Estimated read time: 15-16 minutes
Editor's note: This is the sixth in a series of stories looking at front-line fatigue among health care and other workers in Utah.
MURRAY — Sometimes Melissa Peng wishes there could be an observation area in the intensive care unit so people could see what it's like to treat COVID-19 patients again and again and again while their patients' families often break down.
Instead of impersonal statistics or a five-second snapshot of a prone COVID-19 patient adorned with countless tubes in many media stories, she wishes she could share what it's like to see a newborn who is never going to meet his father, an expecting woman who might lose her baby because of preterm labor brought on by COVID-19, or people her own age, who die and leave their children orphaned, all because of an illness that is largely preventable through vaccination and masking.
After years as an advanced clinical pharmacist in a trauma ICU, these are the scenes that stay with her.
People have grown calloused to numbers of COVID-19 deaths and cases, she said, but she wonders if seeing these heartbreaking scenarios would finally get through to the unvaccinated.
"Those kids can never get their parents back. They won't get their grandparents back. It's the broken families that get to me because it's avoidable," she said.
These haunting scenes are particularly poignant for Peng because she had a baby at the beginning of the pandemic, before the vaccines were fully developed and when scientists were still learning a lot about transmissibility of the virus.
During the day, she would wait until there was a rare quiet moment and go into a call room, disinfect everything as much as possible, and then doff her protective equipment so she could pump milk for her daughter while continuing to work on her computer. But she always grew anxious at the thought of potentially passing the virus to her newborn, who had little to no immune function.
"It always turned out that the 30 minutes I picked to do this, someone could have cardiac arrest or need to be intubated. There were fewer resources in the evening, and there were times when I was mid-pumping and someone would have a cardiac arrest on the floor. I'd have to take off the pump, get the milk in the fridge, put on a different bra, shirt and (protective gear). That part always took an extra couple minutes. I felt some degree of guilt if I couldn't make it back in time," she said.
She would come home after a long day and shower before nursing her baby, wondering if the benefits of breastfeeding outweighed the potential risk of potentially infecting her newborn — or her mother, who was sacrificing nine months of retirement to help care for the baby.
"Feeding your child at a young age is this responsibility and burden and joy, with a huge range of emotions. I had a lot of anxiety about how I was going to feed my kid and not get her sick. It was constantly in the back of my mind, a huge weight and concern," Peng said.
When the vaccine was on the horizon, she felt that weight begin to lift. The fear of bringing the pandemic home to their loved ones — that had loomed over her and her co-workers' heads for so long — seemed like it would finally clear. But then it didn't.
Hospitals are still filled to capacity with unvaccinated people who have COVID-19 and case numbers are as high as they were at this time last year.
Now that her daughter is older, Peng has found that she has to compartmentalize and leave work at work, just so the anger, frustration and burnout she experiences at work don't impact the joy she feels at home with her child.
High stress, low tolerance for error
Being busy isn't new to Robbie Vickers. He and his sister own three pharmacies, including the downtown Cedar City fixture, Bulloch Drug. On top of the medical side of ordering, storing and distributing medicine, he also manages employees and retail. Bulloch Drug also does compounding and packing, things most other pharmacies don't do.
Add COVID-19 testing, antibody testing, polymerase chain reaction testing and COVID-19 vaccination storage and distribution, and Vickers is beyond any previous notion of busy.
Earlier in the pandemic, many pharmacies were doing COVID-19 testing, but the others slowly stopped over time. Now Vickers runs the only pharmacy doing rapid COVID-19 testing in Cedar City. The phones still ring nonstop, and they have had to switch to online scheduling in order to accommodate everyone. It's so busy that the personal feel that comes with engaging with patients on a local level fades.
"I would love to say we have a personal interaction with everybody, but you get to where you can't. We have to employ some sort of automation," Vickers said.
Similarly, Peng gets to the hospital a little before 7 a.m. Before she does anything else in her office, she does "aggressive" cleaning and disinfecting. Then she starts looking at her patient portfolio, starting with the new and the severely ill, examining all the data from labs, imaging, cultures, vital signs and medications. Then she forms an opinion on any changes to treatment that may be necessary.
She then meets with her colleagues — fellows, attendings, medical residents, interns, pharmacists, respiratory therapists and dieticians — during rounds as they talk about every patient and the plan for the day. After those treatments are administered, she assesses how those changes went. She's also responsible for helping teams triage incoming patients, assisting with any interventions on the floor and being constantly available for any acute changes in her patients.
When the pandemic first started, she thought she could maintain the intense workload because it was hopefully a temporary issue. But now, as she's entering the 20th month of the pandemic, she feels even more weighed down and demoralized as well as being overworked because all of the continuing work and illness and death could have been avoided.
"Back then, we felt empowered because we felt like it was the right thing to do. Now it feels like a bit of a slap in the face when people won't get vaccinated, when the rest of us are still dealing with being overworked. It's taking an unrelenting toll on our mental and physical health," Peng said.
Alisyn May, an assistant professor of pharmacotherapy at the University of Utah College of Pharmacy, describes the profession as "high stress with low tolerance for error" — a job that already had a large problem with burnout before the pandemic started.
She noted that pharmacy includes a wide range of practitioners, including people like Peng, in hospitals, to those in local retail pharmacies, like Vickers. But no matter where pharmacists work, the COVID-19 pandemic has drastically increased their workload and resulted in a wave of trained pharmacists and staff abandoning the profession, leaving those who remain with even more work and less support.
"Discussions about burnout and resiliency have just blown up," May said.
And being overworked and overtired can impact cognitive function, which is essential to pharmacy because there is essentially no margin for error. If pharmacists make any mistakes with the type of medicine or the dosage, it can result in serious medical issues or even death for the patient. And the pharmacists are also legally accountable for checking any errors doctors might have made when prescribing a medication.
"People might not know this, but in Utah, the responsibility of the prescription is 50% on the doctor and 50% on the pharmacist," Vickers said.
The pandemic has disrupted supply chains in almost every field, but it has particularly affected medications and medical supplies. Drug companies sometimes have production shortages, so drug shortages are not new, but the pandemic has dramatically exacerbated the issue.
"A lot of these COVID patients have the same problems that require the same medications, and you don't just have a limitless supply. We've had to make some pivots throughout the pandemic due to drug shortages, and pharmacists have the unique role in educating the teams about some of those shortages and highlighting alternatives to that therapy," Peng said.
There are shortages of medications that are not specific to treating COVID-19 that are needed for patients. And then there are human-caused shortages when certain therapies become popularized through the spread of online disinformation, like hydroxychloroquine and ivermectin. Drug companies are faced with an overwhelming demand for medicines that do not usually warrant large-scale manufacturing.
When these shortages occur, specific patient populations that need those medications are left without them. For instance, hydroxychloroquine is used to treat and prevent malaria, as well as treating patients with lupus and arthritis. Not having access to that drug can lead to worsening, painful and potentially even life-threatening conditions that cannot easily be helped by another medication, she said.
Peng explained that in these cases, the patients who are already vulnerable are hit hardest.
"Drug shortages place a high burden on the really sick," Peng said.
Vickers explained that this treatment of the vulnerable patients — in pursuit of a miracle cure — is what makes him angry. He didn't even know what ivermectin was a year ago. If someone had told him six months ago that a deworming drug was going to be the next craze, he wouldn't have believed them. But now, it's the most talked about drug in the U.S. He's constantly worried what the next one will be.
"People are constantly looking at repurposing a drug that other people depend on. When 10,000 people a day take something and then it suddenly turns into 10 million people a day taking it, there's just no supply for it. They create a shortage overnight, and people who relied on that medication for their livelihood don't have it — all because a few people touted it being helpful for COVID," Vickers said.
Vickers said pharmacists are "the gatekeepers."
When there was a shortage of hydroxychloroquine, he had to save what little they had for the patients who needed it, but that often led to confrontation when people wanted it to treat COVID-19, because of misinformation, he said. Since the pandemic began, he has had to train his staff to handle these kinds of confrontations and deescalate.
"Sometimes you have to be the bad guy to be the good guy," he said.
He wants people to come into the pharmacy and feel like family, but this repeated situation has made that goal difficult. So he tries to show his staff that he is there in the trenches with them, and they discuss the confrontations, what worked in terms of deescalation and what didn't.
He recognizes that people are scared and stressed, which makes it hard to think rationally, so he tries to be upfront and explain why he's doing what he's doing, and that he isn't part of a conspiracy.
After all that, sometimes he still gets frustrated when people can't get ivermectin from his pharmacies and instead eat stronger, more concentrated paste that is meant for animals and end up in emergency rooms with their digestive systems completely destroyed.
One of Vickers' fellow Cedar City pharmacists refused to dispense ivermectin to a patient because of statements from the American Medical Association and the American Pharmacists Association urging doctors not to prescribe it and pharmacies not to distribute it. A furious doctor came into the pharmacy, yelling at him for not filling the prescription.
"I've had phone calls from people I knew well, who will call me and say, 'if I had a legal prescription, would you dispense this to me?' They take up time asking hypotheticals and questioning my integrity because of a political battleground. It's unique and challenging, and overall, it's taxing. It weighs down on you," Vickers said.
Peng recalled times when angry COVID-positive patients who didn't believe COVID-19 was real, tried to tear off a health care worker's protective gear.
She regularly witnesses "the spectrum of the unvaccinated" — people scared because of misinformation about vaccines; people who wanted to wait to see what would happen; people who were one or two doses into the vaccine when they got sick but not fully vaccinated; people who realized that not being vaccinated was a mistake and are remorseful; and people who still don't believe, even when they can't present any alternative for what has made them this sick.
But mostly, she deals with families who give weight to vitamin concoctions or unproven drugs like ivermectin and try to dictate their loved one's care.
The two best ways to not get COVID have remained the same: masking and being vaccinated.
–Melissa Peng, pharmacist
"The two best ways to not get COVID have remained the same: masking and being vaccinated. I find it intriguing that these people will blatantly disregard medical advice and rely on really bad data and are willing to settle on these therapies that we use for animals or other cocktails that they read about on a blog," Peng said.
But no matter how many times she hears about these false therapies and how tired of it she gets, she still has to try to remain respectful and compassionate and stick to the fact that the therapies being presented are not well studied or accepted. Those conversations are not usually easy because people don't tend to change their minds, but she tries to focus on the fact that health care workers are responsible for the patients' well-being.
"Even though you're angry and frustrated, you try as best as possible to understand where they're coming from," she said. "They don't have medical degrees. They don't have a science background. They're grasping at something to try to save their loved one. You have to try to put yourself in that mindset."
But Peng added, "We've all lost a bit of faith in the community and in humanity in making the right collective decisions. It's a fraction of the community, but we're seeing the consequences."
Pharmacists across the state and the nation are seeing a decrease in the control of their workload and their sense of community, as well as a lot more burnout, depression, anxiety and emotional exhaustion, May said.
Those that work in the hospitals are on the front lines actively witnessing patients dying from COVID-19 and its many complications. Those on the outpatient side are on the front lines of an angry, mistrusting public, loaded with misinformation.
As a professor, she has been trying to adjust mentor programs, identify students who aren't doing well mentally and connect them with mental health resources, but she is worried about what the long-term effects will be.
Walking on eggshells in a volatile political environment can get taxing over time, and Vickers wonders if he will get to the point where he doesn't have the ability to adapt anymore.
"In some scenarios, you're seeing that happen. People are breaking. And it's a dangerous scenario to put everyone in because it's not necessarily their fault (if they break). It's so taxing and demanding, especially if you don't have any base to come home to or any sort of release mechanism or someone to reassure you. It could be really, really difficult," he said.
Peng did not expect to get emotional during her interview with KSL.com because when she is working, she is doesn't have time to process the hard things. But she found herself choking up as she talked about how she has compartmentalized "the gamut" of emotions — from fear and dread to hope, to frustration and anger.
Seeing as much heartbreak and as much death and as much misinformation that we've seen over the past year and a half, it has a huge desensitizing effect. And that empathy is one of the things that allows us to take really good care of patients.
–Melissa Peng, pharmacist
"Seeing as much heartbreak and as much death and as much misinformation that we've seen over the past year and a half, it has a huge desensitizing effect. And that empathy is one of the things that allows us to take really good care of patients. We need to understand the literature and data, and we also need to have compassion," she said.
But the increased workload has taken away her ability to decompress and spend time with her family, which, she said, has had a significant impact.
"I don't regret being a part of it. I have enjoyed being able to provide care for the sick members of our community. I have enjoyed the camaraderie with my co-workers, but what we're doing isn't sustainable," she said.
A phone call away
All of the pharmacists interviewed said people in the community can help them by being kind, patient and understanding that pharmacists' jobs have dramatically changed and have become a lot more demanding, as have many other things throughout the pandemic. They want the public to know that they are willing to help, and people can come to them instead of trying to interpret data themselves or watching videos from sources who are not professionals.
Peng explained that she understands that a lot of the recommendations have changed over time because scientists have learned more and more and adjusted the recommended safety measures, but to her, some of the best benefits of science and medicine is that society is able to continue to learn and refine knowledge and build on it in order to make the best decisions possible. And right now, scientists have the most information that they've ever had about COVID-19.
In order to become a pharmacist, it requires an undergraduate degree, a four-year doctorate and typically, there's much additional learning and training to stay up to date and relevant. Pharmacists spend a lot of their time learning how to read new studies, research and data in order to make the best recommendations possible for their patients.
"Go to your pharmacists and ask your questions. We know how to read the data. We have extra training to look at the studies because pharmacists are very involved in drug studies. Call your pharmacists. We're just a phone call away," May said.