I moved halfway across Canada to start a new position in a dynamic academic department shortly before SARS-CoV-2 moved to Canada. An understatement, as we Canadians are known for, is that COVID-19 has fundamentally changed the way we practice medicine. My first night of call, I asked a maintenance worker to point me to the trauma room. As I walked away, he said “Thank you for your service”. I was first humbled by this statement, then somewhat unsettled. Isn’t that what we say to members of the military? Don’t members of the military consciously sign-up for the potential of personal harm?
As a civilian, I never anticipated practising anaesthesia would mean placing myself at real risk of personal harm. Sure, we have all donned personal protective equipment (PPE) for the patient who may have tuberculosis, but I wasn’t performing any procedure that actually increases my risk compared to everyone around me. Now we are. In this COVID-19 new normal, the procedures we perform as anaesthetists are placing us (and the healthcare providers who assist us) in high-risk situations repeatedly. We are now consciously signing up for the potential for personal harm. A pandemic calls for the ultimate in human factors training; how to maintain competency and effectiveness in the setting of a potential threat to your own life. How do we integrate this training into medicine?
To answer this, I asked my friend and colleague Dr. Leilani Doyle to tell me about how her military training prepared her for situations where her life could be at stake. We also examined our civilian medical experiences and training. The COVID-19 pandemic calls for a change in medical training to acknowledge and manage the stress and anxiety of providing high-risk healthcare through focussed training and simulation. It also calls for integration of a heightened emotional state into protocols such as the mandatory use of checklists and clarity regarding acceptable and unacceptable equipment supply chain issues. Finally, pandemic response calls for a fundamental shift from our usual civilian practise of attempting to do more with less, to acknowledging changes in protocols take more time and personnel until they become ‘routine’.
Physicians are often reluctant to adopt safety initiatives such as simulation training, checklists, algorithms, protocols and drills that have been embraced in other high-risk industries such as the aircrews, the military or nuclear power plant operators. Simulation is often thought as a useful exercise during training to master decision-making, but not necessarily required once one is a consultant. Algorithms and protocols have been criticised in medicine as an abdication of decision-making. Checklists have also been criticised as causing unnecessary delays prior to surgery. Drills, or practice involving the repetition of an activity to improve a skill, to the point of being able to execute it perfectly even when sympathetically driven, is simply not a part of medical culture. A deficit perhaps only now appreciated during a pandemic.
Some may perceive resistance to these safety initiatives as signs of arrogance or hubris, but we disagree. Medical training and evaluation build and test recalled facts assembled into knowledge used at appropriate times. A ‘good’ physician can recall enormous amounts of information and is definitive in their decision-making. Does that mean a physician seeking the help of others and using written checklists is not? Knowledge retrieval, contextual awareness and communication are all severely tested when our own health is at stake. The COVID-19 pandemic has leveled the playing field between healthcare providers, aircrew or nuclear power plant operators; now our lives are at risk too.
There has been a paradigm shift in civilian healthcare; our workplace may now be a hostile environment where we may be at risk of illness and or death, whether or not a patient appears unwell. Our medical training has left us ill-equipped to deal with this dynamic. Understandably, this has caused great anxiety in many health care providers. As more is known about how COVID-19 spreads, or as supplies of PPE diminish or are substituted, guidelines and checklists will change. Constant change when one’s own health is threatened can also be a nidus of anxiety of what can be perceived as an opaque or confusing healthcare system, a system we once knew so well. Anaesthetists are very familiar with making do despite unavailable or backordered medications and supplies, being presented substitutes without consultation or discussion, or simply ‘MacGyvering’ equipment where there is a perceived need. Anaesthetists are also very used to being asked to do more with less and making their own individual decisions about the management of each patient. Safe anaesthesia care now requires we have a team-based approach where our patient management is predictable and more protocolised. We required more support and more time for procedures while acknowledging, in the short term if not longer, less patient throughput. This calls for a fundamental cultural shift of measuring productivity not simply by patient throughput, but by maintenance of healthcare provider safety and avoidance of harm.
Are there lessons to be learned from aviation or the military where the simple act of going to work, can put our lives at risk? How do pilots and soldiers face these risks and maintain their mental health? There may be a perception that it is simply an acceptance of the risk inherent in these career choices. This is not the only difference. Pilots and soldiers simulate emergencies. It is a mandatory part of training and maintenance of competence. Until recently we’ve only been simulating emergencies where the patient’s life is at risk. We may have intubated thousands of times, but now we’re being told to do it differently, in different environments and wearing PPE that is uncomfortable and inhibits our performance. We became novices again. Recall how anxious you were the first time you performed tracheal intubation on a well patient. Next, recall how anxious you were performing tracheal intubation a very sick and unstable patient. We are almost back to that level of ‘competence’ because we are essentially performing a new procedure. We need to now perform a familiar procedure in accordance to an unfamiliar protocol, in unfamiliar uncomfortable PPE, oftentimes in an unfamiliar environment with healthcare professionals we may be working with for the first time. We must adhere to protocol or risk our own health and the health of those around us. What will help alleviate this stress and speed up our progress to competency? Simulation. Practising over and over again what is required for safety and competency while maintaining the skills of an experienced airway manager. Change as little as possible with how you perform a tracheal intubation in a patient with COVID-19 disease. Be open to changes that make airway management a predictable safe team effort. If you almost never use a bougie, now is not the time to start. Additionally, we need practice. Lots of practise. We need to embrace drills, protocols, checklists and one another’s corrections and suggestions.
A second issue is kit, and PPE is particularly emotive. I’ve heard the cries “COVID-19 is a war. We’d never send our soldiers out without proper weapons and PPE!“. This is not as black and white as civilians would think. There are many examples even from the most recent conflicts of lack of contingency planning, unintended consequences and unanticipated needs. We plan based on past experience, both in medicine and in the military. COVID-19 a novel disease, consequently we have very little evidence what level of PPE is actually required for different procedures; therefore, protocols are a changeable montage. Are protocols changing because we have more evidence, or are they changing in an attempt to preserve PPE stores? Health care providers are understandably skeptical and are assuming the latter.
A good military officer can make their soldiers feel that despite putting them risk (no risk in combat is impossible), that they’ve done everything possible to mitigate unnecessary risks. Additionally, good officers will spend at least some time with the troupes. Decision-makers, from government officials to hospital administrators, are also facing duties the likes they have not seen before. Connecting with one another ‘on the front line’ may benefit both healthcare providers and decision-makers by adding clarity to the physical and emotional issues at hand. There is no substitute for seeing with one’s own eyes what’s going on on the battlefield. Captain Crozier, commanding officer on the USS Theodore Roosevelt, experienced this first-hand. He was faced with a growing number of sailors suffering from COVID-19 disease in crowded conditions. Despite being commanded not to disembark the majority of the 4,865 sailors on board, he sounded a very public alarm in a way he knew would be career ending. He viewed the lives and safety of his crew as more important and placed them before his own career. Healthcare workers need to feel that our leaders would do the same for us.
Finally, what motivates solders to risk their lives is not patriotism, or a good leader, it’s the band of brothers – the women and men in the trenches with them every day. The comradery coming out of Milan, London, New York etc. are similar – the shared experience that has formed bonds between healthcare providers that last a lifetime. We trust and understand one another. In fact, this bond and shared experience is what may help some health care providers weather their psychological trauma storms. We have only recently recognised post-traumatic stress as a formal diagnosis in soldiers. We have known for some time that soldiers facing extreme psychologic distress sometimes needed a break from the horror of the battlefield, but that keeping them away from the front and their buddies for too long would almost guarantee that that soldier would never be able to return to battle. Simply being amongst a group that knew what horrors you’ve lived through somehow helps you weather them. This will no doubt also be the case in healthcare workers who’ve been on the front lines of this pandemic, however we need to be vigilant of the workers who came from away (either other departments or even other cities) as they will lose this close support once they return to their home units. Additionally, we need to be mindful that for many, even with the support of a group, they may need extra resources to overcome their moral injury.
It is an accepted truism that war leads to advances in medicine. This war against Covid-19 is no exception. What I find the most heartening is how silos are being broken down, and not only people from many different specialties are joining the fight, but people from around the world are sharing information too. Opinions and ideas from groups that are diverse (people from different countries, specialties, ethnic backgrounds, gender, etc.) perform better, make better decisions, and are more innovative. This is the battle of our generation; we need to ensure we mobilise all of our resources by building and fostering diverse teams.
We can combine all three things: healthcare providers confident in their new skills because they have drilled them; feel supported by a leadership that has their safety and best interests in mind; and who feel a common bond with the other healthcare providers they’ve worked with. We believe we would not simply feel safer, we would actually be safer, both physically and psychologically as we connect more with those around us.
Leilani N. Doyle and Laura V. Duggan
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