Because I used to be a doctor, I have my finger on the pulse of what it’s been like to be a front-line Covid doctor, even though I’ve been safely sheltered in place since retiring from clinical practice over a decade ago. Among my friends, colleagues, clients, and family members are physicians and nurses who have been relentlessly exposed to the traumas of the front lines, not unlike battle-weary soldiers in seemingly endless wars. They have pandemic fatigue, and it’s brutal.

Those at home can lose touch with what’s happening in places like India and South America. When Covid is surging, decisions were made that are the stuff of nightmares. Who will get an ICU bed? Who will not? Who will get the limited medical attention available from a maxed-out staff? Who will wait in line at the door and die waiting? Who will get life-saving oxygen? Who will suffer when we run out? Who will get ousted from a bed because their future is deemed hopeless? Who will replace them in that bed? Who would have survived if only they’d been able to get treatment for non-Covid related conditions? Who matters more than someone else? So many Sophie’s Choices, so much trauma, so many regrets.

The Back To Back Trauma Of Life On The Front Lines

Nurses, many of them traveling from one outbreak hot spot to the next, bear the brunt of the initial exposure, triaging patients until their Covid status is known, taking the “hit” by potentially exposing themselves to Covid first, to spare the more limited, much needed, and therefore more protected physicians so the doctors don’t get sick or die and leave us all untreated. But nobody can protect the physicians when they’re the ones who have to intubate a coughing, sputtering Covid patient, especially when there’s not enough PPE.

What does this do to the psyches of the nurses, to know that they are considered more expendable on the hierarchy- better a sick nurse than a sick doctor, goes the logic- but these are humans we’re talking about, not commodities. What happens to the psyches of the doctors who have to make the calls of who gets a bed and who doesn’t? Nobody should have that much power. Nobody should be expected to know how to wield it wisely.

Some of the nurses I know quit because they couldn’t tolerate the “moral injury” of observing how either implicit bias or overt racism was impacting these life and death decisions. Put bluntly, white Covid patients were getting prioritized over Black Covid patients, but again, these are humans we’re talking about. And most nurses are empaths. This hurts. If you’re the nurse and you’re advocating for your patient- and losing the advocacy battle preferentially to privileged people- how do you sleep at night?

This doesn’t even touch the trauma of watching your patients die through sheets of glass. Doctors and nurses are accustomed to at least comforting their patients when there is nothing else we can do, to hold hands and coo loving words in those last moments of suffering, to know, at the very least, that the patient’s loved ones are in the room, tending to the emotional and spiritual needs of the patient, even if there’s nothing more that can be done to support the physical body when it’s gasping for breath.

In addition to all the other traumas, many front-line health care workers had to wrestle with realizing that, in doing the best they knew how, many patients were put on ventilators and never taken off. Covid patients who refused the ventilators sometimes survived, while those who were ventilated rarely did. Doctors had to sit with the agony of “Did I kill my patient by doing what I thought was helping?” Nobody knew at the time how ventilating Covid lungs could damage them. Nobody knew that the earliest reports would suggest that 80% of ventilated patients would ultimately die. Although ventilators saved many Covid patient’s lives, it would take months before doctors learned best how to support patients who needed them. By then, much of the damage had been done, both to patients and to the psyches of the doctors responsible for making those decisions.

Unlike many in the general population who run away, avert their eyes, spiritually bypass, avoid or otherwise turn away from suffering and pain, doctors and nurses are wired to lean in and try to help. They find meaning in their work because usually, they can help, and it’s nourishing to be of service and ease suffering when someone is scared, vulnerable, and in pain. But doctors and nurses are not good at feeling helpless, powerless, and defenseless in the face of an invisible enemy they cannot beat, especially if they have to wrestle with feeling responsible for someone’s death or disability. Every patient they lose feels like a failure to them, and every failure can be demoralizing.

On top of all of this, many were treated like pariahs, as if they were walking hosts of contagion because of their frequent exposures. Not only were their friends and families often scared of them, leaving them emotionally isolated or even shunned, they were also treated with the most egregious kind of disrespect and lack of empathy from the nearly half of the country who went the path of conspiracy theories, Covid denialism, anti-science, and fear or even hatred of conventional medicine and everyone involved in it. Every New Age spiritual bypasser, yoga teacher, alternative medicine practitioner, and agenda-driven doctor who claimed that doctors and nurses on the actual front lines were exaggerating, that Covid is just the flu, that case numbers are inflated, that the virus isn’t real, that those who care for their immune system can’t die- stuck a knife in the backs of these brave front line workers who risked everything because they took an oath that promised they would.

What Is Moral Injury?

All of this is traumatic. Some of this causes “moral injury.” As I described in a former blog Doctors Are Suffering From Moral Injury, what many think of as burnout may actually be a kind of wounding of the soul. First described as an injury to war veterans, “moral injury” is described by researchers as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

Harvard physicians Simon Talbot and Wendy Dean explain that “failing to consistently meet patients’ needs has a profound impact on physician well-being—this is the crux of consequent moral injury.”

Talbot and Dean write:

“Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of “death by a thousand cuts.” Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. Many physicians contemplate leaving heath care altogether, but most do not for a variety of reasons: little cross-training for alternative careers, debt, and a commitment to their calling. And so they stay—wounded, disengaged, and increasingly hopeless.” 

Let Us Help The Front Line Heal 

What I’m observing from those I care about who are only just now being able to come up for air a bit in parts of the world where the pandemic is getting better is that they are like shellshocked soldiers. Like Vietnam vets who returned from the front lines and were met not with a hero’s victory parade for the risks they took and the courage it required to stay in the line of fire but with angry hippies who spit on them, our front line hospital workers are not getting adequately supported.

Way too many people are still defiantly uncooperative with public health guidelines, refusing to wear masks, gathering together when the virus is still thriving in close quarters, and touting medical freedom as a reason to not cooperate with the humanitarian efforts of mass vaccination. Every person who refused to cooperate with getting this pandemic under control inflicts a new wound on our front-line workers. From what many have told me, uncooperative defiance of public health recommendations, including vaccination, is akin to saying, “I don’t care whether you get exposed. I don’t care if you have to make hard decisions about life and death that haunt you when you try to sleep. I don’t care if your hospital gets overwhelmed again. I don’t care if you die of Covid. I care more about doing what’s good for myself personally than I care about cooperating with what’s good for our world.”

No wonder many of them are suicidal, wanting to leave medicine, inclined to addictions, depressed, anxious, and suffering from PTSD. No wonder many have lost faith in the goodness of their fellow humans. No wonder they no longer feel safe, even when they’re not in the hospital.

What You Can Do

We need to help our front-line workers heal. We can all start by complying with public health guidelines. Get vaccinated if you’re among the privileged who have the choice to get the vaccine. Socially distance, avoid travel, and wear masks until you’re able to get vaccinated. Practice other holistically healthy behaviors so that if you do get exposed and infected with Covid, you’re less likely to wind up hospitalized.

Then extend your care beyond yourself. Those of us who have safely sheltered in place while they took heroic risks every day need to, at the very least, reach out to every essential worker, not just hospital workers, but all who took the risk so we didn’t have to. Offer our thank you’s and heartfelt gratitude. Bring casseroles over. Volunteer child care so they can get a break. Offer money if you have extra, so they can afford to take a little time off and get away somewhere quiet and restorative. Check on those who have been on the front lines. Help them feel appreciated, safe, nurtured. If you’ve been vaccinated and they have too, hug them and support their nervous system co-regulation. Include them socially in restorative time with friends and family. Give them permission to talk about their experiences- and don’t turn away, even if it’s uncomfortable to hear how hard it was. Listen generously if you can. Open your heart. Tell them you’re so sorry for what they had to go through. Send kind cards, flowers, or gifts to let them know you care about the sacrifices they made this year. Say, “I’m so glad you survived.” Make sure they know you mean it.

Heal The Healer At The Whole Health Medicine Institute

At the Whole Health Medicine Institute, we’re doing our part too. One of the three pillars of this training program for physicians, nurses, and other health care providers is “HEAL THE HEALER.” We provide trauma recovery programs, train our students to learn and practice cutting-edge trauma healing modalities like Internal Family Systems (IFS) and the energy psychotherapy Advanced Integrative Therapy (AIT), as well as training to practice a trauma-informed approach to treating patients with life-threatening and chronic physical illnesses. We bring practitioners together so they can share stories, feel safe, open up, be vulnerable, and feel less alone in the struggle to practice medicine inside a broken system, especially during a pandemic.

If you’re a health care provider in need of healing, we have good news! The Whole Health Medicine Institute just opened enrollment for the Class of 2021, which will be 100% virtual because of our respect for those still battling the pandemic and our sensitivity to the risks of travel and in-person gatherings. Since our students are all over the world, we will be offering this year’s curriculum, including three virtual retreats, from the safety of Zoom.

Learn more and apply for the Whole Health Medicine Institute here.

A Huge Thank You To Our Front Line Heroes

Thank you for your service. Thank you for caring. Thank you for being so brave and compassionate and leaning in when others might lean out. Thank you for all those years you sacrificed to learn your craft. Thank you for the sleepless nights, the skipped meals, the strained relationships, the impact this work takes on your physical and mental health. Thank you for your tender heart and all the hands you haven’t been able to hold the way you normally do. Thank you for risking a broken heart.  Thank you for risking Covid so the rest of us could know we’d be in good hands if we needed help surviving this year. Thank you for all the hard decisions you have to make every day. Thank you for being a survivor, even though we know it’s taken its toll. We’re sorry it’s been so hard. We know you’re exhausted and need a break. We value you and want you to get the help you need to begin your trauma recovery journey. We care about you. You matter. You are loved. You are cherished. We stand with you, even as so many of us had the privilege to shelter at home while you took so many risks. May you be blessed by your service and may you know how many billions of people really do admire, respect, appreciate, and feel grateful for all you’ve done.

I’m in talks with Esalen Institute to try to bring some of the front-line hospital workers to Big Sur for trauma recovery, funded by philanthropists who want to help. So stay tuned. We’re doing what we can to try to tend to your vulnerable bodies, your tender hearts, and your strong souls during this difficult ordeal. May you rest, recover, and wind up flourishing on the other side of all this.

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