Front-line fatigue: Unseen and unappreciated, some respiratory therapists hit mental breaking point

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

PROVO —As a respiratory therapist apprentice, Dominique Elder has the responsibility, under supervision, to turn off the ventilator — the only thing keeping her patient alive.

With guidance from a registered respiratory therapist, she talks family members through the process, telling them that she is going to take their loved one off of life-support. The nurses turn off the medication drips. She pulls the tube from the patient's throat, turns off the ventilator and watches her patient slowly deteriorate and die.

"You have to know that you're, in essence, killing that patient because that's the wishes of the family," Elder said. "You have to just recognize that someone has to be that person. You have to block your mind off and not make it personal. It does become difficult because you also have to show compassion. You know their story, you know their history.

"To be the one to finally see them pass away is really hard."

Lori Green, a long-time respiratory therapist at University of Utah Health, explained the toll that it takes to be the person who withdraws the final piece of what's keeping a patient alive. She feels like it's often the compassionate decision for the patient, especially when she can see in their eyes that they want to be done, but it's hard to handle the pain and grief that comes with it.

"It's tough to listen to the howls and screams of family when the patient does die. I try to get out of the room as quickly as I can," Green said.

Unknown, unseen, unacknowledged

Elder recently spoke about her profession at a high school in Heber City and not a single student knew what a respiratory therapist was. One time even a person who worked in the hospital had no idea what she did.

"So, are you a lung nurse or what are you?" the person asked her in an elevator. She explained that nursing is a completely different department, but he still didn't seem to understand.

Respiratory therapists are generally paid less than nurses, and most of them weren't offered the bonuses or extra pay for overtime that was offered to nurses and doctors during the beginning of the pandemic.

They didn't receive much of the appreciation of "health care heroes" back when the pandemic first started. In fact, Green said she was often told they weren't essential workers, because no one understood that they were working with COVID-19 patients day in and day out.

"Who do you think is running these ventilators? We're in a respiratory pandemic," she said.

Even before the pandemic, respiratory therapists didn't receive much credit, Green explained, to the point that they sometimes refer to themselves as "the ninjas of health care."

"We're probably one of the most undervalued departments in the entire hospital," Elder told KSL.com. "We're often completely overlooked. In fact, one of my teachers told us no one knows who a respiratory therapist is until you need one, and then you never forget."

So, what does a respiratory therapist do?

"Anytime anything has to do with heart or lungs, respiratory therapists are there," Elder said.

They monitor patients coming out of anesthesia to make sure their heart rate isn't depressed. They test and treat infants with croup, RSV or any other condition that makes it difficult for them to breathe.

When a baby is born, either vaginally or via C-section, the respiratory therapists make sure the baby's lungs are clear, and, if not, they are required to stimulate, suction and sometimes even intubate or resuscitate that baby. Every time a patient codes, the respiratory therapists stand at the head of the bed to give life-saving advice to other caregivers.

Safety precautions and ventilators are not new to them even before pandemic, though they may be new to the health care workers who don't typically work with airborne illnesses.

In a more specific COVID-19 world, they often handle the initial assessments to test a patient's oxygen saturation levels and ability to breathe. They can give nebulizer treatments and look at X-rays. They suction out their patients' lungs and advise when a patient should be "proned," or flipped onto their belly to make it easier to breathe.

And if the patient worsens, respiratory therapists are the only other people besides physicians who can intubate patients and are usually the ones handling the ventilators and adjusting settings.

Unlike nurses who are usually assigned to certain rooms or a certain floor, respiratory therapists have roles and patients throughout the entire hospital.

"Respiratory therapy is a very fast-paced, busy profession," Green said. "Sometimes you're the only therapist in the ICU with six to eight ventilators."

However, even though the workload has dramatically increased during the pandemic, this typical fast pace is slowed down significantly by the need to put on and take off layers and layers of personal protective equipment and thoroughly wipe it all down. Eventually at Green's hospital, they had to schedule in that time, and it sometimes ends up taking two to three times longer.

'Night and day difference'

Green and her team were among the first in the state to be vaccinated. After they got the shots, they all cheered for each other and took a picture of the department showing their biceps and the bandages from the shot. The photo was featured on the state's coronavirus information website.

When the ICUs were beyond capacity at the beginning of the pandemic, hospitals nationwide opened surge ICUs, floors and units not meant for intensive care that were turned into temporary ICU spaces to treat the flood of COVID-19 patients.

Green remembers the day that the surge ICU closed after the vaccines came out and the COVID-19 cases started to decrease. Soon the emergency tents went down, and she felt like she was finally glimpsing that hope.

"We thought, 'We made it. We survived. Great job everybody!' And then we started hearing about the delta variant," she said. "It was a night and day difference between the two surges. It was like a completely new disease. We thought we kind of new what to expect, but then the patients came in and these guys are sicker."

The COVID-19 patients she is seeing now are younger and initially healthier — and almost all unvaccinated, which affects morale because this surge could have largely been prevented.

But the change isn't just in the severity of the illness or the age of the patients, it's also in the surrounding culture. Health care workers were celebrated and now they are criticized and cursed, Green said.

"We don't have that support. We get called liars. Patients are yelling at us. Families are yelling at us. I've never been sworn at or screamed at or cussed out as much as I have in the past few months," she said. "We're fighting this battle alone now."

The biggest issue that respiratory therapists see in COVID-19 patients is pneumonia, Elder said, which occurs when the mucus settles into the lungs and infection sets in. In order to prevent this, patients are instructed to lie prone on their stomachs, so the blood at the base of the lungs can pump to the front of the lungs. But some of her patients simply refuse the treatments, saying that it's uncomfortable.

Patients who follow her instructions — like remaining as active as possible, walking around or sitting up in chairs instead of laying down – often recover. The patients who don't fight at all generally end up on a ventilator.

"You can't make a person participate in a treatment," Elder said. "It's really heartbreaking. You're thinking, 'Just do it! Do you want to die?' You want to shake them, but you can't make them lie prone or participate in very simple but effective treatments."

Green said that sometimes when she tells patients they need to be intubated, they ask if it's too late to get the vaccine and she has to tell them — yes. Then there are patients and families who still don't believe the pandemic is real.

"I had one patient who said, 'I didn't get vaccinated because I just wanted to see what happened.' It's definitely a struggle to see these people dying of COVID and saying, 'I'm not dying of COVID,'" she said. "We gave an oath not to do harm and to treat all those who come through our doors, regardless of vaccination status. It's hard when people come in begging for horse dewormer."

Long, hard days

Respiratory therapists, like many health care workers, usually put in three 12-hour shifts a week, which often doesn't include breaks because of the number of COVID-19 cases coming in and the protective gear the workers need to put on and take off. They are required to wear both an N95 and a regular medical mask, two sets of gloves, eyeglasses or face shields, and a powered air purifying respirator which looks kind of like a vacuum on the workers' backs connected to a white hood.

After a long, hard day, these workers come home and have minimal time with family and minimal sleep before having to go back and do it again.

Now many of them are working mandatory overtime on top of those long, hard days because of the high volume of COVID-19 patients flooding in and the high volume of health care workers pouring out. Respiratory therapist teams are extremely short-staffed because of people getting burned out or switching to traveling positions or to home care to try to relieve some of the personal stress.

The staffing problem has gotten so severe that the American Association for Respiratory Care recently announced a change so that students like Elder who are studying to be respiratory therapists can move up from respiratory aides to respiratory apprentices in the last year of schooling as opposed to just the last semester, with the hopes of bringing more people in to help with the resurgence from the delta variant.

Elder describes her typical day treating COVID-19 patients during her clinicals: She dons her protective gear and has to check on each patient every two hours, at a minimum, to make sure that their ventilators or high-flow nasal cannula are working. With supervision, she does a full assessment and usually suctions out some of the mucus in her patients' lungs, which makes them cough.

"A lot of these patients have been on ventilators so long and are upset and so sick and tired of the condition. They're not happy to see you. You are not their friend. You're trying to help them get better, but it's not a pleasant experience," Elder said.

By the time she's done, she's already half an hour into another round for another patient, so she gets done with this patient and immediately goes to the next with no break, over and over again. If you do catch up, it's usually at the expense of your lunch break, she said.

Green also works in a neonatal ICU, which have been particularly full as COVID-19 can cause pregnant women to go into labor and give birth prematurely and both baby and mom can need help breathing for a while. She also sees a fair amount of full-term babies who still come out needing respiratory assistance.

At University of Utah Health, the NICU is being remodeled, which decreases the space where babies can safely be held.

"We're running out of places to put babies," Green said.

Gently guiding to the light

When Green first heard about the novel coronavirus, she wasn't too concerned about it — because the medical community had always managed to get some control over the spread of similar viruses. She even posted on Facebook saying, "Why is everyone so worried about this? It's no worse than the cold or the flu."

Then cases started trickling into the U.S., and she told herself that they could just treat COVID-19 like H1N1, or the flu. The guidance about masks kept changing, so she was always pulling her mask down and wasn't really buying into masking.

Then she started seeing patients coming in who were sicker than she thought they would be. The news came in that supplies were back-ordered nationally, including ventilators and high-flow nasal cannulas and other respiratory devices. On top of that, the treatments that respiratory therapists usually used for the flu or another similar illness didn't work on her patients. It seemed like every day brought changes, like the nebulizers didn't really help treat it and certain drugs usually used in treatment did not help, so she had to trust in the scientific research being done.

Now, she is utterly exhausted by the misinformation that contradicts science; and, the fact that people are choosing not to get a vaccine that has been proven to be safe and effective with only extremely rare side effects. Despite her initial issues with masks, she now wears one consistently, in order to practice what she preaches. She said she cringes when she sees large, unmasked crowds at sporting events.

Elder unknowingly contracted COVID-19 and passed it to her grandmother through a hug. When they started having symptoms, she was talking to her grandmother on the phone, and her grandmother asked, "How did you pass it to me? We're both vaccinated!" She had to explain to her grandmother that it is still possible to spread the virus even if you are vaccinated.

This fact was behind the Center for Disease Control and Prevention's recommendation for all people, vaccinated or not, to wear masks in indoor spaces.

"I don't think people should be forced to be vaccinated, but the large majority of the patients in the ICU are unvaccinated. There's a lot of controversy and things, but it comes down to that — it's effective. People are really too strongly opinionated. There are a lot of conspiracy theories and misinformation out there, but when it comes down to it, you should get it," she said.

Taking it home

Green's team break room used to be loud, full of cajoling and laughing, but now it is eerily silent. The fear of bringing the disease home to their loved ones is always present, but health care workers are also afraid of bringing home the trauma and the burnout.

"You can see it in (the co-workers') eyes and their long, drawn-out faces. Fatigue. Recently almost every one of us within the last two or three weeks has hit our breaking point," she said. "You can just see it in their mannerisms. People aren't as jovial and joyful as they have been. Some of my co-workers have gone through divorces because they've taken this home.

"The break room once was a refuge and now it's not. It's just haunting. Each of us is just dealing with our own demons. People with glimmers in their eyes have lost it and instead, you see this, 'I am not doing well' look."

Green and her co-workers have talked about the symptoms of post-traumatic stress disorder they experience when they walk on the floor that used to be the surge ICU. Any time they have to walk onto the floor, she said, they leave as fast as they possibly can.

The most heartbreaking thing for her, she said, is "seeing the fear in people's eyes when they realize they can't breathe and realizing from my side that I've maxed out what I can do."

"They don't know what's wrong with them. They don't know why they can't breathe. There's nothing else I can do, but the health care worker in me is saying 'make them better,'" Green said.

She hit her breaking point last week after being physically, mentally, emotionally and spiritually drained. A patient yelled at her during the entire treatment, and something finally broke. She went home for the day and broke down in tears to her mom.

"I'm so tired of people's choices affecting my life. My career that I loved — I don't like it anymore," Green said. "I cannot go back to work. I have got to disconnect for a while."

She found she didn't want to eat or drink or interact with anyone. Even the things she enjoys, she had no interest in, except exercise. The tension from the hospital causes tension headaches and body aches from being so tightly wound all the time.

So Green took a break, and she is so glad she did. Although she still feels that tension, she has decided that she will stay in the profession she's worked in for a decade.

When Elder reaches the end of the week, she feels like crying. It feels like she's having the same week over and over again.

At work she becomes numb because of the horrible and tragic endings she sees. She spoke about the codes (hospital speak for "death") during which utterly exhausted CNAs and nurses are fully gowned up and dripping with sweat. There aren't as many success stories as they used to see, and many patients don't make it. At the end of the day, she heads home, does homework and prepares for her classes with no time or energy for her husband.

"You have nothing left to give and you keep going. Those are the moments when you see the burnout truly form. First, there are different phases of frustration and anger. At the end, it's just numbness to get through the day," Elder said.

As a student, she often gets asked why she's joining this profession, if she knows how tough it is. Her cohort is the first in the program to be able to go into COVID-19 rooms as students.

"This is all we've known of the profession," Elder said. "I see, and I'm choosing to get myself into this," though, she admits that the respiratory therapists she works with says she still has "bright, shiny eyes," when most of them feel like they've lost theirs.

Comrades in arms

Rufino Rodriguez, who was a beloved NICU respiratory therapist at Utah Valley Hospital in Provo, died of COVID-19 in January. Green and many of her colleagues saw him as a trusted mentor.

"I honestly feel like we're at war and I've lost a comrade in arms," Green said. "In the end, it doesn't matter who we work for, we're a team. It's just frustrating that we're risking our lives, risking taking it home, separate from family, missing out on experiences because we don't want to be a spreader, and then to be treated the way we are and see people so cavalier about masking and social distancing. It's heartbreaking."

She thinks about the way soldiers are welcomed home after serving and wishes that health care workers would receive similar treatment, but instead are sometimes treated as if they're trying to take away people's freedoms.

"While the world fights over a needle, we're fighting over the desire to continue to serve," Green said. "We're going to come out of this different. We're going to need a lot of loving. Welcoming soldiers home, we need those types of things. We didn't sign up for a pandemic that lasted multiple years and the infighting."

For Elder, one of the things that allows her to stay positive is looking at the caliber of people she's working with.

"You have no idea the grit and dedication of these people and their lives that these (respiratory therapists) have. Be kind," Elder said. "Remember your respiratory therapists. Know who your care teams are. Remember these people who are behind the scenes who are really just sticking their guts out there and putting their time in with no compensation."

Correction: An earlier version did not clarify that Dominique Elder's work with COVID-19 patients was done during clinicals under supervision of a registered respiratory therapist.

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