COMMENTARY

NY Psych Residents Describe 'Tsunami' of COVID-19 Patients

Jeffrey A. Lieberman, MD

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June 26, 2020

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This transcript has been edited for clarity.

Jeffrey A. Lieberman, MD: Hello. This is Dr Jeffrey Lieberman of Columbia University, speaking to you for Medscape.

Everything now is really focused on the COVID-19 pandemic that we've been in the throes of for weeks, going on months. Today we wanted to share with the listening audience what the experience has been like for psychiatrists here in northern Manhattan, an area that was not just the epicenter of the epidemic but really was almost ground zero as one of the most heavily affected locations.

To do so, we're getting the perspective of psychiatrists who were deployed in various services at the surge and the peak of the epidemic, our house staff. I've asked three of our residents — Dr Nina Gao, a PGY1 resident; Dr Meredith Senter, a PGY4 resident; and Dr Alana Mendelsohn, a PGY3 resident — who have toiled in the front lines for the past 8-plus weeks to share some of their experiences with us. Thankfully, because the epidemic in New York has been contained to the extent that it's peaked and is declining, but has clearly not dissipated, we've been able to repatriate all of them. First, I'd like to introduce Dr Nina Gao to share her experience.

Nina Gao, MD: I was on neurology in March and we were told not to wear any masks at all because we were supposed to conserve PPE. We were also not supposed to have any COVID patients, although we did. The result was that we ended up becoming carriers and spreading the virus from room to room, which was later confirmed by testing. And then we had to watch those patients, who had just been awaiting discharge, start to deteriorate. And then we had to close the door because of infection control.

I wound up covering for the emergency room in April. At that point, there was no denying on any of the services in the main hospital that there was a pandemic. We had patients lining the emergency room halls, which is not atypical. But what was different was that so many of them were really unstable. They were on max-flow non-rebreathers, which means they were on oxygen tanks that had to be changed basically every 20 minutes. There were nights where I literally did nothing but walk around and change oxygen tanks. They didn't have all access to wall oxygen, because at that point we had so many patients who were intubated and just waiting for beds upstairs.

These periods of intense work were punctuated by feelings of guilt and sadness for a lot of the providers, especially after overnight emergency room shifts. I used to get calls on my phone all throughout the day for families looking for their father, mother, wife, brother. And a lot of times my name was the last name on that person's file because there had been so many transfers, even though I hadn't seen the patient in 2 days.

There's also the impact of the deaths. There were a lot of deaths in the emergency departments as well as the wards. I've walked into my shift multiple times at 6 AM and started the day by doing a death exam on somebody I'd never met, usually someone who was either admitted or transferred to us overnight.

Dying in the hospital in a pandemic is not something that I would wish for anyone. It's really awful to be alone, ventilated, and not have any access to family or friends nearby. So it's been really horrible for a lot of the families, and I'm sorry for any of them that lost someone in that way.

In spite of that, I think a lot of the psych interns, nearly universally, wanted to convey how much they felt the community really behind us. This was early on, through PPE donations and bringing us food on shift, but mostly just being so kind with their words when we had to give really, really bad news to families over the phone.

One example is when I was covering the ICU, I had to call a daughter and tell her that her father was breathing worse because of a ventilator-associated pneumonia and would need a tracheostomy. At the end of that conversation, she just said, "I can only imagine what it's like for you guys working at the hospital right now. And your family must be so worried." My colleague has a story about how she called a patient's family to say that the patient had died and the family responded by sending a pizza to the unit.

I think it's important to contextualize that in this moment of international and national protests, at least from where we stand here in New York. There's been so much private pain, grief, and loss in our community, and in more ways than one and oftentimes differentially. I think in a way these protests have brought private hurt out into the open, which is really, really big. I hope that that's an opportunity for us to look at our public policy and to think about how we can practice psychiatry now and in the future.

Mental Illness Continues

Lieberman: While some people in psychiatry were required to support the medical ICU emergency services, we also had to take care of our psychiatry patients throughout this and in our own emergency room. To talk about what that experience has been like, we have Dr Meredith Senter.

Meredith Senter, MD: Thank you so much for this opportunity, Dr Lieberman. And Nina, thank you for sharing your experiences and your thoughts. It's so appreciated.

I'm going to focus today on the experience of what it's been like for residents in the comprehensive psychiatric emergency program (CPEP), but also on what we're seeing that's changed in terms of the mental health of the population. I think it's important for all of us to realize what's going to be coming down the pipeline as a consequence of this pandemic.

In terms of the CPEP, it's been interesting. I was on for a week of nights there at the very beginning in March, and there was a pretty significant decline in the number of cases there. It was weird and eerie to be there overnight and have two or three patients come in. That was really atypical. Usually it's at least seven or eight patients. We had a feeling that people were avoiding the emergency room. As we know, they also were avoiding the medical emergency room because of a fear of getting COVID. We were worried. We wondered where the patients were and what that might mean in terms of how people were faring.

When I went back about 6 weeks later, in late April, things really had changed. We were seeing a lot of different sorts of presentations in the emergency room. From the standpoint of our chronic, severely mentally ill patients who we sometimes see repeatedly in the CPEP, a lot of them had been out of their usual care for 1-2 months, presenting very psychotic or manic. This is no one's fault in particular. Providers in the community are doing the best they can. This is a vulnerable population that might not have access to remote treatment because they don't have the internet or things like that. We were seeing more of these people presenting in a decompensated state because of that lack of access.

Additionally, we've been seeing patients who are new to psychiatric services or at least new to emergency psychiatric services. These are people who are in crisis, secondary to the pandemic. They may be suicidal for a number of reasons related to COVID-19 — for example, job loss. One story that comes to mind is of someone who was working in construction and suddenly there was no work there. This person became suicidal and fortunately presented to the emergency department.

There's been a lot of people like that presenting that we've been involved with care for. There are also people presenting with multiple deaths in their family. They may have been living with several family members, who then died, and they just didn't know what to do or how to go on. These are really devastating stories to hear that completely upend their entire lives.

There's also the issue of frontline workers feeling worried about infecting their loved ones, in some cases responsible for infecting their loved ones. There is one case a colleague told me about where someone felt responsible for the death of a loved one. A frontline worker was living with a spouse who was able to work from home. Basically, the only exposure the spouse had was this frontline worker. The spouse got sick and ultimately passed away from COVID-19. The tremendous guilt that this person felt was just unbearable and they were having suicidal thoughts as well. Of course, any of us would say it's not that person's fault, that they were taking all the precautions that they possibly could at home, and they had to go to work. But that was still a weight on this person.

These are just a sampling of the psychiatric consequences that we're already starting to see, and I think we're going to see a lot more.

Pivoting to the ICU

Lieberman: All of you residents have certainly had a unique experience that most postgraduate trainees don't. We won't get into whether it's a lucky or unlucky development, but you certainly are learning a lot from it.

Alana, as one of the senior members of the residency, what's this experience been like for you?

Alana Mendelsohn, MD: One of the things that has been interesting as an upper-level psychiatry resident is that we have been operating as frontline workers in this crisis in multiple different capacities. I and my classmates in the PGY3 class have been working in the ICUs along with interns like Nina. We've been in the psychiatric emergency room working alongside Meredith. And we've also been at home seeing our clinic patients remotely.

I think that's a perspective that is different from a lot of other mental health providers' who are more senior to us, who may be more specialized in their clinical work, or because they're no longer house staff, are not working in a medical capacity within the hospital. This has given us a sort of bird's-eye view of the pandemic in a way that I think a lot of people haven't seen.

Looking back on my own experience over the past couple of months, I was one of the first residents who was redeployed from the upper levels on our psychiatry program back to the ICU. A week later I was seeing my patients in clinic, and then on the weekends I was in the emergency room. So as my patients were telling me about their experiences, I was seeing it mirrored in the number and type of patients that were being hospitalized medically and we were seeing in the emergency room.

Although we were on the front lines as providers in this crisis from a medical perspective, I feel like we've also been on the front lines in the psychology of the crisis as it unfolded. I can see it in my own clinic panel, which is not a huge number of people, a microcosm of the crisis. I have patients who have lost family members due to COVID-19, who've lost their jobs, who are concerned about losing their housing. I have a patient who is at home dealing with an intimate partner violence issue, patients who are college students who lost their housing and returned to families, some of which are not necessarily supportive. I have patients who've been separated from their family members or spouses for extended periods of time due to social distancing guidelines.

I'm also seeing the particular vulnerabilities and strengths of our outpatient population, and I've watched it unfold week to week. At the beginning of the crisis, many of my patients were actually doing quite better than I think a lot of even us as providers were doing, because they had worked so hard to develop coping skills and techniques for managing distress. They were perhaps even better prepared than a lot of people for dealing with the initial stressors raised by this pandemic. As the weeks have unfolded and these stressors have emerged in different ways, I've watched my patients react and experience this crisis in a new way. It's been very illuminating as a provider to see week to week how the crisis has unfolded and how the psychology of the pandemic is evolving.

One of the things that's unique about this particular crisis is that it is both so universal and so particular at the same time, in the sense that many of these stressors that our patients are experiencing, frankly, we as providers are experiencing too. Our patients are talking to us about being cooped up at home, about not being able to see family members, about being worried about finances, about being worried about getting the infection or spreading it to family members. And we're living that as well.

Looking Forward

Lieberman: It was like a tsunami that basically hit the hospitals. People had to scramble to try to do the best they could. But there was no way that we were prepared.

What I'm hearing from your stories is that on one hand you're thinking that this is unprecedented and overwhelming, and at the same time you're asking how you're going to do your best in managing the situation.

Gao: I think the really difficult part emotionally was actually coming off of service. In a lot of ways, you went from this scenario where you were running around trying to get everything done at once, to then kind of being quiet, on your own, and maybe feeling guilt for having more patients die than you would normally. A very large amount of your patients die.

And you're not able to use the coping mechanisms that you normally would, like reaching out to your fellow residents, going out with friends, trying to talk to your family about it, who don't really understand what's been going on in the hospitals in New York. So I think the isolation coming off of service was a really big emotional struggle for providers.

Lieberman: This virus has been hard for everybody, but it's been particularly hard for individuals in certain ethnic and racial minority groups and socioeconomic groups. In several of the neighborhoods in northern Manhattan, we have populations that are severely affected.

Meredith, when you were seeing people, was this disproportionate impact on certain constituencies apparent? Or was it more that these are just patients who are affected like everybody else?

Senter: It was really apparent to me a couple of weeks ago when I was in the ICU. Of my panel of patients, the vast majority were racial and ethnic minorities. I found it striking. I didn't have a huge panel of patients, just a small list. But we noticed it and felt it. And I think we all know that as a society, we have to do better.

Lieberman: This wasn't something any of you anticipated having to go through when you decided to do a residency at Columbia. What's served you well during this experience? What did you learn about yourself in the course of this?

Mendelsohn: In terms of how do we deal with it, spending time talking together has been very important. Staying engaged with our patients, with our colleagues, has been important. And I also think turning to history is something that's important. I think young people especially can have this perspective that perhaps we're the first people to ever go through something like this. People older than us have been through similar experiences. I've been hearing a lot of stories from my patients, from my friends, from my family, of their parents and grandparents who went through collective traumas. I think there is a lot that we can learn from those experiences to help inform how we heal as a community.

But I think the biggest thing is letting go of our prior expectations about our careers and our roles as physicians, and understanding now that a lot of this is out of our control and that that is somehow okay. Also, understanding that it's okay to be sad about that.

I think Kübler-Ross pointed out very beautifully that the grieving process comes in waves. There are some days where we feel on top of it and there are some days where we feel very out of control and very helpless. That is a natural part of this experience.

Lieberman: It's not something that one could have known was coming or prepared for, but assuming that we've gotten through the worst of it, everybody's come through it having acquitted themselves very well and probably in the long run will be the better for it. It's along the lines of the old saying: Whatever doesn't kill you makes you stronger. And it sounds like each of you had a really very trying but extraordinary experience.

I want to thank you, Nina, Meredith, and Alana, for sharing your experiences with us. It was very illuminating. We don't get to talk this candidly about what we've been going through that often, so I'm glad that this opportunity afforded us an occasion to do that. And I hope this was interesting to the listening audience.

I'm Dr Jeffrey Lieberman from Columbia University, speaking to you today for Medscape.

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