The sun is sinking below the horizon as another night shift begins. I have a long 12 hour shift ahead of me but in the peaceful moments, which are few and far between, my mind drifts to the series of events that has led me to this moment in time. I am thinking about moral injury in healthcare.
Most of the focus of my writing in recent months has been how cancer has ravaged my body and my life, but there is another antagonist in my life’s story I talk much less about and that is COVID. I discuss this rarely because most people simply don’t want to hear about the virus anymore.
COVID
In the world at large COVID is now a non-issue. Not so for healthcare workers and the immunocompromised and I am a member of both of these groups. Those who continue to care for the critically ill know first had that the COVID pandemic is by no means behind us. We are still regularly tasked with the herculean efforts of trying to save the lives of deteriorating COVID patients.
Those who have compromised immune systems secondary to cancer, immune diseases, or organ transplants continue to be at high risk of progression to severe disease, organ failure, and death. Within the past two weeks alone, I have seen a post-liver transplant patient end up on mechanical ventilation and life support due COVID. It doesn’t matter what propaganda is spread by the governor, I am on the frontline and know COVID continues to be a deadly threat.
Work in the intensive care unit has always been difficult. When “intensive” is in the name, how could you expect anything less. Pulmonary critical care doctors, also known as “intensivists” have always had one of the highest levels of burnout and it’s no surprise why. The hours are long, the work is stressful, and the moral injury that can develop can be extreme.
Moral injury describes the deep emotional wounds that develop in those who witness intense human suffering and often while simultaneously experiencing a life threat. There is finally a growing acknowledgement that moral injury is a serious problem in our broken healthcare system and traumatic stress is not only sustained by those in the military, but also healthcare workers.
COVID brought moral injury into every corner of medicine, but in the ICU it is not a new phenomena. We have always witnessed human suffering. We have always lost many patients to cruel and incurable diseases, but certainly never to such a magnitude.
As a group, healthcare workers are injured. We are hurting. Our moral injury has changed us. We can not unsee the horrors that we have experienced over the past years. And we will never be the same.
Life In The COVID ICU and ECMO Unit
In the early months of the pandemic I was the critical care attending of a large medical COVID unit. We knew very little about the virus. No one who required a ventilator survived…no one. Patient after patient I ran to their bedside, intubated them when their lungs failed, and ultimately, with family on video chat, withdrew life support when their bodies finally gave out.
Next, for almost a year I was the critical care attending of a large surgical ECMO unit, a second line Hail Mary form of life support where blood is oxygenated outside the body in a machine and then returned to the heart by large blood-filled catheters. The human suffering I witnessed in the COVID ECMO unit was unparalleled. Young patients bleeding to death and dying in front of me while I stood powerless to prevent it. Lungs collapsing on a daily basis.
Each patient was so full of tubes they no longer looked human. I hated every moment of it. Watching the suffering was unbearable. Even when we understood more and had some treatments, we were powerless to stop the progression of the virus.
My Moral Injury Worsens
Every night I went home, took my clothes off in the yard, and rushed to the shower, praying I would not bring the virus home to my family. With every tickle in my throat I wondered…is this it, is this how I die? The protective gear was painful. Our faces were marred with deep painful lines from the tight fitting N95s. I had constant facial pain and headaches.
I saw my own feelings reflected in the hollow eyes of my colleagues. Day after day, week after week, the fatigue was unshakable (though it turned out in my case I had breast cancer and didn’t know it).
And worse of all, when I left the hospital, I faced a society that didn’t care. Vaccine refusal and refusal to wear masks or social distance was rampant. False information was everywhere. Doctors were accused of withholding treatments and keeping patients sick for profit. I was faced with the painful reality that my personal sacrifices meant absolutely nothing to the people in my community or in government.
On social media I was accused of “fake news” when I shared my first hand bedside experiences. The online bullying towards physicians and healthcare providers was so extreme, I gave up social media entirely. My own husband didn’t even believe what I was experiencing on a daily basis and accused me of fear mongering, over exaggeration, and giving into anxiety.
And still, every day I put my life in danger to help the people who called doctors liars and chose instead to listen to slanted news media reports, google “experts”, conspiracy theorists, and propagandized government press conferences. And every day my internal moral injury grew.
Then at the end of the deadly delta wave I was diagnosed with breast cancer and learned I was myself immunocompromised. This brought a new level of danger to my daily COVID exposure. Now with new highly contagious omicron variants I must be exceedingly careful. I see myself in each crashing immunocompromised patient. I am scared their story might someday be my own.
Now two and a half years in, I still have to strictly social distance and wear N95s. I still can’t safely be in groups. Yet, through all of the danger I have continued to work at the bedside and try to save what lives I can.
What Comes Next?
I know my moral injury runs deep. The faces of the dead haunt me. I can still see the fear in their panicked eyes. I can still hear their families wails of grief. I am still hurt by society’s treatment of physicians. I am still hurt by my husband’s refusal to believe my experiences. I still bear the weight of every patient I couldn’t save even knowing that saving them was impossible. I am clearly still suffering.
I often feel it is time for me to move away from critical care. I have dedicated more than a decade to acutely saving lives and I have simply seen too much. I am too hurt. I have lost too much. I need some time away for emotional healing and reflection.
I feel guilty when I consider leaving. There are so many people who need help and there is still a critical shortage of ICU doctors. So I will stay for now, and tonight, like many other nights, I will put these hurts aside and continue on. Even so, I am coming to accept that there will be a time when I will need to step away and focus on healing myself instead of healing others. But not tonight. Tonight, it’s go-time.
