of many physicians who had to "put every other aspect of our career on hold."

Brown is a Harvard-educated ICU physician at Intermountain Medical Center and a medical researcher and associate professor of pulmonary and critical care medicine and medical ethics and humanities at the University of Utah. He also serves as the director of the Center for Humanizing Critical Care at Intermountain. He explained that after long clinical shifts in the ICU, he goes home only to keep working on his research. The pandemic has affected his ability to conduct that research, which is an essential part of his job.

"We were hungry to get back to the good stuff we were doing before then, but it was taken from us by misinformation campaigns and partisan wrangling. And then to get yelled at for taking care of patients. ... It's just demoralizing," Brown said.

He was also holding out hope that he would be able to spend more time taking care of his family. At the beginning of the pandemic, Brown was working over 100 hours a week while his wife handled every other responsibility. She told him that she could handle it for six months, but then something had to change. Six months passed and the work had not gone away. But when the vaccine came, he hoped it would mean a respite from the long hours.

"ICU docs notoriously work too much, even before the pandemic. You are exhausted and thought that the pandemic was calmer and the crisis had somewhat abated. Then a large group decided not to get a highly effective and safe vaccine and all of a sudden, the plans you had to take a week off with your family and go somewhere fun are ruined," Brown said.

The couple found a compromise, with him working about 70 to 80 hours a week, but he worries about all the work still left to be done.

"There's always more to be done. It's a tricky process of give and take and trying to communicate well," Brown said.

No beds, no room

Brown describes the typical day for an ICU doctor right now as a constant struggle to find beds, as the ICUs across Utah and across the nation are beyond capacity. He said that, because COVID-19 deaths are usually slow, patients can be in the ICU for much longer than a typical patient. The only way a bed is freed up is if a patient recovers or if they die. Either way, that bed is immediately filled by another patient.

"We have the traffic police role above and beyond all of our other duties. I usually spend an hour-and-a-half looking at ICUs across Utah just to place one patient," he said.

Idaho has declared a statewide "crisis standards of care," which permits hospitals there to ration care — meaning that scarce resources like ICU beds will be given to patients who are deemed most likely to survive.

Even in Utah hospitals, there sometimes aren't enough resources or dialysis machines, and the doctors are forced to make decisions on who will get them and who will have to wait.

"I've personally felt that we recently have been not too far off of doing what's being done in Idaho. It would not surprise me to see that," Poole said.

He explained that because Salt Lake City is a medical hub for Utah and neighboring states, his hospital gets calls daily from smaller, rural hospitals that don't have the resources or expertise to treat their patients. And almost every time the answer has to be no, because there is no space. Having to say no again and again to people who truly need help can be hard and exhausting and goes against everything medical caregivers are trained to do.

"You know that when you have to say no that those patients are going to do worse and maybe die because smaller hospitals just don't have the expertise. We feel that very acutely," he said.

Empathy and expertise

Once while Poole was working with the other staff, trying to resuscitate COVID-19 patients who were actively dying, another COVID-19 patient made a comment about how he felt like his care was being neglected. He was sick, but he wasn't sick enough not to notice the rushing and the noise as the medical team tried to save his COVID-19-ward neighbors.

"It was purely just a lack of empathy, even as sick as he was," Poole said.

Every physician who spoke with KSL.com mentioned an argument they hear frequently — that they knew what they were getting into when they chose their medical profession and they should just suck it up. Expressions of concern for personal mental health brings a chorus of criticism that if they couldn't handle it, they shouldn't go into health care. But even physicians who have been in the profession for a long time say that the conditions under the pandemic have been far beyond the normal stresses of the job.

"This is worse, by far, than anything I've ever seen. In terms of the morale and exhaustion, I've never seen anything like this in 20 years," Brown said.

Poole spoke of the "in the trenches" mentality that nurses also mentioned in a "Front-line fatigue" story published last week. Even people who have worked in health care before cannot understand what this pandemic has been like unless they've been in the thick of it, he explained.

"This is what we signed up for, but at the end of the day we have to acknowledge just how brutal this has been with the amount of illness and death that we have seen," he said.

McOmber noted that there is a large group of people who are dismissive and untrusting of doctors because of how often recommendations have changed during this pandemic, when in fact science is always changing. That means treatment and recommendations surrounding a virus like the novel coronavirus and its variants is likely to change as doctors and scientists discover more about the disease.

These changes don't mean that the scientists are consistently getting things wrong and are untrustworthy, but rather, that the rapid pace at which the treatments and vaccine are developed points to the value of scientists and doctors doing their jobs correctly, she explained.

"It's frustrating to physicians to be put in that category of basically not being any kind of expert in any way. How can we reach (the people who don't believe), especially after it going on for so long?" McOmber asked. "Things may change over time, but the basic principles of hand washing and mask wearing and social distancing are still there. People just don't want to hear it."

Both Poole and Brown mentioned that patients and family members verbally attack doctors because they don't believe in the COVID-19 diagnosis or the treatment. Some say that the doctors are making up a false diagnosis. Others are convinced that they need medicine like ivermectin, which is usually used as a dewormer for horses, cows and sheep and is not an FDA-recommended treatment for COVID-19. Or, they get recipes for medicine concoctions on the internet and become livid if they don't get the unproven alternative treatment.

"Conversations like that often don't go very well," Poole said. "People have pretty strong opinions. They don't trust us at all about the vaccine, but then they trust us to give them critical therapy in the ICU that is not as supported as the vaccine.

"What we don't see (in the ICU) is people dying from the vaccine."

'Heavy in the soul'

At the start of Poole's residency in an ICU rotation, he thought some of his attending physicians seemed unfazed and unbothered by the illness and death that surrounded them. He believed that it was appropriate to feel sorry and thought, "I hope I never get that way."

But this summer, he had to learn to check his feelings at the door of the hospital, especially when it came to patients whose illness could have been prevented if they had chosen to be vaccinated.

"I'd think, 'OK, all right, they died.' And then have to continue. It was a rude awakening to me about how depersonalized I had to become to deal with it," Poole said. And then immediately they are replaced with another patient and the doctor and his emotionally depleted staff has to carry on.

But that doesn't mean he doesn't care about his patients or doesn't feel for them. He has heard a lot of criticism from the community about how health care workers need to let go of any frustration and just treat the patients, even if they made questionable life choices like not being vaccinated.

"Some people have tried to compare it to smoking or drunk driving, but we see people who make terrible life decisions all the time and we care for them," he said. "This feels different. I've never had a smoker who denied that smoking was bad for you or a drunk driver who thought that it was beneficial to drive drunk. People know that it's bad. But people have just been fed so many false fears or information that a lot of them truly believe them not getting vaccinated is the right choice."

Brown talks about how, as a physician and an ICU physician in particular, the work has a deeper meaning that comes with a sense of balance and calm in the face of crisis and how that balance gets thrown off when people don't believe you or are yelling at you, combined with fewer breaks, fewer opportunities with family and a lot more work.

"You're doing hard things because you know you have a therapeutic bond with the patients. You have the opportunity to carry them through a life-threatening illness and get them through to the other side or treat them with great respect and tenderness as they head off to the next life. You feel the quiet awareness that your sacrifice is an important one, but you lose that to anger," Brown said.

"It just sits heavy in the soul for ICU docs."

The enemy

Poole has always loved the view from inside the University of Utah Health building, overlooking the Salt Lake Valley, but now when he looks out, he's reminded of all the division and hate. He sees the state Capitol and thinks of the politicization of the pandemic that has led people to not take necessary precautions and end up in his ICU.

He thinks of the unvaccinated COVID-19 patients he has treated and how easy it can be to judge them for their decisions, but when he gets them to open up, he usually finds that their beliefs stem from two things: disinformation spread by someone who should know better; and young people who assumed that because they had a healthy immune system and took care of themselves physically they couldn't be affected. These reasons are often not the same expressed by the vocal anti-vaccination crowd, Poole explained.

"The enemy here is the virus. It's not each other. The broader conversation has really tried to turn it that way. At the beginning of the pandemic, reasonable people could disagree with procedure and mandates and how the government should handle the pandemic. Now, the science has indisputably demonstrated that the safest way is the vaccine.

"It's hard to see all the fighting. It's hard to see the lack of empathy and respect," he said.

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