Welcome, everyone, to the Trauma Center Association of America's audio web on healthcare workers, mental health, and COVID-19 awareness, response, and resiliency. The past several months have been challenging as we continue to face the COVID-19 pandemic. Please know the TCA is committed to helping our members through this. We're actively working with the hospital preparedness and national healthcare preparedness programs under ASPR to share data and information as soon as it becomes available. This information and others are shared on the TCA website on the COVID-19 page and in the TCA news section, as well as through COVID email updates. Our moderator for this webinar is Dr. Samir Fakhry, Vice President, Clinical Services Group, and he is over the Center for Trauma and Acute Care Surgery Research with HCA Healthcare. In addition, Dr. Fakhry instituted a PTSD and mental health care after-injury course and is a TCA past chairman. Before I turn it over to Dr. Fakhry, we ask for you to only utilize the questions tab for your questions. For any operational or logistic problems, please use the chat tab. Dr. Fakhry? Thank you very much, Jennifer. Welcome everybody who has joined us. We're really pleased that there's been such a great turnout for this webinar. I wanted to start by saying thank you to everyone who is out there doing all the hard work on the very challenging situation here in the United States and actually all over the world. Because, you know, without the selfless contributions of so many of you, there would be no hope for us to vanquish this particular enemy. I want to thank my panelists, who you'll meet in just a second. I really want to thank Jennifer and Deborah and the team at the Trauma Center Association of America for putting this webinar together, because I think it would really make an important contribution to the challenges that we're all facing at the front lines and actually not just at the front lines, but everywhere as we try to deal with this situation. I'm going to get started by ... Next slide, please. I'm going to get started by showing you the list of our panelists and welcome them. Fran Sullivan from Flushing, New York, New York Presbyterian Queen, the Trauma Program Manager there. Dr. Jessica George from Dallas, Texas, Parkland Hospital. Dr. Terry DeRoon-Cassini from Milwaukee, the Medical College of Wisconsin. Doug Zasic and Kathleen Maloney from Seattle, the University of Washington. And Dr. Almadel Smith from the Medical University of South Carolina in Charleston, South Carolina. So thank you to all of them for joining us, and you'll get a chance to meet them individually as they give certain portions of this presentation. Next slide, please. I'm going to start with a few words of introduction. Those of you who recognize this book, The Black Swan, know that it's about the highly improbable events that can happen and that sometimes we think will not happen. And the truth is, when they do happen, they have such great impact that we always go back and say, I should have known. We're now facing a Black Swan event, and it's really taking a huge toll on our healthcare system in the United States and around the world. It's taking a huge toll on our healthcare workers, because this is an experience that for most people is totally novel, and in honesty, we're probably not as prepared as we could have been or should have been. There are continued serious concerns among all the healthcare workers at the front lines that I've spoken to and that I've met and I work with about resources, about adequate protection, and about being prepared for a crisis of this magnitude. Next slide, please. We know on the next slide that we've had past experience with this before. There have been epidemics like H1N1 back in 1917, 1918, the SARS epidemics and the Ebola epidemics of recent years, natural disasters and tragedies. We know that there'll be effects on our healthcare workers and on anybody dealing with the situation. These effects are including stress and anxiety, depression, but they also include fear for self and something new for many of us, fear for our families or our loved ones or our friends as we go back into our homes or into the places we go to of spreading this disease. There's a feeling for many people of helplessness and not knowing. All of this has created some significant mental health issues and will likely contribute to PTSD and other effects in the long term as well. Next slide. Although it's early and we have data from the past, we're beginning to see some publications and some data from some of the places that have experienced this ahead of us. This is a report from a group in Wuhan in China that appeared in the Journal of the American Medical Association Network, and they report on some early findings, and it's good at the next slide, Jennifer. Then this group surveyed people that had been involved either at the front lines or supporting the front lines, and they surveyed over 1,200 individuals and found a surprisingly perhaps, but maybe not so much incidence of mental health concerns among these healthcare workers. As you can see there, 50%, 44%, 34%, 70% for depression, anxiety, insomnia, and distress. And they concluded, next please, they concluded that this was a significant problem, as you might imagine, but importantly, they also noted that nurses and women were at higher risk, as were people at the epicenter and the people at the front lines, although not exclusively, but these individuals were at higher risk than normal. So clearly we have a challenge before us, and we thought that we would go over this challenge by providing a firsthand account from somebody who is in New York City who's dealing with this, and then we would go through some of the expert opinions that you'll hear from our panelists about these subjects as ways to perhaps deal with these new challenges we're facing and things that we can do, our organizations can do, and we can do to help each other. So I'd like first to ask Fran Sullivan, who's the Director of the Trauma Program at New York Presbyterian Queens, to give us her firsthand account of what she and her team have experienced with the COVID epidemic. If we could go to the next slide, please. Fran, it's all yours. Hi. Good afternoon, everyone. Thank you for the opportunity for being here and discussing this really important topic. So as many of you know, Queens, New York, we got hit with our first COVID patient in March 1st, and we're still undergoing and seeing a lot of patients that are becoming COVID-positive. They're extremely sick people, as many of you know, and it's affected our healthcare workers in many different ways. It's actually affected our trauma program. I'm the Trauma Program Director, Trauma Program Manager, and I have been deployed and working in the emergency room for the past three weeks. On the night shift, I actually worked last night. My whole entire staff, the registrars, they've been deployed with patient care services, and they're making callbacks to patients' families. So it's affecting them in a different way because they don't know how to speak to these family members. They're seeing stable vital signs in a patient's chart, and two hours later, family members call back and the patient is fired, and they don't know how to handle that. I have one of my registrars going firsthand in the CCU and the ICUs and speaking with family members and doing FaceTime with them so they can actually see their family member intubated for the last time before they most likely will pass away. So it's taking a toll on our mental aspects within our group ourselves. The two nurses that I have in my unit, one of them is working concurrently with me in the emergency department, and the other one is working in the surgical ICU area. So we are seeing firsthand what is going on within the whole COVID system. Our trauma surgeons are actually the surgical and ICU doctors now because they're all critically care trained, and we've had an increased need of the ICU beds. We went from 50-bed ICU to over 120 patients that are ICUs currently right now within our institution. Everyone is vented, and they're extremely ill, and there are some extremely ill patients. As many of you see within the hospital, your own hospitals, on the floors, we're trying to get them and make space for them in the ICUs. There is just a feeling of everyone being overwhelmed. We feel helpless. We have this chaos. Working in the emergency room for over 13 years, 14 years, there's always this organized chaos, but this is something that is just extremely different. Two, three weeks ago, we were admitting 200 to 250 patients every single day. A lot of patients were sent home as well that didn't need to be intubated. We had a specific criteria on intubating these patients, so seeing a lot of patients coming in, especially young patients, what has been really affecting us, because we thought from hearing in Italy that there were a lot of older patients getting affected by this, and now seeing 20-year-olds, 30-year-olds, 40-year-olds, 50-year-olds getting affected by this, and coming in with oxygen levels of 70 to 80%, one right after the other, oxygen tanks laying all over the place, just trying to get a sense of getting some organized chaos out of it has been overwhelming. We feel a loss of control. It's horrific seeing people that you want to do more, and it's especially hard for us when we have to continue to go to the next person because they're so ill that we can't take care of them fully the way we normally would have. They're a month and a half into it. Our census is now coming down, which is great. We get a feeling of reprieve in the ED a little bit, but the same thing is going on consistently in the ICU. The patients that are coming in still in the emergency room are extremely sick, with oxygen levels of 70%, needing to be intubated one through three, and looking for space. Their ICU patients, we probably had about 10 ICU patients last night within the emergency department. We are getting nurse, tribal nurses and doctors coming in to help us, but there's definitely a fear of getting COVID. There's a fear of spreading it to our family members and our friends. There's a sense of gloom. We hear the rapid responses overhead consistently. We hear the codes overhead consistently. We're hoping that it's getting better. It is coming down a little bit, but we still know that there are really sick people out there. Every single time you hear a rapid response or a code, it really gets to you. We're seeing this, and there's no sense of coming out of this. I worked during 9-11. I worked during the SARS epidemic. 9-11 was horrific. Never thought I could see anything like that again, but it was very short-lived. This is just ongoing, and there's just no sense of reprieve. I think that that's making it even worse. I spoke to a few of our surgical residents because I haven't had a chance to even go to the ICUs. They are just ... I can't even explain what they're going through. One resident put it as a level one trauma constantly in the ICUs. There's one patient that's unstable. They're taking care of that patient. As soon as they take care of that patient, put them on more drips, start CBDH, prognome, doing what they need to do with that other patient, the next patient next door to them is ready to code and doing the same thing. There's no sense of ever coming out of this black hole that they have. It's terrifying. There's a lot of new nurses that I've seen in the emergency room. Obviously, they've never seen anything like this. I've been a nurse for over 20 years, and I've never seen anything like this. I come home. There are days that I come home and I cry. There are days that I come home and I don't know how to speak to my family because I don't even know if I want to burden them with what I see. I do want to burden them with what I see. We do have some resources out there in our institution. They've made it abundantly clear, getting help for us, and some people have reached out. We huddle at every shift. Last Wednesday night, we huddled, and the director of the emergency room, we say prayers. We have our team come up and visit the ICU, so we have our pastoral care that can give us support, which do help. Wednesday night, our emergency room director came in and just wanted to give us a sense of not letting these patients who are dying actually die alone because their families aren't with them. It's really taking a toll on us because we want to be there for them, yet we want to help the next patient. There's just so much going on at any given moment that it's really difficult to take it all in and put your best foot forward and go forward every single shift. It's difficult, but hopefully it's getting better. We are on that curve. It's getting better for us. Hopefully, it doesn't return. Trent, thank you very much for that heartfelt and I'm sure very difficult testimonial. We really appreciate your telling us about what you and all the others are experiencing. We thank you for the time and for the commitment. We're going to go ahead now and go to our first panelist who will provide us with hopefully some of the answers that we need to address this crisis. Dr. Jessica George is going to discuss staff support and peer support. Jessica, go ahead and take over if you would. Okay. Thank you so much. My name is Jessica George. I'm a psychologist at the Reese Jones Trauma Center at Parkland in Dallas. I also thank you, Fran, for telling us that we're a lot behind you. We haven't even hit our surge, so it's hard to imagine being at that place you're at. I wanted to start out before talking about staff support that all those things that you just talked about are totally normal reactions to an abnormal situation. It's totally understandable and valid. Before we get to saying PTSD and depression and all these things, we're not there yet and you're all having normal reactions. I think we have to remember what our trauma patients and families teach us, that even if you face the most difficult thing in your life, most of them are okay. Hopefully there's some hope. I know we're going to talk about resilience later. I don't think we should pathologize what we're experiencing, but we also shouldn't ignore it. That's why we need a staff support system. Next slide, please. Thank you. What I'm going to talk about is a tiered staff support model, which is what we're using now. If you start at the bottom there, it's tier one, that's the frontline response, and that is really based on peer support. Peer support is non-behavioral health staff who are trained in psychological first aid to meet with staff who are stressed. We know that staff are not likely, especially trauma staff, to reach out to the employee assistance programs and traditional psychotherapy, so they seem to be more inclined to reach out to peers. At Parkland, what we've used, we used grant money to purchase training from the John Hopkins RISE program, which maybe some people who are listening are part of that consortium. It's a well-established peer program. Right now, actually, for a resource, they are providing their peer support training manual for free. If you go to their website, you can email and get a free peer support training manual, which is a great resource they're providing. We have 73 peer supporters right now. Luckily, we have this in place a year in advance of the COVID pandemic. They're from all over the hospital. They're VPs, techs, pharmacists, IT, anybody who volunteers and has been identified by their leader as being a good listener and someone who would be good at this job. They provide that support, so we have 24-7 call and page, and that's really important because you know night shift needs to have the same opportunity for peer support as day shift. You need to have 24-7 capabilities. I will tell you from February to March, we've had a 1,200% increase in our call volume, so clearly people are distressed and not even at the point where they are in New York. The peer supporters, the first tier, what they respond to is mild to moderate, just the normal distress that you were talking about. If it gets more severe than that, they escalate it to tier two, which you can see right there. What that is, that's peer support as well, but it's licensed behavioral health professional peer support, so people like myself and counselors will meet with them. We've told our frontline peer supporters to look for critical incidents, like you were talking about, Fran, with the registrars who are doing things they don't normally do. That would be escalated to the more advanced psychological first aid on site. We respond within 30 minutes to the call, and then within 24 to 48 hours, we provide the psychological first aid. If you don't have peer supporters already trained, I think what you're doing is great in New York by using the chaplains. They are peer supporters by nature, and they understand the system, so that's good. Also, you could have units identify people who people are naturally going to. There's usually on every unit somebody who's that support person, so you could mobilize them and give them some training to provide support. If you don't have a behavioral health staff who could be dedicated to this, you could look for people who already do have licenses, so we found some licensed clinical social workers who normally don't do therapy and things like that, but they volunteered to be backup for staff support. Also, in talking to our trauma surgeons and residents, they mentioned that they don't really feel comfortable talking to someone who's not a provider, so it also is important to have some providers who have some training, and that's also in our Tier 2, where we have provider peers who can talk directly to providers if they request that. And lastly, our Tier 3 is what you would think of as that traditional psychotherapy and counseling, patient counseling, so that would be the escalation to there, and that's for people who are going to be having those moderate to severe symptoms, and maybe they have a history of trauma, history of mental health issues, and they need that extra support. What we've done is we've partnered with our behavioral health service line. They're donating their time to provide telehealth to staff who need support for COVID stressors. If you don't have that, you can look locally. There's so many agencies right now that are donating teletherapy, Talkspace.com. There's a million of them. Even if you don't have it locally, look around and see what you can do there. So the peer supporters are the gatekeeper, and then they escalate up as needed. Next slide, please, thank you. A little bit more about the peer supporters. I've already talked a little bit about their qualities, who would be a good peer supporter. The most important thing you can look at under competencies is boundaries. We do want to protect the person who's calling, so we don't want peers to provide amateur therapy. This is intended to be a one-time encounter, a psychological first aid to just get people going so they can get back to work, so the peer supporter needs to be able to have good boundaries for that. In addition, we want to protect our peer supporters. This is probably the first time ever where peer supporters are going through the exact same thing as the people who are calling. So what we've done for that is we've set up our report for the supporters, so we have twice-weekly meetings with the peer supporters to check on them, talk about self-care. We want to prevent there being third and fourth victims, and we want them to say, hey, I can't do this right now, and they can, without consequence, say that they aren't able to provide peer support at the time. So we want to make sure we have boundaries. As far as the task, the most important task that peer supporters can play right now is being ambassadors of support in their unit. So because we have peer supporters across the system, including trauma, they can be informally and proactively providing support, education, resources, and referrals, which is really helpful. So we might not actually get calls to our official system because they're already providing it. So that's the benefit of having it across the system. What are they doing in their encounters? The main thing they're doing is coping. All the things that you guys have questions about and that Fran was talking about, they're giving ideas for how to deal with the stress, the lack of control, and all of these things, and providing a safe space to talk about it, which really goes a long way for some people. Next slide, please. Here's a few more strategies and resources. So if you're going to have a staff support program, you do need to have multiple ways that people can learn about it and can contact. So phone number, pager, email, screensavers, videos, bathroom flyers, I think we even started doing. So people don't have time to check their email sometimes even, so you want to make sure that they can find out about it. Also, especially trauma people, they might not be talk therapy type people. They might not want to sit in a room and chat privately. So you want to have other options for things they can do, like we were talking about with the prayer huddle. If you're doing that too, that's a great way that people can get support without having to talk about their feelings. I think we're doing little yoga moments. We're also handing out lists of apps. There's all these free apps for doctors and healthcare workers right now for meditation. There's fitness apps. So you want to give people a lot of options to help with their stress, other than just sitting in a room with someone. Proactively, we're going to units. We don't normally go to units and say, hey, does anybody need support, but we're doing it now because people can't get away. They might not even think about their own stress. So we're going to the high acuity unit, not only trauma and ICU, but also places like environmental services, language services. They all need the support too, maybe more in some ways, because they may lack resources generally. We made a little tiny pocket resource card that just fits in your scrub pocket. We have it everywhere. We can send it electronically with all the COVID specific resources. And then we also, because we can't meet in person, we've changed all our conference rooms into respite rooms. So they're all over for staff to go just sit and hang out if they need time away. Ultimately, my main message, I guess, to take away for staff support is that we're all staff supporters right now. If you see someone stressed, say something. Trauma people are not normally going to ask for help, and a lot of us in healthcare don't even recognize when we are stressed. So we all need to be looking at each other and making sure we have buddy systems and just ways to help someone. If you see someone stressed, say something. So that would be my take home message is to be not only watching yourself, but watching your colleagues. And if they're not right, letting them know what is available. Thank you. Thank you, Dr. George. Just a quick reminder to all the panelists and the organizers, could you please make sure your phone is muted and your system is muted during the presentation? We're getting some static in the back. We're going to move on. Next slide, if you would, please. Next, I'd like to turn it over to Dr. Terri Darun-Castini from the Medical College of Wisconsin. We've worked together on the PTSD and Mental Health course at the Trauma Center Association of America. And today, Dr. Darun-Castini is going to talk to us about assessment. So, Terri, you're on. Thank you very much. Thank you, Dr. Fakhry, and thank you to all the panelists and Fran for sharing your heartfelt story about your experiences on a day-to-day basis. I also want to say thank you to all the healthcare professionals out there that are working so hard. It's truly inspiring to see what everybody's doing and how much they're dedicating to the care of the patients coming in. My name is Terri Darun-Castini, and I'm the Director of Trauma Psychology for our Level One Trauma Center here in Milwaukee at Prater Hospital and the Medical College of Wisconsin. So I normally provide care to our trauma patients, which we're continuing to do, but I wanted to talk today about how do we self-assess where we're at in coping with what we're going through as healthcare providers. And I want to also say that there's many providers at this institution that I'm lucky and fortunate to work with and have to collaborate with on how do we support our healthcare professionals here at our institution. I'm going to mention some of them when I talk, but there's quite a few that are very dedicated to helping individuals as we cope with the patient care. If you could go to the next slide, please. One of the ways that we've really tried to frame and understand where people are at in their coping is really thinking about it really on a public health model approach of primary versus secondary prevention. And so this really echoes the sentiments of Dr. George when we really think about if we're stressed right now, that's pretty normal. If we're feeling heightened stress and it's kind of constant, that's because it's mimicking an appropriate response to a very abnormal situation. And so it's important, as Dr. George indicated, and I think it's so important we need to repeat this, that if individuals are distressed right now, that's not necessarily indicative of psychopathology. That's indicative of individuals experiencing stress and continuous stress. When we think about the prevention model, we really want to think about primary and secondary prevention. And the way we're thinking about that related to stress after trauma or after COVID or experiencing COVID is where people are at in the continuum of resiliency and distress. Primary prevention is this idea of really trying to prevent long-term consequences of the stressor from happening, where secondary prevention is really focused on working with individuals who are experiencing distress and maybe having more targeted intervention towards those symptoms in order to prevent that long-term distress that might happen. As Dr. Fakhry had presented, we're seeing an increased rate of depression and anxiety in individuals in the Hunan province who are taking care of COVID-positive patients. We want to try to prevent that from happening in our own healthcare workers. Schreiber and colleagues had developed a model to really think about how do we do primary prevention in cases like this. This is really a way of evaluating where am I on the resilience continuum and what can I be doing to continue to maximize resilience, because we know the majority of the people are going to be resilient. One way to do that is to really anticipate stress and evaluate coping. We all can anticipate that these experiences are stressful. We want to evaluate how we're coping ourselves. For example, if one way that we would normally cope when we're stressed is by connecting with others and being social, we know that therefore there's a barrier to that currently. That leads into the third bullet point here is once we evaluate how do we normally cope with stress, we want to identify are there particular barriers to that coping. In this instance, obviously, getting together with some friends to decompress and cope with some sort of stress isn't possible, but are there other ways that that can happen? That leads to the next bullet point. Can we revise our coping as necessary and activate new ways of coping when signs of stress occur? I bring this up, it's very intuitive. We want to be able to evaluate where we're at and we want to say, what do we have as a resource for ourselves in order to deal with this stress? Are those resources available to us? Do we need to change a little bit of how we're coping? If so, when do we know that we need to activate that coping? I encourage anybody listening to really think about where you are with this. What are the ways that you typically cope and are you able to engage in that? If we could go to, I think I just lost all visual, but if we could go to the next slide. There we go. When we talk about secondary prevention, this is really about reducing distress. As Dr. George pointed out, the majority of people are going to be experiencing resilience as a result of the stressors that we're experiencing, but some people and less so, less individuals will experience some distress. What can that look like? Thinking about what does that look like for you and where you're at right now? Some of the things that have been pointed out in the literature recently and in relation to other epidemics are difficulty falling or staying asleep. It's important to distinguish what is it that is preventing you from being able to fall asleep? Is it ruminative thoughts and worries about what's happening? What is preventing you from being able to stay asleep? If you're able to evaluate and assess where you're at with that, that might help to inform some way of doing some sort of intervention to help with your sleep. Other common responses that are exhibiting distress are anxiety, anxious, worried thinking. When we heard Fran's testimony to what's going on in New York, there's lots of things to be concerned about, right? Being concerned about infecting loved ones after returning home from a shift. Worried about am I being able to provide the highest quality of care to all these patients that are presented in front of me when you keep having to just run from patient to patient to patient? Those worried thoughts are indicative of experiencing anxiety and are, again, very normal because you want to be able to identify what are your challenges and what do you need to work towards? We know that this anxious state also, at times, can experience agitation and just a general sense of hyperarousal and stress, and that's just that sympathetic nervous system being constantly activated and constantly looking and evaluating the situation. Others can kind of present also with some more of a dysphoric presentation, so experiencing sadness and spontaneous crying, feeling down, and that leads into a little bit of the grief piece. There was a wonderful webinar a couple weeks ago about what in the world is it that we're experiencing because it's hard to pinpoint the surrealness of what's going on across the country and world. It's even hard to put words to what we're all feeling because it's not something that we've really ever felt before, and some of that is a component of really experiencing loss, a loss of way of life, literal loss of life, depending if it's a loved one or a patient, and that can lead to just kind of a feeling of surrealness and ambivalence. A lot of us can experience different spectrum or phenotypes, if you will, of these different symptoms, and it's important to ask yourself, okay, am I in any one of these kind of categories, and if you are, thinking about, okay, I might want to reach out in order to talk through this with somebody. I can say in response also to what Dr. George presented, we have a three-tier peer support model at Trader Hospital and the Medical College of Wisconsin. It's led by Drs. Tim Klatt and Alicia Polarski, who has been the main force of it. It started over a year ago. And we've been able to set up a process, too, where we're visiting especially the units that are hard hit by COVID. And so we're doing that on a daily basis. And we have a tier two and a tier three provider that are going together and just touching base with people. The way in which we're touching base is very informal, but we do know that over time if we need to, we can escalate support to those that are experiencing kind of the distress components that I talked about, while also just, you know, having opportunities to really talk about the successes and stay and also maintaining resilience with our healthcare workers. So one of the themes that I thought was really wonderful that Dr. Klatt shared when he visited a unit the other day was that the providers really wanted to be able to highlight the success stories of those who were COVID positive patients who ended up being discharged and going home. And so they created a poster that they have on the unit. And every time that they discharge a COVID positive patient, they update the numbers on that poster. And it's something that they really celebrate. So really trying to also identify ways in which the positives of what's happening are being celebrated was a beautiful thing that kind of came out of one of the debrief sessions that our tier program did. So I think I, I don't think I have another slide. Let's, let's move forward. Yeah. Oh, actually, sorry about that. I forgot about this slide. So these are just some tips and thinking about where you are on the continuum of distress and what you can do from an intervention standpoint. So changing sleep surroundings or no electronics 30 minutes before bed could potentially help with sleep. We are getting inundated on our phones, right between emails and what's available on social media about COVID and really trying to step back from that before you try to sleep and giving yourself that 30 minute buffer is really important. Another thing that can help with in relation to anxiety is really acknowledging change and focusing on what is controllable. You know, there's so much that's in control of our hospital systems and leadership that as providers, we have no control over. So acknowledging that things have definitely changed and then in moving towards a point of acceptance with that, but then focusing on what, okay, well, what do I have the ability to work towards today and cope with and change? Because I can, I'm sure when we can, we want something to be different and we can't make it different. It's like pushing a brick wall, right? We're not going to get anywhere, but we're going to use a lot of energy to make something, try to change that we have no control over. For symptoms that are more dysphoric in nature, engaging in activities that are possible, even like the socializing through Zoom. I know there's been a lot of people that have been connecting virtually. It's not the same, absolutely, but it's also an opportunity to see your loved ones or see the people that are support providers for you and really being able to connect, even if it's a little different than the way we used to connect. And finally, related to grief, naming and accepting the loss that we've experienced, whether it's the loss of loved ones, the loss of coworkers, or really the loss of kind of our normal way of life and focusing on what is going on in the present. That present focus can help us as there's lots of things that have changed. Daily things are changing for all of us and so really focusing on the present can be a way for us to feel a sense of acceptance in what's going on. And I'll leave it there. Thank you. Thank you very much, Tara. We appreciate that review and pointing out all the important things that perhaps we can do to help each other, help ourselves. We're going to move on now to a presentation from Kathleen Maloney and Dr. Doug Zatzick. Dr. Zatzick is not on the video because he was just giving patient care and is going to be with us. Quarantine. Yeah. Yeah. And then so Kathleen and Doug, please go ahead and share with us your thoughts on frontline provider ethical tension. Thank you. All right. Well, I'm Kathleen Maloney, as Dr. Fakhry just said, and I'm a research coordinator working in the Trauma Survivors Outcomes and Support Group with Dr. Zatzick. And first of all, I just want to say that it was really great to listen to everyone's talks and to your firsthand perspective, Francesca. So thank you all for being here today and for everyone for tuning in. So today we'll be talking about some of the ethical tensions that the TSOS team faced during the first two weeks of the COVID-19 outbreak in Seattle, Washington. And to give you a little background on our team, we're made up of patient peers, frontline clinicians, and research coordinators like myself, and we all work at Harborview Level 1 Trauma Center in Seattle. Next slide, please. Thank you. And so this will seem like ancient history in the context of a pandemic, but as the map on the left shows back in early to mid-March, Seattle was the U.S. epicenter, at least in terms of mortality for COVID-19. So we were experiencing a really serious outbreak at that time. And our group in normal times is focused on early interventions for survivors of traumatic injury. So we work with patients at the emergency department, at the ICU, in acute care inpatient wards, and in-person interactions are really critical for our engagement, but obviously a big coronavirus exposure risk as well. So what we found was that during the early part of the pandemic, there was a lot of tension between fulfilling these clinical obligations that we had to our patients on the one hand, and then on the other hand, preventing that exposure to coronavirus. So it was a really hard time. There was a lot to grapple with there. And we were constantly looking for guidance or information on how we should sort of like handle these decisions, but because the situation was developing so rapidly, it seemed that information would change on a daily, sometimes even hourly basis. So it was really hard to get clear guidance. There would be things released by the CDC, by our own university, the University of Washington, and from other official sources, but because everything was changing so rapidly, it seemed like things would be out of date almost as soon as they were released. So our team already had a morning meeting that was part of our daily routine, and that meeting would usually include members, all team members, our patient peers, our clinicians, and all the research team members as well. And that meeting naturally sort of evolved into a discussion of COVID-19. So it became sort of a huddle that we began every day discussing the multiple sort of complex layers of this pandemic as a team. And what was really, really important about that huddle was that it was sort of an open forum for any questions that team members had, any concerns they needed to express around coronavirus, whatever that might be. And a lot of times there wasn't necessarily a clear-cut answer that could come out of that huddle because the information was changing so rapidly, but we would try and keep a log of any questions that couldn't be answered or concerns and then bring those to a local on the ground point of contact at Harborview if we could find one or a local on the ground expert and try and receive the most like timely updates possible that we could so we were using up-to-date information. So we've captured some of those observations that evolved out of these early discussions and experiences. And for example, if you could move to the next slide, we've outlined here some of the ethical tensions that our team was really experiencing during the early weeks of the pandemic. So our team was experiencing sort of these poles as they tried to fulfill obligations to patients, to their own families and protecting their family safety, and to broader society as a whole. And to give you an example of how this played out on our own team, we had a clinician on the team who had an aging parent who was housed at a long-term care facility in Seattle. And as I'm sure everyone is well aware at this point, many of the early fatalities in King County occurred when coronavirus spread throughout a long-term care facility. So this was even early in March, we knew that this was clearly not the best place for an aging parent to be right now. But on the other hand, the provider was also exposed to coronavirus potentially throughout the course of her clinical duties at the hospital. She had spent a lot of time in person with patients at the hospital. And because testing was very limited at the time, university regulations didn't allow asymptomatic providers to be tested. So she was really left to grapple without a clear answer of whether or not she had been exposed with whether it was better to bring her mother home and house her in her own home and potentially risk exposing the mother herself or to leave the mother in the long-term care facility where she could potentially be exposed as well. So we were kind of deliberating this early on without any clear-cut answers. And about two weeks after we were discussing this issue, an article came out in the New England Journal of Medicine discussing this exact thing that there had been a really rampant spread of coronavirus through these long-term care facilities with really high fatality rates. But again, it was just an example of an issue that came up really early on that there wasn't clear-cut guidance yet at the time that we were discussing it. So another example of how this played out on our team was that we, early on in the pandemic, had really painstaking deliberations every day at the huddle about whether or not we should have our patient peers continue to see patients in person. And they're a really important part of our intervention in that in-person engagement is a very critical component for our patients and the care that they receive. But one of our peers is over the age of 70. Some of our other peers have chronic health conditions that would put them at higher risk for developing a severe case of COVID-19 if they were to be exposed. So we were really struggling early on with how to weigh those competing tensions. On one hand, we have this commitment to our patients to provide them the best care possible. And on the other hand, we have a commitment to protect the safety of our team members. So we would discuss this every day, check in about it, see if there had been any updates. And I think Francesca touched on this earlier, but there was sort of this idea early on that younger team members wouldn't be as vulnerable to the virus if they were to be exposed, that they wouldn't develop a really severe case. But about two weeks into our discussions around this, we learned that a 44-year-old emergency room doctor was intubated at a nearby hospital after contracting the virus during the course of his treating patients that had come to the emergency room, and that his own colleagues were now caring for him in the ICU. So with this new information, we decided to pull all non-essential staff immediately from in-person meetings with patients. So there were just constantly instances like this where new information was coming in, and we had to really quickly adapt and decide as a team what to do. So this issue with whether or not to have patient peers meet with patients in person might seem like old news at this point. This was the first two weeks of March, and what was being debated at the time has long since been decided. But the key point to take away from all this, and if you could go to the next slide. The key point to take away from all this is that we all need an awareness of what the issues are, because there will always be these sorts of decisions that we need to make without a clear-cut answer or the best guidance available, as the pandemic is always changing rapidly, and that it's really critical for us to have a place to bring these issues and questions such as this huddle that our team had, so they can be safely discussed. This slide kind of outlines the various phases of disaster response, and long-term, what we all need to be thinking about proactively is how to keep buoyant in the face of potential dips into disillusionment, which are sort of a natural part of the cycle of every disaster response, but can definitely be prolonged and deepened by this feeling of having these decision-making tensions inside you that you don't have a place to discuss. So everything we've discussed on this call, including proactive awareness and the ability to discuss tensions that frontline providers may face, can potentially facilitate this resilience in what looks to be definitely an enduring pandemic at this point. So we just hope that some of these examples were helpful in helping some of you think through some of the decision-making tensions that you might be going through right now. Yeah, great job, Kathleen. And Francesca, just to, you know, hearing you, like I've been through 9-11, but this is like, you know, that's a sprint, this is a marathon. We did, our team did disaster relief work in Haiti, and, you know, this is a long-term sort of set of issues for trauma care providers, and it's really important that we stay aware of the potential sort of dip that takes place when you're done with the sprint. I think it's a key issue for us all. Anyway, great job, Kathleen. And we'll be quiet now and let Alma do her thing, so. Great, Kathleen and Doug, thank you very much for your presentation. We're going to move on now to Dr. Alma Del Smith from MUSC in Charleston and ask her to talk to us a bit about enhancing personal resilience, because as you're hearing, this is not a sprint, it's a marathon, and resilience plays a huge role. So, Alma Del, please go ahead. Hi there. It's great to listen to all of you, and we've been tracking everyone's work so closely. I work at the National Mass Violence and Victimization Resource Center, and it's usually responding to, you know, bombs and shootings, and I'm a victim of violence and victimization. I'm a victim of bombs and shootings and things like that, but this is a mass violence incident on a massive scale. Let's start with the first slide. Just as people have spoken, you may be scared, angry, discouraged. All of that is really realistic. I think one of the things people don't talk about as much is the angry part, which is, like, somehow this isn't fair, how can this be, and that's part of the reaction to the loss is that we want to, you know, say, couldn't it have been different, or finding who to blame, and, you know, this is not the time to do that. We can do that afterwards. Right now, it's that quick, but if you're feeling these feelings, just remember you're also courageous, and persistent, and awesome, and that's as real as those moments where you go home and cry, or you're crying in the Uber going home, and nobody to talk to, because if you tell your loved ones, they're going to be upset, and if you tell your peers, they're already in the middle of it. So, it's really important what we've identified, those people who are, like, not on the front lines, but who understand and can hear you out, and, you know, that you're not alone, and I think my last line here, you may be tempted to focus on coping with the crisis, and forget to take care of your biggest asset, and that is your own health and well-being, and somehow, we're, like, how can I take care of myself when people are dying, but you put on your own mask before assisting others. Next slide. So, just as a quick list of what helps you with resilience, these are all things you probably know, and I'm just encouraging you to be reminded and fine-tune those of you who are out there on those front lines, your health, and one of the main things is to sleep. It's been mentioned before, soldiers on the front line know if you have an opportunity to sleep, take it. You may have to delegate things at home, and not be as available to other people when you're off duty, but you may need to just go home and sleep. Sometimes people think a glass of wine or alcohol will help them sleep. This is really not so great, a little bit, maybe, but often alcohol will interfere with sleep. If your mind is racing, there are these sleep apps, and also the breathing technique that I'm going to do at the end, which will also help you with slowing the mind and just coming back to the body and talking yourself into sleep. Eat well, not too much sugar, don't start your day with a donut. Try to get, start your day with as good an efficient as you can. Again, you're running around, but exercise that's aerobic to get your heart rate up, even if it's just jumping jacks for 10 minutes in your kitchen. These are ways that your body cleans out the toxins. You're really, the stress will start, will release a lot of adrenaline, which is that kind of brassy taste in your mouth. You can really taste that fear, that intensity of the adrenaline, and so allowing, sometimes exercise will help you kind of metabolize that out. Managing energy is another thing, because sometimes we get really hyper, and how do we slow it down? There's a lot of pressure on you, there's, I mean, I'm feeling it, I'm talking fast, that kind of thing, and then it's just like, pause, take that breath, slow down. You know, when you drive your car, if you're driving between 40 and 60 miles an hour, you'll get there, you know, and you won't crash. If you go too fast, you might make mistakes, so learning to, when to pick it up the pace, and when to take that pause. Accept this rolling coaster of emotions, they're all human emotions. Sometimes we can escalate a feeling by the kind of thoughts we have, the kind of self-talk, so that you can, you can actually make it worse by dwelling on, it's not fair, how could this happen, or how awful it is. It is what it is, you're going to do the best you can, and that positive mindset of, you all have a real purpose here, this is extremely meaningful work that you're doing, and people talk about hope, and Viktor Frankl wrote a lot after his concentration camp experiences in the war, and he talks about hope in the middle of tragedy, and it's that glimmer that this is happening, yes, as somebody mentioned, you're not in control of everything, but if you have control of something, and that one moment of compassion to your fellow workers, that moment of compassion to the families, and the person who's perhaps dying or suffering, this means an awful lot. It does matter what you do in all these small ways, so trying to come back to that sense of optimism there, we are seeing such loving care, we are seeing amazing people doing amazing things in the face of something that's just, you know, it's the tsunami. That ability to solve problems and think clearly, again, if we, when you're really stressed, if you're able to pause and slow down and take that breath, that helps you think more clearly, and know what is the next thing to do. You've got 10 things in front of you, you can only do three, so that choosing perseverance, but also knowing when to rest. We've talked a lot about relationships, and there's a couple of things in the research and resilience, and that those people who have good support do better, period. Whether it's heart attacks, whether it's loss of a loved one, whether it's exhaustion, and some people have wide networks, and some people just have a few, but if you have one or two people that you ask, can I lean on you during this time, that's a good thing, and they may be far away, and it may be your journal, but that kind of support is important. The other thing that's important, it's hate to say this, but having good connections. One of the things they found after Fukushima, those people who knew people who knew who could help, like how do you get a mask? Who knows who who can get masks? Who knows who who can get us this, and some ethnic groups don't have those connections to power or influence, and so we have to be particularly supportive of those folks who may be different from, who may have come from a different background, and may not have those kinds of political and social connections that we do, and so in that instance, be conscious of how you can reach out and help others who may not have the resources, because having a lot of resources makes a big difference, as you all know, and then there's this last part of accepting what is and out of control, but next slide. Let's move on. Yeah, we only had a couple minutes. Workplace support. You've talked about programs that are wonderful to have workplace support. Your leadership is important. Getting good supervision is important. Taking the time to supervise those, especially young ones and experienced ones, are going to have more trouble than those people who have 10 or 15 years of experience. Meaningful participation is really important as we go forward, and also in the long term, as we look back and do the after action reports, like being able to share this is what we learned. Let's not do that again. The training, and you asking for training and the specific things that you may need that you don't feel completely trained about, and certainly this health and wellness. Next slide. I think, let's, is there one more slide? One of them got jumped. Here we go. That's the one I want. So, let's go back to stay calm. There. I'm going to ask everybody listening right now to just take a long, slow breath and relax your shoulders. We've been talking about really difficult things. We've been talking about really difficult things. You're facing really difficult things. But as somebody mentioned, this is a marathon. And sometimes, you know, you're not racing for time, you're racing for survival. And if you need to just stop and rest, even, and those of you who do like athletics and work out, you know that a two minute rest can make all the difference in your ability to pick up that weight again. Certainly, nine hours of sleep is a beautiful gift. So, the idea of taking like three or four slow breaths in through the nose, out through the mouth, counting on a count of four. When you do slow deep breathing, your heart rate slows. We know it's sinus arrhythmia, as cardiologists know that. And if you do several, as your heart rate slows, it signals to the rest of your body, signals to your gut, signals to your muscles, drop your shoulders, and it's okay. In this moment, just slow down. And that brief rest allows you to get up and go again. One of the other things that happens when you do the slow breathing and the counting, four in, hold it, and four out, the mind shifts from the multiple thoughts that are going on, the memories of what happened that morning, yesterday, and it grounds you in the present moment and allows your mind to become still and quiet. So, it's let my arms feel heavy and relaxed. Let my breathing be gentle and even. Let my mind become calm and quiet. I have used that particular thing in my entire career since internship. To take three minutes, eight minutes, if you have it, in that respite room, if you have it, when you come home and you're crashed on your couch, rather than watch TV or distract, just take the time to completely let it go. If you drop off to sleep for even two minutes, it's different, but it may help you also to sleep your nine hours. And that last one, let it go of what you can't control. You may also have practices. You may do yoga. For some people, their exercise is a way of just being in the present moment. You may knit. One guy played racquetball because as long as he was following that ball, he couldn't think about work. You have those ways that you know, and I'm just saying, you need this more than ever. The resilience is also this belief that somehow, and we don't completely know how, we're going to get through this and that's enough. Dr. Zaheer, thank you very much. I think we've ran out of time, unfortunately, and so I'm going to take a second, first of all, to thank all of our panelists and then all of our participants. We have time for, I think, one or two questions. We've had questions sent in before, so I'm going to only be able to address, I think, one of them, and I think a lot of material has been covered today, but one thing that I think a lot of people have asked us about is what about the individuals who are not at the front line and who perhaps feel a sense of either guilt or not being there to help or not doing enough. Is there any advice that our panel can give to somebody who feels those feelings for not being there to help or not being able to help, whether it's because they're not in a place that needs additional individuals or because they've aged out or have comorbidities that prevent them from being at the front line? So perhaps by a show of hands, if one of the panelists would like to address that, and we probably have to close after that. Do you want me to do that? Sure. We've got probably about 30 seconds, Dr. Smith, if you don't mind adjusting that. That would be great. Thank you. I think one of the things is to be one of those listeners that you're not there, but you can hear whatever it is that someone has to vent. And also those little messages of support I think makes a difference. And to know that guilt is one of the feelings that people have, and we ride that feeling out, resentment, we notice them, we feel them, and we come back as best you can to a positive framework. That's great. Thank you. And if anybody else would like to add any other comments, Dr. George, did you want to add to that? Yeah. I was thinking it's actually beneficial to have these people at home right now who are going to be able to have the energy and be charged up, because once this powers down, the people who are in it right now and have to be at work are going to be exhausted and are going to need relief. So that's really one of the best things and best case scenarios to have these backup people who, when it's time, they're going to have such an important job to come and relieve people. So I think that if you can be patient and get to that point, that's going to be one of the most important and meaningful jobs you have. Thank you, Dr. George. And then finally, several people have asked, and I think we do have to address that even though we're running out of time, but are we getting enough support from our institutions? Are we getting enough support from the people in positions of authority in government? What does the individual do who feels that sense of helplessness or not having enough PPE or not knowing whether they're going to have any help to get off their shift the next day? What can we do to help allay that feeling of stress and anxiety and helplessness that some individuals might be feeling because of these pressures that are outside of their control? Yes, Dr. Dominguez-Singh, thank you. This is hard to answer. This might be hard to answer just because everybody's situation might be a little different. But really going back to this idea that there are certain things that maybe should have happened sooner or we should have had certain levels of PPE available and we didn't. But unfortunately, the reality is what it is. And so really thinking about, okay, who can I communicate in my leadership chain who I can express my concerns to? But then also, some of the things we saw in our units was that the nurses on our units in particular really came together in their concerns and they went through a brainstorming of, okay, how can we reach out to get appropriate PPE and even get masks on our floor? And in the early stages of the pandemic here in Wisconsin, we were getting PPE from basic science labs and that they were just getting dropped off on the units. And so it was a moment of, yes, this is really stressful and frustrating. Let's communicate with leadership on what we would like to see happen. But also as a group, how can we problem solve this? So that gives us a sense of control and action towards the problem. Thank you, Terri. I think we've had a lot of excellent input from everybody. Thank you very much, panel, for all your contributions, all the work you're doing to help our frontline healthcare workers. Again, I appreciate the opportunity to moderate this panel with you and thank the TCA for all they've done. I'm going to take away a couple of messages from what I've heard today. And the first one is, I know there's going to be other Black Swans, and I think we're going to learn something about ourselves and how prepared we could be or should be when we come out of this. And we will one day. I think we've learned a lot of lessons. And if we haven't before, because this has happened to us before, hopefully this time we've learned the lessons to be prepared, to help each other, to take care of ourselves. But I think the future is going to hold another surprise or two for us. And so I'm going to take the optimistic perspective and say, as hard as this is, we'll come out of this stronger than we were before. And we're going to lose a lot of people, and there's going to be a lot that we're going to have to grieve about. But there will be an end to this. And I suspect that we will do better when we're faced with this again. So to all of you out there who are doing the hard work that needs to be done, thank you again. And to the panelists, again, thank you. And we appreciate the audience. We appreciate the opportunity to share some of these thoughts with you. So thank you very much to everyone, and hope you have a great week, in spite of everything. Thank you. Thank you, everyone. Take care. Thank you. Bye-bye.

healthcare workers

mental health

COVID-19 pandemic

challenges

prioritizing mental health

ethical tensions

staff support

peer support

assessment of mental health

personal resilience