Adam Linehan deployed to Afghanistan as a platoon medic in 2010. One day while out on patrol, an Afghan man in a white robe walked into the middle of the patrol formation and self-detonated an improvised explosive device. Linehan was uninjured but found himself surrounded by a mix of Afghan and American casualties, wounded and dead, as he quickly began triage to decide who to treat.
“Many people won’t want to hear the stories of health care workers, who will have to carry their memories isolated in the truth,” Linehan says.
Similar incidents followed throughout a tour that left him suffering from PTSD and what he refers to as survivor’s guilt, an anxiety disorder that is increasingly recognised as a type of moral injury. This affliction of conscience—described as an invisible wound to the soul—most often occurs when a person commits, fails to prevent, or witnesses an act that is anathema to their moral beliefs.
“It happens especially under high stakes situations where no good choice is possible or when emergency situations require rapid responses by instinct or training with no time to weigh a decision,” says Rita Brock, co-author of Soul Repair: Recovering from Moral Injury After War, and the director of the Shay Moral Injury Center.
With COVID-19 spreading around the United States, rampaging in areas such as New York state, health care workers are finding themselves in similar positions to army medics like Linehan on a battlefield—prioritizing who gets treated and who doesn’t. In essence, deciding who might live and who dies.
“Few people in health care have had real-life experience with triage in which a significant number of life-and-death decisions had to be made because of equipment shortages,” says Arthur Markman, a professor in the department of psychology at the University of Texas at Austin. “That increases the chances that they may experience moral injury as a result of their jobs. The overload of work that first responders and medical professionals are experiencing are likely to prevent a lot of real reflection on this moral injury in the moment.”
Fortunately, not all U.S. hospitals are swamped yet. The situation health care workers face varies widely across the country, depending on the severity of the local COVID-19 outbreak.
“Right now, we are scared but are not in moral injury range yet,” says Stuart Wolf, associate chair for Clinical Integration and Operations at Dell Medical School in Austin, Texas. “That is [happening] in New York and just a few other places in the U.S. We are probably a few weeks away from the surge.”
Once that happens, he acknowledges, the “risk of moral injury will be very high.”
“It is already high,” Wolf adds. “In the planning phases we are having to make decisions about what providers will get personal protective equipment and which ones won’t. It is only going to get worse—not only deciding who will live and who will die, but our own personal safety and that of our loved ones will be part of the equation.”
A nurse working in a pediatric intensive care unit in New York City that has had to take on adult patients with COVID-19, who wished to remain anonymous to discuss internal matters, says her department was caught totally unprepared for the outbreak.
As a result, she says, she found herself having to take charge of managing inventory for personal protective equipment and following up on orders. Already nurses are having to work with only surgical masks and no visors for eye protection.
“The charge nurse was overwhelmed and did not have leadership experience to effectively communicate with vital team players like housekeeping and EVS,” the nurse says (a hospital’s EVS—environmental sciences department—plays a crucial role in infection control).
She says staff are not being tested for COVID-19 and have to self-monitor their temperatures in the employee bathroom. Having run out of disposable thermometers, they are using a portable thermometer and wiping it down afterwards, which is “wholly unsuitable, and I’m very concerned about that.”
Even when off shift the pressure doesn’t let up. The nurse hasn’t been able to hold her baby daughter for four weeks and “won’t be [able to] anytime soon” due to her work with COVID-19 patients. Her mother is looking after her baby so she can continue working, though this entails its own logistic dilemmas to mitigate the risk of cross infection.
“I bought a fridge for my mom, her own toaster, and coffee maker,” the nurse says. “I have a spacious place but only one bathroom which poses a significant threat. I bought a brand-new washer and dryer because I can’t send laundry out New York City-style. I was bleaching COVID scrubs outside my apartment and walking straight into my home naked, then straight to the shower.”
Around the world, health care workers are being applauded for their bravery and sacrifices, with many dying after catching COVID-19.
Linehan cautions, though, that he sees a parallel in this “lauding of health care workers” with the heroic narratives much applied to veterans that can often prove so frustrating and discombobulating for those on the receiving end.
“One of the hardest things is being told you are a hero, yet feeling anything but a hero—it creates this massive disconnect,” Linehan says. “You are perceiving me as one thing, but I know I am the opposite: That’s at the root of why so many veterans feel alienated.”
Adam Linehan
Adam Linehan on deployment in Afghanistan.
Another potential parallel between veterans and health care workers could come from a sense of betrayal by authorities. Research in the United States has identified how, for many veterans, the pride in once wearing their uniforms collides with a belief that military leaders failed or deceived them and their fallen comrades. The resulting sense of violation can further fuel the lingering crisis of the conscience and spirit, thereby deepening a moral injury.
“The President had dismantled safeguard systems designed specifically to deal with a pandemic, then stalled while warnings were clear,” Brock says. “He called the threats a hoax then minimized the threat, failed to press for adequate testing, and sent many medical personnel virtually unarmed into battle against an invisible enemy.”
The potentially destructive and lethal impact of PTSD and moral injuries is illustrated by the large numbers of veterans who kill themselves.
“In an ideal world, these health care workers would get very good medical leadership, indigenous supports, professional respite and care, and unburdening with others in the same boat would and should do the trick, but the support systems are plagued by the same impairments,” says Brett Litz with the Massachusetts Veterans Epidemiological Research and Information Center, and a professor of psychological and brain sciences at Boston University.
This means, Litz explains, the support systems and individuals that might mitigate stress, grief, and moral injury have “little to give or do not want to go there or can’t,” which increases the risk for health care workers in saturated areas of “burnout, PTSD-like symptoms—being haunted by various images and experiences—and moral injury.”
“A pretty awful combination of problems,” Litz adds.
At the same time, as can happen on a military operational deployment, the enormity of the task is pulling health care workers together.
“We are not running scared even though we are scared,” the nurse says. “I am very proud of my ICU team and [that’s] everyone on all levels, from housekeeping to upper management.”
“Moral injuries are not inevitable,” Markman says. “Everyone in the profession needs to recognize that they are trying to do the least harm possible in a situation in which it is impossible to provide the highest-quality care to every patient in need.”
He adds that leaders of hospitals need to communicate with the people working for them that “they are using their training to make the best possible decisions under horrible circumstances.”
Another potential factor in mitigating the psychological fallout for healthcare workers coming to terms with decisions they have to make, Brock says, will be how society reacts once the pandemic subsides and everyone’s lives are getting back to normal.
“This will have been a traumatic event for everyone, for the whole of society,” Linehan says. He notes how this could even produce echoes of the reception that greeted veterans returning from Vietnam for those health care workers leaving their communities to help in COVID-19 hotspots. Returning to their home communities afterward, they may find everyone simply wants to move on and not address the messy reality that transpired.
“Many people won’t want to hear the stories of health care workers, who will have to carry their memories isolated in the truth,” Linehan says.
On April 6, the United States crossed the threshold of 10,000 deaths from COVID-19. The first 5,000 deaths came in just over a month’s time, the second 5,000 followed in fewer than five days.
“I definitely have concerns about health care workers of all ages,” Wolf says. “The older ones might have a little more experience which might help, but frankly unless the health care worker has served in an active war zone or was involved with immediate care during a disaster, none of us have the necessary experience.”